Management of Multiple Pubic Rami Fractures

Initial Assessment and Classification

The management of multiple pubic rami fractures 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 using systems like Young & Burgess to guide treatment decisions 1
Early detection of pelvic injuries is crucial for reducing mortality, which remains high (8-15%) in patients with severe pelvic ring disruptions 2

Immediate pelvic ring closure and stabilization is the first-line treatment for patients with pelvic fractures showing hemodynamic instability 1, 2
Pelvic closure can be achieved using external fixators, pelvic binder, bed sheet, or pelvic C-clamp 2
Preperitoneal packing should be performed when bleeding is ongoing and angioembolization cannot be achieved in a timely manner 1, 2
Angiography and embolization are highly effective for controlling arterial bleeding that cannot be controlled by fracture stabilization 2
Damage control surgery should be employed in severely injured patients with deep hemorrhagic shock, signs of ongoing bleeding, coagulopathy, acidosis, or concomitant major injuries 2, 3

Early definitive pelvic fracture fixation (within 24 hours) is recommended for hemodynamically stable patients with mechanically unstable fractures and no physiologic derangement 1
Definitive fixation should be postponed until after day 4 post-injury in physiologically deranged polytrauma patients 1

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 1
Conservative management includes appropriate pain control, activity modification, and early mobilization as tolerated 1

Markers of pelvic hemorrhage include anterior-posterior and vertical shear deformations, CT 'blush' (active arterial extravasation), pelvic hematoma volumes >500 ml, and ongoing hemodynamic instability despite adequate fracture stabilization 2

For rotationally unstable fractures (APC-II, LC-II) and vertically unstable fractures (APC-III, LC-III, VS, CM), definitive internal fixation is required 1
Pubic symphysis plating is the treatment of choice for "open book" injuries with pubic symphysis diastasis >2.5 cm 1

Postoperative care should include appropriate pain management, antibiotic prophylaxis, correction of postoperative anemia, and early mobilization as tolerated 1
Regular assessment of cognitive function, pressure sores, nutritional status, renal function, and wound care is essential for optimal recovery 1
Follow-up imaging is driven by the patient's clinical condition, with CT scan with delayed phase imaging recommended for moderate to severe injuries 4
Return to sport activities should be allowed only after microscopic hematuria is resolved 4

Pelvic binders are indicated only as a pre‑operative or emergency measure for hemodynamically unstable pelvic fractures; they should not be applied after definitive internal or external fixation has been performed. 5

Continuous hemodynamic monitoring during the first 24–48 hours is essential to identify ongoing bleeding or vascular compromise following surgical repair of pelvic fractures and associated vascular injuries. 6

Post‑operative fluid resuscitation must maintain adequate perfusion to the repaired vascular structures while preventing fluid overload that could compromise respiratory function. 6