What is the management for a fracture at the sacrococcygeal junction?

From the Guidelines

The management of a fracture at the sacrococcygeal junction primarily involves conservative treatment focused on pain control and supportive care. This approach is based on the understanding that most pelvic ring injuries, including those at the sacrococcygeal junction, can be managed non-operatively if they are stable, such as antero-posterior compression type 1 (APC-I) and lateral compression type 1 (LC-I) injuries 1. The initial management includes rest, ice application for the first 48-72 hours to reduce swelling, and pain medications such as NSAIDs or acetaminophen for mild to moderate pain. For more severe pain, short-term opioid analgesics may be prescribed. Patients should use cushioned seating or donut-shaped pillows to reduce pressure on the coccyx when sitting.

Key Considerations

• The goal of treatment is to achieve anatomic reduction and stable fixation as a prerequisite for early functional rehabilitation, but this is more relevant to unstable pelvic ring injuries 1.
• Conservative management is effective for stable fractures because the area has good blood supply and limited mobility requirements for healing.
• Physical therapy may be beneficial after acute pain subsides, focusing on pelvic floor exercises and stretching.
• Surgery is rarely indicated and reserved only for cases with severe, persistent pain unresponsive to conservative measures after a significant period, typically more than 6 months.

Surgical Indications

Surgical fixation is typically indicated for posterior pelvic ring instability, including rotationally unstable and/or vertically unstable pelvic ring disruptions 1. However, for a fracture specifically at the sacrococcygeal junction, the decision for surgical intervention must be made on a case-by-case basis, considering the stability of the fracture, the presence of other injuries, and the patient's overall condition. The technical modality of posterior pelvic ring fixation, including spinopelvic fixation, may be considered for vertically unstable sacral fractures, allowing for immediate weight bearing 1.

Outcome Prioritization

In managing a fracture at the sacrococcygeal junction, the primary outcome of interest is the reduction of morbidity and improvement in quality of life, with mortality being less of a concern for this specific type of injury. Therefore, the treatment approach prioritizes pain management, early mobilization, and the prevention of long-term complications such as chronic pain and disability.

From the Research

Management of Sacrococcygeal Junction Fractures

The management of fractures at the sacrococcygeal junction can be complex and depends on various factors, including the type and severity of the fracture, as well as the presence of any neurological deficits.

• The treatment options for sacrococcygeal junction fractures include conservative management, such as pain relief and physical therapy, as well as surgical intervention, such as open reduction and internal fixation or percutaneous screw fixation 2, 3, 4.
• Conservative treatment is often recommended for patients with isolated transverse sacral fractures, as it has been shown to be associated with excellent results in terms of pain relief and return to pre-injury activity level 2.
• However, surgical intervention may be necessary for patients with more complex fractures, such as those involving the central canal or those with significant neurological deficits 3, 5, 4.
• The classification of sacral fractures is also important in determining the management plan, with different classification systems available, such as the Denis classification system 5.
• The use of imaging studies, such as CT scans, is crucial in diagnosing and classifying sacral fractures, as well as in planning the management strategy 2, 5.

Classification and Treatment

The classification of sacral fractures is based on the location and severity of the fracture, as well as the presence of any neurological deficits.

• The Denis classification system is commonly used to classify sacral fractures into three zones: Zone I (ala sacralis), Zone II (foramina), and Zone III (central canal) 5.
• The treatment plan is often based on the classification of the fracture, with Zone I and II fractures typically being treated conservatively, while Zone III fractures may require surgical intervention 3, 5.
• The use of percutaneous screw fixation has been shown to be a safe and effective treatment option for certain types of sacral fractures, such as crescent fracture-dislocation of the sacroiliac joint 4.

Complications and Outcomes

The management of sacrococcygeal junction fractures can be associated with various complications, including neurological deficits, residual pain, and long-term morbidity.

• Neurological deficits are more common in patients with Zone III fractures, and can include bowel and bladder incontinence, as well as sexual dysfunction 3, 5.
• Residual pain is a common complication of sacral fractures, and can be managed with pain relief medications and physical therapy 2, 6.
• Long-term morbidity, such as residual pain and neurological deficits, can persist for many patients, highlighting the importance of proper management and follow-up care 6.