What are the guidelines for stretching with a sacral fracture?

Guidelines for Stretching with a Sacral Fracture

For patients with sacral fractures, stretching should be avoided during the acute healing phase, with gradual introduction of gentle range-of-motion exercises only after fracture stabilization and under professional guidance to prevent displacement and delayed healing. 1

Classification and Assessment of Sacral Fractures

Sacral fractures can be categorized into three main types:

1. Sacral fractures occurring with pelvic ring injuries (most common)
2. Isolated sacral fractures of lower segments
3. Isolated sacral fractures of upper segments (least common but with highest neurological implications) 2

The stability of the fracture is the primary determinant for rehabilitation protocols:

• Stable fracture patterns (APC-I, LC-I): Can be managed non-operatively with controlled rehabilitation 1
• Unstable fracture patterns (APC-II/III, LC-II/III, VS, CM): Require internal fixation before rehabilitation can begin 1

Acute Phase Management

During the acute phase after a sacral fracture:

• Complete bed rest is indicated to avoid weight-bearing on the fracture site 1
• Pain management with NSAIDs, analgesics, or opioids as necessary 1
• Positioning should avoid pressure on the sacral area to prevent pressure ulcers 1
• Visual and tactile checks of pressure areas at least once daily 1
• Repositioning every 2-4 hours with pressure zone checks 1

Rehabilitation Timeline and Progression

Phase 1: Immediate Post-Injury/Post-Surgery (0-6 weeks)

• No stretching or active mobilization until the fracture is stabilized either surgically or through natural healing 1
• For surgically treated patients with spinopelvic fixation, immediate weight bearing may be permitted 1
• For conservatively managed patients, weight-bearing should be restricted 3
• Early mobilization only when spine is stabilized 1

Phase 2: Early Rehabilitation (6-12 weeks)

• Once healing begins (typically 6-8 weeks for extracapsular fractures):
  • Begin gentle range-of-motion exercises under supervision 1
  • Avoid above chest level activities until fracture healing is evident 1
  • Avoid overly aggressive physical therapy that may increase risk of fixation failure 1

Phase 3: Advanced Rehabilitation (12+ weeks)

• After confirmed healing (typically 12+ weeks):
  • Progress to appropriate rehabilitation program including physical training and muscle strengthening 1
  • Gradually introduce balance training and multidimensional fall prevention 1
  • Long-term continuation of balance and strength training is recommended 1

Special Considerations

For Osteoporotic Fractures

• Assess bone mineral density (BMD) before beginning rehabilitation 1
• Consider vitamin D and calcium supplementation 1
• Bisphosphonate therapy may improve fracture repair 1
• More cautious approach to weight-bearing progression 1

For Neurological Involvement

• Neurological assessment should guide rehabilitation approach 2
• Gabapentinoid treatment may be needed for neuropathic pain management 1
• More conservative approach to stretching and mobilization 2

Common Pitfalls to Avoid

1. Premature stretching or mobilization before fracture stabilization can lead to displacement and non-union
2. Overly aggressive physical therapy in the early phases can cause fixation failure 1
3. Neglecting pain as a warning sign during rehabilitation activities
4. Inadequate monitoring of healing - CT scans are more reliable than X-rays for assessing sacral fracture healing 4
5. Failing to address osteoporosis in patients with insufficiency fractures, which can lead to recurrent fractures 5

Monitoring Healing Progress

• CT scans are the gold standard for assessing fracture healing 1, 4
• Traditional radiographs may be unreliable for determining healing status 4
• Clinical indicators of healing include decreased pain with movement and weight-bearing 3
• Complete healing of sacral fractures typically takes 12 weeks, during which patients should follow restricted activity protocols 4

Remember that the primary goal of rehabilitation after sacral fracture is to regain pre-fracture mobility and independence while ensuring proper healing of the fracture 1.