Pubic Rami Fractures

Pubic rami fractures involve the superior and/or inferior pubic rami. They may be isolated (ring intact) or associated with posterior ring injury (sacral fracture, SI joint injury).

• Elderly Fragility Fractures: Most common presentation. Low-energy fall.
• Young High-Energy: MVA, Fall from height. Often part of major pelvic ring injury.
• Incidence: Very common fragility fracture. Often under-recognized.

• Superior Pubic Ramus: Connects pubic body to acetabulum (forms anterior column).
• Inferior Pubic Ramus: Connects pubic body to ischium.
• Pubic Symphysis: Fibrocartilaginous joint at midline.

• The pelvic ring is a closed loop: Sacrum, SI joints, Innominate bones (Ilium, Ischium, Pubis), Symphysis.
• A complete ring cannot break in only one place. If rami are fractured, look posteriorly.

• Insufficiency Fractures: Osteoporotic bone can have incomplete or subtle posterior fractures (Sacral insufficiency fractures).

• Mechanism: Low-energy fall (elderly)? High-energy (young)?
• Pain Location: Groin, anterior pelvis.
• Mobility: Can they walk? Weight-bear?

• Tenderness: Pubic rami (groin/anterior pelvis).
• Deformity: Usually none (isolated stable fractures).
• Compression/Distraction: May elicit pain.
• Gait: Antalgic.
• GU Exam: Blood at meatus? Urethral injury in high-energy (especially males).
• PR/PV Exam: Assess for associated injury.

• The longer male urethra is the one at risk. The membranous urethra at the urogenital diaphragm is the classic site in pelvic-fracture (anteroposterior) injuries; the bulbar urethra is torn in straddle mechanisms.
• Signs: blood at the external meatus (the cardinal sign), inability to pass urine, a high-riding or boggy / impalpable prostate on rectal examination, and a perineal or scrotal "butterfly" haematoma.
• The rule that wins marks: if a urethral injury is suspected, do NOT pass a urethral catheter. Perform a retrograde urethrogram first — blind catheterisation can convert a partial tear into a complete disruption and worsen later stricture.

• Gross haematuria is the cardinal sign and mandates a CT cystogram (retrograde gravity filling, not just a passively clamped catheter).
• Extraperitoneal rupture is the common pattern with pelvic-ring fractures and is usually managed with catheter drainage alone.
• Intraperitoneal rupture (free leak into the peritoneal cavity, often a dome tear) requires operative repair.

1. X-ray (AP Pelvis): Shows rami fractures. May miss posterior injury.
2. CT Pelvis: Essential. Assess posterior ring (Sacrum, SI joints).
3. MRI: If CT negative but high clinical suspicion. For occult sacral insufficiency fractures.

• Rami Fractures: Usually visible on X-ray.
• Sacral Compression (LC-1): May be subtle on CT. Look for buckling of sacral ala.
• Sacral Insufficiency Fracture: Classic 'H-sign' (Honda sign) on bone scan / MRI (bilateral sacral ala + transverse fractures).

• Prompt, opioid-sparing analgesia — multimodal, with consideration of regional blocks — so the patient can actually move; pain that prevents mobilisation is itself a driver of mortality.
• Mobilisation from day 1 with physiotherapy, weight-bearing as tolerated, and an aid (frame/walker); the explicit aim is to break the immobility cascade (DVT/PE, pneumonia, deconditioning, pressure injury).
• Delirium prevention and screening (e.g. the 4AT), with reorientation, sensory aids, hydration, sleep hygiene, and avoidance of precipitating drugs.
• Pressure-area, continence, nutrition and hydration care, plus review and deprescribing of falls-risk and sedating medications.
• Venous thromboembolism risk assessment and appropriate prophylaxis.

• Enrol the patient in a fracture liaison service, arrange bone-density assessment, and start the osteoporosis work-up; this fragility fracture is a sentinel event signalling high future fracture risk. (Specific drug selection — anti-resorptive vs anabolic agents — is developed in the osteoporosis topic.)
• Undertake a multifactorial falls assessment (gait/balance, vision, postural blood pressure, home hazards) to prevent the next fracture.

• National hip-fracture programmes and their best-practice standards (early surgery where relevant, orthogeriatric review, bone-health and falls assessment) increasingly bring pelvic fragility fractures onto the same audited pathway, recognising them as an equivalent frailty event rather than a benign isolated injury.

• Mobilize Day 1.
• Walker/Frame.
• Physio daily.
• Discharge when safe (Home vs Rehab).

• Mobilize same day or next day.
• Weight-bear as tolerated.
• Follow-up X-ray.

• No dedicated pelvic-fragility registry exists; data come from national hip-fracture registries and trauma databases, which increasingly capture pelvic fragility fractures under the same frailty pathways.
• Bone-health drugs (bisphosphonates, denosumab, and anabolic agents such as teriparatide/romosozumab) are standard secondary prevention after a fragility fracture; agent choice and access vary by region and fracture risk.

• High-resource settings: routine CT, orthogeriatric co-management, fracture liaison services, and percutaneous fixation/sacroplasty for refractory pain.
• Limited-resource settings: diagnosis often rests on plain radiographs (risking missed posterior injury), with conservative analgesia and mobilization the mainstay and surgery reserved for clear instability.