Skip to main navigation menu Skip to main content Skip to site footer

Original article

Vol. 143 No. 3738 (2013)

Pubic rami fractures in the elderly – a neglected injury?

  • Patrick Studer
  • Norbert Suhm
  • Björn Zappe
  • Nicolas Bless
  • Marcel Jakob
Cite this as:
Swiss Med Wkly. 2013;143:w13859


OBJECTIVE: To evaluate the patient characteristics and natural history of pubic rami fractures in geriatric patients, with a special focus on the frequency of concomitant posterior pelvic ring lesions and the percentage of secondarily operated patients as a result of conservative treatment failure.

STUDY DESIGN: Retrospective cohort study. Patients were treated in a university hospital that is equivalent to a level I Trauma centre.

PATIENTS AND METHODS: We analysed 132 consecutive patients (113 women, 19 men), >65 years old, presenting with low energy-trauma pubic rami fractures at our emergency department from January 2009 to December 2011.

RESULTS: Mean age of patients was 84 years (range 66–100). Women were affected six times more frequently than men. Almost 30% of patients lost their previous independence permanently owing to the injury. Ninety eight percent of previously independent patients (community dwellers) required temporary hospital care for a median duration of 39 days (interquartile range [IQR] 28–52). One-year mortality was 18.5%. A concomitant posterior pelvic ring lesion was identified by computed tomography in 54% of patients. In 4% of the patients secondary operative fracture stabilisation was performed.

DISCUSSION: Pubic rami fractures are frequently associated with concomitant posterior pelvic ring injuries, making these injuries more unstable than generally assumed. Based on this fact and the long duration of hospital stay, more aggressive management of these injuries may be considered. The principle aims in this patient population are satisfying pain management, early mobilisation, conservation of independence and return to previous place of residence.


  1. Kannus P, Palvanen M, Parkkari J, Niemi S, Järvinen M. Osteoporotic pelvic fractures in elderly women. Osteoporosis Int. 2005;16(10):1304–5.
  2. Schapira D, Militeanu D, Israel O, Scharf Y. Insufficiency fractures of the pubic ramus. Semin Arthritis Rheum. 1996;25(6):373–82.
  3. Alost T, Waldrop RD. Profile of geriatric pelvic fractures presenting to the emergency department. Am J Emerg Med. 1997;15(6):576–8.
  4. Boufous S, Finch C, Lord S, Close J. The increasing burden of pelvic fractures in older people, New South Wales, Australia. Injury. 2005;36(11):1323–9.
  5. Melton LJ 3rd, Sampson JM, Morrey BF, Ilstrup DM. Epidemiologic features of pelvic fractures. Clin Orthop Relat Res. 1981;(155):43–7.
  6. Kannus P, Palvanen M, Niemi S, Parkkari J, Järvinen M. Epidemiology of osteoporotic pelvic fractures in elderly people in Finland: sharp increase in 1970–1997 and alarming projections for the new millennium. Osteoporos Int. 2000;11(5):443–8.
  7. Suhm N, Lamy O, Lippuner K, Reto B, Marc-Antoine K, Olivier L, et al. Management of fragility fractures in Switzerland: results of a nationwide survey. Swiss Med Wkly. 2008;138(45-46):674–83.
  8. Callaway DW, Wolfe R. Geriatric trauma. Emerg Med Clin North Am. 2007;25(3):837–60.
  9. Lippuner K. The future of osteoporosis treatment – a research update. Swiss Med Wkly. 2012;142:w13624.
  10. Rizzoli R, Kraenzlin M, Krieg MA, Mellinghoff HU, Lamy O, Lippuner K. Indications to teriparatide treatment in patients with osteoporosis. Swiss Med Wkly. 2011;141:w13297.
  11. Pennal GF, Tile M, Waddell JP, Garside H. Pelvic disruption: assessment and classification. Clin Orthop Relat Res. 1980;(151):12–21.
  12. Gertzbein SD, Chenoweth DR. Occult injuries of the pelvic ring. Clin Orthop Relat Res. 1977;(128):202–7.
  13. Isler B, Ganz R. Classification of pelvic ring injuries. Injury. 1996;27(Suppl 1):S-A3–12.
  14. Shuler TE, Boone DC, Gruen GS, Peitzman AB. Percutaneous iliosacral screw fixation: early treatment for unstable posterior pelvic ring disruptions. J Trauma. 1995;38(3):453–8.
  15. Beall DP, D'Souza SL, Costello RF, Prater SD, Van Zandt BL, Martin HD, et al. Percutaneous augmentation of the superior pubic ramus with polymethyl methacrylate: treatment of acute traumatic and chronic insufficiency fractures. Skeletal Radiol. 2007;36(10):979–83.
  16. Frey ME, Depalma MJ, Cifu DX, Bhagia SM, Carne W, Daitch JS. Percutaneous sacroplasty for osteoporotic sacral insufficiency fractures: a prospective, multicenter, observational pilot study. Spine J. 2008;8(2):367–73.
  17. Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chron Dis. 1987;40(5);373–83.
  18. Dechert TA, Duane TM, Frykberg BP, Aboutanos MB, Malhotra AK, Ivatury RR. Elderly patients with pelvic fracture: interventions and outcomes. Am Surg. 2009;75(4):291–5.
  19. Hill RM, Robinson CM, Keating JF. Fractures of the pubic rami. Epidemiology and five-year survival. J Bone Joint Surg Br. 2001;83(8):1141–4.
  20. Koval KJ, Aharonoff GB, Schwartz MC, Alpert S, Cohen G, McShinawy A, et al. Pubic rami fracture: a benign pelvic injury? J Orthop Trauma. 1997;11(1):7–9.
  21. Leung WY, Ban CM, Lam JJ, Ip FK, Ko PS. Prognosis of acute pelvic fractures in elderly patients: retrospective study. Hong Kong Med J. 2001;7(2):139–45.
  22. Morris RO, Sonibare A, Green DJ, Masud T. Closed pelvic fractures: characteristics and outcomes in older patients admitted to medical and geriatric wards. Postgrad Med J. 2000;76(900):646–50.
  23. O’brien DP, Luchette FA, Pereira SJ, Lim E, Seeskin CS, James L, et al. Pelvic fracture in the elderly is associated with increased mortality. Surgery. 2002;132(4):710–14.
  24. Krappinger D, Kammerlander C, Hak DJ, Blauth M. Low-energy osteoporotic pelvic fractures. Arch Orthop Trauma Surg. 2010;130(9):1167–75.
  25. Kenzora JE, McCarthy RE, Lowell JD, Sledge CB. Hip fracture mortality. Relation to age, treatment, preoperative illness, time of surgery, and complications. Clin Orthop Relat Res. 1984;(186):45–56.
  26. Zuckerman JD, Sakales SR, Fabian DR, Frankel VH. Hip fractures in geriatric patients. Results of an interdisciplinary hospital care program. Clin Orthop Relat Res. 1992;(274):213–25.
  27. Fitzgerald JF, Moore PS, Dittus RS. The care of elderly patients with hip fracture. Changes since implementation of the prospective payment system. N Engl J Med. 1988;319(21):1392–7.
  28. Sexson SB, Lehner JT. Factors affecting hip fracture mortality. J Orthop Trauma. 1987;1(4):298–305.
  29. Keller JM, Sciadini MF, Sinclair E, OʼToole RV. Geriatric trauma: demographics, injuries, and mortality. J Orthop Trauma. 2012;26(9):161–5.
  30. Scheyerer MJ, Osterhoff G, Wehrle S, Wanner GA, Simmen HP, Werner CM. Detection of posterior pelvic injuries in fractures of the pubic rami. Injury. 2012;43(8):1326–9.
  31. Wetzel E, Strauss LR, Göpfrich M, Oellers B. Potentialities of radiological diagnosis of injuries to the dorsal pelvic ring. Rofo. 1985;142(3):291–5.
  32. Schädel-Höpfner M, Celik I, Stiletto R, Giannadakis K, Froehlich JJ, Gotzen L. Computed tomography for the assessment of posterior pelvic injuries in patients with isolated fractures of the pubic rami in conventional radiography. Chirurg. 2002;73(10):1013–8.
  33. Hoffmeyer P, Seigne JM, Garcia J, Vasey H. The value of computerized tomography in fractures of the pelvic ring. Int Orthop. 1984;8(1):1–8.
  34. Alnaib M, Waters S, Shanshal Y, Caplan N, Jones S, St Clair Gibson A, et al. Combined pubic rami and sacral osteoporotic fractures: a prospective study. J Orthop Traumatol. 2012;13(2):97–103.
  35. Henes FO, Nüchtern JV, Groth M, Habermann CR, Regier M, Rueger JM, et al. Comparison of diagnostic accuracy of Magnetic Resonance Imaging and Multidetector Computed Tomography in the detection of pelvic fractures. Eur J Radiol. 2012;81(9):2337–42.
  36. Peichel P, Holzer LA, Maier R, Holzer G. Parathyroid hormone 1-84 accelerates fracture-healing in pubic bones of elderly osteoporotic women. J Bone Joint Surg Am. 2011;93:1583–7.

Most read articles by the same author(s)