What is the management for superior and inferior pubic rami fractures?

Management of Superior and Inferior Pubic Rami Fractures

For most superior and inferior pubic rami fractures, conservative management with early mobilization as tolerated, adequate pain control, and close follow-up is the recommended approach, as these are typically stable injuries that heal well without surgical intervention. 1

Initial Assessment and Stabilization

• Evaluate for hemodynamic instability, which may indicate significant bleeding:

  • If unstable, consider pelvic binder application and urgent CT with contrast to assess for arterial bleeding 2, 1
  • Check for associated injuries, particularly in high-energy trauma cases

• Imaging:

  • Plain radiographs (AP pelvis) for initial assessment
  • CT scan with contrast for definitive evaluation of fracture pattern and to rule out associated injuries 2, 1
  • Consider 3D reconstruction for complex fractures to aid in treatment planning 1

Treatment Algorithm

Stable, Isolated Pubic Rami Fractures

1. Conservative management:

   • Weight-bearing as tolerated, guided by pain levels 1
   • Appropriate assistive devices (walker, crutches) 1
   • Adequate pain control with multimodal analgesia
   • Early physical therapy and mobilization

2. Pain management options:

   • Oral analgesics (acetaminophen, NSAIDs if not contraindicated)
   • Consider regional anesthesia techniques like PENG (pericapsular nerve group) block for severe pain 3
   • Judicious use of opioids for breakthrough pain
   • Avoid excessive sedation that might limit mobilization

3. Follow-up:

   • Regular clinical and radiographic assessment to ensure proper healing
   • Monitor for complications including delayed union, nonunion, or persistent pain 1

Unstable Pelvic Ring Injuries (with Pubic Rami Fractures)

1. Surgical management indicated for:

   • Unstable pelvic ring injuries (Tile B or C patterns)
   • Fractures that become displaced during treatment
   • Fractures causing intolerable pain with mobilization 1

2. Fixation options:

   • External fixation for temporary stabilization in emergency settings
   • Internal fixation for definitive treatment
   • Minimally invasive techniques like titanium elastic nails for superior pubic rami may be considered 4

Special Considerations

Elderly Patients

• Higher mortality rates compared to age-matched controls, particularly in patients >90 years 5
• Increased risk of complications due to comorbidities
• Consider osteoporosis treatment and fall prevention strategies
• Early mobilization remains crucial despite challenges

Patients with Ipsilateral Total Hip Replacement

• Higher risk of acetabular extension or prosthesis displacement 6
• Obtain CT scan to exclude acetabular involvement before mobilization
• Consider more conservative weight-bearing protocols

Open Pelvic Injuries

• Require specialized care in referral centers
• Prioritize bleeding control and management of contamination 2, 1
• Multidisciplinary approach involving trauma, orthopedic, and plastic surgery

Monitoring and Complications

• Monitor for:

  • Hemorrhage (especially in patients on anticoagulants) 7
  • Thromboembolic events
  • Urinary tract injuries (common with pelvic fractures) 1
  • Pain control adequacy and mobility progression

• Rare but serious complications:

  • Bleeding from corona mortis (vascular anastomosis between external iliac and obturator vessels) 7
  • Acetabular extension in patients with pre-existing hip replacements 6

Follow-up Care

• Regular outpatient visits to assess:

  • Fracture healing
  • Functional recovery
  • Pain control
  • Return to baseline activities

• Consider bone health assessment and treatment for osteoporosis in elderly patients to prevent future fractures

The 1-year mortality rate is significantly higher in patients with pubic rami fractures compared to age-matched controls, particularly in the elderly, highlighting the importance of comprehensive care beyond just fracture management 5.