What is the best course of management for a patient with a history of pubic rami fracture, who recently fell and now presents with new pains, and has imaging results showing nonunion of an old C2 midbody fracture, moderate osteoarthritis in the cervical and lumbar spine, and early healing of bilateral pubic rami fractures?

Clinical Documentation for Post-Fall Imaging Follow-Up

Immediate Priority: Neurosurgical Consultation Required

This patient requires urgent neurosurgical evaluation for the nonunion C2 fracture with 7mm anterior displacement, which represents a potentially unstable cervical spine injury that could lead to catastrophic neurological complications. 1

Assessment of Imaging Findings

Critical Finding - Cervical Spine

• Nonunion of C2 midbody fracture with 7mm anterior displacement identified on cervical spine radiographs 1
• This represents an unstable fracture pattern requiring specialist evaluation, as C2 fractures are the most common cervical spine fractures and can cause significant morbidity despite often presenting without neurological deficits 1
• The absence of prevertebral swelling does not exclude instability 1
• Immediate action: Neurosurgical consultation is mandatory, as surgical intervention may be required for unstable C2 fractures to prevent neurological deterioration 1

Pelvic Findings

• Bilateral pubic rami fractures showing early healing without displacement 2
• Critical consideration: 96.8% of patients with pubic rami fractures have associated posterior pelvic ring injuries that may be missed on plain radiographs 3
• The patient's new pain following the fall warrants consideration of CT pelvis to exclude occult posterior ring injury or secondary displacement, as 30-50% of initially nondisplaced fractures develop secondary displacement 2

Spinal Degenerative Changes

• Moderate osteoarthritis throughout cervical and lumbar spine with old L1-L2 compression fractures status post vertebroplasty 4
• These findings indicate significant osteoporosis requiring medical management 4

Right Shoulder

• Normal examination without acute injury 4

Recommended Management Plan

1. Urgent Neurosurgical Referral

• Immediate consultation required for C2 nonunion evaluation 1
• Obtain MRI cervical spine without contrast to assess ligamentous integrity and spinal cord status 4
• Consider CT angiography if vascular injury suspected 1
• Surgical stabilization may be indicated for this unstable nonunion pattern 1

2. Advanced Pelvic Imaging Consideration

• Obtain CT pelvis without contrast to evaluate for:
  • Occult posterior pelvic ring injuries (present in 96.8% of pubic rami fractures) 3
  • Secondary displacement of healing pubic rami fractures 2
  • Sacral fractures, ligamentous avulsions, or lateral mass compression fractures 3
• This is particularly important given new pain after fall and the high association of posterior injuries with anterior pubic rami fractures 3

3. Osteoporosis Management

• Initiate comprehensive fracture liaison service evaluation including: 4
  • DXA scan of spine and hip for bone mineral density assessment 4
  • Laboratory evaluation: ESR, serum calcium, albumin, creatinine, TSH, vitamin D, protein electrophoresis 4
  • FRAX score calculation for 10-year fracture risk 4
• Pharmacological treatment: Given multiple fragility fractures (bilateral pubic rami, old L1-L2 compressions), initiate bisphosphonate therapy (alendronate or risedronate as first-line) 4
• Non-pharmacological interventions: 4
  • Calcium 1000-1200 mg daily plus vitamin D 800 IU daily 4
  • Smoking cessation and alcohol limitation 4, 2
  • Fall prevention program with balance training 4, 2

4. Pain Management and Mobilization

• Continue appropriate analgesia for pubic rami fractures 2
• Weight-bearing as tolerated to prevent complications of prolonged immobilization 2
• Physical therapy focusing on gait training, strengthening, and balance 2
• Monitor for venous thromboembolism risk given fracture history 2

5. Follow-Up Protocol

• Serial radiographs of pelvis every 4-6 weeks to monitor for secondary displacement of pubic rami fractures 2
• Clinical reassessment for new neurological symptoms given C2 nonunion 1
• Coordinate care between neurosurgery, orthopedics, and primary care 4

Clinical Pitfalls to Avoid

• Do not assume pubic rami fractures are isolated injuries - nearly all have associated posterior ring pathology requiring CT evaluation 3
• Do not delay neurosurgical consultation for C2 nonunion with displacement, as this represents potential spinal instability 1
• Do not overlook osteoporosis treatment in patients with multiple fragility fractures, as secondary fracture risk remains high 4
• Do not immobilize excessively - early mobilization with weight-bearing as tolerated reduces complications in pubic rami fractures 2

Documentation of New Pain Correlation

The patient's new pain following the fall requires correlation with:

• Potential progression of C2 nonunion (requires neurosurgical assessment) 1
• Possible secondary displacement of healing pubic rami fractures (requires CT pelvis) 2, 3
• Occult posterior pelvic ring injury (present in 96.8% of cases) 3