Elsevier

Injury

Volume 43, Issue 8, August 2012, Pages 1326-1329
Injury

Detection of posterior pelvic injuries in fractures of the pubic rami

https://doi.org/10.1016/j.injury.2012.05.016Get rights and content

Abstract

Background

Fractures of the pubic rami are associated with prolonged pain, bed rest and increased morbidity and mortality. Often no further diagnostic work-up is undertaken and the pubic rami fractures are classified as stable injuries. However, fractured pubic rami seem to be only part of the picture and are often associated with posterior pelvic ring injury.

This retrospective study was designed to evaluate the posterior ring for undetected injury in patients diagnosed with pubic rami fractures.

Methods

All patients (n = 233) with diagnosed fractures of the pubic rami were retrospectively retrieved. All patients with a CT scan available at time of admission (n = 177) were included in the study.

Results

In 28.8% of the cases a fracture of the acetabulum was found additionally to the pubic rami. In cases without obvious other injury of the ap radiograph, an injury of the posterior pelvic ring was found on CT scans in 96.8% of the patients. Most lesions represented transforaminal sacral fractures, avulsion fractures of ligaments or compression fractures of the lateral mass. All patients with dorsal injuries could initially be treated conservatively, nevertheless 30% of them needed operative treatment in the course.

Conclusion

Nearly all cases with fractures of the pubic rami do have a lesion elsewhere within the pelvic ring. In patients with prolonged pain and immobility following ‘pubic rami fractures’ one should be aware that they probably represent an undiagnosed pelvic ring injury and further diagnostic work-up – sometimes even surgery – is warranted.

Introduction

Anterior lesions of the pelvis, especially fractures of the pubic rami are amongst the most common fractures in trauma patients. They represent a frequently encountered lesion especially in patients with osteoporosis.

As a result of the demographic developments towards an older population the incidence of this injury will further increase in the future.

The association of chronic pain, recurrent pain, increase of morbidity and mortality as well as a decrease in the quality of life following these fractures1, 2, 3 is an individual as well as economical problem. Hill et al. showed in a prospective study that patients with a fracture of the pubic ramus had a significantly worse survival than an age-matched cohort from the general population.2 Koval et al. could demonstrate that in elderly patients with pubic rami fractures the need of substantial healthcare resources based upon length of stay and need for home care services was increased.4

In major pelvic trauma, injuries at more than one site within the pelvic ring are common. However, there is limited information about the existence of isolated fractures of the pubic ramus in low energy trauma. Using scintigraphy, Gertzbein et al. could demonstrate that these obviously isolated injuries were associated with disruptions elsewhere within the ring in six consecutive cases – usually the acetabulum or sacroiliac joints.5

These occult lesions may explain the complications associated with presumably “isolated” fractures of the anterior pelvic ring.1, 2, 3 In order to avoid inappropriate therapy it is essential that the pelvic ring injury is classified properly and involvement of the posterior arch is excluded. Knowledge about the prevalence of isolated fractures of the pubic rami may be of value when planning the therapeutic concept such as partial weight-bearing on one side or even percutaneous fixation of the posterior pelvic ring.

The aim of this study was to assess the possibility of only isolated anterior pelvic ring injuries in a population of patients with a fracture of one or more pubic rami. We hypothesised that in all cases of a fracture of the pubic rami – in young patients with high velocity trauma as well as in old with osteoporotic fractures – a lesion of the posterior elements of the pelvic ring could be detected as well.

Section snippets

Patients and methods

Patients with a fracture of a pubic ramus who were initially admitted for assessment to the emergency ward of a Trauma 1 centre were included in this study.

All patients with one ore more fractures of the pubic rami admitted to our institute between June 2004 and February 2010 were included in this study. Further inclusion criteria were an initial radiography (Multix with an Optitop 150/40/80 tube, Siemens, Munich, Germany; 71–90 kV, 25–40 mAs) of the pelvis in ap-, inlet- and outlet-view followed

Results

Between June 2004 and February 2010, two hundred and thirty-three patients with fractures of the pubic rami were admitted to department. Fifty-six people were excluded from this study due to the absence of computed tomography examination. A total of 177 patients between 15 and 101 years were included. One hundred patients (56.5%) were female and 77 (43.5%) male. The mean age was 56, 5 years and the median age 59. The median age of female patients was 72 years considerably higher in contrast to

Discussion

Fractures of the pubic rami are often described as harmless injuries. Krappinger et al., however, concluded that pubic rami fractures might not be as benign as previously thought especially in patients with severe preexisting co-morbidities.6 Hill et al. reported an overall survival after fracture of the pubic rami at one and five years of 86.7% and 45.6% respectively.2 Although the mortality rate at one year was significantly better compared to hip fractures; at five years there was no more

Conflict of interest

All authors declared that there are no conflicts of interest.

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