What is the recommended treatment plan for a patient with chronic hip pain and a CT scan showing a fracture of the right superior and inferior pubic rami and edema of the superior pubic ramus fracture extending into the anterior acetabulum, with pain persisting for 5 months?

Treatment Plan for Chronic Hip Pain with Pubic Rami and Acetabular Fractures at 5 Months

Immediate Diagnostic Reassessment

Given the persistent pain at 5 months post-injury, you must obtain an MRI of the pelvis and hip without IV contrast to evaluate for occult posterior pelvic ring injuries, acetabular component displacement, and soft tissue pathology that may be driving ongoing symptoms. 1, 2

• Nearly 97% of patients with pubic rami fractures have associated posterior pelvic ring injuries that are frequently missed on initial imaging, including transforaminal sacral fractures, ligamentous avulsion fractures, or lateral mass compression fractures 3
• The fracture extending into the anterior acetabulum requires specific attention, as acetabular extension in pubic rami fractures can lead to displacement and chronic pain if not adequately evaluated 4, 3
• CT may have already been performed, but MRI is superior for detecting soft tissue injuries, occult fractures, and evaluating healing status at this chronic stage 1, 2

Pain Management Strategy

Implement a multimodal analgesia protocol that minimizes opioid use while facilitating mobilization:

• Scheduled acetaminophen (paracetamol) should be prescribed regularly unless contraindicated, as it forms the foundation of non-opioid analgesia 1
• Consider a continuous pericapsular nerve group (PENG) block with catheter technique, which has demonstrated effectiveness specifically for superior and inferior pubic rami fractures with immediate pain relief and facilitation of mobilization 5
• Opioids should be used cautiously, particularly given the likely presence of renal dysfunction (40% of hip fracture patients have GFR <60 mL/min/1.73m²) 1
• NSAIDs are relatively contraindicated given the high likelihood of renal impairment in this patient population 1

Surgical Evaluation

At 5 months with persistent pain, you must obtain orthopedic consultation to evaluate for surgical fixation, particularly given the acetabular involvement:

• Pubic rami fractures with acetabular extension require thorough CT evaluation prior to mobilization to exclude acetabular component displacement 4
• Percutaneous screw fixation of the superior pubic ramus provides definitive pain relief and is the current standard, though it has a 15% failure rate 6
• Alternative fixation options include a novel intramedullary splinting implant for superior pubic ramus fractures, which shows equivalent biomechanical properties to conventional screws with potentially lower failure rates 6
• Retrograde percutaneous inferior pubic ramus screw fixation is effective for stabilizing the ischiopubic segment, particularly when acetabular involvement is present, and permits early weight-bearing 7
• 30% of patients with posterior pelvic ring injuries initially treated conservatively ultimately require operative treatment 3

Mobilization and Rehabilitation

Despite the chronic nature at 5 months, structured physiotherapy remains essential:

• Exercise-based treatment should be implemented for at least 3 months duration, focusing on hip and trunk strengthening with functional components 1
• Early mobilization is advocated as central to managing these fractures, but only after excluding acetabular displacement 4, 3
• Physical activity should be encouraged as tolerated, with progressive loading based on pain response 1

Critical Pitfalls to Avoid

• Do not assume this is a "stable" isolated pubic rami fracture - the acetabular extension and 5-month duration of pain strongly suggest either inadequate initial evaluation or progression of injury 4, 3
• Do not continue conservative management without advanced imaging - persistent pain at this timeframe warrants MRI to exclude occult injuries and evaluate fracture healing 1, 2, 3
• Do not mobilize aggressively without confirming acetabular stability - acetabular extension can displace with early mobilization, leading to worse outcomes 4
• Delays in definitive treatment are associated with increased complications, length of stay, and mortality in pelvic fractures 1

Algorithmic Approach

1. Order MRI pelvis/hip without contrast immediately to evaluate posterior ring, acetabular stability, and soft tissue pathology 1, 2, 3
2. If MRI shows posterior ring injury or acetabular instability → urgent orthopedic consultation for surgical fixation 7, 3
3. If MRI shows stable fractures with soft tissue inflammation → implement PENG block catheter for pain control and intensive physiotherapy 5, 1
4. If pain persists despite optimal conservative management → surgical fixation should be strongly considered given the 5-month duration 6, 7