What is the treatment for a pubic fracture?

Treatment for Pubic Fractures

The treatment for pubic fractures primarily consists of weight-bearing as tolerated guided by pain levels, with appropriate assistive devices such as crutches, along with adequate pain management and mobilization. 1

Initial Assessment and Classification

• Evaluate for pelvic ring stability, as management depends on whether the pubic fracture is:

  • Isolated and stable (nondisplaced pubic ramus fracture)
  • Part of a more complex pelvic ring injury
  • Associated with posterior pelvic ring injury (present in up to 96.8% of cases) 2

• CT imaging is crucial as plain radiographs may miss associated posterior pelvic injuries that can affect stability and treatment decisions 2

Treatment Algorithm

For Stable, Nondisplaced Pubic Fractures:

1. Conservative Management:

   • Weight-bearing as tolerated with appropriate pain control 1
   • Use of assistive devices (crutches, walker) based on pain and stability 1
   • Analgesics for pain management
   • Progressive mobilization to prevent complications of prolonged bed rest

2. Monitoring:

   • Regular follow-up to ensure proper healing
   • Assessment for development of chronic pain
   • Evaluation for potential posterior ring injuries if pain persists 2

For Unstable Pelvic Fractures or Complex Injuries:

1. Immediate Stabilization:

   • Patients with pelvic ring disruption in hemorrhagic shock require immediate pelvic ring closure and stabilization 3
   • External fixation using a Ganz clamp (for Tile C fractures) or anterior pelvic external fixator (for Tile C and B1/B3 fractures) 3

2. Hemorrhage Control:

   • For ongoing hemodynamic instability despite stabilization: early preperitoneal packing, angiographic embolization, and/or surgical bleeding control 3
   • For severe open pelvic trauma: bleeding control and management of perineal contamination are primary objectives 3

3. Definitive Management:

   • Surgery is indicated if the fracture becomes displaced during treatment, causes intolerable pain with mobilization, or is part of an unstable pelvic ring injury 1

Special Considerations

Elderly Patients:

• Higher mortality rates compared to age-matched controls, especially in patients ≥90 years 4
• Extended hospital stays (median 39 days) and rehabilitation periods 5
• 30% may lose previous independence permanently 5
• Risk factors include osteoporosis, rheumatoid arthritis, renal failure, corticosteroid use, and prior pelvic irradiation 6

Complications to Monitor:

• Prolonged immobility leading to deconditioning
• Thromboembolic events
• Pressure ulcers
• Pneumonia
• Urinary tract infections

Prognosis

• Most isolated, stable pubic fractures heal well with conservative management
• For elderly patients who survive the initial injury and treatment period, 92% return to prefracture ambulatory status and 95% return to previous performance in activities of daily living 7
• Early diagnosis and treatment of insufficiency fractures typically leads to complete or partial recovery 6

Common Pitfalls

1. Missing posterior pelvic ring injuries: Up to 96.8% of patients with pubic rami fractures have concomitant posterior pelvic ring injuries that may be missed on plain radiographs 2

2. Underestimating severity in elderly patients: These injuries can lead to significant morbidity and mortality in older adults, with 1-year mortality rates of 18.5% 5

3. Inadequate pain control: Poor pain management can lead to immobility, which increases the risk of complications

4. Delayed mobilization: Extended bed rest increases the risk of complications; early mobilization should be encouraged as pain allows