What is the recommended hospital treatment for a patient with a fracture of the right sacral ala with extension to the right Sacroiliac (SI) joint?

Hospital Treatment of Sacral Ala Fracture with SI Joint Extension

For a fracture of the right sacral ala extending to the right SI joint, immediate pelvic stabilization is the priority, followed by determination of hemodynamic stability to guide definitive management—unstable patients require emergent pelvic closure/stabilization with consideration for preperitoneal packing or angioembolization, while stable patients can be managed with conservative treatment or percutaneous fixation depending on fracture displacement and pain severity. 1

Immediate Assessment and Stabilization

Hemodynamic Status Determination

• Assess for active hemorrhage immediately upon presentation, as pelvic ring disruptions with SI joint involvement carry high mortality risk from venous and arterial bleeding 1
• Markers predicting significant hemorrhage include: anterior-posterior or vertical shear deformations, CT evidence of active arterial extravasation ("blush"), pelvic hematoma volumes >500 ml, and ongoing hemodynamic instability despite resuscitation 1
• Sacroiliac joint disruption is a reliable predictor of patients who would benefit from angiographic intervention 1

Emergency Pelvic Stabilization (If Hemodynamically Unstable)

• Perform immediate pelvic ring closure using a pelvic binder, bed sheet, or pelvic C-clamp to control venous and cancellous bone bleeding 1
• This provides tamponade effect and reduces the pelvic volume to contain hemorrhage 1
• External fixators can also be used for initial hemorrhage control 1

Hemorrhage Control Algorithm (Unstable Patients)

• If hemodynamic instability persists despite adequate pelvic stabilization, proceed urgently to:
  • Preperitoneal packing (can be performed simultaneously with or soon after initial stabilization) 1
  • Angiographic embolization for arterial bleeding 1
  • Surgical bleeding control if above measures fail 1
• Preperitoneal packing decreases the need for pelvic embolization and addresses venous bleeding 1
• Angiography with embolization is highly effective for arterial bleeding that cannot be controlled by fracture stabilization alone 1
• Avoid non-therapeutic laparotomy, as this is associated with high mortality in major pelvic injuries 1

Diagnostic Imaging

Initial Imaging

• Obtain multiplanar CT scan with reformatted images as the primary diagnostic modality 1, 2
• CT provides superior visualization of sacral fracture patterns, SI joint disruption, fracture displacement, and associated injuries compared to plain radiographs 2
• CT is essential for surgical planning if operative intervention is considered 3

Additional Imaging Considerations

• Plain radiographs have poor sensitivity for sacral fractures and should not be relied upon alone 1
• MRI is more sensitive than CT for detecting early sacral insufficiency fractures (showing hypointense signal on T1 and hyperintense signal on T2/STIR sequences), but is primarily indicated when inflammatory sacroiliitis is suspected or CT findings are equivocal 1, 4
• For this acute traumatic fracture with SI joint extension, CT remains the imaging modality of choice 2

Pain Management

Multimodal Analgesia Protocol

• Initiate multimodal analgesia immediately, prioritizing non-opioid medications 5
• First-line agents: scheduled acetaminophen combined with NSAIDs (if no contraindications) 5, 6
• Avoid opioids as first-line treatment due to increased risk of delirium, falls, and mortality, especially in elderly patients 5, 6
• If opioids become necessary, reduce dose and frequency by 50% in elderly patients and avoid codeine entirely 6
• Consider regional nerve blocks if available and patient is not anticoagulated 7

Treatment Decision Algorithm

For Hemodynamically Stable Patients

Non-Operative Management Indications:

• Minimally displaced or non-displaced fractures 4, 2
• Stable pelvic ring (no significant displacement or instability) 2
• Patient can tolerate mobilization with acceptable pain control 4

Non-Operative Protocol:

• Protected weight-bearing with assistive devices 4
• Aggressive multimodal pain management 4
• Early mobilization as tolerated to prevent thromboembolism, pressure ulcers, pneumonia, and deconditioning 5, 6
• Physical therapy for core stabilization and gait training 8

Operative Management Indications:

• Displaced fractures with pelvic instability 2
• Spinopelvic dissociation 2
• Persistent severe pain despite adequate conservative management 4, 2
• Inability to mobilize due to pain or instability 2

Surgical Techniques (When Indicated)

Percutaneous Fixation Options:

• CT-guided or fluoroscopy-guided iliosacral screw fixation is the preferred minimally invasive technique for reducible fractures 4, 3
• Advantages include direct visualization of screw trajectory, reduced soft tissue trauma, and lower complication rates compared to open approaches 3
• Transsacral bar or screw fixation for bilateral injuries 4
• Sacroplasty for insufficiency fractures without significant displacement 4

Open Fixation Indications:

• Irreducible fractures requiring manipulation 2
• Spinopelvic dissociation requiring lumbopelvic fixation 4, 2
• Associated anterior pelvic ring injuries requiring combined fixation 2

Surgical Approach Selection:

• Posterior pelvic fixation techniques (iliosacral screws, transsacral fixation) for isolated posterior injuries 2
• Lumbopelvic fixation for spinopelvic dissociation 2
• Consider anterior pelvic fixation when sacral fractures are associated with anterior pelvic ring injuries to increase stability and reduce posterior implant failure risk 2

Thromboembolism Prophylaxis

• Initiate pharmacologic VTE prophylaxis with low molecular weight heparin as soon as hemorrhage is controlled 5, 6, 7
• Combine with mechanical compression devices (intermittent pneumatic compression) 6
• If anticoagulation is contraindicated due to bleeding risk, use mechanical prophylaxis alone 5
• Early mobilization is critical for VTE prevention and should begin within 24 hours when feasible 6

Multidisciplinary Management

Comprehensive Assessment

• Implement orthogeriatric co-management for elderly patients to reduce mortality, complications, and length of stay 5, 6
• Assess nutritional status, electrolyte balance, anemia, cardiac/pulmonary comorbidities, cognitive function, and medication review 5
• Monitor for delirium using multi-component non-pharmacological prevention strategies 6

Secondary Fracture Prevention (Especially in Elderly)

• Systematically evaluate for osteoporosis and subsequent fracture risk 5, 6
• Sacral insufficiency fractures in elderly patients are fragility fractures indicating need for anti-osteoporotic treatment even without DXA scan 5, 4
• Initiate bisphosphonate or denosumab with calcium and vitamin D supplementation 6
• Address underlying causes: vitamin D deficiency, corticosteroid use, metabolic bone disorders 4

Critical Pitfalls to Avoid

• Do not delay pelvic stabilization in hemodynamically unstable patients—immediate closure is lifesaving 1
• Do not perform laparotomy as primary intervention in unstable pelvic fractures without first achieving pelvic stabilization 1
• Do not rely on plain radiographs alone—CT is mandatory for accurate diagnosis and surgical planning 2
• Do not immobilize excessively—early mobilization prevents life-threatening complications 5, 6
• Do not prescribe opioids as first-line analgesia, particularly in elderly patients 5, 6
• Do not miss associated neurologic injuries—perform thorough neurologic examination as spinopelvic dissociation carries high risk of permanent deficits 2
• Do not forget VTE prophylaxis—pelvic fractures carry extremely high thromboembolism risk 5, 6

Expected Outcomes and Prognosis

• Patients with isolated sacral ala fractures and SI joint extension generally have good outcomes with appropriate treatment 4, 2
• Patients with spinopelvic dissociation and neurologic injury rarely recover completely, with residual lower-limb deficits, urinary problems, and sexual dysfunction 2
• Proper fracture reduction and stabilization techniques improve outcomes and reduce chronic pain 2, 3
• Elderly patients with insufficiency fractures require aggressive management of underlying osteoporosis to prevent subsequent fractures 4