What is the recommended management for an adult patient with mildly displaced fractures of the superior and inferior pubic rami?

Management of Mildly Displaced Superior and Inferior Pubic Rami Fractures

Mildly displaced fractures of the superior and inferior pubic rami should be managed conservatively with adequate pain control, early mobilization within 48 hours, and comprehensive multidisciplinary care including orthogeriatric comanagement in elderly patients. 1

Initial Management Approach

Pain Control

• Provide adequate analgesia as the cornerstone of treatment to enable early mobilization 1
• Consider regional anesthesia techniques such as continuous pericapsular nerve group (PENG) block for severe pain that limits mobilization, particularly when opioids are inadequate 2
• Traditional management relies on opioid analgesia, but regional techniques can facilitate earlier physiotherapy participation 2

Hospitalization and Multidisciplinary Care

• Expect hospitalization in approximately 95% of cases, with average length of stay around 14 days 3
• Implement orthogeriatric comanagement, especially in elderly patients, to improve functional outcomes, reduce hospital stay, and decrease mortality 1
• Patients with three or more medical comorbidities or those requiring assistive devices pre-fracture are likely to require hospitalization exceeding two weeks 3

Critical Diagnostic Considerations

Rule Out Life-Threatening Complications

• Obtain CT scan of the pelvis before mobilization, particularly in patients with ipsilateral hip arthroplasty, to exclude acetabular extension 4
• Monitor for acute bleeding complications from corona mortis injury or anticoagulation, which can develop 24-48 hours post-injury and present with contralateral pelvic hematoma, progressive anemia, and acute abdominal pain 5
• Initial radiographs miss pubic rami fractures in approximately 17% of cases; if clinical suspicion remains high with negative radiographs, obtain advanced imaging 3

Mobilization Protocol

Early Weight-Bearing

• Initiate early mobilization and progressive weight-bearing as tolerated within 48 hours of adequate pain control 1
• Early mobilization is central to management and reduces complications 4, 3
• Ensure pain is adequately controlled before attempting mobilization to prevent treatment failure 2

Rehabilitation Program

• Implement early postfracture physical training and muscle strengthening 1
• Continue long-term balance training and multidimensional fall prevention strategies 1
• 92% of patients return to prefracture ambulatory status by one year with appropriate rehabilitation 3

Secondary Fracture Prevention

Mandatory Evaluation for All Patients ≥50 Years

• Systematically evaluate every patient aged 50 years and older for osteoporosis risk 1
• Perform DXA scanning of spine and hip 1
• Review clinical risk factors and evaluate falls risk 1
• Image the spine for vertebral fractures 1

Pharmacological and Non-Pharmacological Treatment

• Ensure adequate calcium and vitamin D supplementation 1
• Initiate pharmacological treatment with drugs proven to reduce vertebral, non-vertebral, and hip fractures 1
• Counsel on smoking cessation and alcohol limitation 1
• Establish Fracture Liaison Service coordination for comprehensive secondary prevention 6

Surgical Considerations

When to Consider Operative Management

• Surgery is generally not indicated for isolated, mildly displaced pubic rami fractures 1
• Operative intervention may be considered if conservative management fails to control pain or enable mobilization after appropriate trial 7
• Percutaneous screw fixation or novel intramedullary splinting techniques are available but associated with failure rates up to 15% 7

Common Pitfalls to Avoid

Diagnostic Errors

• Do not rely solely on initial radiographs—17% of fractures are missed initially 3
• Always obtain CT pelvis in patients with ipsilateral hip arthroplasty before mobilization to exclude acetabular involvement 4
• Monitor anticoagulated patients closely for delayed bleeding complications up to 48 hours post-injury 5

Management Errors

• Do not underestimate the morbidity of these "stable" fractures—they require substantial healthcare resources and carry mortality risk 3, 5
• Inadequate pain control will prevent early mobilization and prolong hospitalization 2
• Failure to implement secondary fracture prevention misses a critical opportunity to prevent subsequent fractures 1

Expected Outcomes

• 84% of patients have no or mild hip/groin pain at one year 3
• 92% return to prefracture ambulatory status 3
• 95% return to prefracture performance in activities of daily living 3
• 92% of surviving patients live independently at home at one year 3