What is the treatment for superior and inferior ramus fractures?

Treatment of Superior and Inferior Ramus Fractures

Most superior and inferior pubic ramus fractures can be managed non-operatively with pain control, limited weight-bearing, and appropriate rehabilitation, unless there is significant displacement or instability requiring surgical fixation. 1

Initial Assessment and Classification

• Evaluate for:

  • Fracture displacement (>5mm)
  • Pelvic ring stability
  • Associated injuries
  • Patient's functional status and mobility
  • Osteoporosis risk factors

• Diagnostic imaging:

  • Weight-bearing radiographs to evaluate stability
  • CT scan for complex or intra-articular fractures
  • Assess medial clear space (<4mm indicates stability) 2

Treatment Algorithm

1. Non-displaced or Minimally Displaced Fractures

• Conservative management is the first-line treatment for most ramus fractures 1, 3:

  • Analgesics for pain control
  • Limited weight-bearing with assistive devices (walker, crutches)
  • Progressive mobilization as tolerated
  • Thromboprophylaxis for high-risk patients

• Rehabilitation protocol:

  • Early postfracture introduction of physical training
  • Progressive muscle strengthening
  • Long-term continuation of balance training
  • Multidimensional fall prevention 1

2. Displaced Fractures or Unstable Pelvic Ring

Surgical fixation is indicated for:

• Displacement >5mm
• Pelvic ring instability
• Failure of conservative management
• Patients requiring early mobilization

Surgical options include:

• Superior ramus fractures:

  • Percutaneous retrograde medullary screw fixation 4
  • Novel intramedullary splinting implants 3
  • Partially or fully threaded cannulated screws

• Inferior ramus fractures:

  • Plate fixation (provides better mechanical stability) 5
  • Combined superior and inferior ramus fixation for Tile B pelvic injuries 5

Special Considerations

Elderly Patients with Osteoporotic Fractures

• Evaluate systematically for risk of subsequent fractures 1
• Implement osteoporosis treatment:
  • Calcium and vitamin D supplementation
  • Consider pharmacological treatment with agents demonstrated to reduce fracture risk 1
• Implement a Fracture Liaison Service (FLS) model for comprehensive care 1

Postoperative Care

• Appropriate pain management
• Correction of postoperative anemia
• Regular assessment of cognitive function
• Assessment for pressure sores
• Monitoring of nutritional status and renal function
• Early mobilization 1

Clinical Outcomes

Recent biomechanical studies show that fixation of both superior and inferior ramus fractures (when both are present) leads to:

• Earlier weight-bearing functional exercise
• Earlier bony union
• Better functional outcomes
• Lower incidence of sexual dysfunction 5

Pitfalls and Complications

• Non-operative treatment risks:

  • Prolonged immobilization leading to deconditioning
  • Thromboembolic events
  • Chronic pain with non-union

• Surgical risks:

  • Implant failure (up to 15% with percutaneous screw fixation) 3
  • Screw misplacement or migration 6
  • Neurovascular injury
  • Infection

• Prevention strategies:

  • Careful preoperative planning
  • Consideration of modified techniques for challenging anatomy (e.g., pre-bent guidewire for curved transpubic corridors) 6
  • Early mobilization and rehabilitation

Remember that appropriate treatment of fractures in elderly and multimorbid patients requires a balanced approach regarding operative versus non-operative treatment and careful selection of fixation devices and techniques 1.