Inferior Pubic Ramus Research Articles

Ultrasound-guided injection of the intrapelvic portion of the obturator internus in a cadaver model.

Musculoskeletal dysfunction of the pelvic floor is common. One of the intrapelvic muscles, the obturator internus (OI), can be substantially stressed during its sharply angulated exit from the pelvis. However, there may be considerable overlap between symptoms and signs arising from the OI and other potential pain generators including the levator ani in the pelvic region. Accurate diagnosis for the OI might permit more efficient treatment combined with OI-specific exercise and behavior modification. Therefore, we hypothesized that ultrasound (US)-guided needle insertion in the intrapelvic portion of the OI would be accurate when a pararectal approach is used for diagnostic and therapeutic purposes. Bilateral US-guided intramuscular injections in the pelvic area were performed using 6 fresh, nonembalmed male cadavers. When the needle was positioned in the targeted muscle, 0.5 mL of green filler was injected. After the injection procedure, each specimen was dissected to evaluate the accuracy of US-guided injection into the intrapelvic portion of the OI. Twelve injections were made into the targeted muscles in the 6 cadaveric specimens. All injections placed filler into the OI muscles just medial to the inferior pubic ramus. There was no case in which a needle passed through unintended structures, such as neurovascular structures. The newly developed US-guided pararectal approach allowed accurate insertion of a needle into the intrapelvic portion of the OI. This US-guided method facilitated a more precise approach to the intrapelvic portion of the OI and may help differentiate conditions or symptoms caused by other structures.

Fat embolism syndrome: improved diagnosis through the use of bedside echocardiography

Echocardiography Douglas T. Summerfield, MD Kelly Cawcutt, MD Robert Van Demark, MD Matthew J. Ritter, MD Departments of Anesthesia and Pulmonary/Critical Care Medicine Mayo Clinic Rochester, MN Case Report A 77 year old female with a past medical history of dementia, chronic atrial fibrillation requiring anticoagulation, hypertension, biventricular congestive heart failure with a preserved left ventricular ejection fraction, pulmonary hypertension, and chronic obstructive pulmonary disease (COPD) presented to the emergency room after she sustained a ground level fall while sitting in a chair. The patient reportedly fell asleep while sitting at the kitchen table, and subsequently fell to her right side. According to witnesses, she did not strike her head, and there was no observed loss of consciousness. As part of her initial evaluation, at an outside hospital, radiographs of the pelvis, hip, and knee were obtained. These identified a definitive right superior pubic ramus fracture with inferior displacement and a questionable fracture of the right femoral neck. Shortly thereafter, the patient was transferred to our hospital for further management. On exam, the patient had a painful right hip limiting active motion and her right lower extremity was neurovascularly intact without paresthesias or dysesthesias. The remainder of the exam was unremarkable. In the emergency room, a repeat radiograph showed no evidence of a right femur fracture. Later in the evening a CT scan of the pelvis with intravenous contrast showed acute fractures through the right superior and inferior pubic rami with associated hematoma. Multiple tiny bony fragments were noted adjacent to the superior pubic ramus fracture (Figure 1).

Atraumatic bilateral inferior pubic rami fractures in a young female: a rare case

A 46-year-old female presented to our clinic with a complaint of bilateral groin pain. There was no history of trauma antecedent to the groin pain. Initially she had pain in the right groin, which was settling gradually when she had a new onset pain in the left groin for which she was referred to the orthopaedic service. This lady was well built with a body mass index of 22. She was in a sedentary job. She had no history of any sporting activity, apart from being a regular walker. Her walking schedule comprised of a daily walk of almost 10 km through uneven hilly terrain. She did not have any regular warm-up or stretching exercises before undertaking such long walks. Initial radiograph showed that she had a healing fracture of her right inferior pubic rami (Fig. 1). Given her young age and atraumatic history, she had extensive blood investigations, which were all normal. A computerised tomography (CT) scan of the thorax abdomen and pelvis was then organised to see for any occult malignancy. However, this scan was negative for any malignancy, and the pubic rami fractures were visible to be in different stages of healing (Fig. 2). There was no disruption seen of the posterior pelvic ring on the CT scan. A bone densitometry scan revealed that the T score was normal; hence, any metabolic bone disease was ruled out. This patient was completely asymptomatic at her final follow-up at 6 months. Her final radiograph revealed that both her pubic rami fractures had healed (Fig. 3). Discussion

Parallel analysis of finite element model controlled trial and retrospective case control study on percutaneous internal fixation for vertical sacral fractures.

BackgroundAlthough percutaneous posterior-ring tension-band metallic plate and percutaneous iliosacral screws are used to fix unstable posterior pelvic ring fractures, the biomechanical stability and compatibility of both internal fixation techniques for the treatment of Denis I, II and III type vertical sacral fractures remain unclear.MethodsUsing CT and MR images of the second generation of Chinese Digitized Human “male No. 23”, two groups of finite element models were developed for Denis I, II and III type vertical sacral fractures with ipsilateral superior and inferior pubic ramus fractures treated with either a percutaneous metallic plate or a percutaneous screw. Accordingly, two groups of clinical cases that were fixed using the above-mentioned two internal fixation techniques were retrospectively evaluated to compare postoperative effect and function. Parallel analysis was performed with a finite element model controlled trial and a case control study.ResultsThe difference of the postoperative Majeed standards and outcome rates between two case groups was no statistically significant (P > 0.05). Accordingly, the high values of the maximum displacements/stresses of the plate-fixation model group approximated those of the screw-fixation model group. However, further simulation of Denis I, II and III type fractures in each group of models found that the biomechanics of the plate-fixation models became increasingly stable and compatible, whereas the biomechanics of the screw-fixation models maintained tiny fluctuations. When treating Denis III fractures, the biomechanical effects of the pelvic ring of the plate-fixation model were better than the screw-fixation model.ConclusionsPercutaneous plate and screw fixations are both appropriate for the treatment of Denis I and II type vertical sacral fractures; whereas percutaneous plate fixation appears be superior to percutaneous screw fixation for Denis III type vertical sacral fracture. Biomechanical evidence of finite element evaluations combined with clinical evidence will contribute to our ability to distinguish between indications that require plate or screw fixation for vertical sacral fractures.

Musculoskeletal Problems in the Female Athlete

Musculoskeletal injuries in the female athlete are, for the most part, similar to those in the male athlete. However, there are differences in the incidence of these injuries and in the sports in which they tend to occur. Stress fractures are more common in the female athlete because of the higher prevalence of disordered eating and subsequent energy imbalance that leads to detrimental effects on bone. In addition, female athletes have a higher rate of noncontact anterior cruciate ligament (ACL) injuries than male athletes. Other musculoskeletal problems are also more common in females, such as multidirectional instability of the shoulder, adhesive capsulitis, and patellofemoral pain. Finally, as a function of greater participation by females in certain sports, such as dance and gymnastics, injuries specific to those sports are more common in females. This chapter addresses injuries that are seen commonly in the female athlete and reviews unique issues related to exercise and the female reproductive system. Figures depict the management of stress fractures, a stress fracture of the inferior pubic ramus, the tension aspect of the femoral neck, stress fractures of the rib, multidirectional shoulder instability, adhesive capsulitis, spondylolysis, proper squat landing technique, and the female athlete triad. A table outlines the recommended intake of both calcium and vitamin D for bone health at various ages.This chapter contains 9 figures, 1 table, 59 references, and 5 Board-styled MCQs.

Pudendal nerve in pelvic bone fractures

IntroductionPelvic ring injuries rank among the most serious skeletal injuries. According to published data, pelvic fractures constitute 3–8% of all fractures. There has been a threefold increase in the number of these fractures over the last 10 years. A significant factor determining the choice of the therapeutic procedure, timing and sequence of individual steps, and also the prognosis of the patient with a fractured pelvis, are associated injuries defined as injuries to the organs and anatomical structures found in the pelvic region. Published data describes the incidence of injury to neurogenic structures as ranging between 9 and 21%, to the urogenital tract between 5 and 11%, to the gastrointestinal tract in 3–17% and to the gynecologic organs up to 1%. The pathway of the pudendal nerve may be affected in types B and C fractures where the root fibers emerge from the foramina sacralia and plexus sacralis is formed, on the one hand, and in types A, B and C fractures during the nerve's course alongside the inferior pubic ramus. Materials and methodsIn order to determine the frequency of potential injury to the pudendal nerve, a set of 225 pelvic fractures treated between 2007 and 2009 was assessed; 38 fixed hemipelves were also used to study the length of the course of the pudendal nerve alongside the inferior pubic ramus, on the one hand, and the distances from the symphysis pubica at the crossing of the branches of the n. pudendus–n. dorsalis penis and the branches for the muscles of the diaphragma urogenitale on the other hand. ConclusionThe work elucidated the selected distances and discuss their possible clinical relevance for evaluation of the seriousness of pelvic fractures from the perspective of late sequelae in the region innervated by the pudendal nerve.

“Superior cleft sign” as a marker of rectus abdominus/adductor longus tear in patients with suspected sportsman’s hernia

We describe a new imaging sign, the "superior cleft sign", identified at both symphysography and MRI, which should be used as a marker of rectus abdominis/adductor longus attachment tearing. A study population of 25 patients presenting with clinically suspected sportsman's hernia, who had undergone both symphysography and MRI of the groin were included for study. In each case, images were reviewed to determine the presence of a superior cleft, secondary cleft, and or both abnormalities. Images of all patients complaining of groin crease discomfort similar to sportsman's hernia revealed the presence of a superior cleft at the rectus abdominis/adductor longus attachment. This "superior cleft sign" correlated with the side of symptoms in each case, and, in contrast to the previously described secondary cleft along the inferior margin of the inferior pubic ramus, occurred parallel to the inferior margin of the superior pubic ramus. The presence of the "superior cleft sign" should be sought in addition to the previously described secondary cleft sign in sportspeople presenting with exercise-related groin pain or pubalgia. It should specifically be sought in patients referred with suspected sportsman's hernia.

Fractured Inferior Pubic Ramus with Ipsilateral Total Hip Replacement: A Case Report and Review of the Literature

Pubic rami fractures are common. They are associated with significant morbidity and mortality. These fractures are usually classified as stable injuries and traditionally receive limited orthopaedic input. Management typically involves hospital admission and early input from physiotherapists and occupational therapists. Early mobilisation is advocated as a central part of managing these patients, with emphasis on secondary prevention. We report a case diagnosed as minimally displaced inferior pubic ramus fracture in a patient with an ipsilateral total hip replacement (THR). The patient was mobilised early and despite analgesia continued to complain of groin pain. Repeat radiographs showed a fracture of the acetabulum with displacement of the acetabular component of the hip replacement. We advocate early orthopaedic input for all pubic rami fractures, particularly in patients with hip arthroplasty, and thorough investigation including a CT scan of the pelvis to exclude acetabular extension prior to mobilisation.

Effects of Curved Periacetabular Osteotomy on the Stress Fields of the Pubic Rami and Ischium: A Finite Element Model Analysis

Background: Postoperative pubic or ischial stress fracture may be a complication after curved periacetabular osteotomy (CPO). The discontinuity of the superior pubic rami is a risk factor for this complication. We investigated the stress field differences in standing and sitting positions after CPO. Methods: We used finite element analysis to assess the effects of inferior pubic rami and ischial fractures with or without discontinuity of superior pubic rami. We used the “union model”, obtained from a bony union at the osteotomy site of the superior pubic rami from 38-year-old woman who had undergone CPO for left hip dysplasia. We deleted the bony union region and created a discontinuity in the superior pubic rami equal to the non-union, creating the “discontinuity model”. We compared the stress field and stress value in the simulated standing and half weight-bearing positions on the operative side, one-legged standing position on the non-operative side, and the sitting position. Findings: In 4 cases, the inferior rami experienced the highest stress. Stress values in the discontinuity model were higher than those in the union model: 1.7 times in the case of one-legged standing on the operative side, 2.4 times in the case of half weight-bearing on the operative side, 3.8 times in the case of one-legged standing on the non-operative side, and 2.0 times in the sitting position, respectively. Interpretation: We recommend patients delay weight bearing on the operative side, avoid the sitting position as long as possible, and sit down slowly to prevent inferior pubic rami and ischial fractures after CPO.

Enhanced Callus Formation After Six Weeks of Parathyroid Hormone Treatment in a Man with Multiple Pelvic Fractures and Osteogenesis Imperfecta Type IV: A Case Report.

Osteogenesis imperfecta (OI) is a genetic disorder involving a defect in collagen synthesis1-3. OI is characterized by impaired bone formation, low bone mass, and deterioration of bone architecture in adults4,5. Typical bone features are a decrease in trabecular thickness and number of trabeculae, as well as thin cortices. As a result, there is increased bone fragility with recurrent fractures, leading frequently to skeletal deformities. Currently, no supportive therapy for fracture-healing is available, although preclinical studies show promise for the use of teriparatide (parathyroid hormone [PTH] 1-34)6-9. We present the case of a patient with multiple pelvic fractures and osteogenesis imperfecta type IV who demonstrated enhanced callus formation after treatment with PTH. The patient was informed that data concerning the case would be submitted for publication and he provided consent. A seventy-eight-year-old man with osteogenesis imperfecta (Sillence type IV) was admitted to the hospital with severe pelvic pain following pelvic fractures in five locations (the superior and inferior pubic rami on both the left and right sides and the sacrum), which had been sustained three months earlier after a fall. The initial office visit had been in a specialized trauma center. The patient had been treated with bisphosphonate therapy (alendronate followed by ibandronate) for a minimum of ten years. Since the occurrence of the pelvic fractures, the patient had been confined to a wheelchair and had been dependent on analgesics (tramadol hydrochloride, metamizol, diclofenac) for severe, chronic pain. The earlier fracture history had consisted of numerous nonvertebral fractures after minor trauma in the left radius, right malleolus, right thumb, left femoral neck (followed with total endoprosthesis), ilium, and multiple ribs. The spine had been stabilized from T12 to L2, with posterior lumbar interbody fusion …

Early results of a European multicentre experience with a new self‐anchoring adjustable transobturator system for treatment of stress urinary incontinence in men

To report our experience with a new self-anchoring adjustable transobturator male system (ATOMS®; AMI, Vienna, Austria) for the treatment of stress urinary incontinence (SUI) in men. A total of 99 men, in a number of centres, were treated for SUI with the new ATOMS® device. The device was implanted in all patients using an outside-in technique by passing the obturator foramen and anchoring the device to the inferior pubic ramus. The titanium port was placed s.c. on the left symphysis region. Adjustments were performed via port access. Postoperative evaluation consisted of physical examination, 24-h pad test, and 24 h-pad count. Preoperatively and at 6-month follow-up, patients completed a validated quality-of-life questionnaire. Two-way ANOVA was used to analyse changes over time. Within-group effects for time were tested using post hoc Dunnett's contrasts of baseline values vs subsequent measurements. The most common indication was SUI after radical prostatectomy (92.9%). Failure of previous surgeries was present in 34.3% patients and 31.3% patients had undergone secondary radiation. The mean (SD; range) surgery time was 47 (13.8; 29-112) min. Temporary urinary retention occurred in two patients (2%) and transient perineal/scrotal dysaesthesia or pain was reported by 68 patients (68.7%) and resolved after 3-4 weeks of non-opioid analgesics. There were four (4%) cases of wound infection at the site of the titanium port leading to explantation. No urethral or bladder injuries related to the device or erosions occurred. The mean (SD; range) number of adjustments to reach the desired result (dryness, improvement and/or patient satisfaction) was 3.8 (1.3; 1-6). After a mean (SD; range) follow-up time of 17.8 (1.6; 12-33) months, the overall success rate was 92% and the mean pad use decreased from 7.1 to 1.3 pads/24 h (P < 0.001). Overall, 63% were considered dry and 29% were improved. Treatment of male SUI with this self-anchored adjustable system is safe and effective.

Mesh in prolapse surgery: an imaging perspective

Mesh in prolapse surgery: an imaging perspective

En bloc resection of extra-peritoneal soft tissue neoplasms incorporating a type III internal hemipelvectomy: a novel approach

BackgroundA type III hemipelvectomy has been utilized for the resection of tumors arising from the superior or inferior pubic rami.MethodsIn eight patients, we incorporated a type III internal hemipelvectomy to achieve an en bloc R0 resection for tumors extending through the obturator foramen or into the ischiorectal fossa. The pelvic ring was reconstructed utilizing marlex mesh. This allowed for pelvic stability and abdominal wall reconstruction with obliteration of the obturator space to prevent herniations.ResultsAll eight patients had an R0 resection with an overall survival of 88% and with average follow up of 9.5 years. Functional evaluation utilizing the Enneking classification system, which evaluates motion, pain, stability and strength of the affected extremity, revealed a 62% excellent result and a 37% good result. No significant complications were associated with the operative procedure. Marlex mesh reconstruction provided pelvic stability and eliminated all hernial defects.ConclusionThe superior and inferior pubic rami provide a barrier to a resection for tumors that arise in the extra-peritoneal pelvis extending through the obturator foramen or ischiorectal fossa. Incorporating a type III internal hemipelvectomy with a simple marlex mesh reconstruction allows for complete tumor resection without functional compromise, acute infectious issues, obturator or abdominal hernia defects.

Traumatic Divergent Elbow Dislocation in an Adult with an Associated Fracture of the Distal Part of the Humeral Shaft and an Open Perilunate Dislocation: A Case Report.

Divergent dislocation of the elbow represents an extremely rare injury. The proximal radioulnar joint is disrupted as the distal part of the humerus is driven between the radius and ulna, and the forearm dislocates posteriorly. We believe that DeLee, in 1981, reported the first modern case of divergent elbow dislocation that was confirmed by radiographs in a child1. Subsequently, to the best of our knowledge, there have been twenty-one additional reported cases of divergent elbow dislocation in children2-19. We identified only one previously published case report of traumatic divergent elbow dislocation in an adult20. We present an adult patient with a traumatic divergent dislocation of the elbow with an associated humeral fracture and an open perilunate dislocation. The patient was informed that data concerning the case would be submitted for publication, and he provided consent; the institutional review board approved the submission. ### Initial Patient Presentation A twenty-nine-year-old right-hand-dominant man presented to our emergency department after landing on the outstretched left upper extremity following a 15-foot fall from a ladder. Initial physical examination of the extremity revealed gross deformity of the midhumerus and swelling of the left elbow. A 2-cm wound over the lateral part of the elbow communicated with the radiocapitellar joint. Carpal bones were extruded through a second wound over the volar aspect of the wrist on the same extremity. The patient’s hand was well-perfused with palpable pulses. He reported paresthesias in the median nerve distribution. Radiographs demonstrated a displaced mid-diaphyseal humeral fracture and an open divergent elbow dislocation (Figs. 1-A and 1-B). Distally, the patient had an open trans-scaphoid perilunate dislocation, fracture of the trapezium, and left fourth and fifth metacarpal fractures (Figs. 2-A and 2-B). Additional injuries included fractures of the lumbar transverse processes, ribs, superior and inferior pubic rami, iliac wing, …

Measuring the Angle of the Subpubic Arch Using Three-Dimensional Transperineal Ultrasound Scan: Intraoperator Repeatability and Interoperator Reproducibility

A method of measuring the subpubic arch angle using three-dimensional transperineal ultrasound scan (3DTUS) was developed, and the intraoperator repeatability and interoperator reproducibility were investigated. Using 3DTUS, volume data sets were obtained from the nine nulliparous pregnant women by three operators (A, B, and C) in each of the three study sessions. With volume reconstruction, a plane along the inferior edges of bilateral inferior pubic rami was obtained on the axial section. The angle made between the innermost points of both inferior pubic rami at the level of urethra and the inferoposterior point of symphysis pubis was measured as the subpubic arch angle. The intraoperator repeatability of the experienced operator (A) and the interoperator reproducibility between A, B, and C were assessed by the repeatability coefficient and the interoperator intraclass correlation (ICC), respectively. A total of 27 women were examined. The intraoperator repeatability was 4.73 degrees. The overall interoperator ICC was 0.860, and increased from 0.794 in the first session to 0.945 in the third session. With 3DTUS, it is feasible to measure subpubic arch angle with satisfactory intraoperator repeatability and interoperator reproducibility. This easy-to-learn technique extends the possibilities of future pelvimetry research using 3DTUS.

Inferior pubic ramus fracture in a child with an associated fracture-haematoma induced inflammatory response

Insufficiency fractures of the pubic rami in elderly patients are commonly encountered in orthopaedic practice and their incidence is reported at 25.6 per 100,000 per year. Fractures of the pelvis in children are relatively uncommon and constitute approximately 1% of admissions at paediatric trauma units, and are associated with significant morbidity and mortality. The mechanism of injury most commonly associated with paediatric pelvic fractures involves a pedestrian being hit by a car. The incidence of isolated pubic ramus fractures in the skeletally immature pelvis has yet to be reported. We report a case of an inferior pubic ramus fracture sustained during a game of rugby that presented with fever and groin pain.

Obturator Foramen Dissection for Excision of Symptomatic Transobturator Mesh

Groin pain after transobturator synthetic mesh placement can be recalcitrant to conservative therapy and ultimately requires surgical excision. We describe our experiences with and technique of obturator foramen dissection for mesh excision. The records of 8 patients treated from 2005 to 2010, were reviewed. Obturator dissection was performed via a lateral groin incision over the inferior pubic ramus at the level of the obturator foramen, typically in conjunction with orthopedic surgery. Five patients had transobturator mid urethral sling surgery for stress urinary incontinence, 2 had mid urethral sling and trocar based anterior vaginal wall mesh kits with transobturator passage of mesh arms for stress urinary incontinence and pelvic organ prolapse, and 1 had an anterior vaginal wall mesh kit for pelvic organ prolapse. Patients had 0 to 2 prior transvaginal mesh excisions before obturator surgery. All patients presented with intractable pain in the area of the obturator foramen and/or medial groin for which conservative treatment measures had failed. Six patients underwent concurrent vaginal and obturator dissection and 2 underwent obturator dissection alone. In all cases residual mesh (3 to 11 cm) was identified and excised from the obturator foramen. Mesh was closely associated to or traversing the adductor longus muscle and tendon with significant fibrous reaction in all cases. Postoperatively 5 patients were cured of pain and/or infection, and 3 reported no or some improvement at a mean followup of 6 months (range 1 to 12). Our experience suggests that surgical excision of residual mesh can alleviate many of the symptoms in many patients. In all cases mesh remnants were identified and removed, and typically involved neuromuscular structures adjacent to the obturator foramen.

Histiocytosis: An Uncommon Presentation with Hypopituitarism

Langerhans cell histiocytosis is a multi system disorder with a certain predilection for involving hypothalamic pituitary axis. We hereby report a 7 year old girl presenting with polyuria, polydipsia and growth retardation. The girl had a past history of pain in right hip joint and nodular region over chest. Water deprivation test confirmed the diagnosis of central diabetes inspidus. Other investigations revealed Growth hormone deficiency and central hypothyroidism. X-ray and MRI hip revealed absent right inferior pubic ramus with bone marrow biopsy confirming the diagnosis of histiocytosis. Patient was treated with nasal Arginine Vasopressin spray, subcutaneous growth hormone and oral thyroxine. Key words: Histiocytosis; Diabetes inspidus; Growth hormone deficiency; Central hypothyroidism DOI: http://dx.doi.org/10.3126/jnps.v32i1.5343 J. Nepal Paediatr. Soc. Vol.32(1) 2012 81-84

Pelvic Bone Fractures Mimicking Bone Metastases in a Patient with Hepatitis B Virus-Associated Liver Cirrhosis and Hepatocellular Carcinoma

Pelvic Bone Fractures Mimicking Bone Metastases in a Patient with Hepatitis B Virus-Associated Liver Cirrhosis and Hepatocellular Carcinoma

Groin Pain- Distance Running

HISTORY: A 41-year-old ultra-distance runner developed progressive aching pain deep in the right groin with running over a 1-month period. The pain would gradually worsen with longer distance runs. He was running his usual 70 miles per week at the time of pain onset. He has completed multiple 100-mile runs throughout the last 10 years without prior injuries. PHYSICAL EXAMINATION: Examination revealed a slightly antalgic gait with reduced step length on the right, normal and symmetric lower extremity ROM, leg length, strength, and sensation. He had tenderness near the right pubic ramus and ischial tuberosity. DIFFERENTIAL DIAGNOSIS: 1. Tendinopathy of adductors or proximal hamstring. 2. Bone stress reaction or fracture of pubic ramus. 3. Intra-articular hip pathology. TESTS AND RESULTS: Right hip anterior-posterior and lateral x-ray: -Faint linear sclerosis and cortical irregularity at the right inferior pubic ramus Pelvis MRI: -Low signal intensity fracture line through the right inferior pubic ramus, with associated bone marrow edema -No evidence of labral or tendon pathology. DEXA Scan: -Lowest z-score= -1.9 standard deviations in the right femoral neck consistent with low bone mass. Laboratory and historical work-up for secondary causes of low bone mass revealed: -Vitamin D deficiency and low-normal testosterone levels -Vegan diet for the last year -History of childhood asthma and several courses of steroids for exacerbations in childhood -History of SSRI use for depression FINAL/WORKING DIAGNOSIS: Grade 4 fatigue fracture of the right inferior pubic ramus in setting of multi-factorial low bone mass in an ultra-distance male runner. TREATMENT AND OUTCOMES 1. Crutches for 12 weeks, based on symptoms. Recumbent bike or swimming to maintain fitness. 2. Supplemented Calcium (1500mg/day) and Vitamin D (ergocalciferol 50000 units weekly) 3. Liberalized diet to include meat and dairy. 4. He replaced his SSRI with buproprion for depression. 5. Repeat x-ray at 12 weeks showed increasing sclerosis indicative of early bony healing. 6. Tenderness nearly resolved by 12 weeks. 7. Anticipate initiation of ROM and non-impact loading exercise at 15 weeks. 8. Incremental return to running by 24 weeks, expecting normal strength, ROM, improved bone density and painless running by that time.