Sacral fractures are common injuries associated with the pelvic ring, often under-diagnosed and linked to neurological issues. Diagnosis typically involves pelvic radiographs supplemented by CT scans for comprehensive evaluation. Treatment options vary from nonoperative to surgical, based on factors such as fracture displacement and associated injuries.

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.