Superior Pubic Ramus Fracture Research Articles

Union and displacement characteristics following percutaneous screw fixation of superior pubic rami fractures.

To determine union and displacement metrics following percutaneous screw fixation (antegrade or retrograde) of superior pubic rami fractures. This is a retrospective cohort study from a single level 1 trauma center. Skeletally mature patients with at least one superior pubic ramus fracture present as part of a lateral compression-type pelvic ring injury were included. Eighty-five (85) patients with 95 superior pubic rami fractures met the study's inclusion criteria. LC1, LC2, and LC3 injuries occurred in 76.5%, 15.3%, and 8.2% of patients, respectively. The majority of patients underwent concurrent posterior pelvic ring fixation (94.1%). Superior ramus screw placement occurred predominantly via retrograde technique (81.1%) with cannulated screws of size 6.5mm or larger (93.7%). Of the 95 eligible fractures, 90 (94.7%) achieved union at a mean of 14.0weeks (7-40weeks). Of these united fractures, 69 (76.7%) healed with no measurable displacement, while the remaining 23.3% healed with residual mean displacement of 3.9mm (range: 0.5-9.0mm). Multivariable analysis demonstrated a positive association between age (p = 0.04) and initial displacement (p = 0.04) on the final degree of residual displacement at union. A Kaplan-Meier survival analysis identified increased age to be significantly related to increased time to union (X2 (2) = 21.034, p < 0.001). Union rates following percutaneous screw fixation of superior pubic rami fractures associated with lateral compression-type pelvic ring injuries approach 95%. Though minimal in an absolute sense, increasing age and a greater degree of initial displacement may influence the final degree of residual displacement at union. IV.

A Novel Implant for Superior Pubic Ramus Fracture Fixation-Development and a Biomechanical Feasibility Study.

Background and Objectives: Pubic ramus fractures are common in compound pelvic injuries known to have an increased rate of morbidity and mortality along with recurrent and chronic pain, impeding a patient's quality of life. The current standard treatment of these fractures is percutaneous screw fixation due to its reduced risk of blood loss and shorter surgery times. However, this is an intricate surgical technique associated with high failure rates of up to 15%, related to implant failure and loss of reduction. Therefore, the aim of this biomechanical feasibility study was to develop and test a novel intramedullary splinting implant for fixation of superior pubic ramus fractures (SPRF), and to evaluate its biomechanical viability in comparison with established fixation methods using conventional partially or fully threaded cannulated screws. Materials and Methods: A type II superior pubic ramus fracture according to the Nakatani classification was created in 18 composite hemi-pelvises via a vertical osteotomy with an additional osteotomy in the inferior pubic ramus to isolate the testing of three SPRF fixation techniques performed in 6 semi-pelvises each using either (1) a novel ramus intramedullary splint, (2) a partially threaded ramus screw, or (3) a fully threaded ramus screw. Results: No significant differences were detected among the fixation techniques in terms of initial construct stiffness and number of cycles to failure, p ≥ 0.213. Conclusion: The novel ramus intramedullary splint can be used as an alternative option for treatment of pubic ramus fractures and has the potential to decrease the rate of implant failures due to its minimally invasive implantation procedure.

Evaluation of cannulated compression headless screws as an alternative implant for superior pubic ramus fracture fixation: a biomechanical study

Background/purposePubic ramus fractures account for the most common types of pelvic fractures. The standard surgical approach for superior pubic ramus fractures (SPRF) is a minimally invasive percutaneous screw fixation. However, percutaneous closed reduction and internal fixation of anterior pelvic ring injuries have high failure rates of up to 15%. The aim of this biomechanical study was to evaluate the stability of SPRF following stabilization with retrograde placed cannulated compression headless screw (CCHS) versus conventional fully and partially threaded screws in an artificial pelvic bone model.MethodsSPRF type II as described by Nakatani et al. was created by means of osteotomies in eighteen anatomical composite hemi-pelvises. Specimens were stratified into three groups of six specimens each (n = 6) for fixation with either a 7.3 mm partially threaded cannulated screw (group RST), a 7.3 mm fully threaded cannulated screw (group RSV), or a 7.5 mm partially threaded cannulated CCHS (group CCS). Each hemi-pelvic specimen was tested in an inverted upright standing position under progressively increasing cyclic axial loading. The peak load, starting at 200 N, was monotonically increased at a rate of 0.1 N/cycle until 10 mm actuator displacement.ResultsTotal and torsional displacement were associated with higher values for RST versus CCS and RSV, with significant differences between RST and CCS for both these parameters (p ≤ 0.033). The differences between RST and RSV were significant for total displacement (p = 0.020), and a trend toward significance for torsional displacement (p = 0.061) was observed. For both failure criteria 2 mm total displacement and 5° torsional displacement, CCS was associated with significantly higher number of cycles compared to RST (p ≤ 0.040).ConclusionCCHS fixation presented predominantly superior stability to the standard surgical treatment and could therefore be a possible alternative implant for retrograde SPRF screw fixation, whereas partially threaded screws in group RST were associated with inferior biomechanical stability.

Percutaneous screw fixation assisted by hollow pedicle finder for superior pubic ramus fractures

BackgroundPubic ramus fracture was an injury of anterior pelvic ring, the anterior pelvic ring plays an important role in maintaining the stability of the pelvis. The purpose of this study was to investigate the effect and indication of percutaneous retrograde pubic screw fixation assisted by hollow pedicle finder for pubic ramus fractures.MethodsThe clinical data of 68 patients with pubic ramus fracture treated with cannulated screw from March 2008 to March 2020 were retrospectively analyzed. According to the surgical methods, they were divided into traditional surgery group (32 cases in group A, with traditional retrograde pubic screw fixation) and modified surgery group (36 cases in group B, with percutaneous retrograde pubic screw fixation assisted by hollow open circuit device). Operation time, blood loss, incision length, screw length and complications were recorded and compared between the two groups. On the second day after surgery, the maximum fracture displacement over plain radiographs, entrance radiographs and exit radiographs of the pelvis was evaluated according to Matta criteria to evaluate the postoperative fracture reduction. Majeed score was used to evaluate the hip function at 12 months after surgery.ResultsThe operations were successfully completed in both groups. The operation time, blood loss and incision length in group B were significantly less than those in group A (P < 0.05). There was no significant difference in screw length between the two groups (t = 0.797, P = 0.431). All patients were followed up for 8–38 months (mean 21.8 months). There were no vascular and nerve injury, fracture of internal fixator, screw entry into joint cavity, fracture nonunion and other complications in both groups. The fracture healing time of the two groups was 23.1 ± 2.1 weeks in group A while 22.7 ± 2.1 weeks in group B, respectively, and there was no statistical difference in the fracture healing time between the two groups (P > 0.05). In group A, there were 3 cases of incision infection, 1 case of incision fat liquefaction and 2 cases of lower extremity deep venous thrombosis, and the complication rate was 18.8%. There was only 1 case of lower extremity deep vein thrombosis in group B, and the complication rate was 2.8%, which was significantly lower than that in group A. The fracture in one case after surgery was found to be displaced in group A and no fracture was found in group B. There was no significant difference between the two groups in Matta imaging evaluation on the next day after surgery and Majeed function evaluation at 12 months after surgery (P > 0.05).ConclusionPercutaneous retrograde pubic ramus screw fixation assisted by hollow pedicle finder is effective in the treatment of pelvic pubic ramus fracture. It has the advantages of less incision, shorter operation time, less blood loss and lower incidence of complications compared with traditional methods. However, correct surgical indications should be required when we apply this surgical method.

Contributions of Pubic Rami Fracture Morphology and Fixation to Pelvic Ring Stability in Type 1 Lateral Compression Injuries: A Biomechanical Cadaveric Study.

Treatment of lateral compression type 1 (LC-1) injuries has historically been nonoperative with immediate weight-bearing. However, management of these injuries remains controversial, with reports of displacement at follow-up for nonoperatively managed LC-1 fractures. The goal of our study was to determine the effect of superior pubic ramus fracture morphology and fixation construct on pelvic stability. Ten fresh-frozen cadaveric were transected into hemi-pelvises. Incomplete Denis type 1 sacral fractures were made. Hemi-pelvises were randomized to receive a transverse-type or oblique-type superior pubic ramus fracture with the contralateral hemi-pelvis receiving the opposing morphology. A lateral load to 135N was applied with an Instron materials testing machine and lateral displacement of the hemi-pelvis was recorded. Deflection and stiffness were calculated. Statistical analysis was conducted using a t test assuming unequal variances with an alpha = 0.05. Oblique-type superior pubic ramus fractures allowed more deflection compared with transverse-type fractures in the absence of fixation (P = 0.018). The posterior-only and combined anterior and posterior fixation configurations on average reduced deflection more than no fixation or anterior fixation only. In all fixation configuration cases, the average deflection for transverse-type fractures was less than that of the oblique-type fractures. Our findings suggest that displacement of LC-1 pelvic injuries may be related to pubic rami fracture morphology. When looking at initial injury imaging, oblique-type pubic rami fractures may suggest an increased potential for displacement over time. In such cases, we recommend an examination under anesthesia to evaluate for underlying instability and consideration for fixation. Therapeutic Level V.

Factors Associated With Failure of Superior Pubic Ramus Screws.

Examine factors associated with fixation failure in patients treated with superior intramedullary ramus screws. Retrospective. Single, Level 1 trauma center. Unstable pelvic ring fractures amenable fixation that included superior intramedullary ramus screws. Percutaneously inserted intramedullary superior ramus screw fixation of superior pubic ramus (SPR) fractures. Loss of reduction (LOR) of the SPR fracture defined as >2 mm displacement on pelvic radiographs at any time point in follow-up. Two hundred eighty-five fractures in 211 patients (age 44, 95% confidence interval 40.8%-46.4%, 59.3% women, 55.1% retrograde screws) were included in the analysis. 14 (4.9%) of fractures had LOR. Patients were significantly more likely to have LOR as age increased (P = 0.01), body mass index (BMI) increased (P = 0.01), and if they were women (P < 0.01). There was a significantly decreased LOR (P < 0.01) as fractures moved further from the pubis symphysis. Retrograde screws were significantly (P < 0.01) more likely to have LOR. In SPR fractures treated with retrograde screws, failure was significantly associated with increasing BMI (P = 0.02), the presence of an inferior ramus fracture (P = 0.02), and trended toward significance with increasing age (P = 0.06), and decreased distance from the symphysis (P = 0.07). Superior ramus screws are associated with a low failure rate (4.9%), which is lower than previously reported. Retrograde screw insertion, distance from the symphysis, increasing age, increasing BMI, decreased distance from the symphysis, and ipsilateral inferior ramus fractures were predictors of failure. In these patients, alternative modalities should be considered, although low rates of failure can still be expected. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Minimally Invasive Surgery for Anterior Pubic Rami Fractures Under Fluoro-Navigation Using the Medtronic O Arm System and Calcium Phosphate for Internal Fixation

Introduction: The incidence of anterior pubic rami fractures in elderly female patients over the age of 65 has been reported to be 64 %. Osteoporosis plays a role with these fractures, as they are caused by minimal low energy injuries from a fall. Indications for internal fixation of anterior pelvic ring are controversial because of the etiology being low energy trauma and the location being a non-weight bearing surface. In contrast to conventional open pelvic surgery, percutaneous screw fixation has gained popularity in the treatment of pelvic fractures, mainly because of minimal soft tissue damage, less operative blood loss, early surgical intervention, and comfortable mobilization of the patient. The use of calcium phosphate as a form of internal fixation further advances the advantages of minimally invasive surgery for internal fixation with less morbidity by the use of screw fixation. The incorporation of fluoro-navigation is a new surgical technique in orthopedic trauma surgery. (Figure 1) This study is to report our clinical results of fluoro-navigation surgery in anterior pelvic pubic rami fractures using calcium phosphate as the fixation of choice. This is the first report of this method of treatment using a new combination of visualization and internal fixation. Materials and Methods: From April 2018 to December 2019, 30 patients with anterior pubic rami fractures were treated with percutaneous cannulated calcium phosphate delivery under Medtronic O arm (fluoro-navigation) control. There were 5 male and 25 females, with a mean age of 84.6 years (range 80-104) for females and mean age of 90 years (84 – 99) for the 5 males. According to the AO and Orthopedic Trauma Association classification, all were considered lateral compression types of fractures. All patients were operated on when their general medical condition stabilized after emergency management and admission. The pain score on admission was reported as 10/10 in all cases. Plain standard pelvic x-rays were obtained on admission as well as CT scans of the pelvis. All the anterior pubic rami fractures were fixed using percutaneous delivery of calcium phosphate with the Zimmer trocar system by one senior surgeon. The Medtronics O arm fluoro-navigation was used in all cases. The surgeon was familiar with the navigation system and had much experience in the computer-assisted percutaneous placement of the trocars. Results: A total of 30 patients were treated with this new combination of surgical treatment of anterior pubic rami fractures. No screws were inserted or found to be necessary for fracture treatment. Each case used 2 trocars from the kits supplied from Zimmer. One end delivery trocar was directed to the inferior pubic ramus fracture and the second which was a side delivery trocar was used for the superior pubic ramus fracture. A total of 10 cc of calcium phosphate was used in each case, 5 cc per trocar. The position of the trocars were placed using the fluoro-navigation control of the O arm. Once the trocars were properly placed the calcium phosphate was delivered and viewed under flouro control and then again viewed with the spin sequence using the Medtronics O arm. Total patient time in the operating room was 56 minutes; Total surgery time was 26 minutes. Anesthesia in most cases was MAC or light sedation with local skin infiltration using 1% lidocaine. Blood loss during the operation was considered very minimal with derma bond used to cover the percutaneous sites as well as a small band-aid. No superficial or deep infections occurred. No patient sustained recognized neurologic, vascular, or urologic injury because of the percutaneous pubic rami fixation with calcium phosphate. Extravasation of the calcium phosphate from the fracture’s sites did not pose any sequelae with soft tissue injury or with fracture healing. All patients were encouraged to get out of bed and weight bear according to comfort on post-op day 1. All fractures united at the last follow-up. Conclusions: This study presented for the first time two new techniques for the operative treatment of pubic rami fractures of the pelvis. The delivery of calcium phosphate for fracture fixation of pubic rami fractures has been found to be safe, minimally invasive, providing pain relief and stability permitting early mobilization. The addition of intra-operative fluoro- navigation technique makes the fracture treatment an accurate, and rapid method for the treatment of pubic rami fractures. Consistency of the operative procedure and teaching are mandatory for the success of this procedure. The learning curve for most orthopedists should be very short. The outcomes have been shown to benefit patient mobilization, decrease morbidity and decrease hospital stay

Integrity of the pectineal ligament in MRI correlates with radiographic superior pubic ramus fracture displacement.

Estimating the stability of pelvic lateral compression fractures solely by static radiographs can be difficult. In this context, the role of anterior pelvic soft tissues as potential secondary stabilizer of the pelvic ring has hardly been investigated. To correlate the initial radiographic appearance of the pubic ramus fracture with the integrity of the pectineal ligament, a strong ligament along the pecten pubis. In total, 31 patients with a pelvic lateral compression fracture (AO/OTA 61- B1.1/B2.1) with 33 superior pubic ramus fractures and available post-traumatic radiographs (pelvis anteroposterior, inlet, outlet) and magnetic resonance imaging (MRI) of the pelvis with fat-suppressed coronal images were reviewed retrospectively. Radiographic superior pubic ramus fracture displacement was measured and correlated to the degree of MR-morphologic alterations of the pectineal ligament (grade 0 = intact, grade 3 = rupture). In the majority of fractures (72.7%), associated MR-morphologic alterations of the pectineal ligament were present. Radiographic displacement and MRI grading showed a strong positive correlation (Spearman rho = 0.783, P < 0.001). The sensitivity and specificity for a radiographic displacement of >3 mm on plain radiographs to detect a structural ligament lesion on MRI (grade 2 and higher) were 73% and 100%, respectively. Radiographic displacement of superior pubic ramus fractures >3 mm is a strong indicator for a structural lesion of the pectineal ligament. Future studies should investigate the potential biomechanical importance of this ligament for pelvic ring stability.

Assessing the Pelvic X-ray Findings of High-energy Multiple Trauma Patients in Emergency Department of Rajaee Trauma Hospital, Shiraz-October 2013 to May 2014

1. Abstract <span style=font-size:10.0pt;font-family: times= new= roman,serif;mso-fareast-font-family:times= roman=>1.1. Background: Because of the significance of pelvic fracture, anteroposterior pelvic X-ray (PXR) is routinely performed for all patients referring to the emergency department with multiple trauma. But routine performance of PXR may have several complications and might not be necessary in all cases. Thus, we performed PXR selectively for patients. <span style=font-size:10.0pt;font-family: times= new= roman,serif;mso-fareast-font-family:times= roman=>1.2. Objectives: We aimed to assess the PXR findings in traumatized patients referring to emergency department of Rajaee Trauma Hospital, a level 1 triage center, by reviewing PXR findings of multiple trauma patients. <span style=font-size:10.0pt;font-family: times= new= roman,serif;mso-fareast-font-family:times= roman=>1.3. Methods: This prospective study was conducted in Rajaee Trauma hospital of Shiraz, the level one Trauma center in south of Iran during October 2013 to May 2014. Shiraz is the center of Fars Province with the population of 2 million and 5 million for the province. Four-hundred traumatic patients were recruited for the study. PXR was performed for selected patients according to the criteria of Rajaee Trauma Hospital. Demographic data, including age, sex, type of accident, and type of hip fracture was recorded. <span style=font-size:10.0pt;font-family: times= new= roman,serif;mso-fareast-font-family:times= roman=>1.4. Results: Most patients (80%) were men with a mean ± SD age of 36.1(17.5) years. The most frequent pelvic fractures were left superior and inferior pubic ramus (12.8 and 12.5%) followed by right inferior pubic ramus fracture (10.5%). The most frequent causes of injury included car turnover and car to pedestrian accident. Chi-square test revealed significant difference between men and women in motor to car accident, car to pedestrian accident, and car to car accident groups (P=0.02, 0.001 and 0.004, respectively). <span style=font-size:10.0pt;font-family: times= new= roman,serif;mso-fareast-font-family:times= roman=>1.5. Conclusion: <span style=font-size:10.0pt; font-family: times= new= roman,serif=>PXR is an appropriate diagnostic tool for pelvic fractures and is most proper to be selectively performed in patients with the criteria mentioned in the current study and more attention should be paid to superior and inferior pubic ramus fractures, as it was found to be the most frequent fractures observed in the present study. 2. Keywords: Emergency; Hospital; Multiple Trauma; Patients; Pelvic X-Ray; Radiography

A radiographic simulation study of fixed superior pubic ramus fractures with retrograde screw insertion

ObjectivesThe study's aim is to calculate the parameters for retrograde insertion points for fixed superior pubic ramus fractures. MethodsFrom the pubic symphysis, diameter and length of the screw were measured, as well as the angle between the screw axis and the 3 planes. ResultsWhen the diameter was fixed at 4.5mm, the maximum lengths were 125mm and 119mm. ConclusionsWhen the fracture occurs in Zone I, the penetration point could be selected in the pubic symphysis pubis angle to ensure that medial fracture fragments have sufficient screw channel length.

Biomechanical comparison of plate and screw fixation in anterior pelvic ring fractures with low bone mineral density

IntroductionOsteosynthesis of anterior pubic ramus fractures can be challenging, especially in poor bone quality. The aim of the present study was to compare plate and retrograde endomedullary screw fixation of the superior pubic ramus with low bone mineral density (BMD). Materials and methodsTwelve human cadaveric hemi-pelvises were analyzed in a matched pair study design. BMD of the specimens was 35±30mgHA/cm3, as measured in the fifth lumbar vertebra. A simulated two-fragment superior pubic ramus fracture model was fixed with either a 7.3-mm cannulated retrograde screw (Group 1) or a 10-hole 3.5-mm reconstruction plate (Group 2). Cyclic progressively increasing axial loading was applied through the acetabulum. Relative interfragmentary movements were captured using an optical motion tracking system. ResultsInitial axial construct stiffness was 424±116.1N/mm in Group 1 and 464±69.7N/mm in Group 2, with no significant difference (p=0.345). Displacement and gap angle at the fracture site during cyclic loading were significantly higher in Group 1 compared to Group 2. Cycles to failure, based on clinically relevant criteria, were significantly lower in Group 1 (3469±1837) compared to Group 2 (10,226±3295) (p=0.028). Failure mode in Group 1 was characterized by screw cutting through the cancellous bone. In Group 2 the specimens exclusively failed by plate bending. ConclusionsFrom biomechanical point of view, pubic ramus stabilization with plate osteosynthesis is superior compared to a single retrograde screw fixation in osteoporotic bone. However, the extensive surgical approach needed for plating must be considered.

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).

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.

Massive haemorrhage from the internal iliac artery following a low energy superior pubic ramus fracture in a 73-year-old man.

We report a case of a 73-year-old man with a background of aspirin use who fell and sustained a minimally displaced right superior pubic ramus fracture. He subsequently developed hypotension that necessitated fluid resuscitation, associated with a significant drop in blood haemoglobin levels that required a packed red blood cell transfusion. CT scans revealed the presence of two pelvic haematomas, with ongoing bleeding. An angiogram demonstrated bleeding from the superior vesical branch of the anterior division of the right internal iliac artery, which was successfully embolised with gelfoam slurry. The patient recovered uneventfully thereafter. This is a unique case involving an unexpected injury to the superior vesical branch of the anterior division of the internal iliac artery following low energy trauma to an elderly man. We recommend that patients who develop hypotension following a seemingly-benign isolated pubic ramus fracture be evaluated for concomitant arterial injuries with the relevant CT imaging and angiography.

Pubic Ramus Radiolucencies in Infants: The Good, the Bad, and the Indeterminate

The purpose of this study was to examine imaging findings that differentiate inflicted injuries from developmental variants of the superior pubic ramus in healthy and abused infants. A superior pubic ramus fracture and a developmental variant can be difficult to differentiate radiographically. A smoothly marginated vertical radiolucency of the superior pubic ramus detected without other features suggesting infant abuse should not be interpreted as a fracture.

Superior Pubic Ramus Fractures Fixed With Percutaneous Screws: What Predicts Fixation Failure?

The purpose of this study is to present the early complications of percutaneous screw fixation of superior pubic ramus fractures and to present a new classification scheme for superior pubic ramus fractures. Retrospective. Level 1 trauma center. One hundred and twelve patients with pelvic fracture between the ages of 14 to 89 years underwent percutaneous screw fixation of 145 pubic ramus fractures. Eighty-one patients with 107 surgically repaired fractures were followed to fracture union. Follow-up averaged 9 months (range 2-52 months). One additional patient who sustained fixation failure 4 days after surgery was included to yield a study group of 82 patients with 108 surgically repaired ramus fractures. Patients underwent percutaneous screw fixation of a superior pubic ramus fracture. Superior pubic ramus fractures were classified according to a new scheme, the Nakatani system, which categorizes superior ramus fractures according to location with respect to the obturator foramen. Patient radiographs were examined for evidence of loss of reduction, defined as any motion at the ramus fracture site or hardware motion, after fracture surgery. Of the 82 patients followed to union or fixation failure, 12 (15%) had loss of reduction on follow-up radiographs. The average age of patients who lost reduction was 55 years. The most common mechanism of reduction loss was a collapse of the pubic ramus over the screw, with recurrence of an internal rotation deformity of the injured hemipelvis. Ten patients who lost reduction were women, and 11 had undergone ramus screw placement in retrograde fashion. No loss of reduction was seen in Zone III ramus fractures (those that involve the bone lateral to the obturator foramen). No patient sustained recognized neurologic, vascular, or urologic injury as a result of percutaneous screw fixation of a superior pubic ramus fracture. The prevalence of loss of reduction after percutaneous screw fixation of pubic ramus fractures is 15%. Loss of reduction is more common in elderly and female patients and in patients whose ramus screws are placed in a retrograde fashion. Also, loss of reduction appears to be more common in fractures medial to the lateral border of the obturator foramen.

Percutaneous augmentation of the superior pubic ramus with polymethyl methacrylate: treatment of acute traumatic and chronic insufficiency fractures

The injection of polymethylmethacrylate (PMMA) is a minimally invasive image-guided procedure that is typically used to treat vertebral body fractures due to osteoporosis or neoplastic involvement. The injection of PMMA into various other locations including the sacrum, acetabulum, pedicles, femur and tibia has been reported previously, and these procedures have, overall, been highly effective at alleviating pain and discomfort. Although the injection of PMMA into the vertebral body is a very common procedure that has been performed for over 2 decades for the percutaneous treatment of vertebral body fractures, the percutaneous injection of PMMA has not been reported in the English literature as treatment for superior pubic ramus fractures. We report the percutaneous treatment of an acute superior pubic ramus fracture and of a chronic insufficiency fracture of the superior pubic ramus using a parasymphyseal approach to access the region of injury.

Internal Fixation of the Unstable Anterior Pelvic Ring: A Biomechanical Comparison of Standard Plating Techniques and the Retrograde Medullary Superior Pubic Ramus Screw

Summary: The purpose of this study was to evaluate pubic ramus fracture fixation. This biomechanical evaluation compared standard plating techniques with retrograde medullary screw fixation of a superior pubic ramus fracture in a pelvic fracture model. Six fresh-frozen, cadaveric pelvic specimens with a mean age of 79 years were harvested. These specimens were physiologically loaded according to the following modifications and instrumentations: (a) intact; (b) an APC-II unstable pelvic injury, specifically, unilateral superior and inferior rami osteotomies combined with ipsilateral anterior sacroiliac (SI) joint, sacrospinous, and sacrotuberous ligamentous disruptions, without fixation; (c) disrupted as in (b) but fixed anteriorly with a 10-hole 3.5-mm reconstruction plate contoured to the superior ramus and secured with four 3.5-mm cortical screws; (d) disrupted as in (b) but fixed anteriorly with a 10-hole 3.5-mm reconstruction plate contoured to the superior ramus and secured with six 3.5-mm cortical screws; (e) disrupted as in (b) but fixed anteriorly with a 4.5-mm retrograde medullary superior pubic ramus cortical screw 80 mm long (medial to the hip joint); and (f) disrupted as in (b) but fixed anteriorly with a 4.5-mm retrograde medullary superior pubic ramus cortical screw 130 mm long that was extraarticular and engaged the lateral iliac cortex cephalad to the ipsilateral hip joint. The posterior disruptions of the pelvic ring were not fixed. The APC-II injury created in this study resulted in significant (p < 0.05) motion at the disrupted rami and the injured SI joint, compared with the intact pelvic specimen. When compared with the disrupted specimen without fixation, displacement at the superior ramus was significantly (p < 0.05) decreased by all forms of ramus fixation evaluated. Plate fixation decreased pubic ramus and sacroiliac deflections slightly better than retrograde screw fixation did, yet not significantly better. The number of screws in the plate did not significantly affect displacement measurements at either the disrupted ramus or the disrupted SI joint. Similarly, the length of the retrograde ramus screw did not significantly alter displacements at either the injured pubic ramus or the disrupted SI joint. Sacroiliac joint deflections were not significantly (p < 0.05) decreased by any of the forms of anterior pelvic fixation. Flexion at the disrupted SI joint was slightly, but not significantly (p < 0.05), decreased with all forms of fixation when compared with the disrupted specimen. The long retrograde screw and the plate with six screws decreased flexion slightly, but not significantly, better than the short retrograde screw and the plate with four screws.

Internal Fixation of the Unstable Anterior Pelvic Ring: A Biomechanical Comparison of Standard Plating Techniques and the Retrograde Medullary Superior Pubic Ramus Screw

The purpose of this study was to evaluate pubic ramus fracture fixation. This biomechanical evaluation compared standard plating techniques with retrograde medullary screw fixation of a superior pubic ramus fracture in a pelvic fracture model. Six fresh-frozen, cadaveric pelvic specimens with a mean age of 79 years were harvested. These specimens were physiologically loaded according to the following modifications and instrumentations: (a) intact; (b) an APC-II unstable pelvic injury, specifically, unilateral superior and inferior rami osteotomies combined with ipsilateral anterior sacroiliac (SI) joint, sacrospinous, and sacrotuberous ligamentous disruptions, without fixation; (c) disrupted as in (b) but fixed anteriorly with a 10-hole 3.5-mm reconstruction plate contoured to the superior ramus and secured with four 3.5-mm cortical screws; (d) disrupted as in (b) but fixed anteriorly with a 10-hole 3.5-mm reconstruction plate contoured to the superior ramus and secured with six 3.5-mm cortical screws; (e) disrupted as in (b) but fixed anteriorly with a 4.5-mm retrograde medullary superior pubic ramus cortical screw 80 mm long (medial to the hip joint); and (f) disrupted as in (b) but fixed anteriorly with a 4.5-mm retrograde medullary superior pubic ramus cortical screw 130 mm long that was extraarticular and engaged the lateral iliac cortex cephalad to the ipsilateral hip joint. The posterior disruptions of the pelvic ring were not fixed. The APC-II injury created in this study resulted in significant (p < 0.05) motion at the disrupted rami and the injured SI joint, compared with the intact pelvic specimen.(ABSTRACT TRUNCATED AT 250 WORDS)