From the Guidelines
The next step for a 28-year-old male with a traumatic sacrum fracture and pain identified on MRI should be a comprehensive pain management approach combined with appropriate orthopedic consultation. I recommend starting with analgesics including acetaminophen 1000mg every 6 hours and an NSAID such as ibuprofen 600mg every 6 hours (if not contraindicated) 1. For more severe pain, a short course of opioids may be necessary, such as oxycodone 5-10mg every 4-6 hours for 3-5 days. Physical rest with limited weight-bearing using crutches or a walker is essential for 4-6 weeks, depending on fracture severity. The patient should be referred to an orthopedic surgeon or spine specialist within 1-2 weeks to determine if surgical intervention is needed, as some sacral fractures require stabilization 1.
Key Considerations
- Physical therapy should be initiated after the acute phase (typically 2-4 weeks post-injury) to restore mobility and strength.
- Most sacral fractures heal within 8-12 weeks with appropriate management.
- Regular follow-up imaging (X-rays at 6 weeks, possibly repeat MRI at 12 weeks) is important to monitor healing progress and ensure proper alignment of the fracture.
- It is crucial to evaluate for any associated injuries, such as urethral or ano-rectal lesions, which may require additional diagnostic tests like retrograde urethrogram (RUG) or rigid proctoscopy 1.
Management Approach
- The management approach should prioritize pain control, fracture stabilization (if necessary), and early mobilization to prevent complications and promote healing.
- A multidisciplinary team involving orthopedic surgeons, physical therapists, and pain management specialists may be necessary to ensure comprehensive care.
- The use of CT scans with 3-Dimensional bone reconstruction can be helpful in reducing tissue damage during invasive procedures and improving patient recovery times 1.
Outcome Prioritization
The primary goal is to minimize morbidity, mortality, and improve the quality of life for the patient. Therefore, the management plan should focus on achieving these outcomes by providing adequate pain control, preventing complications, and promoting timely healing and rehabilitation 1.
From the Research
Diagnosis and Treatment of Sacral Fractures
The diagnosis and treatment of sacral fractures can be complex and challenging. According to 2, when a complete neurological examination cannot be performed, imaging studies such as pelvic X-rays, CT scan, hip and pelvis MRI, lumbosacral MRI, and lower extremities evoked potentials are useful.
Treatment Options
The treatment options for sacral fractures depend on the type and severity of the fracture, as well as the presence of neurological deficits. According to 2, a patient with cauda equina syndrome associated with a sacral fracture represents an absolute indication for sacral reduction and the correct timing for reduction is "as early as possible".
- For patients with a displaced sacral fracture and neurological deficit, sacral decompression followed by surgical fixation may be indicated 2, 3.
- For patients with a low-energy trauma and an isolated and complete radicular neurological deficit of the lower limbs, laminectomy after reduction may be indicated 2.
- For patients with a high-energy trauma and an isolated and incomplete radicular neurological deficit of the lower limbs, laminectomy after reduction is not indicated 2.
Conservative vs. Surgical Treatment
The decision to treat a sacral fracture conservatively or surgically depends on the severity of the fracture and the presence of neurological deficits. According to 3, patients who were treated conservatively achieved the best scores in every domain of the SF-36 questionnaire, when compared with those who were treated operatively.
- Conservative treatment may be suitable for patients with stable, nondisplaced fractures or those with minimal neurological deficits 4.
- Surgical treatment may be necessary for patients with significantly displaced fractures, cauda equina syndrome, or progressive neurological deficits 2, 4.
Imaging Studies
Imaging studies play a crucial role in the diagnosis and treatment of sacral fractures. According to 4, while displaced fractures can be easily diagnosed on high-quality plain radiographs, nondisplaced or transverse fracture patterns may be difficult to diagnose without a computed tomography scan.