Retrograde pubic ramus screw placement is an effective technique but requires substantial surgical expertise and specialized equipment. The management of osteoporotic anterior pelvic ring injuries remains challenging due to technical difficulties and a high risk of complications.To introduce a novel and simplified surgical approach that utilizes a custom-designed handheld pelvic alignment guide (HPAG) in combination with a 6.0 mm hollow screw, aiming to enhance the accuracy, efficiency, and safety of retrograde pubic ramus screw fixation in osteoporotic pelvic fragility fractures.The HPAG and 6.0 mm hollow screw were employed during surgical treatment. A 2.0-3.0 cm incision was made to expose the optimal screw entry point. Intraoperative pelvic inlet and obturator oblique views were used to monitor fracture reduction and guide screw insertion. Clinical outcomes and fracture reduction quality were evaluated using Matta, visual analog scale, and Majeed scores during follow-ups. A representative case is presented to demonstrate the surgical procedure in detail.No perioperative complications were observed. The mean operative time was 35.2 ± 6.97 minutes, with a screw insertion time of 7.25 ± 1.86 minutes, an average incision length of 2.8 ± 0.67 cm, and mean blood loss of 43.25 ± 15.64 mL. At one-year follow-up, seven patients achieved excellent Majeed scores and three achieved good scores.The HPAG technique significantly shortens operative time, minimizes surgical trauma, and facilitates accurate screw placement. It presents a promising and efficient approach for managing fragility fractures of the pelvis, especially in osteoporotic patients.©The Author(s) 2025. Published by Baishideng Publishing Group Inc. All rights reserved.