SACRAL FRACTURES

The forgotten bone

Dr Akimu C Mageza
MBCHB (UZ) FCS Orth(ECSA)
Orthopaedics & Trauma Surgeon
Special Interest in:
Introduction

• Under-diagnosed
• Under-treated
• Often not looked at
• Common in pelvic ring injuries 30-
45%
• Associated neurologic injury 25%
• Neuro injury often missed
• Open fracture ~10%
Anatomy
 Anatomy

• Lower Sacral Nerve roots

•

• Anal sphincter tone

• Voluntary contraction
• Perianal sensation
• Bulbocarvenosus reflex
• Sexual function
•

• Unilateral nerve preservation

adequate for bladder & bowel fxn
Sacral dysmorphysim

• Variable morphology
• Lumbosacral seg fusion
• Neural tube defects (Sacral
dysraphysm)
• SI joint anatomy variations
Aetiology
High energy injuries
•

• Motor vehicle crash

• Fall from a height

•

• 30-45% of pelvic ring

frx
 Insufficiency Sacral Fracture

• 2’ to osteoporosis

• Comorbidities common

• Incidence unknown- often unrecognised

• >500 reported in literature

• Common cause of geriatric low back pain

Initial evaluation of sacral fracture pt

• ATLS - polytrauma
• History
• Head to toe examination
• Pelvic spring test
• Neurological exam
•

• Perianal sensation
• Anal tone
Imaging
•

• Plain X-rays - AP
•

-Inlet

-Outlet
• Pick up rate 30%
•

• CT scan
•

•
CT Scan Pelvis
CT Scan Pelvis
Classification of sacral fractures

• Descriptive
•
Classification of sacral fractures

• Descriptive
•
Denis Classification of sacral fractures
Classification of sacral fractures
Management

• Non Operative
•

• Neurologically intact with No or

• Operative
minimum displacement

Insufficiency fractures
•
•

•
• Fractures distal to S3
Closed reduction
• Bed rest- traction
•

• Open reduction
•

•
Indications for operative fixation

• Unstable injuries
• Displacement >10mm
• Neurological involvement
• Soft tissue compromise
• Failed non-operative management
 Operative management

• Closed reduction + percutaneous SI screw fixation

• Open reduction + internal fixation

• Anterior approach

• Posterior midline

• Posterior SI approach
Fixation options
Only if we could have…
 Percutaneous Screw insertion

• SI Screw

•
Case 1 J.M
Post operative images
Case 2 JS
CT scan
Posterior Midline approach
Wound cover - Prevena vac dressing
Post - operative images
Case 3 - DM

• Still cooking
• Father not supportive
• NO CT scan
• No clearance for emergency
surgery
• Time will tell
Complications

• Chronic backache
•

• SI joint arthritis
• Lumbosacral instability
• Non union
• Far ‘out’ Syndrome
• Bowel & bladder dysfunction
Take Home Message

• Under-diagnosed
• Under-treated
• Often not looked at
• Common in pelvic ring injuries
• Associated neurologic injury
• Neuro injury often missed
• Open fracture
• They are treatable with good outcome