Management of Multiple Displaced Pubic Rami Fractures

Initial Assessment and Classification

For patients with multiple displaced pubic rami fractures, management should be determined based on hemodynamic stability, mechanical stability of the pelvic ring, and associated injuries, with immediate pelvic ring closure and stabilization recommended for unstable fractures with hemodynamic compromise 1
Pelvic fractures should be classified according to stability patterns, with the Young & Burgess classification system commonly used to guide treatment decisions 2
In the pre-hospital setting, application of a pelvic binder is recommended when a pelvic fracture is suspected to limit life-threatening bleeding 1

Immediate pelvic ring closure and stabilization is strongly recommended (Grade 1B) for hemodynamically unstable patients with multiple displaced pubic rami fractures 3, 1
Temporary extra-peritoneal packing should be performed when bleeding is ongoing and angioembolization cannot be achieved in a timely manner for patients with life-threatening bleeding 1
Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) may be considered as a bridge to definitive hemorrhage control in patients with life-threatening bleeding 1
Definitive pelvic fracture fixation should be postponed until after successful resuscitation and hemodynamic stabilization for patients with multiple displaced pubic rami fractures 4, 2

Early definitive pelvic fracture fixation (within 24 hours) is recommended for hemodynamically stable patients with mechanically unstable fractures and no physiologic derangement 4, 2
Patients with negative CT scans and no other injuries requiring treatment can proceed directly to definitive mechanical stabilization for hemodynamically stable patients with mechanically unstable fractures 2, 5
Definitive fixation should be postponed until after day 4 post-injury in physiologically deranged polytrauma patients with multiple displaced pubic rami fractures 4, 2

Stable fracture patterns such as antero-posterior compression type 1 (APC-I) and lateral compression type 1 (LC-I) injuries can be managed non-operatively with functional rehabilitation and early weight bearing for patients with stable fracture patterns 2
Conservative management includes appropriate pain control, activity modification, and early mobilization as tolerated for patients with stable fracture patterns 6, 7

For rotationally unstable fractures (APC-II, LC-II) and vertically unstable fractures (APC-III, LC-III, VS, CM), definitive internal fixation is required for patients with unstable fracture patterns 2
Pubic symphysis plating is the treatment of choice for "open book" injuries with pubic symphysis diastasis >2.5 cm for patients with rotationally unstable fractures 2, 5
Selected lateral compression patterns with rotational instability benefit from adjunctive, temporary external fixation in conjunction with posterior pelvic ring fixation for patients with unstable fracture patterns 2

Postoperative care should include appropriate pain management, antibiotic prophylaxis, correction of postoperative anemia, and early mobilization as tolerated for patients after surgical fixation of multiple displaced pubic rami fractures 6, 7
Regular assessment of cognitive function, pressure sores, nutritional status, renal function, and wound care is essential for optimal recovery for patients after surgical fixation of multiple displaced pubic rami fractures 6