Sacral Fractures , Review - Everything You Need To Know - Dr. Nabil Ebraheim

Dr. Ebraheim’s educational animated video describes the condition of sacral fractures, The signs and symptoms, the diagnostic tests, and the treatment options.

Sometimes it is hard to see sacral fractures on x-rays. The sacrum is connected to the pelvis through the sacroiliac joint. The fracture could probably be missed on x-rays. Neurological deficit will decide the outcome of the patient. Neurological deficits may be a nerve root injury or involvement of the cauda equine which affects bladder, bowel and sexual function. The involved nerve root may be L4-L5 causing foot drop or it may involve the sacral nerve roots.
There are three types of sacral fractures: fractures in zone I, zone II and zone III. Zone I fractures are a fracture of the ala. They are common in about 50% of patients with fractures of the sacrum. L5 nerve root involvement including foot drop in about 5% of the patients may occur.
Zone II fracture is through the foramen. A vertical shear fracture with about 30% of these fracture types having sacral nerve injury. Zone II is usually stable, however they can be very unstable with a vertical shear force. A vertical shear fracture is the worst type of fracture. Fixation may not hold because it is a difficult fracture to fix and it may displace after fixation. This instability will increase the risk of fracture displacement, nonunion, failure of fixation and very poor functional outcome.
A zone III fracture usually enters the spinal canal. It is 60-90% neurological deficit and affects the cauda equina. Zone III may either by longitudinal or transverse (u-shaped). Longitudinal involve the sacral canal. Axial loading causes transverse sacral fracture at the weakest area located between S2-S3. One part that goes with the spine and one part goes with the pelvis. It creates a spinopelvic dissociation.
Clinical presentation: A patient with a fracture of the sacrum will have about 25% neurological injury. Make sure the patient has a rectal exam and examination of the S2-S5 dermatomes, especially the sensation around the perianal area.
Imaging: X-rays could miss the sacral view. Need to get AP, inlet and outlet views. The outlet views will show the foramen very well and will also show any vertical displacement of the fracture. AP views will show the disruption of the arcuate lines and possible involvement of the foramen. Lateral sacral x-rays will show the u-shaped fractures, which is similar to the transverse fracture. CT scan is the study of choice. An MRI will show the status of the nerve root and if there is any encroachment on the nerve root through the foramen.
Treatment: Minimally invasive sacral fractures, do progressive weight bearing plus crutches or a walker. Surgical fixation if the fracture is unstable, displaced or if there is neurological deficit. Avoid over-compression of the fracture because it may cause a nerve injury. You may need to decompress the nerve roots for improvement of the neurological status of the patient.
Fixation may be done in different ways: Screws, posterior tension band plating or compression bar technique (do not use a lot of compression). The best technique is combined iliosacral and lumbopelvic fixation (triangular fixation). It has the greatest stiffness for unstable sacral fractures.

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