Does a patient with right superior and inferior pubic rami fractures, especially an older adult or one with underlying medical conditions (e.g. osteoporosis), warrant an orthopedic (ortho) referral?

Orthopedic Referral for Superior and Inferior Pubic Rami Fractures

Yes, superior and inferior pubic rami fractures warrant orthopedic referral, particularly in older adults, because these injuries require systematic multidisciplinary assessment, carry significant morbidity and mortality risk, and may have occult associated injuries that necessitate specialist evaluation. 1

Why Orthopedic Referral is Essential

Multidisciplinary Care Requirements

• All fragility fractures in patients over 50 years require management within a multidisciplinary clinical system that guarantees adequate preoperative assessment, pain management, and coordinated care. 1
• The EULAR/EFORT guidelines emphasize that orthogeriatric comanagement should be provided, especially in elderly patients with pelvic fractures, to improve functional outcomes, reduce hospital length of stay, and decrease mortality. 1
• The critical point is not which specialty manages the patient, but that all patients receive optimal care through structured collaboration between healthcare workers. 1

High Risk of Occult Associated Injuries

• Up to 32% of patients with pubic rami fractures have associated sacral fractures that are missed on initial plain radiographs. 2
• These occult sacral fractures can be the source of intractable lower back pain and groin pain, requiring advanced imaging (CT or MRI) for detection. 3, 2
• In patients with ipsilateral total hip replacement, pubic rami fractures can extend into the acetabulum, causing displacement of the acetabular component—a complication that requires urgent orthopedic intervention. 4

Significant Morbidity and Mortality

• Pubic rami fractures carry a 1-year mortality rate that exceeds age-matched controls, with the difference becoming statistically significant in patients ≥90 years of age. 5
• Age is the strongest predictor of 1-year mortality in these patients, and pain-dependent immobilization poses serious hazards to patients with severe preexisting comorbidities. 5
• These fractures are associated with progressive inguinal pain, limping, inability to walk, and disproportionately slow recovery in some patients. 6, 2

Immediate Management Priorities

Pain Control and Assessment

• Provide immediate multimodal analgesia before diagnostic workup to prevent immobility-related complications. 7
• Avoid opioids as first-line treatment due to increased risk of falls, delirium, and mortality in elderly patients. 7
• Consider nerve blocks as part of multimodal pain management. 1

Comprehensive Evaluation

• Systematic assessment must include: nutritional status, electrolyte and volume status, anemia screening, cardiac and pulmonary comorbidities, cognitive function baseline, complete medication review, and renal function. 7
• Obtain CT scan of the pelvis to exclude acetabular extension and sacral fractures prior to mobilization, particularly in patients with hip arthroplasty or disproportionate pain. 4, 2
• Bone scintigraphy or MRI may be necessary when initial radiographs are negative but clinical suspicion remains high. 6

Early Mobilization with Caution

• Early mobilization is advocated as central to managing these patients, but only after excluding unstable or occult injuries. 4, 5
• Implement pharmacologic VTE prophylaxis with low molecular weight heparin and mechanical prophylaxis. 7

Secondary Fracture Prevention

Osteoporosis Evaluation

• Each patient aged 50 years and over with a pubic rami fracture should be evaluated systematically for risk of subsequent fractures. 1
• Anti-osteoporotic treatment can be started even without a DXA scan in typical fragility fracture patterns like pubic rami fractures. 1, 7
• Predisposing factors include osteoporosis, rheumatoid arthritis, renal failure, prolonged corticosteroid treatment, pelvic irradiation, and mechanical changes after hip surgery. 6

Common Pitfalls to Avoid

• Do not assume these are benign "stable" injuries—they carry significant morbidity and mortality, particularly in frail elderly patients with comorbidities. 5
• Do not rely solely on plain radiographs—obtain CT scan to exclude sacral fractures and acetabular extension, especially if pain is disproportionate or the patient has hip arthroplasty. 4, 2
• Do not delay pain management waiting for imaging—provide analgesia immediately. 7
• Do not mobilize patients before excluding occult injuries—this can lead to displacement of undiagnosed acetabular fractures or worsening of sacral fractures. 4
• Do not discharge without arranging osteoporosis evaluation and fall prevention strategies—these patients are at high risk for subsequent fractures. 7