Updated: 8/22/2021

Sacral Fractures

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https://upload.orthobullets.com/topic/1032/images/zone 2.jpg
https://upload.orthobullets.com/topic/1032/images/sacral_fx_1o.jpg
https://upload.orthobullets.com/topic/1032/images/Xray - AP Pelvis - L sacral fx_moved.jpg
https://upload.orthobullets.com/topic/1032/images/zone 1.jpg
  • Summary
    • Sacral fractures are common pelvic ring injuries that are under-diagnosed and often associated with neurologic compromise.
    • Diagnosis can made with pelvis radiographs but frequently require pelvic CT scan for full characterization.
    • Treatment may be nonoperative or operative depending on fracture displacement, associated pelvic ring instability and patient activity demands. 
  • Epidemiology
    • Incidence
      • common in pelvic ring injuries (30-45%)
    • Bimodal distribution
      • young adults
        • as a result of high energy trauma
      • elderly
        • as a result of low energy falls
    • Associate injuries
      • 25% are associated with neurologic injury
        • frequently missed
          • 75% in patients who are neurologically intact
          • 50% in patients who have a neurologic deficit
  • 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
    • Denis classification
      Zone 1
      • Fracture lateral to foramina
      • Most common (50%)
      • Nerve injury rare (5%). 
           -usually occurs to L5 nerve root
      Zone 2
      • Fracture through foramina
      • May be stable vs. unstable
      • Zone 2 fracture with shear component highly unstable
      • Unstable fractures have higher risk of nonunion and poor functional outcome
      Zone 3
      • Fracture medial to foramina into the spinal canal
      Highest rate of neurologic deficit (60%)
          -bowel, bladder, and sexual dysfunction
    • Transverse sacral fractures
      • higher incidence of nerve dysfunction
    • U-type sacral fractures
      • results from axial loading
      • represent spino-pelvic dissociation
      • high incidence of neurologic complications
  • Presentation
    • History
      • motor vehicle accident or fall from height most common
      • repetitive stress
        • insufficiency fracture in osteoporotic adults
    • Symptoms
      • peripelvic pain
    • Physical exam
      • inspection
        • soft tissue trauma around pelvis should raise concerns for pelvic or sacral fracture
      • palpation
        • test pelvic ring stability by internally and externally rotating iliac wings
        • palpate for subcutaneous fluid mass indicative of lumbosacral fascial degloving (Morel-Lavallee lesion)
        • perform vaginal exam in women to rule-out open injury
      • neurologic exam
        • rectal exam
        • light touch and pinprick sensation along S2-S5 dermatomes
        • perianal wink
        • bulbocavernosus and cremasteric reflexes
      • vascular exam
        • distal pulses
          • if different consider ankle-brachial index or angiogram
  • Imaging
    • Radiographs
      • only show 30% of sacral fractures
      • recommended views
        • AP
        • lateral
          • effective screening tool for sacral fractures
          • often of poor quality
        • inlet view
          • best assessment of sacral spinal canal and superior view of S1
        • outlet view
          • provides true AP of sacrum
      • findings
        • L4 or L5 transverse process fractures
        • asymmetric foramina
        • anterior pelvic ring disruptions
        • stepladder sign
          • seen on AP view
          • results from displacement with overriding of transverse fracture fragments
          • indicates disruption of anterior sacral foramina and lumbrosacral facets
    • CT
      • diagnostic study of choice
      • recommend coronal and sagittal reconstruction views
    • MRI
      • recommended when neural compromise is suspected
  • Treatment
    • Nonoperative
      • progressive weight-bearing +/- orthosis
        • indications
          • <1 cm displacement and no neurologic deficit
          • insufficiency fractures
    • Operative
      • surgical fixation
        • indications
          • displaced fractures >1 cm
          • soft tissue compromise
          • persistent pain after non-operative management
          • displacement of fracture after non-operative management
      • surgical fixation with decompression
        • indications
          • any evidence of neurologic injury
  • Techniques
    • Percutaneous screw fixation
      • screws may be placed as sacroiliac, trans-sacral or trans-iliac trans-sacral
      • useful for sagittal plane fractures
      • technique
        • screws placed percutaneously under fluoroscopy
        • beware of L5 nerve root
        • avoid overcompression of fracture
          • may cause iatrogenic nerve dysfunction
        • screw placement posterior to the ICD ensures safe screw placement
          • non-dysmorphic sacrum
      • cons
        • may result in loss of fixation or malreduction
        • does not allow for removal of loose bone fragments
        • do not use in osteoporotic bone
    • Posterior tension band plating
      • approach
        • posterior two-incision approach
      • technique
        • may use in addition to iliosacral screws
      • pros
        • allows for direct visualization of fracture
      • cons
        • wound healing complications
    • Iliosacral and lumbopelvic fixation
      • approach
        • posterior approach to lower lumbar spine and sacrum
      • technique
        • pedicle screw fixation in lumbar spine
        • iliac screws parallel to the inclination angle of outer table of ilium
        • longitudinal and transverse rods
      • pros
        • shown to have greatest stiffness when used for an unstable sacral fracture
      • cons
        • invasive
    • Decompression of neural elements
      • technique
        • indirect
          • reduction through axial traction
        • direct
          • posterior approach followed by laminectomy or foraminotomy
  • Complications
    • Venous thromboembolism
      • often as a result of immobility
    • Iatrogenic nerve injury
      • may result from
        • overcompression of fracture
        • improper hardware placement
    • Malreduction
      • more common with vertically displaced fractures
  • Prognosis
    • Presence of a neurologic deficit is the most important factor in predicting outcome
    • Displacement confers an increased risk of neurologic dysfunction
    • Mistreated fractures may result in
      • lower extremity deficits
      • urinary dysfunction
      • rectal dysfunction
      • sexual dysfunction

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(SBQ18SP.3) A 25-year-old female was involved in a high-speed motor vehicle accident and sustained the injuries shown in Figures A-C. Which of the following provides the most stable fixation construct?

QID: 211135
FIGURES:
1

Triangular osteosynthesis

56%

(1062/1910)

2

Bilateral iliosacral screws

17%

(320/1910)

3

Anterior pelvic ring plating with bilateral iliosacral screw fixation

8%

(162/1910)

4

Transsacral bar fixation

13%

(243/1910)

5

Posterior tension band fixation

6%

(109/1910)

L 4 A

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(SBQ12TR.81) A 24-year-old patient presents after a fall from the balcony of a third story building in which he landed on his feet. He reports lumbar back pain and numbness in his perineum region. Radiographs of his hips and pelvis are seen in Figure A, while CT images are shown in Figures B and C. How is this fracture pattern best classified?

QID: 3996
FIGURES:
1

Young-Burgess APC Type II

2%

(66/4015)

2

Young-Burgess LC Type I

2%

(62/4015)

3

"U" Type Spinopelvic Dissociation

76%

(3066/4015)

4

Denis Zone-I

1%

(54/4015)

5

Denis Zone-II

18%

(739/4015)

L 2 B

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(OBQ11.2) A 35 year-old female presents after prolonged extrication from a motor vehicle collision complaining of severe pelvic pain. Physical examination reveals diminished perianal sensation. She is otherwise neurologically intact. Figures A through D are radiographs and representative CT cuts of her injury. Which of the following nerve roots has likely been injured by the acute trauma?

QID: 3425
FIGURES:
1

L3

0%

(10/3425)

2

L4

1%

(20/3425)

3

L5

7%

(252/3425)

4

S1

9%

(311/3425)

5

S2

82%

(2819/3425)

L 2 C

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(OBQ11.35) A 20-year-old patient presents after jumping from the window of a burning building with a sacral fracture. Which of the following fracture patterns seen in Figures A through E would give this patient the highest risk of associated nerve injury?

QID: 3458
FIGURES:
1

Figure A

73%

(3206/4369)

2

Figure B

2%

(78/4369)

3

Figure C

23%

(1023/4369)

4

Figure D

1%

(33/4369)

5

Figure E

0%

(10/4369)

L 2 C

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(OBQ05.32) Which of the following is the most stable construct for fixation of an unstable transforaminal sacral fractures?

QID: 69
1

External fixation

1%

(11/1442)

2

Iliosacral osteosynthesis

11%

(164/1442)

3

Combined iliosacral and lumbopelvic fixation (triangular osteosynthesis)

66%

(955/1442)

4

Anterior pelvic ring plating with bilateral sacroilliac percutaenous screw fixation

16%

(231/1442)

5

Transiliac bars with anterior pelvic ring plating

5%

(75/1442)

L 2 C

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