What is the management for a patient with a multiple displaced pubic rami fracture?

Management of Multiple Displaced Pubic Rami Fractures

For patients with multiple displaced pubic rami fractures, management should be determined based on hemodynamic stability, mechanical stability of the pelvic ring, and associated injuries, with immediate pelvic ring closure and stabilization recommended for unstable fractures with hemodynamic compromise. 1

Initial Assessment and Classification

• Pelvic fractures should be classified according to stability patterns, with the Young & Burgess classification system commonly used to guide treatment decisions 1
• Patients with suspected pelvic fractures should undergo immediate assessment for hemodynamic stability and CT imaging to evaluate for associated posterior pelvic ring injuries, which are present in up to 96.8% of cases with pubic rami fractures 2
• In the pre-hospital setting, application of a pelvic binder is recommended when a pelvic fracture is suspected to limit life-threatening bleeding 1

Management Algorithm Based on Stability

For Hemodynamically Unstable Patients:

• Immediate pelvic ring closure and stabilization is strongly recommended (Grade 1B) 1
• Temporary extra-peritoneal packing should be performed when bleeding is ongoing and angioembolization cannot be achieved in a timely manner 1
• Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) may be considered as a bridge to definitive hemorrhage control in patients with life-threatening bleeding 1
• Definitive pelvic fracture fixation should be postponed until after successful resuscitation and hemodynamic stabilization 1

For Hemodynamically Stable Patients with Mechanically Unstable Fractures:

• Early definitive pelvic fracture fixation (within 24 hours) is recommended for patients without physiologic derangement 1
• Patients with negative CT scans and no other injuries requiring treatment can proceed directly to definitive mechanical stabilization 1
• Definitive fixation should be postponed until after day 4 post-injury in physiologically deranged polytrauma patients 1

For Stable Fracture Patterns:

• Stable fracture patterns such as antero-posterior compression type 1 (APC-I) and lateral compression type 1 (LC-I) injuries can be managed non-operatively with functional rehabilitation and early weight bearing 1
• Conservative management includes appropriate pain control, activity modification, and early mobilization as tolerated 1

Surgical Fixation Techniques

• For rotationally unstable fractures (APC-II, LC-II) and vertically unstable fractures (APC-III, LC-III, VS, CM), definitive internal fixation is required 1
• Pubic symphysis plating is the treatment of choice for "open book" injuries with pubic symphysis diastasis >2.5 cm 1
• Minimally invasive techniques such as retrograde transpubic screw fixation or intramedullary elastic titanium nails may be considered for pubic rami fractures to decrease wound-related complications 3, 4
• Selected lateral compression patterns with rotational instability benefit from adjunctive, temporary external fixation in conjunction with posterior pelvic ring fixation 1

Special Considerations

• Patients with ipsilateral total hip replacements and pubic rami fractures require thorough investigation including CT scan of the pelvis to exclude acetabular extension prior to mobilization 5
• Nearly all 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 2
• Elderly patients with fragility fractures of the pelvis have higher one-year mortality rates compared to age-matched controls, with age being the most significant predictor of mortality 6
• External fixation is not recommended in elderly patients due to the risk of pin track infection and pin loosening 4

Post-Treatment Care

• Postoperative care should include appropriate pain management, antibiotic prophylaxis, correction of postoperative anemia, and early mobilization as tolerated 1
• Regular assessment of cognitive function, pressure sores, nutritional status, renal function, and wound care is essential for optimal recovery 1
• Patients should be monitored for prolonged pain and immobility, which may indicate undiagnosed pelvic ring injuries requiring further diagnostic workup or surgical intervention 2