What is the recommended treatment for an elderly patient with a pubic body fracture?

Management of Pubic Body Fractures in Elderly Patients

For elderly patients with pubic body fractures, conservative non-surgical management is the recommended first-line treatment, consisting of pain control, limited weight-bearing, and early mobilization with appropriate assistive devices. 1

Initial Assessment and Classification

• Evaluate fracture stability and displacement through appropriate imaging:
  • Standard radiographs (may miss some fractures)
  • CT scan (recommended for better visualization)
  • Bone scintigraphy (useful for detecting occult fractures)
• Assess hemodynamic stability, as even non-displaced pubic rami fractures can rarely lead to significant bleeding 2
• Evaluate for associated injuries, which are present in up to 70% of elderly patients with pelvic fractures 3
• Check for predisposing factors: osteoporosis, rheumatoid arthritis, renal failure, prolonged corticosteroid treatment, pelvic irradiation, and mechanical changes after hip surgery 4

Treatment Algorithm

For Stable, Non-displaced Pubic Body Fractures (most common in elderly)

1. Conservative management:

   • Appropriate pain management (NSAIDs if not contraindicated, opioids if necessary)
   • Limited weight-bearing with assistive devices (walker, crutches)
   • Gradual mobilization as tolerated
   • Bed rest only during acute phase of pain

2. Duration of treatment:

   • Progressive mobilization over 2-4 weeks
   • Average hospital stay may be around 14-25 days 3, 5
   • Longer hospitalization likely for patients with ≥3 medical comorbidities or pre-existing mobility limitations 5

For Unstable or Displaced Pubic Body Fractures

1. Hemodynamically unstable patients:

   • Pelvic stabilization
   • Aggressive hemostatic resuscitation
   • Consider angioembolization (particularly important in elderly patients regardless of hemodynamic status) 1

2. Surgical intervention considerations:

   • Reserved for unstable fracture patterns or significant displacement
   • Surgical fixation may be considered for patients who can tolerate surgery and have:
     • Posterior pelvic ring instability
     • Vertical instability
     • Displacement >2mm
     • Inability to mobilize due to pain 1, 6

Rehabilitation Protocol

1. Early phase (0-2 weeks):

   • Pain management
   • Limited weight-bearing with assistive devices
   • Prevention of complications (DVT prophylaxis, pressure sore prevention)

2. Intermediate phase (2-6 weeks):

   • Progressive weight-bearing as tolerated
   • Gentle range of motion exercises
   • Assessment of functional improvement

3. Late phase (6+ weeks):

   • Strengthening exercises
   • Balance training
   • Fall prevention strategies
   • Return to pre-fracture mobility level (achieved by 92% of patients within one year) 5

Special Considerations for Elderly Patients

• Systematic evaluation for osteoporosis:

  • DXA scan
  • Assessment for vertebral fractures
  • Evaluation of falls risk 1

• Supplementation:

  • Calcium (1000-1200 mg/day)
  • Vitamin D (800 IU/day)

• Fracture Liaison Service referral for comprehensive secondary fracture prevention 1

• Close monitoring for complications related to immobility:

  • Pressure sores
  • Deep vein thrombosis
  • Pneumonia
  • Cognitive decline

Prognosis

• With appropriate treatment, most elderly patients with pubic rami fractures show good long-term outcomes:

  • 92% return to pre-fracture ambulatory status
  • 95% return to previous level of activities of daily living
  • 84% have no or mild complaints of hip/groin pain at one year 5

• Mortality risk is increased with:

  • Higher Injury Severity Score (>25)
  • Multiple medical comorbidities
  • Advanced age
  • Delayed mobilization 3

Pitfalls to Avoid

• Underestimating bleeding risk: Even non-displaced pubic rami fractures can cause significant hemorrhage, particularly in elderly patients on anticoagulants 2
• Prolonged immobilization: Extended bed rest increases risk of complications and should be avoided
• Missing associated fractures: Pubic rami fractures often occur with other pelvic or acetabular fractures
• Inadequate pain control: Poor pain management can delay mobilization and increase complication risk
• Overlooking osteoporosis treatment: Secondary fracture prevention is essential for long-term outcomes