How long should an orthotic brace be worn for an S3 (sacral) fracture and when should follow-up X-rays be taken?

Management of S3 (Sacral) Fractures: Orthotic Bracing and Follow-up X-rays

For S3 (sacral) fractures, orthotic bracing should typically be worn for 6-8 weeks followed by a weaning period of approximately 6 weeks, with follow-up X-rays recommended at 6 weeks post-injury and at the cessation of immobilization to assess healing.

Orthotic Bracing Duration

Initial Immobilization Period

• For sacral fractures, an initial period of 6-8 weeks of full-time bracing is recommended, followed by a gradual weaning period of approximately 6 weeks 1
• Thoracolumbar orthoses (either a moulded plastazote lined polythene brace or a Taylor brace) have shown good outcomes in managing spinal fractures when used for this duration 1
• The type of brace may vary based on the specific fracture pattern, with spinopelvic fixation having the benefit of immediate weight bearing in patients with vertically unstable sacral fractures 2

Weaning Period

• After the initial 6-8 weeks of full-time bracing, a gradual weaning period of approximately 6 weeks is recommended to prevent muscle weakness and allow for gradual return to normal function 3
• The weaning process should be guided by patient symptoms, with progressive reduction in hours of brace wear per day 1

Follow-up X-ray Timing

Initial Follow-up X-rays

• Follow-up X-rays should be obtained at approximately 6 weeks post-injury, as most "sintering" (compression) of vertebral bodies after fracture is typically completed by this time 4
• This timing allows for assessment of fracture stability and healing progression before any modification to the bracing protocol 2

Subsequent Imaging

• Additional X-rays should be obtained at the cessation of immobilization (approximately 12 weeks post-injury) to confirm adequate healing before discontinuing bracing completely 2
• Further imaging may be clinically indicated in cases of new trauma, pain score >6 on the VAS scale, loss of range of motion, or the presence of neurovascular symptoms 2

Important Considerations

Fracture Stability Assessment

• The need for continued bracing should be reassessed based on the 6-week X-ray findings, particularly looking for signs of progressive deformity or instability 2
• Patients with vertically unstable fracture patterns may require longer bracing periods or consideration of surgical intervention if significant displacement occurs 2

Age and Bone Quality Considerations

• While age and pre-existing osteoporosis have not been shown to significantly influence the final results of bracing treatment, these factors should be considered when determining the total duration of bracing 4
• Elderly patients may benefit from longer periods of bracing to ensure adequate healing 1

Monitoring for Complications

• Regular clinical assessment during the bracing period is essential to monitor for potential complications such as skin breakdown, neurovascular compromise, or progressive deformity 3
• If significant pain persists beyond 6 weeks or if there is evidence of progressive deformity on X-rays, further evaluation with advanced imaging (CT or MRI) may be warranted 2

Cautions and Pitfalls

• Avoid premature discontinuation of bracing before adequate healing, as this may lead to increased deformity or instability 1
• Be aware that bracing alone may be insufficient for highly unstable fracture patterns, which may require surgical intervention 2
• While reducing the number of radiographs obtained in follow-up may reduce cost and radiation exposure, there is value in obtaining radiographs at key intervals (6 weeks and at cessation of immobilization) to ensure proper healing 2