What are the treatment options for superior and inferior pubic ramus fractures?

Treatment Options for Superior and Inferior Pubic Ramus Fractures

Conservative management is the primary treatment approach for most superior and inferior pubic ramus fractures, focusing on pain control and early mobilization as tolerated, with surgical intervention reserved for complex or unstable fractures. 1

Initial Assessment and Classification

• Pubic rami fractures are commonly classified as stable injuries but require thorough evaluation as they may be part of more complex pelvic ring disruptions 2
• CT scanning is recommended for all suspected pubic rami fractures as nearly 97% have associated posterior pelvic ring injuries that may be missed on plain radiographs 2
• Evaluation for associated injuries is critical, particularly in patients with ipsilateral hip replacements, where acetabular extension should be excluded before mobilization 3

Conservative Management

• For uncomplicated, stable pubic rami fractures:

  • Pain management with appropriate analgesia 1
  • Early mobilization as tolerated to prevent complications of prolonged immobility 1
  • Physical therapy for gait training and progressive weight-bearing 1
  • Regular follow-up to monitor healing and functional recovery 1

• Special considerations:

  • Elderly patients require close monitoring due to higher mortality rates compared to age-matched controls, particularly those ≥90 years 1
  • Patients with severe pre-existing comorbidities may require more cautious mobilization protocols 1

Surgical Management

Surgical intervention is indicated in the following scenarios:

• Complex fractures with pelvic ring instability 4
• Fractures associated with bladder or urethral injuries 4
• Fractures requiring internal fixation for orthopedic stability 4
• Fractures with displacement that may compromise functional outcomes 5

Surgical Techniques

• Percutaneous screw fixation:

  • Currently the standard treatment for surgical cases due to reduced blood loss and shorter surgery times 5
  • Options include partially or fully threaded cannulated screws 5
  • Technical challenges exist with failure rates up to 15% related to implant failure and loss of reduction 5

• Novel intramedullary splinting:

  • Emerging technique showing comparable biomechanical stability to screw fixation 5
  • Potential to decrease implant failure rates due to minimally invasive implantation 5

• Titanium elastic nails:

  • Alternative minimally invasive technique for simple pubic rami fractures associated with posterior pelvic ring disruptions 6
  • Preserves soft tissues and may reduce wound-related complications 6

Management of Associated Injuries

• For bladder injuries associated with pubic rami fractures:

  • Extraperitoneal bladder ruptures may be managed conservatively with urinary drainage via urethral or suprapubic catheter 4
  • Complex extraperitoneal bladder ruptures (bladder neck injuries, lesions associated with pelvic fractures requiring internal fixation, or rectal/vaginal injuries) should be surgically explored and repaired 4

• For urethral injuries:

  • Immediate urinary drainage should be established 4
  • Blunt anterior urethral injuries should initially be managed conservatively with urinary drainage 4
  • When posterior urethral injury is associated with complex pelvic fracture, definitive surgical treatment with urethroplasty should be performed after the healing of pelvic ring injury 4

Follow-up and Monitoring

• CT scan with delayed phase imaging is the method of choice for follow-up of associated bladder injuries 4
• Ureteroscopy or urethrogram are recommended for follow-up of urethral injuries 4
• Return to normal activities should be guided by resolution of symptoms and radiographic evidence of healing 4
• Patients should be monitored for chronic pain, which can significantly impact quality of life 5

Pitfalls and Caveats

• Failure to identify associated posterior pelvic ring injuries may lead to inappropriate treatment and poor outcomes 2
• Early mobilization, while generally recommended, should be approached cautiously in patients with potential acetabular extension, particularly those with ipsilateral total hip replacements 3
• Prolonged pain and immobility following pubic rami fractures may indicate undiagnosed pelvic ring injury requiring further diagnostic workup and potentially surgical intervention 2
• Age is the most significant predictor of 1-year mortality in patients with pubic rami fractures, with significantly higher mortality rates in patients over 90 years compared to age-matched controls 1