This ppt is helpful in sacral trauma / fracture with introduction, etiology, classification diagnosis & treatment

1. Sacral Fracture
- DR ABHINAV BHUTE
MBBS,MS ORTHO
SPINE SURGEON FELLOW

2. INTRODUCTION
 Sacral fractures involve a break in one or more sacral bones (S1-S5)
 Estimated incidence is about 1-3% of all spine fractures

3. EPIDEMIOLOGY
 Incidence: common in pelvic ring injuries
(30-45%)
 Bimodal distribution
 Young adults: high energy trauma
 Elderly: low energy falls
 Associate injuries
 25% have neurologic injury
 75% in neurologically intact patients

4. Anatomy
 Formed by fusion of 5 sacral vertebrae
 Articulates with:
 5th lumbar vertebra proximally
 Coccyx distally
 Ilium laterally
 Contains 4 foramina for sacral nerves

6. Nerves
 L5 nerve root runs on top of sacral
ala
 S1-S4 nerves through sacral
foramina
 S1 and S2 nerves have higher injury
rates
 Lower sacral nerves control:
 Anal sphincter
 Bulbocavernosus reflex
 Perianal sensation

7. Presentation
 - History: Trauma, falls in elderly
 Symptoms: Peripelvic pain
 Exam findings:
 Palpate stability, swelling, open injuries
 Neurological exam of lower extremities
 Vascular exam of distal pulses

8. Classification Systems
 Denis fracture
 AO classification system
 Isler classification

9. Denis classification
 Zone 1
 Fracture lateral to foramina
 Most common (50%)
 Nerve injury rare (5%).
-usually occurs to L5 nerve root
 Zone 2
 Fracture through foramina
 May be stable vs. unstable
 Zone 2 fracture with shear component highly unstable
 Unstable fractures have higher risk of nonunion and poor functional
outcome
 Zone 3

 Fracture medial to foramina into the spinal canal
Highest rate of neurologic deficit (60%)
 -bowel, bladder, and sexual dysfunction

10. Denis classification

11. Morphologic injury patterns of zone 3 fractures in
denis fracture
• “H” shaped fracture
• “U” shaped fracture
• “ʎ” (lambda) shaped fracture
• “T” shaped fracture
• Transverse and U-type fractures are also associated with nerve
dysfunction

12. AO classification of sacral injuries
• type A: lower sacrococcygeal injuries
• type B: posterior pelvic injuries
• type C: spinopelvic injuries

13. AO classification of sacral injuries

14. Isler classification
 Used for fractures that involve the lumbosacral
articulation:
• Isler 1: fracture occurs lateral to the L5/S1 facet
• Isler 2: fractures line involves the L5/S1 facet
• Isler 3: fracture line extends medially to the L5/S1
facet

15. Imaging
 Radiographs show only 30% of fractures
 CT is diagnostic study of choice
 MRI for suspected neural compromise

16. Xray
CT
Sacral insufficiency
fracture on mri

17. Treatment
 Nonoperative: <1 cm displacement, no deficit
 Operative: Displaced >1 cm, soft tissue injury, persistent pain

18. Non-operative
 Pelvic binder/brace
 Bed rest
 NSAIDS, CALCIUM & VIT D3 SUPPLEMENTS
 Physiotherapy rehab

19.  Surgical Approaches for Sacral Fractures
 Common approaches
 Posterior approach
 Anterior approach
 Combined anterior and posterior approach
 Factors determining choice of approach
 Location and pattern of fracture
 Associated injuries
 Surgeon preference/experience
Operative

20.  Fixation Options
 Posterior fixation
 Percutaneous iliosacral screws
 Spinopelvic fixation
 Sacroiliac plating
 Anterior fixation
 Sacral plating
 Iliosacral screws
 Lumbopelvic fixation
 Decompression for neurologic injury
Goal is to achieve stabilization and allow bone healing

21. Post-operative Care & Rehabilitation
Early mobilization as tolerated
Physical therapy
Range of motion exercises
Strengthening
Balance and gait training
Management of bowel/bladder dysfunction if present
Follow up imaging to assess healing
Goal is to maximize function and quality of life

22. Complications
 Venous thromboembolism
 Nerve injury
 Malreduction

23. Prognosis
 Prognosis
 Neurologic deficit predicts outcomes
 Displacement increases risk

24. SUMMARY
o Sacral fractures are common pelvic ring injuries that are under-diagnosed and
often associated with neurologic compromise.
o Diagnosis can made with pelvis radiographs but frequently require pelvic CT
scan for full characterization.
o Treatment may be nonoperative or operative depending on fracture
displacement, associated pelvic ring instability and patient activity demands.