Treatment for Sacral Fractures
The treatment of sacral fractures depends primarily on fracture stability, with stable non-displaced fractures typically managed conservatively while unstable or significantly displaced fractures require surgical fixation through techniques such as percutaneous iliosacral screws, posterior sacral tension band fixation, or lumbopelvic fixation. 1
Initial Assessment and Diagnosis
Physical Examination
- Perform thorough neurological assessment including:
- Motor strength testing of lower extremities
- Sensory testing of perineum and posterior thighs
- Assessment of anal sphincter tone and bulbocavernosus reflex 2
- Evaluate for pelvic ring instability (30% of sacral fractures occur with pelvic ring injuries)
- Check for leg length discrepancy which may indicate vertical displacement
- Assess pain with specific maneuvers:
- Direct compression of iliac wings
- Anteroposterior compression of pelvis
- Passive hip rotation 2
Imaging
- Initial radiographs have low sensitivity (15-35%) for sacral fractures due to overlying structures 2
- CT scan is the gold standard for bone fractures with 69-87% sensitivity 2
- MRI without contrast is preferred for detecting bone marrow edema, soft tissue injuries, and neurological involvement with nearly 100% sensitivity 2
- 3D CT reconstruction is helpful for surgical planning and reduces tissue damage during invasive procedures 1
Treatment Algorithm
1. Stable Non-Displaced Fractures
- Conservative management is recommended for stable fractures (e.g., APC-I and LC-I patterns) 1
- Treatment includes:
- Pain control with NSAIDs, analgesics, or opioids as necessary
- Initial bed rest to avoid load
- Gradual mobilization when pain subsides
- Regular clinical assessment until pain-free 2
2. Rotationally Unstable Fractures
- Surgical fixation is indicated for rotationally unstable patterns (APC-II, LC-II) 1
- Treatment options include:
- Pubic symphysis plating for "open book" injuries with symphysis diastasis >2.5 cm
- Temporary external fixation for selected lateral compression patterns (LC-II, LC-III) 1
3. Vertically Unstable Fractures
- Definitive internal fixation is required for vertically unstable patterns (APC-III, LC-III, VS, CM) 1
- Surgical techniques include:
- Percutaneous iliosacral screw fixation for unstable sacral fractures
- Spino-pelvic fixation (triangular osteosynthesis) for vertically unstable sacral fractures
- Tension band plating for posterior pelvic ring injuries 1
4. Special Considerations for Insufficiency Fractures
- For patients over 50 with fragility fractures:
- Ensure adequate calcium (1000-1200 mg/day) and vitamin D (800 IU/day)
- Consider pharmacological treatment with oral bisphosphonates
- Regular BMD assessment and continued drug therapy 2
Timing of Surgical Intervention
- Hemodynamically unstable patients should be resuscitated before definitive fixation 1
- Hemodynamically stable patients can undergo early fixation within 24 hours post-injury 1
- In polytrauma patients with physiological derangement, definitive fixation should be postponed until after day 4 post-injury 1
Complications and Pitfalls
- Neurological deficits occur in 15.1% of patients with sacral fractures 3
- Risk of neurological impairment increases with:
- Greater pelvic instability (up to 63.6% in central fractures)
- Avulsion fractures of the sacrum
- Comminuted and bilateral fracture lines 3
- Sacral fractures are frequently missed on initial evaluation (30% identified late) 2
- Avoid single unilateral screw fixation as it may lead to screw disengagement 4
Rehabilitation
- Physiotherapy may be required after the acute phase
- Regular follow-up to monitor healing and neurological recovery
- For surgically treated patients, early functional rehabilitation is the goal to decrease long-term morbidity and chronic pain 1
By following this structured approach to sacral fracture management, clinicians can optimize outcomes while minimizing complications and long-term disability.