Pubic rami fractures

Most pubic rami fractures seen in the elderly are in the anterior ring and are managed non-operatively. It is possible that associated posterior ring pathology is often overlooked in the elderly population.

Pubic ramus fractures, occurring as part of major trauma, present as parasymphysial fractures, mid ramus fractures and pubic root fractures in association with distraction and compression injuries of the pelvis.

Classification

Pubic rami fractures are classified as fractures of the anterior pelvic ring, usually occurring secondary to lateral compression. From a biomechanical point of view they are considered stable fractures that allow full weight bearing.

Epidemiology

Pubic rami fractures in the elderly often occur as a result of a fall from standing. However, many are atraumatic and therefore diagnosis may be missed or delayed. These fractures represent the most frequent type of pelvic fractures.

Osteoporosis is a major risk factor for pubic rami fractures, and as a result, incidence peaks in older age. In young athletes, the injury my present as stress fractures.

Presentation

• May occur in elderly patients following a fall or present as difficulty mobilising, or with hip and pelvic pain during movement, often in the context of osteoporosis.
• May present as severe groin pain in athletes such as runners.

A high level of suspicion is required for both cohorts.

Examine for other potential causes of pain, e.g. referred abdominal pain, inguinal hernia.

May also present as part of major trauma, which is not covered in this tool.

Imaging

• Plain x-rays are usually adequate for admission.
• CT or bone scan is indicated when there is pain and/or immobility without clear radiological evidence of a fracture on X-rays.

Management options

These fractures commonly require hospital admission for pain management and mobilisation, especially among elderly patients.

Referral and follow up requirements

Geriatrics and orthopaedics follow-up as required, particularly in cases of major trauma, or unstable or complicated fractures.

Potential complications

• High risk of missing underlying comorbidities which may have precipitated fracture from fall or be exacerbated it.
• Decreased mobility and associated complications, e.g. DVT.
• Risk of narcotic analgesia increasing delirium, hypotension and depressing respiratory drive.

Patient advice

• 6-8 weeks healing time
• Adequate analgesia