Sacral Fractures

Hitesh Gopalan UIndia

SICOT Educational Day 2013SICOT Congress Hyderabad

Sacral fractures- Incidence

• 45% of all pelvic injuries

• Often Missed( Upto 50% in neurologically intact patients)

• Missed open fractures( in females)- PV Exam

Mehta S, J Amer Acad Orthop Surg.2006; 14(12):656-665.

Sacrum- Physiology

• S1-S5 nerve roots

• Inferior Hypogastric Plexus

• Bladder, Bowel, Sexual function

Mechanism

• Lateral compression- Stable

• Vertical Shear- Unstable

• Lumbopelvic instability- Dissociation

Neurological Injury

• Neuropraxia

• Incomplete

• Transection

• Cauda Equina

Basic Imaging

• Pelvis Xray- Series: Inlet/outlet views

• Lateral view: Sagittal displacement

• CT Scan

• MRI

Classification

• Denis Classification

• Descriptive: H type, U type, Lambda and T type

• Subclassification of Denis 3: Roy Camille et al.

• Isler class: Lumbosacral Junction

Denis

Denis F et al..Clin Orthop Relat Res. 1988; (227):67-81.

Roy Camille- Strange-Vognsen and Lebech: TRANSVERSE #

Roy Camillle et al..Spine. 1985; 10(9):838-845Strange-Vognsen HH, Lebech A. J Orthop Trauma. 1991; 5(2):200-203..

Predictor of Neurology

• Denis 3> Denis 2> Denis 1

• Transverse #: 97%(Robles et al..)

Robles et al..Spine J. 2009;9(1):60-69.

Lumbosacral Stability

Isler B et al..J Orthop Trauma. 1990;4:1-6.

Clinical Exam- Key

• L5 to S4 nerve roots exam

• Reflexes

• Sensation

• Anal spinchter tone

• Bulbocavernous, Cremasteric, Anal Wink reflexes

• Sensation

Clinical Exam

Treatment

Non operative• No pelvic ring disruption, • Fractures not involving the lumbosacralJunction• fractures without neurologic injury.

Displaced Fractures

• Initial Management with Skeletal Traction

• Optimum Time for intervention

• Nerve Root Decompression

Surgical

• Percutaneous Iliosacral Screws

• Posterior Tension Band plating

• Anterior plating

• Transsacral Rods/Transiliac Rods

• Lumbopelvic fixation

Nerve Root Decompression

• Controversial

• Early(24- 72 hours)

• Indirect reduction Vs Laminectomy

• Electrodiagnostic Testing

Percutaneous Iliosacral Screws

SAFE CORRIDOR

Percutaneous Screws

• Safe corridor

• Sacral Dysmorphisms

• Intraoperative Radiation Exposure

• Lumbopelvic instability

Iliosacral Screws: Nork et al..

• 13 patients

• Denis Zone II or III injuries

• No deterioration of sacral kyphosis

• Bilateral screws in H or U zone III fractures

Nork SE, Jones CB, Harding SP, Mirza SK, Routt ML Jr. Percutaneous stabilization of Ushaped sacral fractures using iliosacral screws: technique and early results. J Orthop Trauma. 2001;15:238-46.

Posterior SI Joint Tension Band Plating

Posterior Plating

• Exposure

• Hardware and Wound breakdown

• Anterior Injury should be treated first

Lumbopelvic fixation

• Lumbopelvic instability

• Isler 3

• H type and U type

Roy Camille 2- Transverse sacral

Lumbopelvic fixation- Triangular Osteosynthesis

Spino-Pelvic Fixation

Lumbopelvic Fixation

• Invasive• Fixation of lumbar pedicles• Spine Surgeon• Superior Biomechanics

Schildhauer TA, Ledoux WR, Chapman JR, Henley MB, Tencer AF, Routt ML Jr. Triangular osteosynthesis and iliosacral screw fixation for unstable sacral fractures. A cadaveric and biomechanical evaluation under cyclic loads. J Orthop Trauma. 2003;17:22-31.

Conclusion

• Good Physical Examination

• Evaluation of Motor and Sensory system

• Per Vaginal examination in females to avoid missing an open fracture

Conclusion

Decompression: No Level 1 Evidence.

• Level 4 evidence: No reporting of severity on pre and post surgery neural recovery

• Denis et al..: Operative

• 80% improvement regardless of treatment(Schmidek et al.. Neurosurgery 1984;15:735-746)

Conclusion

Fixation Methods:• Trend towards percutaneous iliosacral screws

• No level 1 Evidence

• Lumbopelvic fixation: Invasive

• Iliosacral screw Vs Lumbopelvic fixation

Conclusion

• Long term pain in 30% patients regardless of fixation

• Paucity of High Quality Evidence

Thank You

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