What is the approach to taking a medical history in a patient with a suspected sacral fracture?

History Taking for Sacral Fracture

When evaluating a patient with suspected sacral fracture, immediately assess hemodynamic stability and mechanism of injury, then systematically inquire about pain characteristics, neurological symptoms, and associated injuries—particularly focusing on bowel/bladder dysfunction, lower extremity weakness, and perineal trauma.

Immediate Assessment Priorities

Hemodynamic Status

• Document vital signs immediately, specifically looking for systolic blood pressure <90 mmHg, shock index >1, or requirement for bolus infusions/transfusions 1, 2
• Ask about any fluid resuscitation or blood products already administered, as transfusion requirement of 4-6 units within 24 hours indicates hemodynamic instability 2
• Inquire about symptoms of ongoing bleeding (lightheadedness, continued pain, abdominal distension) 1

Mechanism of Injury

• Determine the energy level of trauma: high-energy mechanisms (motor vehicle collision, fall from height >3 meters, crush injury) strongly suggest sacral fracture, particularly when associated with pelvic ring injury 3, 4, 5
• Ask specifically about the direction of impact, as this predicts fracture pattern and associated injuries 3
• In elderly patients or those with minimal trauma, inquire about osteoporosis risk factors, radiation history, or prolonged corticosteroid use, as these suggest insufficiency fractures 1

Pain Characterization

Location and Radiation

• Ask about lower back, pelvic, or sacral pain that worsens with weight bearing—this is the classic presentation of sacral insufficiency fractures 1
• Inquire about hip or groin pain, as sacral stress fractures can radiate to these areas 1
• Document whether pain is unilateral or bilateral, as this correlates with fracture zone and neurological risk 3, 6

Functional Impact

• Ask about loss of mobility and independence, particularly inability to bear weight 1
• Inquire about intractable pain despite analgesics 1

Neurological Symptoms (Critical for Risk Stratification)

Bowel and Bladder Function

• Specifically ask about urinary or fecal incontinence—this indicates Zone III (central canal) fractures with 57-63% risk of neurological deficit 3, 6
• Inquire about urinary retention, constipation, or loss of rectal tone awareness 6

Lower Extremity Symptoms

• Ask about numbness, tingling, or weakness in the legs, buttocks, or perineum 4, 6
• Document whether symptoms are unilateral (suggesting Zone I/II fractures with 24-29% neurological risk) or bilateral (suggesting Zone III fractures with 57-60% risk) 3, 6
• Inquire about foot drop or difficulty walking 4, 6

Sexual Dysfunction

• In appropriate clinical context, ask about erectile dysfunction or loss of genital sensation, as these indicate sacral nerve root involvement 4

Associated Injuries (Present in 89.4% of Cases)

Genitourinary Trauma

• Ask about blood in urine or at urethral meatus—urethral injury occurs in 7-25% of pelvic ring fractures 1, 2
• Inquire about perineal or scrotal hematoma 1, 2
• Document any difficulty voiding or catheter placement attempts 1

Other Body Regions

• Systematically review for head, chest, abdominal, and extremity injuries, as polytrauma is typical 3, 4
• Ask about loss of consciousness, chest pain, abdominal pain, or other extremity injuries 3

Special Populations

Pregnant Patients

• In women of reproductive age, determine pregnancy status immediately—pregnancy-related sacral fractures occur in the third trimester or postpartum period 1
• Ask about calcium supplementation and vitamin D intake during pregnancy 1
• Inquire about multiple pregnancies or prolonged breastfeeding 1

Elderly or Osteoporotic Patients

• Ask about previous fragility fractures, particularly vertebral compression fractures 1
• Inquire about corticosteroid use, as this reduces bone scintigraphy sensitivity and increases fracture risk 1
• Document history of cancer or pelvic radiation, which predisposes to insufficiency fractures 1

Timeline and Progression

• Establish symptom onset: insidious onset over days to weeks suggests insufficiency fracture, while acute onset follows trauma 1
• Ask about symptom progression—worsening pain or new neurological symptoms indicate need for urgent imaging 4, 5
• Document any delay in seeking care, as 30% of sacral fractures are diagnosed late 4, 5

Critical Pitfalls to Avoid

• Do not rely solely on patient-reported symptoms to exclude sacral fracture—clinical examination has only 81% sensitivity for spine fractures 2
• Never assume isolated low back pain excludes sacral fracture, as presentation is often insidious 1
• Do not dismiss vague pelvic pain in elderly patients as "arthritis" without imaging 1
• Always ask about neurological symptoms even if not volunteered, as deficits may be subtle initially 4, 6