What is the treatment approach for a patient with inferior and superior pubic rami fractures accompanied by a same side sacral alar fracture?

Treatment of Inferior and Superior Pubic Rami Fractures with Ipsilateral Sacral Alar Fracture

The treatment approach depends critically on hemodynamic stability and mechanical stability of the pelvic ring—hemodynamically unstable patients require immediate pelvic ring closure/stabilization followed by preperitoneal packing and/or angioembolization, while hemodynamically stable patients with posterior ring instability (which your fracture pattern suggests) require definitive surgical fixation with posterior pelvic ring stabilization and consideration of anterior fixation. 1

Initial Assessment and Stabilization

Hemodynamically Unstable Patients

• Immediate pelvic ring closure using a pelvic binder, bed sheet, or C-clamp to control venous and cancellous bone bleeding 1
• Preperitoneal pelvic packing (PPP) should be performed in conjunction with pelvic stabilization, as 80-90% of bleeding in pelvic fractures is venous in origin and inadequately controlled by angioembolization alone 1
• Angiography with embolization for arterial bleeding if hemodynamic instability persists despite adequate pelvic ring stabilization 1
• CT scan arterial contrast extravasation ("blush") is a good indicator for angioembolization need 1

Hemodynamically Stable Patients

• Proceed with CT imaging to fully characterize fracture pattern and assess mechanical stability 1
• Patients who are hemodynamically stable but mechanically unstable with negative CT for active bleeding can proceed directly to definitive mechanical stabilization 1

Definitive Surgical Management

Indications for Surgery

Your fracture pattern (bilateral pubic rami with sacral alar fracture) represents posterior pelvic ring instability and requires surgical fixation. 1

• Posterior pelvic ring instability (which includes sacral alar fractures) represents a surgical indication for anatomic fracture reduction and stable internal fixation 1
• The sacral alar fracture component indicates this is likely a lateral compression type II (LC-II) or potentially higher grade injury requiring operative management 1

Surgical Techniques

Posterior Ring Fixation (Primary Priority):

• Minimally invasive percutaneous iliosacral screw fixation for the sacral alar fracture and sacroiliac joint stabilization 1
• Spinopelvic fixation (triangular osteosynthesis) has the benefit of immediate weight bearing in patients with vertically unstable sacral fractures 1
• Less invasive lumbopelvic fixation using percutaneous pedicle screw systems can be considered, particularly in elderly patients with multiple traumas 2
• Angular stable bridge plating or transsacral positioning bar for osteoporotic bone 3

Anterior Ring Fixation:

• Superior and inferior pubic rami fractures typically do not require isolated fixation unless there is significant displacement 1
• Temporary external fixation may benefit selected lateral compression patterns with rotational instability (LC-II, LC-III) for 6 weeks post-injury to protect anterior ring stability 1
• Percutaneous screw fixation of superior pubic ramus can be considered if displacement is significant, though this has a 15% failure rate 4

Timing of Definitive Fixation

• Hemodynamically stable patients can undergo early definitive fixation within 24 hours post-injury 1
• Hemodynamically unstable and coagulopathic patients "in extremis" must be successfully resuscitated prior to definitive fixation 1
• Definitive fixation should be postponed until after day 4 in physiologically deranged polytrauma patients 1

Non-Operative Management Considerations

Non-operative management is NOT appropriate for your described fracture pattern due to posterior ring instability. 1

However, if fractures were minimally displaced and mechanically stable:

• Pain management with multimodal analgesia (consider PENG block for pubic rami pain) 5
• Early mobilization to prevent complications from immobilization 6
• Note: 1-year mortality increases with age in pubic rami fractures, particularly in patients ≥90 years, emphasizing importance of early mobilization 6

Critical Pitfalls to Avoid

• Do not rely on fracture pattern alone to determine need for angiography—arterial contrast extravasation on CT is the key indicator 1
• Do not perform non-therapeutic laparotomy in hemodynamically unstable pelvic fractures, as this increases mortality 1
• Do not delay pelvic stabilization in unstable patients—immediate closure is essential as venous bleeding predominates 1
• Do not assume isolated pubic rami fractures are benign—always image the entire pelvis including sacrum, as concomitant posterior injuries are common 1, 7
• Elderly patients may require angioembolization even with apparently normal hemodynamics and mechanically stable fractures 1

Goals of Treatment

The ultimate goal is anatomic reduction and stable fixation to allow early functional rehabilitation and decrease long-term morbidity, chronic pain, and complications associated with prolonged immobilization. 1