What is the best treatment approach for a 75-year-old female with a sacrum injury from a fall, presenting with pain on sitting and walking, but without radicular symptoms, saddle anesthesia, or incontinence?

Treatment for Sacrum Injury in 75-Year-Old Female After Fall

The optimal treatment for a 75-year-old female with sacrum injury from a fall should include a multimodal analgesic approach with regular intravenous acetaminophen as first-line treatment, combined with non-pharmacological measures such as immobilization and ice packs. 1

Initial Pain Management

• Regular administration of intravenous acetaminophen every 6 hours should be the foundation of pain control, as it is effective, safe, and has fewer side effects in elderly patients 1
• NSAIDs may be considered for severe pain, but must be used cautiously with attention to potential adverse events and drug interactions in elderly patients 1
• Opioids should be avoided or used only for breakthrough pain at the lowest effective dose for the shortest duration possible to reduce risks of over-sedation, respiratory depression, and delirium 1
• Implement non-pharmacological measures including immobilization of the affected area and application of ice packs to reduce pain and inflammation 1

Advanced Pain Management Options

• For more severe pain, consider peripheral nerve blocks which can significantly reduce pain and decrease opioid requirements 1
• Regional anesthesia techniques may be appropriate for selected elderly patients with severe pain 1
• A multimodal analgesic approach (MMA) incorporating acetaminophen, gabapentinoids, NSAIDs, and lidocaine patches should be implemented to maximize pain control while minimizing side effects 1

Mobility Considerations

• Early, progressive mobilization with appropriate assistive devices should be encouraged as most sacral fractures are stable and do not require surgical intervention 2
• Good pain control is essential to facilitate mobility and prevent complications of immobility 2
• The goal should be to help the patient regain the level of mobility and independence enjoyed before the injury 1

Nutritional Support and Bone Health

• Ensure adequate calcium (1000-1200 mg/day) and vitamin D (800 IU/day) intake to support bone healing 1
• Consider evaluation for underlying osteoporosis, as this is a common cause of sacral insufficiency fractures in elderly women 3
• Address modifiable risk factors such as smoking cessation and limiting alcohol intake 1

Monitoring and Follow-up

• Regular assessment of pain control effectiveness is crucial, particularly in elderly patients who may have difficulty communicating pain levels 1
• Monitor for potential complications of both the injury and the treatments, especially when using medications that carry risks in elderly patients 1
• Consider early involvement of physical therapy to develop an individualized rehabilitation plan based on the patient's specific goals and needs 1

Special Considerations

• The absence of radicular symptoms, saddle anesthesia, or incontinence suggests no significant neurological involvement, which is favorable for prognosis 1, 3
• For elderly patients with sacral injuries, careful evaluation of comorbidities is essential as 80% of geriatric trauma patients have at least one chronic disease 1
• If pain persists despite conservative measures, further imaging with MRI may be warranted to better evaluate the extent of the injury 1, 4