sacral fractures

1. SACRAL FRACTURES
DR ASIF JATOI
SENIOR REGISTRAR
CMH RAWALPINDI

2.  The sacrum is an irregularly shaped bone, made up of a group of five fused
vertebrae
 The sacrum plays a central role in the stability of both the pelvis and the
spinal column.
 The important neurologic structures the lower sacral
roots and autonomic nerves that are important for continence of the bowel
and bladder and sexual function

3. ANATOMY

5.  frequently missed at presentation because these
associated with high-energy trauma and present with
multiple injuries & hemodynamically unstable.
 The neurologic evaluation must include DRE to assess
 rectal tone
 maximal contraction of the anal sphincter and
 rectal tears and anterior perineal lacerations.

7.  The L5 nerve is at risk at the anterior junction of the ala
and the sacral promontory, and the S1 nerve root can be
injured within the foramen.
 Extremity motor and sensory testing and rectal
examination

8. IMAGING STUDIOS
 Plain radiographs have not proven sensitive .
 CT scan of the pelvis with 2-mm slices and sagittal and
coronal reformatted images should be obtained
 When associated neurologic deficits with displaced
fractures, MRI also may be of value,

9. DENIS CLASSIFCATION
 Zone 1-lateral to the foramina
 50% of injuries with a 6% incidenceof L5 and S1
injuries
 Zone 2 -through the foramina
 34% of injuries, and 28% with deficits unilaterally at
the L5, S1, or S2 levels
 Zone 3- medial to the foramen
and involve the spinal canal
 Remaining 16% of injuries

10. ROY-CAMILLE CLASSIFICATION

11. ISLER CLASSIFICATION

12. AO CLASSIFICATION
 The classification system describes injuries based on
three criteria:
 morphology of the injury
 neurologic status
 case-specific modifiers

13. MORPHOLOGY OF THE INJURY
 TYPE A INJURIES
 are lower sacro-coccygeal fractures with no impact on the posterior pelvic or spino-pelvic
stability.
 TYPE B INJURIES
 are unilateral longitudinal (vertical) sacral fractures which result in posterior pelvic
instability but no impact on spino-pelvic stability.
 TYPE C INJURIES
 include unilateral B injuries with L5-S1 facet involvement, bilateral longitudinal
(vertical) sacral fractures and U fracture variations resulting in spino-pelvic
instability.

16. NEUROLOGY
 Neurological injuries are classified as follows:
 Nx: Cannot be examined
 N0: No neurological deficits
 N1: Transient neurological injury
 N2: Nerve root injury
 N3: Cauda Equina Syndrome/Incomplete SCI
 N4: Complete SCI*

17. MODIFIERS
 These modifiers are added to distinguish
features that may impact treatment of a given
fracture type.
 M1: Severe soft Tissue Injury
 M2: Metabolic Bone Disease
 M3: Anterior pelvic ring injury
 M4: Sacroiliac joint injury

18. TREATMENT
 Type A1 and A2 are managed conservatively
 Type A3, by sacral alar plating or laminectomy
 Type B1,B2, B3 are managed with illiosacral screws or
spinopelvic fixation.

20. C0 Nondisplaced U-fracture
 This is a nondisplaced
sacral U-type fracture,
result from low-energy
injuries.
 commonly seen as
insufficiency fractures in
patients with metabolic
bone disease.
 Treated conservatively
or by Iliosacral screws
(ISS)

22. TYPE C1
 This is any unilateral B-type
fracture involving a fracture of
the ipsilateral L5-S1 joint.
 This fracture type may impact
spino-pelvic instability and is
therefore classified as a C
fracture

23. TYPE C2
 This is a bilateral B-type
fracture without a
transverse component.
 These fractures are more
unstable and have a
higher risk of neurological
injury than C1.

24. TYPE C3
 This is a displaced U-type
fracture. It has a similar
instability profile as C2,
 but due to the transverse
fracture displacement it has
a higher likelihood of
neurological injury.


25.  Type C1, C2 and C3 are treated surgically by
spinopelvoc fixation and Fixation of associated pelvic
ring injuries.

28. ILIOSACRAL SCREW (ISS) FIXATION
 Iliosacral screw (ISS) fixation is a fluoroscopically
guided, percutaneous procedure.
 Its primary use is for fixation of satisfactorily reduced
sacral fractures or sacro-iliac joint disruptions.
 Anatomic reduction must be obtained before ISS
insertion.

29. REDUCTION

30.  entry point should be
anterior in S1 and
inferior to the iliac
cortical density (ICD),
which parallels the sacral
alar slope, usually
slightly caudal and
posterior

32. INSERTION OF ILIAC SCREW
 There are two standard
iliac screw starting points
within the ilium and one
within the sacrum.

33. THE TRADITIONAL ENTRY POINT
 The traditional entry point is in the posterior iliac crest
and countersunk to prevent pressure ulcers over the
implant.
 An oscillating drill (3.5 mm) or awl is used to penetrate
between the two cortices in a ventral, caudal direction
toward the anterior inferior iliac spine.

34. ILIAC STARTING POINT
 is referred to as anatomic starting point. It is more caudal
and medial than the traditional starting point and aligns
better with the lumbar pedicles.
 The more caudal position places this screw in a wider
cross section of bone above the sciatic notch

35. SACRAL ENTRY POINT
 The third starting point is at the inferolateral
aspect of the S1 foramen.