What are the implications of a fracture of the pubic rami (pubic bone fracture)?

From the Guidelines

A pubic rami fracture is typically managed conservatively with pain control and progressive mobilization, with surgery rarely needed unless the fracture is significantly displaced or part of a more complex pelvic injury. The treatment approach prioritizes pain management using acetaminophen (1000mg every 6 hours) and NSAIDs like ibuprofen (400-600mg every 6-8 hours) for 1-2 weeks, gradually decreasing as pain improves 1. Initial bed rest is recommended, followed by progressive mobilization with a walking aid (crutches or walker) as tolerated, typically starting 1-3 days after injury. Physical therapy should begin once pain allows, focusing on gentle strengthening exercises and gait training. Most patients can expect full recovery within 6-12 weeks, though elderly patients may take longer.

Key Considerations

• Complications to watch for include deep vein thrombosis (preventable with early mobilization and sometimes prophylactic anticoagulation in high-risk patients), chronic pain, and delayed healing 2.
• These fractures occur most commonly in elderly patients after minor falls due to osteoporosis, or in younger patients after high-energy trauma.
• Regular follow-up appointments are necessary to monitor healing progress.
• The management of pelvic trauma patients aims to restore homeostasis and normal physiopathology associated with the mechanical stability of the pelvic ring, and should be multidisciplinary and based on the physiology of the patient and the anatomy of the injury 3.

Radiological Workup

• Computed Tomography (CT) is the gold standard for radiological workup, with a sensitivity and specificity for bone fractures of 100% 3.
• CT with 3-Dimensional bone reconstruction is helpful in reducing tissue damage during invasive procedures, reducing the subjective expertise required from clinical staff, and improving patient recovery times 3.

Surgical Indications

• Posterior pelvic ring instability represents a surgical indication for anatomic fracture reduction and stable internal fixation 1.
• Selected lateral compression patterns with rotational instability benefit from adjunctive, temporary external fixation, in conjunction with posterior pelvic ring fixation 1.
• Pubic symphysis plating represents the modality of choice for anterior fixation of “open book” injuries with a pubic symphysis diastasis > 2.5 cm 1.

From the Research

Implications of Pubic Rami Fractures

The implications of a fracture of the pubic rami (pubic bone fracture) can be significant, particularly in the elderly population. Some key points to consider include:

• Mortality rates are higher in patients with pubic rami fractures, especially in those over 90 years of age 4
• Age is a significant predictor of 1-year mortality in patients with pubic rami fractures 4
• Pubic rami fractures can be life-threatening, especially when accompanied by acute bleeding or in patients with severe preexisting co-morbidities 5
• Nondisplacement osteoporotic pubic rami fractures can still be life-threatening due to the risk of hematoma and anemia 5

Treatment and Management

Treatment and management of pubic rami fractures typically involve:

• Conservative therapy, including rest, analgesic medication, and progressive active mobilization 5, 6
• Minimal-invasive stabilization of anterior pelvic ring fractures with retrograde transpubic screws may be recommended in some cases 6
• Surgery may be indicated in patients with concomitant posterior ring fractures or other complications 7

Outcomes and Morbidity

Outcomes and morbidity associated with pubic rami fractures include:

• Significant deterioration in ambulation and independency, with 34% of patients requiring institutionalization at discharge 7
• 49% of patients losing their independent mobility status, and 40% not experiencing a full recovery 7
• One-year mortality rate of 23% in patients with pubic rami fractures 7
• Complications during admission and dependent ambulatory status are significant predictors of 1-year mortality 7

Special Considerations

Special considerations in the management of pubic rami fractures include:

• Careful evaluation of every patient's mobility status to identify those at risk for complications 7
• Consideration of more aggressive management of these injuries, particularly in patients with concomitant posterior pelvic ring lesions 8
• Importance of satisfying pain management, early mobilisation, conservation of independence, and return to previous place of residence in the elderly population 8