Journal of Orthopaedic Surgery 2010;18(2):153-7
Occult posterior pelvic ring fractures in elderly
patients with osteoporotic pubic rami fractures
Tak-wing Lau, Frankie Leung
Department of Orthopaedics and Traumatology, The University of Hong Kong, Queen Mary Hospital, Hong Kong
ABSTRACT
Purpose. To evaluate postoperative walking status of
elderly patients with osteoporotic pubic rami fractures
with or without posterior pelvic ring fractures.
Methods. 33 women and 4 men aged 66 to 95
(mean, 85) years presented with osteoporotic
pubic rami fractures after a fall. 22 (59%) of the
patients had additional posterior pelvic ring
fractures (9 had lateral compression type-II
fractures involving the ilium and 13 had lateral
compression type-I fractures involving the sacro-
alar region). Seven of the 9 patients with lateral
compression type-II fractures underwent open
reduction and internal fixation using plates and/
or screws. The remaining 30 patients were treated
conservatively.
Results. Postoperative walking status was similar in
elderly patients with osteoporotic pubic rami fractures
with or without posterior pelvic ring fractures.
Conclusion. Posterior pelvic ring fractures are easily
missed in elderly patients with pubic rami fractures.
Address correspondence and reprint requests to: Dr Tak-wing Lau, Department of Orthopaedics and Traumatology, The University
of Hong Kong, Queen Mary Hospital, 102 Pokfulam Road, Hong Kong. E-mail: catcherlau@hotmail.com
Routine computed tomography of the pelvis is useful
in making the diagnosis.
Key words: fractures, bone; osteoporosis; pelvic bones;
pubic bone; rehabilitation
INTRODUCTION
Osteoporotic fractures in elderly patients are difficult
to identify and treat, as such patients usually have
poor health and multiple comorbidities. The rates
of geriatric osteoporotic fractures of the hip and
pelvis are increasing.1 Geriatric pubic rami fractures
were usually treated conservatively by bed rest
and analgesics.2 However, such fractures are often
associated with posterior pelvic ring injuries.3–5 On
magnetic resonance imaging, over 90% of patients
with pelvic injuries involve the posterior pelvic ring,2
and over 90% of them have persistent sacral pain.
Surgical stabilisation is indicated when posterior
pelvic ring injuries are unstable.6,7 In some patients,
occult posterior pelvic ring fractures may prolong
rehabilitation.
154 TW Lau and F Leung Journal of Orthopaedic Surgery
(a)
(b)
Figure 1 (a) Lateral compression type-II fracture involving
the right ilium and (b) lateral compression type-I fracture
involving the right sacral alar.
MATERIALS AND METHODS
Between December 2006 and November 2007, 33
women and 4 men aged 66 to 95 (mean, 85) years
presented with osteoporotic pubic rami fractures
after a simple fall. Patients with pathological fractures
related to tumours or irradiation were excluded.
Most patients had multiple comorbidities, including
hypertension, diabetes, ischaemic heart disease,
dementia, and a history of stroke. Only 6 (16%) of
them had a history of osteoporotic fractures.
Patient demographics, pre-injury walking status,
and mode of injury were recorded. Clinical examinations
for other hip fractures and tenderness around the sacral
region were performed. Anteroposterior radiography
and computed tomography of the pelvis were routinely
undertaken, but inlet and outlet radiographs of the
pelvis were not.
22 (59%) of the 37 patients with pubic rami
fractures had additional posterior pelvic ring fractures.
According to the Young and Burgess classification,1 9
Figure 2 Open reduction and internal fixation for a lateral
compression type-II fracture.
had lateral compression type-II fractures involving
the ilium (Fig. 1a) and 13 had lateral compression
type-I fractures involving the sacro-alar region (Fig.
1b). All the patients with sacral fractures had tender
sacro-iliac joints.
Seven of the 9 patients with lateral compression
type-II fractures underwent open reduction and
internal fixation using plates with or without pubic
rami screws (Fig. 2). The remaining 30 patients were
treated conservatively. Rehabilitation protocols for
both treatment groups were similar; full weight
bearing was allowed as long as the patients could
tolerate the pain.
RESULTS
Patients were classified into 3 groups based on
fracture patterns: pubic rami fractures only (n=15),
pubic rami fractures with lateral compression type-
I fractures (n=13), and pubic rami fractures with
lateral compression type-II fractures (n=9). Their
postoperative walking status was compared. At the 3-
month follow-up, 53%, 62%, and 56% of the patients
in the respective groups had returned to their pre-
injury walking status (Table). At the one-year follow-
up, in the respective groups, 4, 3, and 2 patients had
died, and walking status of 5, 2, and 2 patients had
deteriorated (Table).
One patient was complicated by an L5 nerve
root palsy secondary to traction injury, and another
endured fibrous union over the ilium.
Vol. 18 No. 2, August 2010 Occult posterior pelvic ring fractures in elderly patients with osteoporotic pubic rami fractures 155

DISCUSSION osteoarthritis of the knees, etc. Therefore, rehabilitation

The fracture patterns of our patients were of a normal
force exerted on excessively weak bone. The treatment
plan was to take care of the poor stability and healing
of the osteoporotic bone.8 Pre-injury walking status
was usually compromised due to old hip fractures,
for these patients was unpredictable.
In our study, mortality rates associated with
different fracture types were not significantly
different. Patients with pubic rami fractures and
lateral compression type-I fractures tended to have
a relatively stable pelvis and could be managed

Table
Comparison of walking status of patients in 3 different fracture patterns

Patient no. Sex/age Treatment Associated injuries Walking status

(years)
Pre-injury Month 3 Year 1
Pubic rami fracture only
1 F/90 Conservative  - Stick Stick Died
2 F/88 Conservative  - Unaided Stick Stick
3 F/83 Conservative  - Stick Frame Frame
4 F/81 Conservative  - Unaided Stick Stick
5 F/82 Conservative  - Frame Frame Wheelchair
6 F/70 Conservative Left greater trochanter fracture Unaided Unaided Stick
7 F/83 Conservative Left humerus fracture Unaided Stick Died
8 F/83 Conservative  - Unaided Stick Stick
9 M/88 Conservative  - Unaided Unaided Quadripod
10 F/72 Conservative  - Stick Stick Quadripod
11 F/80 Conservative Left femoral neck fracture Unaided Wheelchair Died
12 F/80 Conservative  - Wheelchair Wheelchair Wheelchair
13 F/82 Conservative  - Frame Frame Wheelchair
14 F/89 Conservative  - Stick Wheelchair Wheelchair
15 F/89 Conservative  - Stick Stick Died
Pubic rami fracture and
lateral compression
type-I fracture
16 F/77 Conservative  - Stick Stick Stick
17 M/81 Conservative  - Stick Stick Stick
18 F/77 Conservative  - Unaided Stick Quadripod
19 F/94 Conservative  - Quadripod Quadripod Died
20 F/74 Conservative  - Quadripod Quadripod Quadripod
21 F/83 Conservative  - Unaided Stick Stick
22 M/66 Conservative  - Unaided Unaided Unaided
23 F/77 Conservative  - Stick Stick Stick
24 F/66 Conservative Left distal radius fracture Quadripod Quadripod Died
25 F/88 Conservative Right distal radius fracture Wheelchair Frame Frame
26 F/78 Conservative  - Unaided Unaided Stick
27 F/95 Conservative  - Stick Wheelchair Died
28 F/85 Conservative  - Stick Frame Frame
Pubic rami fracture and
lateral compression
type-II fracture
29 F/92 Plating Left distal radius fracture Frame Stick Died
30 F/92 Plating  - Stick Stick Quadripod
31 F/83 Plating  - Frame Frame Frame
32 F/89 Plating +  - Unaided Quadripod
Frame
superior pubic (fibrous
ramus screw union)
33 M/90 Plating  - Unaided Stick Stick
34 F/83 Plating Right distal radius fracture Unaided Stick Stick
35 F/82 Plating  - Stick Frame Frame (L5
palsy)
36 F/83 Conservative  - Frame Wheelchair Wheelchair
37 F/92 Conservative  - Wheelchair Wheelchair Died
156 TW Lau and F Leung Journal of Orthopaedic Surgery

conservatively with adequate analgesia. Although
such patients may have stayed in bed longer, their
final walking status was similar to those with pubic
rami fracture only. Patients with additional lateral
compression type-II fractures tended to have more
unstable and painful fractures. Displacement of
fractures at their thinned osteoporotic iliac wings
tended to be more severe necessitating surgical
stabilisation. However, surgery poses anaesthetic and
technical difficulties for geriatric patients with severe
osteoporotic bone. The mean age of our patients was
85 (range, 65–99) years, which is older than patients
in other series.3,4 The combination of advanced age,
multiple comorbidities, and intra-operative bleeding
with poor cardiopulmonary reserve makes decisions
about surgery difficult. Moreover, these patients may
be treated successfully by conservative means, with
good functional outcome.7,9 Whether operated patients
enjoy a faster recovery remained controversial.
The causes of deterioration in walking status
vary and include osteoporotic fracture of other
bones, concomitant degenerative back or knee
problems, poor health, poor cardiopulmonary
reserve, and various geriatric problems.
Occult posterior pelvic ring fractures are easily
missed in geriatric patients with pubic rami fractures
following a simple fall. When patients present with
pubic rami fractures, their back should be examined
for tenderness at the sacro-iliac area and the iliac wing
(Fig. 3). Routine computed tomography of the pelvis
is useful in making the diagnosis.

Geriatric pubic
rami fractures

Clinical examination and

computed tomographic
scanning of the pelvis

Posterior
No Yes
pelvic ring
involvement

Lateral compression
Types of
type-I fractures
posterior
ring injury

Lateral compression
Conservative type-II fractures
management &
walking exercise as Surgical stabilisation of the posterior pelvic
pain tolerated ring using screws and/or plates

Figure 3 Management protocol for geriatric pubic rami fractures.

Vol. 18 No. 2, August 2010 Occult posterior pelvic ring fractures in elderly patients with osteoporotic pubic rami fractures 157

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