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

Management of Multiple Pubic Rami Fractures

The management of multiple pubic rami fractures 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 using systems like Young & Burgess to guide treatment decisions 1
• Early detection of pelvic injuries is crucial for reducing mortality, which remains high (8-15%) in patients with severe pelvic ring disruptions 2
• Nearly all cases with fractures of the pubic rami have an associated lesion elsewhere within the pelvic ring, with posterior pelvic ring injuries found in 96.8% of patients on CT scans 3

Management Algorithm Based on Hemodynamic Status

For Hemodynamically Unstable Patients:

• Immediate pelvic ring closure and stabilization is the first-line treatment for patients with pelvic fractures showing hemodynamic instability 2, 1
• Pelvic closure can be achieved using external fixators, pelvic binder, bed sheet, or pelvic C-clamp 2
• Preperitoneal packing should be performed when bleeding is ongoing and angioembolization cannot be achieved in a timely manner 2, 1
• Angiography and embolization are highly effective for controlling arterial bleeding that cannot be controlled by fracture stabilization 2
• Damage control surgery should be employed in severely injured patients with deep hemorrhagic shock, signs of ongoing bleeding, coagulopathy, acidosis, or concomitant major injuries 4, 2

For Hemodynamically Stable Patients:

With Mechanically Unstable Fractures:

• Early definitive pelvic fracture fixation (within 24 hours) is recommended for hemodynamically stable patients with mechanically unstable fractures and no physiologic derangement 1
• Definitive fixation should be postponed until after day 4 post-injury in physiologically deranged polytrauma patients 1

With 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 1
• Conservative management includes appropriate pain control, activity modification, and early mobilization as tolerated 1
• Early mobilization is advocated as a central part of managing these patients, with emphasis on secondary prevention 5

Diagnostic Considerations

• CT scanning is essential for proper evaluation of pubic rami fractures to identify associated posterior pelvic ring injuries 3
• Markers of pelvic hemorrhage include anterior-posterior and vertical shear deformations, CT 'blush' (active arterial extravasation), pelvic hematoma volumes >500 ml, and ongoing hemodynamic instability despite adequate fracture stabilization 2
• In patients with prolonged pain and immobility following pubic rami fractures, further diagnostic work-up is warranted as they likely represent an undiagnosed pelvic ring injury 3

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 methods like intramedullary elastic titanium nails can be used for superior pubic rami fractures, decreasing wound-related complications while preserving soft tissues 6

Special Considerations

• Patients with ipsilateral total hip replacement and pubic rami fractures require thorough investigation including CT scan of the pelvis to exclude acetabular extension prior to mobilization 5
• Pubic rami fractures can be life-threatening when accompanied by acute bleeding, either from an injury to a vessel (corona mortis) or from medication (anticoagulant or antiplatelet) 7
• The 1-year mortality rate is higher in patients with pubic rami fractures compared to the general population, particularly in patients over 90 years of age 8

Post-Treatment Care and Follow-up

• 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
• Follow-up imaging is driven by the patient's clinical condition, with CT scan with delayed phase imaging recommended for moderate to severe injuries 4
• Return to sport activities should be allowed only after microscopic hematuria is resolved 4

Pitfalls to Avoid

• Delaying pelvic ring closure in hemodynamically unstable patients 2
• Removing pelvic packs too early (before 48 hours) 2
• Relying solely on plain radiographs for diagnosis, as they may miss posterior pelvic ring injuries 3
• Assuming pubic rami fractures are always stable injuries, as they are often associated with posterior pelvic ring disruptions 3