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Pubic Ramus Fracture

What we commonly call our “hip bones” are actually each three separate bones: the pubis, the ischium, and the ilium. The pubis itself is made up of two smaller bones: the superior ramus and the inferior ramus. These two rami, located at the front of each side of the pelvis, are what we refer to as our “pubic bones.” The two sides of the pelvis are connected in the middle by the pubic symphysis, a special joint made up of tough fibrocartilage. The pubic rami can break (fracture) either from repetitive stress (known as a stress fracture) or from a collision injury (known as a traumatic fracture).

Pubic Ramus Fracture Hero Image 2

What we commonly call our “hip bones” are actually each three separate bones: the pubis, the ischium, and the ilium. The pubis itself is made up of two smaller bones: the superior ramus and the inferior ramus. These two rami, located at the front of each side of the pelvis, are what we refer to as our “pubic bones.” The two sides of the pelvis are connected in the middle by the pubic symphysis, a special joint made up of tough fibrocartilage.

The pubic rami can break (fracture) either from repetitive stress (known as a stress fracture) or from a collision injury (known as a traumatic fracture). Pubic rami fractures and other pelvic fractures are categorized as either stable fractures (when only one part of the pelvis breaks) or unstable fractures (when the pelvis breaks at multiple points). While only about 3% of fractures among adults are stable pubic rami fractures, some athletes are at greater risk for this injury.

What causes Pubic Ramus Fracture?

Pubic rami fractures in athletes are most commonly “stress fractures” that occur due to repetitive hip movements and repetitive loads on the pelvis, like in long distance running. Stress fractures of the pubic rami are most common in these sports:

• Long distance running
• Track
• Dance
• Soccer
• Football training season
• Lacrosse

It’s also possible to break the pubis in a collision in contact sports such as:

• Football
• Soccer
• Hockey
• Rugby

Symptoms

Athletes with a pubic ramus stress fracture begin to experience slight groin pain that gets worse over time and increases with activity. At first, you may have pain only while practicing your sport. If the fracture goes untreated, it can begin to cause pain with simple weight bearing and then even at rest. Athletes who fracture their pubis due to a collision will experience immediate pain in the groin at the time of the injury.

When to see a doctor

If you suffer an acute injury that causes immediate and severe pain in the groin, you should seek urgent medical attention. If you cannot bear weight on your leg without severe pain, it is safest if you don’t try to. You will need assistance getting to a medical facility.

If you do not have an injury but begin to have groin pain that gets worse over time, make an appointment with your doctor. He/she will ask you questions about your sport and your symptoms, and then do a physical examination of your hip. To determine whether a pubic ramus fracture may be causing your pain, your doctor may also perform a “standing test.” During this test, he/she doctor will ask you to stand on one leg on the side where you’re experiencing pain, to see if pain is worse when you put all your weight on that hip.

Your doctor will almost always order an x-ray to confirm (or refute) the diagnosis of a pubic ramus fracture and determine the exact location and extent of the injury. X-rays will show a pubic ramus fracture that was caused by an acute injury or an advanced chronic pubic ramus stress fracture. Because an x-ray may not detect a stress fracture in its early stages, athletes with chronic groin pain and normal x-rays will often be referred for a magnetic resonance imaging (MRI) scan.

Non-operative treatment

Treatment for stable stress fractures or stable traumatic fractures of the pubic rami is non-surgical, focusing on reducing the weight bearing on the side of the fracture. Treatment may involve:

• Using crutches to take weight off your injured hip
• Medication to alleviate pain
• Prescription blood thinners to prevent blood clots in the pelvis or legs (mostly in cases of traumatic fractures)
• Physical therapy

Surgical Treatment

If you have a single fracture of the pubic ramus, surgery is rarely, if ever, needed. Surgery may be recommended in cases of multiple and unstable fractures, when several parts of the pelvis have broken due to a severe injury. In these cases, pins and screws may be used to surgically stabilize the pelvis while it heals. These kinds of pelvic fractures are uncommon in sports-related injuries.

Recovery

With proper care, you can expect full recovery from a stress-related or traumatic pubic ramus fracture. Athletes can usually begin light weight bearing after four to six weeks, and then full weight bearing at two to three months. Once you can weight bear without pain, you can gradually return to your sport, guided by your doctor. During your recovery, physical therapy can help you regain your hip flexibility, range of motion, strength, and endurance.

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