Updated: 6/24/2021

Sacral Insufficiency Fracture

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  • summary
    • Sacral Insufficiency Fractures are fragility fractures of the sacral spine that occur more commonly in elderly women with osteoporosis.
    • Diagnosis can be made with inlet and outlet radiographs of the pelvis. CT or MRI may be helpful for fracture characterization and operative planning. 
    • Treatment is usually observation and pain control.  Surgical management is indicated for patients with progressive pain and/or difficulty ambulating that fail nonoperative treatment.
  • Epidemiology
    • Incidence
      • 1% of women > 55 years old
        • increases with age
        • estimated to increase by 23% each year
    • Demographics
      • females more commonly affected 2:1
      • average age is 69 years old
    • Risk factors
      • osteoporosis
      • vitamin D deficiency
      • rheumatoid arthritis
      • prolonged immobilization
      • long-term steroid use
      • pelvic radiation
  • Etiology
    • Pathophysiology
      • mechanism of injury
        • low energy trauma (i.e. ground level fall)
    • Associated conditions
      • other fragility fractures (i.e. distal radius, vertebral, hip)
  • Anatomy
    • Osteology
      • formed by fusion of 5 sacral vertebrae
      • articulates with
        • 5th lumbar vertebra proximally
        • coccyx distally
        • ilium laterally at sacroiliac joints
      • contains 4 foramina which transmit sacral nerves
    • Nerves
      • L5 nerve root runs on top of sacral ala
      • S1-S4 nerve roots are transmitted through the sacral foramina
        • S1 and S2 nerve roots carry higher rate of injury
      • lower sacral nerve roots (S2-S5)
        • function
          • anal sphincter tone / voluntary contracture
          • bulbocavernosus reflex
          • perianal sensation
        • unilateral preservation of nerves is adequate for bowel and bladder control
    • Biomechanics
      • transmission of load distributed by first sacral segment through iliac wings to the acetabulum
  • Classification
    • Denis Classification
      Zone 1
      • Fracture lateral to foramina
      Zone 2
      • Fracture through foramina
      Zone 3
      • Fracture medial to foramina into the spinal canal
  • Presentation
    • History
      • low-energy trauma (i.e. ground level fall)
    • Symptoms
      • pain
        • groin, low back, buttock
        • worse with weightbearing
    • Physical exam
      • limited hip motion
      • neurologic deficits are rare
  • Imaging
    • Radiographs
      • recommended views
        • AP
        • lateral
        • inlet view
          • best assessment of sacral spinal canal and superior view of S1
        • outlet view
          • provides true AP of sacrum
    • CT
      • indications
        • negative radiographs but high suspicion for fracture
        • confirmed fracture on radiographs
    • MRI
      • indications
        • negative radiographs and CT but high suspicion for occult fracture
    • Bone scan
      • indications
        • no longer used
      • findings
        • Honda or H sign
          • seen with H-type fractures
  • Studies
    • Serum labs
      • evaluate for causes of osteoporosis
  • Treatment
    • Nonoperative
      • observation, mobilization, analgesia, osteoporosis screening & treatment
        • indications
          • first line of treatment
    • Operative
      • sacroplasty
        • indications
          • minimally displaced zone 1 injuries after failed nonoperative treatment
      • ORIF
        • indications
          • displaced zone 1 injuries after failed nonoperative treatment
          • zone 2 or 3 injuries after failed nonoperative treatment
  • Techniques
    • Sacroplasty
      • technique
        • injection of polymethylmethacrylate cement
      • complications specific to this treatment
        • cement leakage
          • avoid sacroplasty in displaced fractures due to risk of symptomatic cement leakage
    • ORIF
      • technique
        • unilateral iliosacral screws
          • place 2 parallel 7-8mm cannulated screws perpendicular to the fracture plane
            • 2 screws have more stability than 1 screw
            • screws should cross midline
            • stability is dependent on the strength of the sacral cancellous bone
          • use washers to prevent penetration of the screw head through the lateral cortex of the posterior part of the ilium
        • trans-sacral screw
          • place 6mm screw through the sacral corridor of S1
        • posterior bridging plate
          • place plate against sacrum and posterior part of ilium
          • acts as tension band
      • complications specific to this treatment
        • implant loosening
        • hardware failure
  • Complications
    • Non-union
    • Persistent pain

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