Sacral Fractures

Often occurring in conjunction with pelvic ring injuries, sacral fractures are
often diagnosed late and can be associated with neurologic compromise.

Overview

• Usually high-energy (often MVA) trauma or low-energy insufficiency fractures

• 1/3 missed on initial evaluation, so need high suspicion *IMPORTANT*
• Associated with injuries to the pelvis, cauda equina, lumbosacral and sacral
plexuses, sciatic nerve, iliac vessels

History

• Mechanism of injury? (Helps to aid in identifying other concomitant injuries)

• Other musculoskeletal injuries?
• Neurologic deficits, including bowel or bladder dysfunction?
• Other areas of pain along the spine?

Physical Exam

• Monitoring of hemodynamic status

• Trauma evaluation (Appendix A)
• Thorough pelvic, abdominal, and urologic examination (± gynecologic exam for
women)

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• Presence of Morel-Lavallee lesion (lumbosacral degloving injury with palpable

subcutaneous tissue)
• Complete neurologic assessment (including rectal tone, peri-anal wink and sen-
sation, and bulbocavernosus reflex)
• ABIs (± angiogram if abnormal ABI)

Diagnosis

Imaging

• Trauma series (including AP Pelvis, pelvic inlet, and outlet views)

• Lumbosacral X-rays (Fig. 1)
• CT pelvis/sacrum
• MRI to visualize neural compromise

Classification

• Denis Classification (Fig. 2):

◦ Zone 1: lateral to foramina
– Most common
– Least likely for nerve injury (to L5)

Fig. 1 Sacral fractures

Sacral Fractures 93

Fig. 2 Sacral fracture Denis classification

◦ Zone 2: through foramina

– Unstable if shear component
– Risk for nonunion and poor function
◦ Zone 3: medial to foramina
– Most have neurologic deficit
– Subcategories 1–4
• Classification by letter resembled by fracture (e.g.: H, U, T, lambda)
• H-shaped, U-shaped = spondylo-pelvic dissociation
◦ Likely neurologic deficit
◦ High mortality rate
• Transverse: likely neurologic deficit, especially if proximal sacrum affected

Treatment

• Management of associated pelvic ring injury (see Chapter “Pelvic Ring Injury”)
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Nonoperative Treatment

• WBAT, pain control

• Indications: maintained soft tissues, neurologically intact, and stable pelvis

Surgical Treatment

• Surgical Goals:
◦ Reduction of fracture/dislocation, with indirect neural decompression
◦ Direct neural decompression (laminectomy, foraminotomy)
◦ Soft-tissue coverage
• Surgical Options:
◦ Decompression
◦ Open vs. percutaneous reduction/stabilization (e.g.: sacro-iliac, lumbo/
sacral-pelvic)
• Indications:
◦ Associated lumbosacral instability or unilateral facet dislocation
◦ Lumbosacral spondylolisthesis
– Bilateral facet dislocations
– Unilateral facet fracture dislocations
– Trans-sacral fractures
◦ Neurologic deficit with compression
◦ Sacral fractures with poor integrity soft-tissue envelope

References

Kuklo TR, Potter BK, Ludwig SC, Anderson PA, Lindsey RW, Vaccaro AR, et al. Radiographic
measurement techniques for sacral fractures consensus statement of the Spine Trauma Study
Group. Spine (Phila Pa 1976). 2006;31(9):1047–55.
Mehta S, Auerbach JD, Born CT, Chin KR. Sacral fractures. J Am Acad Orthop Surg.
2006;14(12):656–65.