Hip fractures and pubic rami fractures are common in older adults and are generally caused by low-energy trauma. While hip fractures require hospital admission, pubic rami fractures are often managed on an outpatient basis and receive less clinical and scientific attention. The aim of this study was to compare functionality, in-hospital complications, and two-year mortality between both fracture types.
Materials and methodsA prospective descriptive study was conducted in the Orthogeriatric Unit of the Fracture Liaison Service (FLS), including patients over 69 years of age with fragility fractures. Clinical and functional variables at admission and discharge, in-hospital complications, and mortality at 3, 6, 12, and 24 months were analyzed.
ResultsA total of 285 patients were included, 80.35% of whom were women; 83.86% had hip fractures and 16.14% had pubic rami fractures. Length of hospital stay was longer in hip fractures (8.26 vs. 5.47 days; p<0.01), as was the proportion of patients with two or more complications (59.80% vs. 13%; p<0.01). No significant differences were found in baseline or discharge functionality: FIM (hip: 105.5; rami: 104.2; p=0.79), BI (hip: 74.6; rami: 78.5; p=0.36), CAS (hip: 2.47; rami: 2.78; p=0.21), FAC (hip: 1.85; rami: 2.18; p=0.06). Mortality was similar at all follow-up points (p=0.90).
ConclusionsWhen managed in a specialized orthogeriatric setting, pubic rami fractures show comparable outcomes to hip fractures in terms of mortality, functionality, and discharge destination. These findings support the need for rigorous clinical management of this type of fracture as well.
Las fracturas de cadera y de ramas pélvicas son frecuentes en adultos mayores y, generalmente, se deben a traumatismos de baja energía. Mientras que las fracturas de cadera requieren ingreso hospitalario, las de ramas pélvicas suelen manejarse de forma ambulatoria y reciben menor atención clínica y científica. El objetivo de este estudio es comparar la funcionalidad, las complicaciones intrahospitalarias y la mortalidad a dos años entre ambos tipos de fractura.
Materiales y métodosEstudio descriptivo prospectivo realizado en la Unidad de Ortogeriatría del Fracture Liaison Service (FLS), incluyendo pacientes mayores de 69 años con fractura por fragilidad ósea. Se analizaron variables clínicas y funcionales al ingreso y al alta, complicaciones intrahospitalarias y mortalidad a los 3, 6, 12 y 24 meses.
ResultadosSe incluyeron 285 pacientes, el 80,35% mujeres; el 83,86% con fractura de cadera y el 16,14% con fractura de ramas pélvicas. La estancia hospitalaria fue mayor en fractura de cadera (8,26 vs. 5,47 días; p<0,01), así como la proporción de pacientes con dos o más complicaciones (59,80% vs. 13%; p<0,01). No se encontraron diferencias significativas en funcionalidad basal ni al alta: FIM (cadera: 105,5; ramas: 104,2; p=0,79), IB (cadera: 74,6; ramas: 78,5; p=0,36), CAS (cadera: 2,47; ramas: 2,78; p=0,21), FAC (cadera: 1,85; ramas: 2,18; p=0,06). La mortalidad fue similar en todos los puntos de seguimiento (p=0,90).
ConclusionesLas fracturas de ramas pélvicas, cuando se tratan en un entorno ortogeriátrico especializado, presentan resultados comparables a las fracturas de cadera en términos de mortalidad, funcionalidad y destino al alta. Estos hallazgos apoyan la necesidad de un manejo clínico riguroso también en este tipo de fracturas.
Osteoporosis is a systemic skeletal disorder characterised by low bone mass and impaired bone microarchitecture. This increases bone fragility and susceptibility to fractures.1
It is highly prevalent in older people and is often associated with frailty syndrome, sarcopenia, and high morbidity and mortality.2 In this context, low-impact trauma fractures (LITFs), which are defined as fractures resulting from falls from standing height or lower and are also known as osteoporotic or fragility fractures, pose a challenge to public health and to healthcare and social care systems.
It is estimated that the direct and indirect costs of treating and providing long-term care for osteoporotic fractures amounted to €37 billion in Europe in 2010.3 For those affected, these fractures result in pain, loss of function, reduced quality of life, increased risk of further fractures, and higher mortality.4,5
Pubic rami fractures (PRFs) account for 7% of all osteoporotic fractures. They are one of the types of osteoporotic fracture whose incidence has increased in recent decades. The overall incidence of PRFs is 20–37 per 100,000 people per year. This figure rises to 92 per 100,000 people per year when only considering individuals over the age of 65.7,8 Despite generating significant individual and socio-economic costs, PRFs are underestimated,9 underdiagnosed, and undertreated6 osteoporotic fractures.10
PRFs cause severe pain, leading to immobility, functional decline, disability, and dependency in older people. This is associated with increased morbidity and mortality.6,9,10
Currently, PRFs are considered stable and treated as outpatient cases, according to recent observational study data, although this practice does not always align with standardised criteria.11 In some cases, they may go unnoticed and the patient may not seek healthcare.10,12,13
If left untreated, these patients are at high risk of subsequent fracture.6,9
In contrast, hip fracture (HF) is the most extensively researched type of LITF, and significant advances have been made in its management. It is associated with substantial morbidity and mortality in the first year,4,14 reaching a mortality rate of 40% within two years and often necessitating the patient's institutionalisation. In 2019, there were approximately 64,429 hospitalisations due to HF in Spain, with a hospital mortality rate of 4.5%.15
Various studies have shown that ‘Fracture Liaison Services’ (FLS) are a cost-effective care model.16 If all people over the age of 50 in Spain could be cared for within an FLS setting, 1249 fragility fractures could be prevented annually, representing a saving of 18.4 million euros per year.17
The FLS model takes a multidisciplinary approach, integrating hospital care, intermediate care (including orthogeriatric units), and primary care. It systematically identifies fragility fractures, assesses osteoporosis and the risk of falls, initiates specific treatments, and carries out clinical follow-up, while maintaining a centralised register of fracture events. This programme has been implemented in a structured manner at the study centre since 2018, serving a population of over 136,000 according to the 2021 census by the Catalan Institute of Statistics.
Evidence shows that orthogeriatric co-management models significantly improve 30-day and one-year survival following a hip fracture when combined with FLS services, reducing mortality by between 15% and 30% compared with conventional care.18
Based on accumulated clinical experience and the available data, it was decided that PRF patients should be admitted to the Orthogeriatric Unit. The aim was to comprehensively address complications arising from immobility, pain, and functional decline within the framework of the FLS model for secondary post-fracture prevention. Previously, PRF patients treated in the emergency department were discharged directly to their place of residence with recommendations for rest and analgesia, without subsequent assessment of adverse functional outcomes, complications, or mortality.
It was this background that led to the systematic inclusion of these patients in a specialised, interdisciplinary orthogeriatric unit. This strategic decision enables a comparison to be made between PRF patients and HF fractures under homogeneous care conditions within an orthogeriatric setting.
Following the systematic inclusion of PRF patients in the orthogeriatric unit within the FLS model, the central hypothesis of this study emerges: under comparable care conditions and with a structured, interdisciplinary approach, PRF patients over the age of 69 exhibit clinical outcomes, functional status at discharge, and short- and long-term mortality similar to those of HF patients, despite not requiring surgical intervention. This hypothesis highlights the need to reconsider the traditional underestimation of PRFs, and to assess its health impact with the same rigour as that applied to HFs.
Material and methodsThis is a descriptive, longitudinal, prospective study involving individuals diagnosed with HF or PRF, both of osteoporotic origin, admitted to the Orthogeriatric Unit of the FLS between 25 February 2020 and 10 May 2022.
All pelvic fragility fractures were included, regardless of their anatomical location within the pelvic ring, provided they met the radiological and clinical criteria consistent with low-energy trauma.
The inclusion criteria for this study were being over 69 years of age and having been diagnosed with PRF or HF due to osteoporotic fragility, being admitted to the Orthogeriatric Unit during the aforementioned period, and having given informed consent (or a responsible family member or guardian having given consent in the event of incapacity or dementia) to participate in the study.
Conversely, the exclusion criteria were periprosthetic fractures, acetabular fractures, fractures caused by high-impact trauma, and fractures of non-osteoporotic origin.
Demographic variables were assessed, including sex, age, place of origin, and discharge destination. Frailty and pre-admission comorbidity were also assessed using the Frail-VIG index (F-VIG)19,20 and the Charlson Comorbidity Index (CCI).21 Patient functional status was assessed at three time points – pre-admission, on admission, and at discharge – using the Barthel Index (BI),22 the Functional Independence Measure (FIM),23 the Cumulated Ambulation Score (CAS),24 and the Lawton and Brody Index (IADL).25 Walking ability prior to admission and at discharge was also assessed using the Functional Ambulation Classification (FAC).26 Baseline cognitive status was measured using Reisberg's Global Deterioration Scale (GDS).27 Length of hospital stay and two-year all-cause mortality were also recorded.
An analysis of the total number of complications was carried out, classifying them by type as follows: infectious complications, delirium, anaemia requiring transfusion, cardiorespiratory complications, and fluid and electrolyte imbalances.
Patients were assessed by an interdisciplinary team comprising occupational therapists, physiotherapists, nurses, social workers, and doctors, who were involved throughout the patient's hospital stay.
Mortality is assessed after two years of follow-up for each participant, with data recorded via the HC3 computer system (Shared Clinical Record of Catalonia).
This study complies with confidentiality regulations and has been approved in advance by the Parc de Salut MAR Research Ethics Committee under the code 2018/7852/I.
Results are expressed as the mean and standard deviation for continuous variables, and as absolute frequency and percentage for categorical variables. Following the normality test, various statistical tests are applied to the multivariate comparisons, including the χ2 test, the Kruskal–Wallis’ test, and the Shapiro–Wilk test, depending on the type of variable analysed. The Shapiro–Wilk test is used to check the normality of the distribution of quantitative variables, which are expressed as the median and interquartile range.
For the survival analysis, a variable was created to indicate the date of death for patients who died during the study period. Those who survived were assigned the last day of data collection (15 September 2022). This variable was subtracted from the admission date to calculate the number of days of survival. This result was then divided between 30 to express survival in months during the study. The survival analysis was carried out with a 24-month follow-up, using the Kaplan–Meier plot. A logistic regression analysis was performed to identify the patients at higher risk of mortality.
IBM SPSS Statistics v.27 (IBM Corp., 2020, USA) and Wizard 2 (Miller, 2017, USA) were used for the statistical analysis. Results are considered statistically significant if the p-value was less than .05.
ResultsA total of 315 participants were included in the study. Thirty patients with periprosthetic or acetabular fractures, those caused by high-impact trauma, and non-osteoporotic fractures were excluded. A total of 285 patients were finally included; of these, 46 (16.14%) had PRF, and 239 (83.86%) had HF (Fig. 1).
The results obtained for various demographic, clinical, and functional variables at baseline and on admission are detailed below (Table 1).
Baseline demographic, clinical, and functional characteristics of the participants.
| Variable | Total(n=285) | PRF(n=46) | HF(n=239) | p-Value |
|---|---|---|---|---|
| Age (years) | 85.80±7.37 | 86.50±.87 | 85.67±.49 | .48 |
| Sex, n (%) | .67 | |||
| Male | 56 (19.64) | 8 (17.4) | 48 (20.1) | |
| Female | 229 (80.35) | 38 (82.6) | 191 (79.9) | |
| GDS | 2.95±2.06 | 2.74±1.86 | 3.00±2.10 | .43 |
| Origin, n (%) | .13 | |||
| Home | 219 (76.8) | 39 (85.0) | 180 (75.3) | |
| Care home | 52 (18.2) | 6 (13.3) | 46 (19.2) | |
| Intermediate care | 14 (4.9) | 1 (2.2) | 13 (5.4) | |
| Fracture type, n (%) | <.001 | |||
| Ischiopubic | – | 13 (28.3) | – | |
| Iliopubic | – | 11 (23.9) | – | |
| Ilio-ischiopubic | – | 22 (47.8) | – | |
| Extracapsular | – | – | 137 (57.3) | |
| Intracapsular | – | – | 102 (42.7) | |
| Waiting time for surgery (in days) | – | – | 1.35±1.36 | |
| BI | 75.21±76.40 | 78.48±3.54 | 74.58±1.74 | .36 |
| Baseline FIM | 105.29±25.49 | 104.17±4.79 | 105.54±2.17 | .79 |
| FIM at admission | 45.14±16.17 | 48.50±13.58 | 44.60±16.59 | .23 |
| Baseline CAS | 5.72±.77 | 5.76±.13 | 5.71±.07 | .77 |
| CAS at admission | .78±.86 | 1.00±.90 | .74±.85 | .14 |
| FAC | 4.17±1.13 | 4.35±.16 | 4.13±.07 | .24 |
| Lawton | 3.07±2.83 | 3.11±.41 | 3.07±.18 | .93 |
| Charlson | 6.64±2.19 | 7.04±2.52 | 6.56±2.11 | .17 |
| F-VIG | .31±.16 | .31±1.15 | .31±.16 | .77 |
BI: Barthel Index; CAS: Cumulated Ambulation Score; FAC: Functional Ambulation Classification; FIM: Functional Independence Measure; F-VIG: Frail-VIG index; GDS: Global Deterioration Scale; HF: hip fracture; PRF: pubic rami fracture.
Note: BI (0–100) assesses basic activities; FIM (18–126) measures overall functional independence; CAS (0–6) and FAC (0–5) assess ambulation; a higher score indicated greater Independence. F-VIG (0–1) reflects geriatric frailty.
The mean age of PRF patients was 86.50±.87 years, while that of patients with HC was 85.67±.49 years. The overall mean age of the participants was 85.80±7.37 years (p=.48).
In terms of sex, there is a predominance of women in both groups. In the PRF group, 8 (17.04%) were men and 38 (82.60%) were women. In the HF group, 48 (20.08%) were men and 191 (79.91%) were women (p=.67).
No statistically significant differences were found in the origin of the PRF and the HC patients, as 85.0% and 75.3% of each group, respectively, came from their home (p=.13).
Clinical characteristicsThe distribution of fractures by group was as follows: in the PRF group, ischiopubic (28.30%), iliopubic (23.90%) and ilio-ischiopubic (47.80%). For the HF group, extracapsular (57.32%) and intracapsular (42.68%) fractures were reported. The mean waiting time for surgical intervention was 1.35±1.36 days.
Regarding the IF-VIG index, both groups had a score of .31±.16 (p=.77).
The Charlson Comorbidity Index score was 7.04±2.52 for PRF and 6.56±2.11 for HF (p=.17). For the GDS, the scores are 2.74±1.86 for PRF and 3.00±2.10 for HF (p=.43).
Functional evaluationsPRF patients had a mean baseline Barthel Index score of 78.48±3.54, while those with HF had a mean score of 74.58±1.74. The total score was 75.21±76.40 (p=.36).
The Lawton scale score was 3.11±0.41 for PRF patients and 3.07±.18 for HF patients (p=.93).
The baseline FIM Index score was 104.17±4.79 for patients with PRF and 105.54±2.17 for patients with HF; no statistically significant differences were observed between the two groups (p=.79). On admission, the FIM scores were 48.50±13.58 for PRF and 44.6±16.59 for HF (p=.23).
Regarding the CAS, the baseline score was 5.76±.13 for PRF and 5.71±.07 for HF (p=.77). During hospitalisation, the respective scores were 1.00±.90 and .74±.85 (p=.14).
The baseline FAC score was 4.35±0.16 for PRF patients and 4.13±.07 for HF patients (p=.24).
The results of the discharge assessment from the Orthogeriatric Unit are described in Table 2.
Functional status and hospital destination on discharge.
| Variable | Total(n=285) | PRF(n=46) | HF(n=239) | p-Value |
|---|---|---|---|---|
| BI | 39.14±19.24 | 42.90±2.74 | 38.40±1.30 | .05 |
| FIM | 64.09±21.53 | 66.46±20.70 | 63.60±21.75 | .52 |
| CAS | 2.52±1.23 | 2.78±.23 | 2.47±.10 | .21 |
| FAC | 1.90±1.28 | 2.18±.22 | 1.85±.08 | .06 |
| Destination, n (%) | .13 | |||
| Home | 122 (42.8) | 15 (32.6) | 107 (44.8) | |
| Care home | 61 (21.4) | 9 (19.6) | 52 (21.8) | |
| Intermediate care | 93 (32.6) | 22 (47.8) | 71 (29.7) | |
| Death during admission | 9 (3.2) | 0 (.0) | 9 (3.8) | – |
BI: Barthel Index; CAS: Cumulated Ambulation Score; FAC: Functional Ambulation Classification; FIM: Functional Independence Measure; HF: hip fracture; PRF: pubic rami fracture.
Note: BI (0–100) measures functional autonomy; FIM (18–126) measures overall functional independence; CAS (0–6) and FAC (0–5), walking ability.
The IB score at discharge was 42.90±2.74 for PRF and 38.40±1.30 for HF, with an overall mean of 39.14±19.24 (p=.05).
The total mean FIM score at discharge was 64.09±21.53. For PRF patients, the mean was 66.46±20.70, and for HF patients it was 63.6±21.75 (p=.52).
Regarding CAS score at discharge, PRF patients had a score of 2.78±.23, while HF patients had a score of 2.47±.10, with an overall mean of 2.52±1.23 (p=.21).
The FAC score at discharge is 2.18±.22 for PRF and 1.85±.08 for HF, with a total mean of 1.90±1.28 (p=.06).
Regarding discharge destination, it is observed that 15 (32.6%) PRF patients were discharged to their homes, 9 (19.6%) to care homes, and 22 (47.8%) to intermediate care centres. For HF patients, 107 (44.8%) were discharged to their homes, 52 (21.8%) to care homes, and 71 (29.7%) to Intermediate Care Centres (p=.13).
Clinical characteristicsThe length of hospital stay was significantly shorter for the PRF patients (5.47±.44 days) compared with the HF patients (8.26±.32 days), with an overall mean of 7.81±0.29 days (p<.01), as shown in Table 3.
Hospital stay, complications, and mortality.
| Variable | Total(n=285) | PRF(n=46) | HF(n=239) | p-Value |
|---|---|---|---|---|
| Hospital stay (days) | 7.81±.29 | 5.47±.44 | 8.26±.32 | <.01 |
| Complications ≥2, n (%) | 149 (52.3) | 6 (13.0) | 143 (59.8) | <.01 |
| Waiting time to surgery (days) | – | – | 1.35±1.36 | – |
| Mortality, n (%) | .92 | |||
| At 3 months | 32 (10.8) | 6 (10.9) | 26 (10.8) | |
| At 6 months | 40 (13.9) | 7 (15.2) | 33 (13.7) | |
| At 12 months | 71 (25.1) | 12 (26.1) | 60 (24.9) | |
| At 24 months | 101 (35.5) | 16 (34.8) | 85 (35.7) | |
HF: hip fracture; PRF: pubic rami fracture.
It can be observed that 13% of the PRF patients had two or more complications, compared with 59.8% of patients with HF (p<.01).
With regard to mortality, the following data are recorded: for PRF patients, mortality at three months was 10.87%, at six months 15.22%, at 12 months 26.09% and at 24 months 34.78%. For HF patients, mortality was 10.79% at three months, 13.69% at six months, and 24.90% at 12 months; finally, at 24 months, it was 35.68%. No significant differences were found (p=.925), as shown in Table 3 and their overall survival in Fig. 2.
Discussion
The results of this study highlight the need not to underestimate PRF, just as is the case with HF. Despite differences in clinical management (particularly due to the need for surgical intervention in HF), both groups show similar outcomes at discharge in terms of functional ability, mortality, and dependency. This suggests that PRFs should be given the same consideration as HFs, as their clinical and care impact is no less significant, even though the approach differs.
A significant difference was found in hospital stay between the two groups: 5.47±.44 days for PRF versus 8.26±.32 days for HF (overall mean: 7.81±.29; p<.01). In line with the literature,11 this result was significantly higher in the HF group, with 59.8% of patients experiencing two or more complications, compared with 13% in the PRF group (p<.01). This pattern is associated with advanced age and comorbidities.28 The results could be explained by the surgical waiting time and progressive mobilisation in the postoperative period for HF, involving sitting up after 12h and standing after 24h. Underestimating PRF could lead to less rigorous follow-up and unrecorded complications.
In terms of mortality, the three-month rates were similar for PRF (10.87%) and HF (10.79%), rising to 34.78% and 35.68%, respectively, at 24 months. These data reinforce the comparable impact of both fractures on long-term survival, highlighting the need for a rigorous approach to FRP, despite its lower initial complexity.29
This study analyses the clinical similarities between the two types of fracture in a common orthogeriatric setting. The absence of significant differences in variables such as mortality does not imply clinical equivalence, as the small sample size in the PRF group limits the statistical power to detect small differences, in line with what is described in the literature. Future studies should adopt non-inferiority or equivalence designs, with clinically defined margins, to confirm whether both types of fracture have comparable outcomes.
In terms of functionality, no significant differences were observed in pre-existing functional status between PRF and HF patients. While disability and deterioration in quality of life following a LITF have been extensively documented in HF, the functional impact of PRF remains less explored, due to its underrepresentation in the literature.6,9,12,30 Some studies report a reduction in independent walking ability from 71.3% to 3.6% at hospital discharge, and an increase in severe dependence in activities of daily living from 7.9% to 79.5%.30 Our results reinforce this trend, showing that PRF leads to functional impairment comparable to HF, which highlights the need for effective clinical interventions aimed at preserving mobility and limiting the functional impact.
In terms of discharge destination, no significant differences were observed between PRF and HF patients in regard to returning home, to residential care homes, or to intermediate care facilities. This suggests that functional status at discharge, rather than the type of fracture, may be the main determinant in the decision to place a patient in care, a decision also influenced by social and clinical factors not assessed in this study.
The study's main strengths are its prospective design and the application of a standardised care model in an orthogeriatric unit structured according to the FLS approach. This standardisation enables more accurate comparisons to be made between PRF and HF in a multidisciplinary setting with uniform clinical protocols. However, the study has significant limitations. The absence of a comparison group under a conventional care model means that the specific impact of the orthogeriatric approach in a non-FLS context cannot be assessed. Furthermore, the observational nature of the study may introduce biases, such as all-cause mortality not due to LITF, and the lack of follow-up beyond 24 months limits the analysis of long-term outcomes. And fractures of the posterior pelvic ring were not included. Future studies should adopt multicentre designs, with long-term follow-up and including variables such as quality of life and rehabilitation outcomes, to further investigate the impact of PRF and HF and optimise therapeutic strategies.
ConclusionsThe findings of this study highlight the need to take PRF as seriously as HF. Despite differences in length of hospital stay and complication rates – attributable to differences in the care pathway – both types of fracture show comparable outcomes in terms of mortality, functional status, and discharge destination when managed within a specialised and standardised setting such as an FLS Orthogeriatric Unit. These results reinforce the importance of a rigorous and individualised clinical approach to PRF, particularly within a multidisciplinary model during hospital admission.
Similar baseline functional status: Both hip and pubic rami fractures are associated with a comparable baseline functional profile, as measured by FIM, BI, CAS, and FAC. This indicates that both groups present equivalent pre-existing conditions in terms of autonomy, mobility, and walking ability.
Equivalent functionality at discharge: Given similar functional, cognitive, and physical status at admission, no significant differences in functionality at discharge were found, despite the fact that hip fractures require surgical intervention.
Equivalent long-term mortality: Mortality at 3, 6, 12, and 24 months shows no significant differences between the two groups, highlighting the potential severity of pubic rami fractures.
Level of evidence II.
Ethical responsibilitiesAs the author of the study, I declare that all procedures carried out comply with the Declaration of Helsinki.
The study complies with confidentiality regulations and has been previously approved by the Research Ethics Committee of Parc de Salut MAR, under code 2018/7852/I.
Informed consentAll study participants were informed and agreed to participate in the study by signing the verbal informed consent form. The author holds all written consents.
The article does not present individual patient data, and patient privacy and confidentiality have been respected at all times.
FundingNo funding was received to undertake this study.
Conflict of interestsThe authors have no conflict of interests to declare.
We would like to express our sincere gratitude to all the study participants for their cooperation and willingness to help, which were essential to conducting this research.
We would also like to thank our centre for its unwavering dedication and support throughout this process. Its commitment to research and to the health of the community was a constant source of inspiration and enabled us to carry out this work.
