Fracture of pubic rami during hip fracture fixation: a rare case of traction table–related injury

We present a case of an elderly and comorbid patient who was scheduled to undergo a hip fracture fixation using an intramedullary nail. Unfortunately, this was delayed by 3 weeks as the patient was unfit to undergo this procedure. She was placed onto the traction table and intraoperatively sustained a superior and inferior pubic rami fracture while attempting reduction on the traction table. Closed-reduction techniques using traction tables and perineal posts are not without morbidity. Risk factors such as osteoporosis and delayed-fixation should be accounted for when managing this complex and often frail group of patients.

EP.FRI.680 “Avulsion of the Corona Mortis following low energy pubic rami fracture: a rare but life-threatening injury.”

We describe the case of an 81 year old gentleman who presented after a trivial fall with haemodynamic instability and worsening abdominal pain and swelling. An initial trauma CT identified superior and inferior pubic rami fractures associated with a large intra-pelvic collection. A subsequent CT angiogram confirmed a large pelvic haematoma with an active arterial bleeding from a ruptured vessel adjacent to the superior pubic rami fracture. This was managed by resuscitating him with fluids and blood transfusions followed by fluoroscopic guided Internal Iliac artery embolisation. The “Corona Mortis” is an aberrant arterial connection between the inferior epigastric artery and obturator artery and is prevalent in the hemipelvis of more than 49.3% of the population. Very rarely it can be damaged during low energy pubic rami fractures leading to haemodynamic compromise and potential death. For this reason and the fact there is a high chance that it could be missed, we wish to highlight this case, and management and emphasise the need to consider this life-threatening complication even in cases when the mechanism of injury may seem trivial.

My Hips Hurt: An Unusual Presentation of Bilateral Groin Pain in an Adolescent Boy

Van Neck-Odelberg disease (VND) is a rare benign pediatric skeletal abnormality characterized by hyperostosis of the ischiopubic synchondrosis (IPS) and clinical symptoms.1,2,3 IPS is a strip of cartilaginous tissue between the superomedial pubic and posterolateral ischial ossification centers, which develops into the inferior pubic rami and ischial tuberosity, respectively.

Results of minimally invasive quick definitive fixation of unstable bony pelvic disruption by combined retrosacral transiliac rods and anterior external fixator during a critical national period

<p class="abstract">Unstable pelvic ring fractures are challenging injuries regarding their reduction and stabilization. The presented study evaluates the results of a minimally invasive and quick one-stage stabilization of sacral fractures combined with bilateral pubic rami fractures during a period of national limited resources and decreased general security aiming at reduction of the duration of hospital stay and overall costs. Sixteen patients with unilateral sacral fractures and bilateral pubic rami fractures without lumbosacral dissociation were fixed by two retrosacral threaded transiliac rods and an anterior external fixator. Results were assessed with Majeed score and Matta-Tornetta radiologic criteria for post-operative reduction. The follow up period averaged 23 months. There were 9 cases excellent, 4 cases good and 3 cases fair. The duration of surgery and the number of intra-operative X-ray images were recorded. The presented technique is simple, reproducible and quick for one-stage fixation of the unstable pelvic bony disruption. It reduces the operative time, radiation exposure, duration of hospital stays and cost of care during a critical national period with limited resources. </p>

9 Patient Outcomes From A General Inpatient Rehabilitation Ward, Does Frailty or Reason for Admission Make A Difference to Patient Outcome?

Introduction With our ageing population there is increasing number of patients who experience a decline in their mobility either because of their underlying diagnosis or as a consequence of their hospital stay. There are only a limited number of inpatient rehabilitation beds and it is therefore important to identify those that would benefit the most from inpatient rehabilitation. Method We undertook a retrospective study looking at three months of discharges from an inpatient rehabilitation ward in Manchester. Patients were categorised based on diagnosis (Pubic rami fracture, other fractures, fall with no bony injury and finally medical reasons) and Clinical Frailty Score to see if either had any effect on whether patients mobility improved and to what degree. Results Patients with a reduced mobility on admission were identified and then categorised based on diagnosis. Of those patients admitted with a pubic rami fracture 66.7% improved on the ward with 33.3% of patients reaching their baseline mobility. The mobility of 85.7% of patients with other fractures improved with 42.9% reaching their baseline. Patients admitted following a fall without bony injury showed, 75% improvement with 50% reaching their baseline. Of those admitted for medical reasons 88.9% of those improved but only 22.2% reaching their baseline mobility. The lowest proportion of any category. Those admitted for medical reasons also had the longest median average stay on the rehab ward (33.5 days) followed by other fractures (33 days) then fall with no bony injury (21.5 days) and finally the shortest average stay, pubic rami fractures (20 days). Patients were also grouped occurring to their preadmission Clinical Frailty Score. With the exception of those who scored four (only a small number of patients), there was a negative correlation between an increasing frailty score and the proportion of patients whose mobility improved. However as frailty score increased the proportion of patients who improved to their baseline increased. Conclusion Our study has shown that the majority of patients benefitted from their admission regardless of diagnosis, however those admitted for medical reasons had the lowest chance of reaching their baseline mobility despite the longest admissions on the ward. Further research may be beneficial to investigate if they do better in a different rehabilitation setting.

ASSERT (Acute Sacral inSufficiEncy fractuRe augmenTation): Perceptions in the Assessment and Treatment of Pubic Rami and Sacral Fragility Fractures Amongst Healthcare Professionals in Geriatric Medicine and Surgery.

Background: Pubic rami fragility fractures are common in older people and result in significant morbidity and increased mortality. Co-existing fractures of the sacrum are common, but routinely missed. The aim of the study was to explore the perceptions in the assessment and treatment of pubic rami and sacral fragility fractures amongst healthcare professionals. Methods: We interviewed 14 participants about their experience in the assessment and treatment of patients presenting with pubic rami fragility fractures. Data was analysed using an inductive thematic approach.Results: The majority of patients presenting with a pubic rami fragility fracture were managed by geriatricians. However, many of the geriatricians were not aware that these fractures have a high association with co-existing sacral fragility fractures. Furthermore, they were not aware of the limitations of standard x-ray imaging, nor of the potential benefits of surgical intervention for sacral fragility fractures. Spinal surgeons recommended that early, more specialist imaging in patients with public rami fragility fractures failing to mobilise, would change clinical management, if found to have a coexisting sacral fragility fracture, amenable to surgical intervention. Conclusions: The awareness, assessment and management of sacral fragility fractures in patients presenting with pubic rami fragility fractures is poor amongst healthcare professional in geriatric medicine. Spinal surgeons in this study advocate early further imaging and surgical intervention in patients confirmed to have a concomitant sacral fragility fracture who are failing to mobilise.

Orthopaedic Management of Bladder Exstrophy

Bladder exstrophy is an embryologic malformation that affects urogenital and skeletal systems. Non-operative treatment of this rare problem is impossible. Urogenital reconstructions can be facilitated by orthopedic procedures. These reconstructions can be performed in a single stage as a complete repair or multi-stage approaches. The goal of the treatment is closure of the bladder and abdominal wall for the achievement of continence, preservation of renal functions, and cosmetic and functional reconstruction of genital organs. Orthopedic procedures are performed to decrease the tension that complicates the bladder and abdominal wall closure by approximating the pubic rami to achieve a secure closure and a low recurrence rate. Surgical interventions consist of the approximation of the pubic rami with different materials such as suture materials and plaque or the application of different osteotomy types such as posterior iliac, anterior pelvic (pubic), diagonal iliac, horizontal iliac and posterior pelvic resection osteotomies. The age of the patient, the amount of pubic diastasis and history of previous operations that the patient has undergone should be considered during the operation planning. Pubic rami can be approximated without performing pelvic osteotomy in patients who are operated within the first 72 hours after birth. But, osteotomy is required in children older than 2 years of age with severe pubic diastasis, concomitant cloacal exstrophy and unsuccessful operation history. The surgical team should have enough knowledge and experience to perform different osteotomy types in case of need to combine anterior and posterior iliac osteotomies. With these multidisciplinary approaches, much more successful outcomes could be achieved.

ASSERT (Acute Sacral inSufficiEncy fractuRe augmenTation): Perceptions in the Assessment and Treatment of Pubic Rami and Sacral Fragility Fractures Amongst Healthcare Professionals in Geriatric Medicine and Surgery—A Qualitative Study

Background: Pubic rami fragility fractures are common in older people and result in significant morbidity and increased mortality. Co-existing fractures of the sacrum are common, but routinely missed. The aim of the study was to explore the perceptions in the assessment and treatment of pubic rami and sacral fragility fractures amongst healthcare professionals. Methods: We interviewed 14 participants about their experience in the assessment and treatment of patients presenting with pubic rami fragility fractures. Data was analyzed using an inductive thematic approach. Results: The majority of patients presenting with a pubic rami fragility fracture were managed by geriatricians. However, many of the geriatricians were not aware that these fractures have a high association with co-existing sacral fragility fractures. Furthermore, they were not aware of the limitations of standard x-ray imaging, nor of the potential benefits of surgical intervention for sacral fragility fractures. Spinal surgeons recommended that early, more specialist imaging in patients with pubic rami fragility fractures failing to mobilize, would change clinical management, if found to have a coexisting sacral fragility fracture, amenable to surgical intervention. Conclusions: The awareness, assessment and management of sacral fragility fractures in patients presenting with pubic rami fragility fractures is poor amongst healthcare professionals in geriatric medicine. Spinal surgeons in this study advocate early further imaging and surgical intervention in patients confirmed to have a concomitant sacral fragility fracture who are failing to mobilize.

Measurement of Subpubic Angle in Radiograph

Introduction: Subpubic angle, an important parameter used for sex determination in the pelvis, is the angle between two inferior pubic rami below the symphysis pubis. This study was carried out to determine the subpubic angle among the individuals referred for pelvic and KUB radiographs in the department of Radiology and Imaging, Tribhuvan University, Teaching Hospital.Methods: Prospective cross-sectional study was done on 120 individuals. The subpubic angle was measured by drawing two tangent lines on the inferior border of the pubic rami. The subpubic angle of both sexes was measured. An independent sample t-test for equality of means was used to determine the difference between the two sexes regarding the subpubic angle. The correlation between the subpubic angle and the age of subjects was obtained using Pearson Correlation Coefficients in males and females.Results: The range of the subpubic angle in male was 82o to 122° and the mean was 104.72°±10.47°. In females, the range was 96o to 159° and the mean was 137.15°±11.92° with a significant statistical difference from the angle in male (p<0.05). The subpubic angle was not significantly correlated with age in males (r=0.029, p=0.824) whereas, in females, the correlation of subpubic angle with age was significant (r=-0.303, p=0.019).Conclusion: The mean subpubic angle was significantly wider in females than in males in this study. We found a weak negative correlation between subpubic angle and age in females whereas in the male there was no correlation between age and subpubic angle.