What is the management for a patient (Pt) with an acute sacral alar fracture?

Management of Acute Sacral Alar Fracture

For acute sacral alar fractures (Zone I), non-operative management with a thoracolumbosacral orthosis (TLSO) is the recommended treatment for stable, non-displaced fractures, while surgical fixation is reserved for unstable or displaced fractures. 1

Initial Assessment and Imaging

• CT scanning is essential as radiographs miss approximately 35% of sacral fractures and are inadequate for proper diagnosis 1
• MRI should be obtained to detect associated soft tissue injuries and evaluate for neurological compromise 1
• Assess fracture stability using the Denis classification system: Zone I fractures (through the sacral ala) carry a 24% risk of neurological injury, significantly lower than Zone II (29%) or Zone III (57-60%) fractures 2

Treatment Algorithm Based on Fracture Characteristics

For Stable, Non-Displaced Sacral Alar Fractures:

• Prescribe a thoracolumbosacral orthosis (TLSO) as the primary treatment modality 1
• Implement comprehensive pain management immediately, as adequate analgesia is critical before diagnostic workup 3
• Allow weight-bearing as tolerated with the orthosis in place 1
• Include activity modification as part of the treatment plan 1

For Unstable or Displaced Fractures:

• Surgical fixation is mandatory for rotationally or vertically unstable sacral fractures 3, 1
• Spinopelvic fixation allows immediate weight-bearing in vertically unstable patterns 3, 1
• Consider triangular osteosynthesis using S1 pedicle screws and S2 alar iliac screws for unilateral vertically displaced fractures, which preserves L5-S1 joint mobility and requires smaller incisions 4

Neurological Considerations

• Evaluate for neurological deficit at presentation, as Zone I fractures typically cause unilateral lumbar and sacral radiculopathies when nerve injury occurs 2
• If neurological deficit is present, strongly consider early surgical decompression as it results in significantly better neurological improvement (p=0.014) and physical function (p=0.044) compared to non-operative management 5
• Document bowel and bladder function specifically, though these deficits are more common with Zone III (central canal) fractures 2

Critical Pitfalls to Avoid

• Do not rely on radiographs alone for diagnosis, as they have unacceptably high false-negative rates 1
• Do not assume bracing alone is sufficient for unstable fractures requiring surgical fixation, as this leads to poor outcomes 1
• Do not overlook associated pelvic ring injuries that frequently accompany sacral fractures and may alter treatment strategy 3, 1
• Do not delay surgery beyond 48 hours if operative intervention is indicated, as early surgery (within 24-48 hours) significantly reduces mortality and complications from immobility 3

Multidisciplinary Management

• Ensure orthogeriatric comanagement for elderly patients to improve functional outcomes, reduce hospital stay, and decrease mortality 3
• Provide appropriate fluid management and correct electrolyte disturbances preoperatively 3
• Optimize medical comorbidities rapidly before surgery, balancing the risks of delay against the benefits of medical optimization 3

Follow-Up and Monitoring

• Monitor for fracture healing with serial imaging, though most stable Zone I fractures heal with conservative management 6, 7
• Expect neurological deficits to improve spontaneously in most cases with Zone I fractures, though recovery is enhanced with surgical decompression when deficits are present 5, 6
• Reassess at regular intervals for complications including hardware prominence, infection, or loss of reduction if surgical fixation was performed 4, 7