Executive Editor: Peter Trafton

Authors: Rahul Banerjee, Peter Brink, Matej Cimerman, Tim Pohlemann, Matevz Tomazevic

Pelvic ring - Pubic ramus

back to skeleton

Glossary

General considerations

Before proceeding with definitive repairs, the patient must be fully resuscitated, fully evaluated, and fit for anesthesia and surgery by a prepared team.

Minimally displaced pubic ramus fractures are typically stable and require only symptomatic treatment. However the possibility of an associated posterior injury must be remembered, as problems with healing may occasionally occur.

Displaced pubic ramus fractures with pelvic ring instability are often high energy injuries. Surgical treatment of both posterior and associated anterior injury is usually indicated for completely unstable pelvic ring injuries.

For rotationally unstable injuries, anterior arch fixation alone may be sufficient but posterior repair should be considered if posterior stability is questionable.

Nonoperative
Main indication Skill Equipment
Stable undisplaced pubic ramus fracture Basic surgical experience, no specialized skills Basic equipment only

Indications

  • Undisplaced pubic ramus fracture with no evidence of pelvic ring instability

Contra indications

  • Unstable pelvic ring injury
  • Significant ramus fracture displacement

Advantages

  • No surgical treatment needed

Disadvantages

  • Failure to recognize ring instability
  • Pseudoarthrosis rarely occurs
External fixation
Main indication Skill Equipment
Displaced pubic ramus fractures with unstable pelvic ring Some specialized surgical experience Simple surgical and imaging resources

The choice between iliac crest pins and supra-acetabular pins is surgeon's preference.

Indications

  • Temporary splint for hemorrhage control
  • Oblique distracting fixator may be sufficient for definitive B2 (LC-I) ramus fracture
  • Option for pubic ramus fracture fixation after posterior repair
  • Intra-operative reduction aid

Contraindications

  • External fixation alone is inadequate for a completely unstable pelvic ring

Advantages

  • Rapid non-invasive application
  • Adjustable

Disadvantages

  • Pin track problems
  • Limited stability
Pubic ramus plate
Main indication Skill Equipment
Part of combined anterior and posterior fixation for unstable pelvic ring Some specialized surgical experience Simple surgical and imaging resources

Indications

  • Displaced pubic ramus fracture with associated posterior injury (unstable pelvic ring)
  • Displaced fracture, including perineal deformity
  • May be sufficient as sole fixation for B2 (LC-I) rotationally unstable injuries

Contraindications

  • Stable injury without significant deformity
  • Patient not fit for surgery
  • Local soft tissue injury (contusion, Morel Lavallée lesion, etc.)

Advantages

  • Aids reduction and stabilization of displaced pelvic ring injury

Disadvantages

  • Anterior pelvic ORIF alone is insufficient to stabilize a significant posterior ring injury
Pubic ramus screw
Main indication Skill Equipment
Alternative to plate fixation of unstable ramus fractures Highly experienced and skilled surgeon Full specialized surgical and imaging resources

Indications

  • Alternative to plate fixation of ramus fracture (surgeon’s preference)
  • Displaced pubic ramus fracture with repair of posterior pelvic ring injury
  • Displaced medial ramus fracture with symphysis repair (tilt fracture)
  • May be sufficient as sole fixation for B2 (LC-I) rotationally unstable injuries

Contraindications

  • Stable injury without significant deformity

Advantages

  • Potentially avoids open exposure

Disadvantages

  • Requires satisfactory closed reduction
  • Failure rate increased with retrograde screw, lateral fracture location, and osteoporosis
  • Anterior pelvic arch ORIF alone is insufficient to stabilize a Type C posterior ring injury
*Skill
Basic surgical experience, no specialized skills Basic surgical experience, no specialized skills
Some specialized surgical experience Some specialized surgical experience
Highly experienced and skilled surgeon Highly experienced and skilled surgeon
*Equipment
Basic equipment only Basic equipment only
Simple surgical and imaging resources Simple surgical and imaging resources
Full specialized surgical and imaging resources Full specialized surgical and imaging resources

2016-10-20