Sacral fractures: issues, challenges, solutions

Abstract

Sacral fractures are a heterogeneous group of fractures occurring in young people following road traffic accidents and falls from height, or in the elderly with osteoporosis following trivial trauma. This heterogeneity, combined with the low incidence of sacral fractures, determines a lack of experience amongst physicians, often leading to misdiagnosis, underestimation and inadequate treatment. The diagnosis should be made by assessing specific features during the clinical presentation, while computed tomography (CT) scan continues to be the choice of investigation. Sacral fractures can be treated non-operatively or surgically. Non-operative treatment is based on rest, pain relief therapy and early mobilization as tolerated. Surgical techniques can be split into two main groups: posterior pelvic fixation techniques and lumbopelvic fixation techniques. Anterior pelvic fixation techniques should be considered when sacral fractures are associated with anterior pelvic ring injuries, in order to increase stability and reduce the risk of posterior implant failure. To improve fracture reduction, different solutions could be adopted, including special positioning of the patient, manipulation techniques and use of specific reduction tools. Patients suffering from spinopelvic dissociation with associated neurologic lesions hardly ever recover completely, with residual lower-limb neurologic sequelae, urinary problems and sexual disfunction. Herein, we present issues, challenges and solutions related to the management of sacral fractures. Cite this article: EFORT Open Rev 2020;5:299-311. DOI: 10.1302/2058-5241.5.190064

Surgical Fixation of Sacral Fractures in the Elderly Population: Are There Predictors of Outcome? An Analysis of Return to Ambulation and Residential Living Status

“…While high-energy elderly sacral fractures are more likely to be treated surgically in comparison to low-energy fractures, given that reduction is often necessary, these outcomes suggest similar success across both demographics. 15 With respect to living or residential status, 94.9% of patients in the current study who had been living independently preinjury returned to their same residential living status by last follow-up. The relative change in residential living status from pre-injury to post-surgery was statistically significant, such that those living independently prior to injury had a greater likelihood of living independently following surgery than those who were in assisted living facility pre-injury (p ¼ 0.02).…”

Results of minimally invasive quick definitive fixation of unstable bony pelvic disruption by combined retrosacral transiliac rods and anterior external fixator during a critical national period

“…The role of external fixation alone for treatment of pelvic fractures is now limited to the emergency management of hemodynamic instability. 1,2 Acute surgical decompression of sacral nerve roots is associated with risk of bleeding, wound complications and CSF leak however, surgery is considered if there is a chance to restore even a unilateral distal root function for voluntary bowel and bladder control. Neurological improvement of up to 80% is frequent, regardless of the type of operative or conservative management.…”

“…Spinopelvic dissociation associated with neurologic lesions hardly ever recover completely, with residual lower-limb neurologic deficits, urinary problems and sexual dysfunction. [1][2][3] Three cases in our study had preoperative L5-S1 neurologic deficit that showed improvement after reduction and fixation of their Denis-II sacral fractures.…”

“…Disruption of the pelvic ring anteriorly or posteriorly is either a fracture or dislocation and the method of fixation should depend on the nature of injury and the hemodynamic state of the patient at presentation. 1,2 Sacral fractures are present in 45% of all pelvic fractures and 25% of them are associated with neurological injury. Young people are injured due to motor vehicle accidents or falls from a height while insufficiency sacral fractures occur in osteoporotic elderly patients after minor trauma.…”

Diagnostik und Behandlung von sacralen Insuffizienzfrakturen unter besonderer Berücksichtigung der Zementaugmentationsverfahren – eine Übersicht

“…Wenn möglich, sollten, wie in unserer Arbeitsgruppe üblich, die Therapiekonzepte in einer interdisziplinären Fallkonferenz festgelegt werden. Für dislozierte instabile Beckenfrakturen kommt nur die Operation unter Berücksichtigung einer Vielzahl von osteosynthetischen Techniken infrage [13,41,43,86].…”