What is the optimal management approach for an older patient with a pubic ramus fracture and underlying medical conditions?

Management of Pubic Ramus Fractures in Older Patients

Older patients with pubic ramus fractures require immediate orthogeriatric comanagement with multimodal analgesia, early mobilization within 24-48 hours, and systematic evaluation for secondary fracture prevention, as these injuries carry mortality rates comparable to hip fractures despite being traditionally considered "stable." 1, 2

Immediate Assessment and Pain Management

• Provide multimodal analgesia before diagnostic workup to prevent immobility-related complications 3
• Use regional nerve blocks combined with scheduled acetaminophen as first-line treatment 3, 4
• Avoid opioids as first-line agents due to increased risk of falls, delirium, and mortality in elderly patients 3, 5
• If opioids become necessary, reduce dose and frequency by 50% 5

Critical Diagnostic Pitfall

• Initial radiographs miss pubic ramus fractures in approximately 17% of cases 6
• Obtain CT scan of the pelvis before mobilization, particularly in patients with ipsilateral hip arthroplasty, to exclude acetabular extension 7
• Bone scintigraphy may be necessary if clinical suspicion remains high despite negative plain films 8
• Look specifically for concomitant posterior pelvic ring fractures, which occur frequently and increase complication rates from 18% to 44% 2

Orthogeriatric Comanagement Structure

Implement immediate multidisciplinary orthogeriatric comanagement on a dedicated ward to reduce mortality, length of stay, and complications 1, 5

The comprehensive geriatric assessment must systematically evaluate:

• Nutritional status and implement oral supplementation 1, 5
• Electrolyte and volume disturbances requiring correction 1, 3
• Anemia screening with appropriate transfusion thresholds 1
• Cardiac and pulmonary comorbidities 1
• Cognitive function baseline and delirium risk 1, 5
• Complete medication review 3
• Renal function 1

Mobilization Protocol

Begin weight-bearing as tolerated within 24-48 hours to prevent thromboembolism, pressure ulcers, pneumonia, and deconditioning 1, 4, 5

• Early mobilization is the cornerstone of treatment despite these being "stable" fractures 7, 9
• Patients with three or more medical comorbidities or pre-fracture assistive device use typically require hospitalization >14 days 6
• Implement supervised ambulation initially with fall prevention strategies including room modifications 5
• Physical training and muscle strengthening should begin immediately post-fracture 1, 4

Thromboembolism Prophylaxis

• Administer pharmacologic VTE prophylaxis with low molecular weight heparin 3, 5
• Add mechanical compression devices 5
• Use mechanical prophylaxis alone if anticoagulation is contraindicated 3

Delirium Prevention

Implement multi-component non-pharmacological prevention:

• Hydration management 5
• Sleep-wake cycle normalization 5
• Cognitive orientation 5
• Avoid opioids which dramatically increase delirium risk 3, 5

Secondary Fracture Prevention

Systematically evaluate all patients for subsequent fracture risk and initiate anti-osteoporotic treatment even without DXA scan, as pubic ramus fractures in elderly patients are typical fragility fracture patterns 1, 3, 5

The evaluation includes:

• Review of clinical risk factors 1
• DXA of spine and hip when feasible 1
• Imaging of spine for vertebral fractures 1
• Falls risk assessment 1, 4
• Identification of secondary osteoporosis causes 1

Pharmacological treatment:

• Prescribe drugs demonstrated to reduce vertebral, non-vertebral, and hip fractures (bisphosphonates or denosumab) 1, 5
• Ensure adequate calcium and vitamin D supplementation 1, 4, 5
• Monitor regularly for tolerance and adherence 1

Prognosis and Risk Stratification

The 1-year mortality rate is 23%, comparable to hip fractures 2, 9

Key prognostic factors:

• Age is the strongest predictor of mortality, with significantly elevated risk in patients ≥90 years 9
• Complications during admission increase 1-year mortality risk 5-fold 2
• Dependent ambulatory status pre-fracture increases mortality risk 4-fold 2
• Concomitant posterior ring fractures increase complication rates but not mortality 2

Expected functional outcomes at 1 year (in survivors):

• 49% lose independent mobility status 2
• 40% do not experience full recovery 2
• 34% require institutionalization at discharge 2
• However, 92% of survivors return to pre-fracture ambulatory status and 84% have minimal hip/groin pain 6

Implementation Requirements

• Designate a local responsible lead to coordinate secondary fracture prevention 1
• Establish liaison between orthopaedic surgeons, rheumatologists/endocrinologists, geriatricians, and general practitioners 1
• Provide patient education about disease burden, risk factors, follow-up, and treatment duration 1