Case Report...

Hindawi Publishing CorporationEmergency Medicine InternationalVolume 2011, Article ID 741570, 3 pagesdoi:10.1155/2011/741570

Case Report

Isolated Transverse Sacrum Fracture: A Case Report

Cemil Kavalci,1 Gokhan Akdur,1 Mustafa Burak Sayhan,1 Ozgur Sogut,2

and Mehmet Tahir Gokdemir2

1 Department of Emergency Medicine, Faculty of Medicine, Trakya University, Edirne, Turkey2 Department of Emergency Medicine, Faculty of Medicine, Harran University, Sanliurfa, Turkey

Correspondence should be addressed to Cemil Kavalci, cemkavalci@yahoo.com

Received 30 November 2010; Revised 18 March 2011; Accepted 25 April 2011

Academic Editor: Aristomenis K. Exadaktylos

Copyright © 2011 Cemil Kavalci et al. This is an open access article distributed under the Creative Commons Attribution License,which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Sacral fracture commonly results from high-energy trauma. Most insufficiency fractures of the sacrum are seen in women after theage of 70. Fractures of the sacrum are rare and generally combined with a concomitant pelvic fracture. Transverse sacral fracturesare even less frequent which constitute only 3–5% of all sacral fractures. This type of fractures provide a diagnostic challenge. Wereport a unique case of isolated transverse fracture of sacrum in a young man sustained low-energy trauma. The patient presentedto our emergency department after several hours of injury, and diagnosed by clinical features and roentgenogram findings.

1. Introduction

Reports of transverse fractures of the sacrum in the literatureare not common. This issue has been attributed mostly to thechallenge of obtaining diagnostic roentgenograms but also tothe fact that this type of a fracture rarely is suspected [1]. Alongitudinal fracture of the sacrum can be associated withapproximately 45% of pelvic fractures. However, a transversefracture of the sacrum is even less frequent, and accountedfor only 4.5% of sacral fractures in humans [1, 2]. Lowersacral transverse fracture are often due to direct traumaticforce against coccyx, and it is related to fall and resultingin break at the kyphos of sacrum mostly through the bodyof the lower 4-5 sacral vertebrae. Rarely, neurological deficitmay accompany these fractures [2, 3]. There is often a delayin definitive diagnosis, if the quality of the roentgenogramsis not adequate and if they are not examined specifically forthe lesion. Most neurological insults associated with delays indiagnosis [1, 3]. Here, a case of lower fourth sacral vertebraefracture associated with low-energy fall, who was diagnosedby clinical suspicion and appropriate roentgenogram, isreported.

2. Case Report

A 37-year-old male was admitted to the emergency depart-ment (ED) with low back pain and tenderness following

injury. He fell on his back onto a rough surface three hoursago. On examination, there were no weakness or anaesthesiain both the lower limbs, and inability to void urine, andto control bowel function. Roentgenogram of the pelvisrevealed irregularity in the arcuate lines of the lower twosacral foramina associated with a transverse sacrum fracturethrough fourth sacral vertebrae (Figure 1). The fracture linefrom the anterior to the posterior aspect of the fourthsacral segment without narrowing of the sacral canal wasconfirmed later by lumbosacral tomography. As the patienthad no neurological deficit, he was discharged home on thesame day with recommendations for bed rest and analgesics.

3. Discussion

Isolated fractures of the sacrum are rare and generallythese occur in combination with pelvic rim fractures [2].Sacral fracture commonly results from high-energy trauma.Isolated sacral fractures which occur by shear forces on thepelvic ring are seen less commonly, and they are commonlytransversely oriented [4]. Most fractures of the sacrum occurin women (94,3%) of advanced age (mean age : 70,6 years). Acomplete and careful physical and neurological examinationwill contribute a definitive diagnosis in suspecting this rareinjury. Fracture of the sacrum should be suspected in thepresence of low back or sacral pain and tenderness [5]. Inaddition, depending on the degree of root involvement, there

2 Emergency Medicine International

Figure 1: The anteroposterior roentgenogram of the lumbosacralarea demonstrating a transverse fracture line at the right andanterior aspect of the fourth sacral vertebrae.

may be hypesthesia or segment provides sensation to theposterior aspect of the thigh, the posterolateral aspect ofthe calf, and the sole of the foot. The third sacral segmentinvolves not only the superior medial aspect of the thighbut also part of the sacral region. The perianal region,anus, penis, posterior part of the scrotum, and posteriorportion of the labia majora are innervated through the fourthand fifth sacral-nerve roots. These are the areas that mustbe tested carefully to elicit evidence of a sacral fracture[1, 5]. In the present case, despite he was young manand sustained low-energy trauma due to fall on a ground,the injury led to a stable sacral fracture associated withlower back pain and sacral tenderness. Transverse sacralfractures have been classified as upper and lower fractures.Lower sacral transverse fracture are often resulting fromdirect traumatic force. Rarely, it can produce neurologicaldamage [1]. The muscles of the lower limb are supplied bymultiple peripheral nerve roots, predominantly above thesecond sacral level. Therefore, no extensive paralysis willbe developed in patients who have only a sacral fracture,as in the present case. If such paralysis does exist, otherassociated injuries should be suspected. Some of the patientswith transverse sacral fractures demonstrates a neurologicaldeficit of importance which mainly concerns the bowel orbladder [1, 2]. Furthermore, attention should always be paidto the bladder because the neurological deficit may not beapparent immediately after the injury Lumbalgia, pain ofthe lower limbs, functional disability of the bladder, andbowel, seem due to a narrowed lumbar canal, a disc-nervousroot conflict or a vertebral fracture [2]. No neurologicaldeficit in the present case was demonstrated on arrival andduring the 12-hour observation in the ED. As describedby Rowell [6], transverse sacral fractures almost alwaysinvolve the lower three segments of the sacrum (S3–S5).The ligamentous support of this region is achieved by thesacroiliac ligament, the sacrospinous ligament, and, moreimportantly, the sacrotuberous ligament. The coccyx mayact as a lever arm on the body of the sacrum. The force so

applied is resisted primarily by the ligamentous structuresjust mentioned. In the present case, the fractured fourthsacral vertebrae, injured by either of the mechanisms pointedout above, was driven forward, resulting in injury to thesacral region [1, 6]. Diagnosis is often late, or sometimesis not even made. Standard roentgenograms of lumbosacralregion with an adequate quality can able to predict ordinarydegenerative lesions or fracture displacement narrowing thesacral canal in every case, and seem sufficient to makea definitive diagnosis of sacral fractures. If the quality ofthe roentgenograms is not adequate, fractures of sacrumare discreet, without displacement, often hidden by gas,stercoral stasis, or vascular calcifications. In this setting, acomputed tomography of the lumbosacral region is alwaysmandatory to confirm the diagnosis [1]. Treatment oftransverse sacral fractures uncomplicated by neurologicaldeficits should be conservative. However, in case of sacralroot injuries with displaced sacrum fracture, decompressionsuch as gibbectomy is recommended [1, 2, 7]. Outcomes ofoperative decompression are debatable, and even conserva-tive treatment has been advocated [2].

4. Conclusion

Because isolated transverse sacrum fractures are rarelyseen, and it can be a challenge of obtaining appropriateroentgenograms, the early diagnosis might be overlooked.The ED physician should be suspected of this type offractures in the presence of low back or sacral pain andtenderness. Conventional roentgenograms can allow forvisualization of a transverse sacral fracture, if the qualityof the roentgenograms is adequate. In most instances,treatment is consisted of analgesia, sedation, and bed rest.

Conflict of Interests

None of the authors have any financial or other conflict ofinterests related to this paper.

References

[1] S. S. Fountain, R. D. Hamilton, and R. M. Jameson, “Transversefractures of the sacrum. A report of six cases,” The Journal ofBone and Joint Surgery, vol. 59, no. 4, pp. 486–489, 1977.

[2] H. Singh, V. S. Rao, R. Mangla, and V. J. Laheri, “Traumatictransverse fracture of sacrum with cauda equina injury—acase report and review of literature,” Journal of PostgraduateMedicine, vol. 44, no. 1, pp. 14–15, 1998.

[3] R. Roy-Camille, G. Saillant, G. Gagna, and C. Mazel, “Trans-verse fracture of the upper sacrum. Suicidal jumper’s fracture,”Spine, vol. 10, no. 9, pp. 838–845, 1985.

[4] A. Harma, M. Inan, and K. Ertem, “Isolated zone III verticalfracture of first sacral vertebra—a case report,” Acta Orthopaed-ica, vol. 76, no. 3, pp. 451–452, 2005.

[5] H. S. Bhatoe, “Fracture sacrum with neurogenic bladderdysfunction,” Indian Journal of Neurotrauma, vol. 4, no. 2, p.135, 2007.

[6] C. E. Rowell, “Fracture of sacrum with hemisaddle anaesthesiaand cerebro-spinal fluid leak,” The Medical Journal of Australia,vol. 1, no. 1, pp. 16–19, 1965.

Emergency Medicine International 3

[7] M. A. Foy, “Morbidity following isolated fractures of thesacrum,” International Journal of the Care of the Injuried, vol.19, no. 6, pp. 379–380, 1988.

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