Orthotic Management for Sacral 3 Fractures
For sacral 3 (S3) fractures, non-operative management with a lumbosacral orthosis is recommended for stable, non-displaced fractures, while surgical fixation is necessary for unstable or displaced fractures. 1
Fracture Assessment and Classification
- Sacral fractures are often difficult to diagnose and require appropriate imaging for accurate assessment 1
- CT scans are superior to radiographs for diagnosing sacral fractures, as radiographs miss approximately 35% of sacral fractures 1
- MRI is particularly useful for detecting associated soft tissue injuries and neurological compromise 1
- Denis classification system divides sacral fractures into three zones, with Zone III involving the central sacral canal 2
Treatment Approach Based on Stability
Stable S3 Fractures (Non-displaced)
- Non-operative management is appropriate for stable, non-displaced S3 fractures 1, 3
- A thoracolumbosacral orthosis (TLSO) is recommended for stable S3 fractures to reduce spinal movement and promote healing 4, 3
- Lumbar supports have been shown to reduce both gross and segmental spinal movements, though the degree of reduction varies between individuals 4
Unstable S3 Fractures (Displaced or with Neurological Deficit)
- Surgical fixation is indicated for rotationally or vertically unstable sacral fractures 1
- Posterior sacral decompression may be necessary for fractures with neurological compromise 2
- Spinopelvic fixation allows for immediate weight bearing in patients with vertically unstable sacral fractures 1
Orthotic Options for S3 Fractures
- For stable S3 fractures, a thoracolumbosacral orthosis (TLSO) is the recommended orthotic 1, 4
- Common TLSO options include Jewett and Voigt-Bähler designs, both of which significantly reduce spinal movements 4
- The duration of bracing typically ranges from 6-12 weeks, depending on fracture healing 1, 3
Important Clinical Considerations
- Long-term outcomes between patients treated with and without a TLSO for stable thoracolumbar burst fractures show similar pain relief and functional improvement at 5-10 years follow-up 5
- Bracing should be considered as part of a comprehensive treatment plan that includes pain management and appropriate activity modification 1
- For elderly patients with sacral insufficiency fractures, a TLSO may help reduce pain and improve mobility 1
Potential Pitfalls
- Overlooking neurological deficits that may require surgical intervention rather than bracing alone 2
- Failing to recognize that sacral fractures are often associated with other pelvic ring injuries that may influence treatment decisions 1
- Assuming that bracing alone is sufficient for unstable fractures that require surgical fixation 1
- Not recognizing that the effectiveness of bracing varies significantly between individuals, with some patients showing only minimal movement reduction despite proper orthotic fitting 4