What is the initial management and treatment for pelvic pubic ramus fractures?

Initial Management and Treatment for Pelvic Pubic Ramus Fractures

For isolated nondisplaced pubic ramus fractures, initial management includes pain control and early mobilization with weight bearing as tolerated, guided by pain levels, using appropriate assistive devices such as crutches. 1

Assessment and Diagnosis

• Spontaneous pelvic pain in conscious trauma patients should prompt evaluation for pelvic fracture 2
• All trauma patients with shock or altered consciousness should be systematically considered as having potential pelvic trauma 2
• For hemodynamically unstable patients, obtain a pelvic X-ray upon arrival to the trauma center 2
• For hemodynamically stable patients, proceed directly to CT scan with intravenous contrast 2
• Consider performing E-FAST (Extended Focused Assessment with Sonography for Trauma) to identify associated injuries and assist in therapeutic decision-making 2

Treatment Algorithm

1. Hemodynamically Stable Patients with Isolated Pubic Ramus Fractures

• Pain management with appropriate analgesics
• Early mobilization with weight bearing as tolerated using assistive devices (crutches, walker) 1
• No surgical intervention required unless:
  • The fracture becomes displaced during treatment
  • Patient experiences intolerable pain with mobilization attempts
  • The fracture is part of a rotationally or vertically unstable pelvic ring injury 1

2. Hemodynamically Unstable Patients or Complex Pelvic Ring Injuries

• Immediate pelvic stabilization with external compression devices (pelvic binder) 2
• External fixation using:
  • Ganz clamp for Tile C fractures
  • Anterior pelvic external fixator for Tile C and B1/B3 fractures 2, 1
• For ongoing hemodynamic instability despite stabilization, consider:
  • Preperitoneal packing
  • Angiographic embolization
  • Surgical bleeding control 1

Important Considerations

1. Occult Posterior Ring Injuries: Nearly all patients (96.8%) with pubic rami fractures have associated lesions elsewhere in the pelvic ring, most commonly transforaminal sacral fractures, avulsion fractures of ligaments, or compression fractures of the lateral mass 3. These may require further diagnostic workup in patients with prolonged pain and immobility.

2. Mortality Risk: Pubic rami fractures are associated with increased mortality, particularly in elderly patients. Age is the primary predictor of 1-year mortality 4. This highlights the importance of early mobilization to prevent complications of prolonged immobility.

3. Surgical Options for Complex Cases: When surgical intervention is indicated, minimally invasive techniques show advantages:

   • Percutaneous retrograde pubic screw fixation results in shorter operation time, less blood loss, and fewer complications compared to traditional methods 5
   • Intramedullary elastic titanium nails can be used for simple pubic rami fractures associated with posterior pelvic ring disruptions 6

4. Severe Open Pelvic Trauma: For open pelvic injuries, prioritize bleeding control and management of perineal contamination. These cases should be managed in referral centers due to their complexity and need for multidisciplinary care 2, 1

Follow-up and Monitoring

• Regular follow-up to assess fracture healing and functional recovery
• Monitor for complications such as:
  • Delayed union or nonunion
  • Persistent pain requiring further investigation for occult posterior ring injuries
  • Thromboembolic events
  • Mobility-related complications in elderly patients

By following this management approach, most patients with isolated pubic ramus fractures can achieve good functional outcomes with conservative treatment, while those with complex or unstable injuries receive appropriate surgical intervention to restore pelvic stability.