What is the management for a 61-year-old female patient with minimally displaced, minimally comminuted fractures of the left superior pubic ramus, pubic bone, and left inferior pubic ramus, currently in acute care?

Management of Minimally Displaced Pubic Ramus Fractures in a 61-Year-Old Female

This patient requires immediate orthogeriatric comanagement with multimodal analgesia, early mobilization within 24-48 hours, and systematic evaluation for secondary fracture prevention, as pubic ramus fractures in older adults carry mortality rates comparable to hip fractures despite being traditionally considered "stable" injuries. 1

Immediate Assessment and Risk Stratification

Rule Out Life-Threatening Complications

• Obtain hemoglobin level immediately and monitor for progressive anemia, as minimally displaced pubic ramus fractures can cause life-threatening hemorrhage from corona mortis artery injury or bleeding from cancellous bone, particularly in patients on anticoagulation. 2, 3
• Perform serial abdominal examinations to detect expanding pelvic hematoma, which may present with hypogastric mass, thigh swelling, hemodynamic instability, or progressive oliguria. 2, 3
• If hemodynamic instability or progressive anemia develops, obtain emergent CT pelvis with IV contrast to identify active arterial bleeding requiring angiographic embolization. 2, 3

Exclude Acetabular Extension

• If the patient has any history of hip arthroplasty or persistent groin pain despite analgesia, obtain CT pelvis immediately to exclude acetabular fracture extension before mobilization, as early weight-bearing can displace occult acetabular components. 4
• Standard radiographs are insufficient to exclude acetabular involvement in pubic ramus fractures. 4

Pain Management Protocol

First-Line Analgesia

• Initiate multimodal analgesia immediately before diagnostic workup using regional nerve blocks (femoral, obturator, lateral femoral cutaneous) combined with scheduled acetaminophen 1000mg every 6-8 hours. 1, 5
• Document pain scores at rest and with movement before and after analgesia administration. 5

Avoid Opioids as First-Line

• Opioids dramatically increase delirium risk, fall risk, and mortality in elderly patients and should be avoided as first-line agents. 1, 5
• If opioids are necessary for breakthrough pain, use the lowest effective dose with extreme caution if renal function is unknown, as approximately 40% of trauma patients have moderate renal dysfunction. 5
• Avoid NSAIDs until renal function is assessed, as they are relatively contraindicated in patients with impaired kidney function. 5

Orthogeriatric Comanagement Structure

Immediate Multidisciplinary Team Activation

• Implement immediate orthogeriatric comanagement on a dedicated ward to reduce mortality, length of stay, and complications. 1
• Designate a local responsible lead to coordinate care between orthopaedic surgeons, geriatricians, rheumatologists/endocrinologists, and general practitioners. 1

Comprehensive Geriatric Assessment

Systematically evaluate the following within 24 hours of admission: 1

• Nutritional status with implementation of oral supplementation if deficient
• Electrolyte and volume disturbances requiring correction
• Anemia screening with hemoglobin <8 g/dL as transfusion threshold for symptomatic patients 6
• Cardiac and pulmonary comorbidities requiring optimization
• Cognitive function baseline and delirium risk assessment
• Complete medication review with particular attention to anticoagulants
• Renal function assessment before NSAID or contrast administration

Mobilization Protocol

Early Weight-Bearing

• Begin weight-bearing as tolerated within 24-48 hours to prevent thromboembolism, pressure ulcers, pneumonia, and deconditioning. 1
• These fractures are mechanically stable and do not require bed rest or traction. 1
• Implement supervised ambulation initially with fall prevention strategies including room modifications and assistive devices. 1
• Physical training and muscle strengthening should begin immediately post-fracture. 1, 6

Common Pitfall to Avoid

• Do NOT delay mobilization waiting for pain to completely resolve, as prolonged immobility in elderly patients increases mortality risk substantially. 1

Thromboembolism Prophylaxis

• Administer pharmacologic VTE prophylaxis with low molecular weight heparin (e.g., enoxaparin) for minimum 4 weeks. 1, 6
• Add mechanical compression devices (sequential compression devices) while hospitalized. 1, 6
• Use mechanical prophylaxis alone if anticoagulation is contraindicated. 1

Delirium Prevention

• Implement multi-component non-pharmacological prevention including hydration management, sleep-wake cycle normalization, and cognitive orientation. 1
• Avoid opioids which dramatically increase delirium risk. 1
• Assess cognitive function regularly during hospitalization. 1

Secondary Fracture Prevention

Systematic Osteoporosis Evaluation

• Systematically evaluate all patients for subsequent fracture risk and initiate anti-osteoporotic treatment even without DXA scan, as pubic ramus fractures in patients over 50 are typical fragility fracture patterns. 1, 6

Evaluation Components

The evaluation must include: 1, 6

• Review of clinical risk factors for osteoporosis
• DXA of spine and hip when feasible
• Imaging of spine for vertebral fractures (often asymptomatic)
• Falls risk assessment with home safety evaluation
• Identification of secondary osteoporosis causes (thyroid disease, vitamin D deficiency, medications)

Pharmacologic Treatment

• Prescribe drugs demonstrated to reduce vertebral, non-vertebral, and hip fractures (bisphosphonates or denosumab) before discharge. 1, 6
• Ensure adequate calcium (1000-1200 mg/day) and vitamin D (800 IU/day) supplementation. 1, 6
• Monitor regularly for tolerance and adherence with follow-up appointments scheduled before discharge. 1, 6

Patient Education

• Provide education about disease burden, risk factors, importance of follow-up, and expected treatment duration. 1
• Emphasize smoking cessation and alcohol limitation. 6

Surgical Considerations

Conservative Management is Standard

• Minimally displaced pubic ramus fractures are treated conservatively in the vast majority of cases, as they are mechanically stable injuries. 1, 4

Rare Indications for Surgical Fixation

Consider surgical stabilization only if: 7

• Conservative treatment fails after adequate trial with persistent severe pain preventing mobilization
• Fractures are significantly displaced and nonreducible
• Bilateral fractures with posterior pelvic instability (FFP Type II-IV)

Discharge Planning

Criteria for Safe Discharge

• Hemodynamically stable with stable hemoglobin levels 2
• Adequate pain control on oral medications 1
• Able to mobilize safely with assistive devices 1
• Delirium prevention strategies in place 1
• Anti-osteoporotic treatment initiated 1
• Follow-up appointments scheduled with primary care and osteoporosis specialist 1

Expected Hospital Stay

• Median length of stay is approximately 17.5 days for elderly patients with pubic ramus fractures requiring comprehensive orthogeriatric care. 7

Prognosis

• One-year mortality is approximately 10.9%, emphasizing the serious nature of these injuries in elderly patients. 7
• Most patients achieve room or ward-level mobility at discharge with appropriate management. 7