Chapter 164 - Management of Sacral Fractures

Abstract

Treatment of sacral fractures must address the sacrum’s structural and neurologic roles and requires a thorough understanding of neural decompression and skeletal reconstruction techniques. The severity of sacral fractures varies from low-energy insufficiency fractures to complex and widely displaced high-energy fractures. In either situation, treatment must account for associated injuries and medical conditions. CT is the primary diagnostic imaging tool, providing the detail required to determine the full extent of sacral fractures. Routine screening CT of the chest, abdomen and pelvis in trauma patients has reduced delays in diagnosis of sacral fractures. Because neurologic deficits can be limited to bowel, bladder and perineal sensorimotor dysfunction, they may only be recognized on rectal examination. Displaced fractures are typically treated surgically, particularly when associated with neurologic deficits. Surgery usually involves fracture reduction and stabilization, which can provide indirect neurologic decompression, with direct decompression by removal of bony fragments, if required. The AOSpine Sacral Fracture Classification has unified concepts that have evolved over decades, in order to guide treatment. As a general guideline, AO Type A (Lower Sacrococcygeal) fractures are treated either nonoperatively or with decompression alone. Type B (Posterior Pelvic) injuries are usually treated with iliosacral or transiliac-transsacral screw fixation, whereas spinopelvic fixation is typically added to Type C (Spinopelvic) injuries, except for insufficiency fractures in which percutaneous iliosacral or transiliac-transsacral fixation usually suffices. The need for closed vs open reduction and for percutaneous vs open fixation is decided on an individual basis. Neurologic recovery and clinical outcomes correlate inversely with the severity of initial fracture displacement, residual fracture malalignment, and sagittal imbalance.