What is the activity guide and timeline for managing stable sacral fractures?

Activity Guide and Timeline for Stable Sacral Fractures

Stable sacral fractures should be managed non-operatively with a progressive rehabilitation protocol starting with 3 weeks of non-weight bearing, followed by gradual return to weight bearing and activities as tolerated. 1

Classification and Initial Management

Stable sacral fractures are typically classified as:

• Lateral compression type 1 (LC-I) injuries
• Antero-posterior compression type 1 (APC-I) injuries
• Isolated non-displaced sacral fractures

These stable patterns do not require surgical fixation and can be managed conservatively 2.

Initial Assessment

• Confirm fracture stability through appropriate imaging (CT scan is gold standard)
• Rule out posterior pelvic ring instability which would require surgical fixation
• Assess for neurological deficits which may influence management

Rehabilitation Timeline

Phase 1: Initial Rest Period (0-3 weeks)

• Non-weight bearing ambulation with assistive devices for first 3 weeks 1
• Pain management as needed
• Bed rest is not required for stable fractures unless pain is severe

Phase 2: Progressive Weight Bearing (3-6 weeks)

• Begin weight bearing as tolerated after 3 weeks 1
• Progressive walking program starting with short distances
• Increase walking distance to 60-90 minutes daily over this period 2
• Monitor for any pain during weight bearing activities

Phase 3: Functional Rehabilitation (6-12 weeks)

• Introduce low-impact activities such as:
  • Cycling (60-90 minutes daily)
  • Swimming or water therapy
  • Nordic pole walking 3
  • Moderate strength training twice weekly 3

Phase 4: Return to Higher Impact Activities (12+ weeks)

• Begin gradual reintroduction of higher impact activities at 12 weeks if pain-free
• For athletes, running can typically be initiated at 7-8 weeks, with gradual progression to full training volumes over subsequent weeks 3
• Full return to pre-injury activities is typically possible by 12-16 weeks

Key Monitoring Parameters

Clinical Healing Indicators

• Resolution of localized tenderness over the sacrum 2
• Pain-free walking for extended periods 2
• Ability to perform activities of daily living without pain

Follow-up Imaging

• Routine follow-up imaging is not typically required for stable sacral fractures unless there is clinical deterioration 2
• Patients are typically followed clinically until they are pain-free, at which time they can increase activity in a controlled manner 2

Special Considerations

Elderly Patients

• May require longer rehabilitation periods
• Higher risk of osteoporotic insufficiency fractures
• Consider bone health assessment and treatment 2

Athletes

• Can follow a more accelerated rehabilitation protocol if pain-free
• Example timeline for athletes with stable sacral stress fractures 3:
  • 0-2 weeks: Strict physical rest
  • 2-4 weeks: Daily cycling (60-90 min) and moderate cross-training
  • 4-7 weeks: Daily walking, Nordic pole walking, moderate strength training
  • 7+ weeks: Begin running program with gradual increase to pre-injury volumes

Outcomes

Research shows excellent functional outcomes with non-operative management of stable sacral fractures. In a study of LC-1 pelvic ring injuries with incomplete sacral fractures, patients managed non-operatively achieved excellent or good functional outcomes, with the best results seen within 12 months of injury 1.

Common Pitfalls to Avoid

1. Premature weight bearing before 3 weeks may lead to fracture displacement
2. Overlooking neurological deficits that may require different management
3. Missing associated injuries that may affect rehabilitation timeline
4. Failing to address bone health in elderly patients with insufficiency fractures
5. Overly aggressive return to activities causing pain exacerbation

The ultimate goal of management is to allow early functional rehabilitation while decreasing long-term morbidity, chronic pain, and complications historically associated with prolonged immobilization 2.