Sacral injuries

44
SACRAL FRACTURES SACRAL FRACTURES

description

SACRUM FRACTURES

Transcript of Sacral injuries

Page 1: Sacral injuries

SACRAL SACRAL

FRACTURES FRACTURES

Page 2: Sacral injuries

PELVIC ANATOMY ANTERIOR VIEW PELVIC ANATOMY ANTERIOR VIEW

Page 3: Sacral injuries

PELVIC ANATOMY POSTERIOR VIEW

Page 4: Sacral injuries

PELVIC ANATOMY INLET VIEW

Page 5: Sacral injuries

SACRUM ANATOMY

Page 6: Sacral injuries

SACRUM ANATOMY

Page 7: Sacral injuries

POSTERIOR WALL OF PELVIS

Page 8: Sacral injuries

LATERAL WALL OF PELVIS

Page 9: Sacral injuries

SACRAL PLEXUS

Page 10: Sacral injuries

SACRAL PLEXUS

Page 11: Sacral injuries

SACRAL PLEXUS

Page 12: Sacral injuries

SACRUM FRACTURES – NERVE ROOTS

Page 13: Sacral injuries
Page 14: Sacral injuries

SACRUM FRACTURES – DENIS CLASSIFICATIONSACRUM FRACTURES – DENIS CLASSIFICATION

ZONE IAcross sacralNeurological injuries

•due to superior migration of fragments•6% of the whole•lumbrosacral plexus L5,S1 (24%)•Femoral nerve

Page 15: Sacral injuries

ZONE II

• Through the neuroforamina

• Neurological injuries L5, S1 (50%)

• Unilateral sacral anesthesia• Incontinence• Flaccid bowel and bladder• impotence

• Evaluation • Achilles reflex• Bulbocaverosus reflex• Rectal tone

SACRUM FRACTURES – DENIS CLASSIFICATION

Page 16: Sacral injuries

SACRUM FRACTURES – DENIS CLASSIFICATION

ZONE III

• through the body of the sacrum

• Neurological injuries

• 56% of the whole• Cauda equina• Neurogenic bladder• Saddle anesthesia• Loss of sphincter tone• Bowel, bladder dysfunction 70%

Page 17: Sacral injuries

MISCELLANEOUS FRACTURES

• Transverse fractures

• From landing on the buttocks

• U shaped fractures

Page 18: Sacral injuries

• One hand is placed on the iliac crest

• The other hand applies traction to the leg

Displacement in vertical plane

PHYSICAL EXAMINATION

Page 19: Sacral injuries

RADIOGRAPHIC INVESTIGATION

• AP radiographs, inlet and outlet views

• Difficult – complex shape (50% are missed)

• Findings – low lumbar transverse process fractures

- asymmetrical sacral foramen

- irregular trabeculation of the lateral

masses

• Sacral arcuate lines asymmetry: uncomplicated

sacral frx

disorganized: comminuted

sacral frx

Page 20: Sacral injuries
Page 21: Sacral injuries

RADIOGRAFIC INVESTIGATION

Page 22: Sacral injuries

• The most accurateThe most accurate

• Especially for transverse fracturesEspecially for transverse fractures

• Useful for detecting large defects as tarlov cystsUseful for detecting large defects as tarlov cysts

• Diagnosis of coexisting malignant lesionsDiagnosis of coexisting malignant lesions

CT SCAN

Page 23: Sacral injuries
Page 24: Sacral injuries
Page 25: Sacral injuries
Page 26: Sacral injuries

CD SCAN

Page 27: Sacral injuries

• The most sensitive

in detection of fractures

- soft tissue edema

- marrow changes

MRI

Page 28: Sacral injuries

TREATMENT

ZONE I

• Without neurologic deficits and stable

• Symptom relief

• Bed rest (7-10 days)

• Log-rolled

Page 29: Sacral injuries

TREATMENT

ZONE II and III

• Without neurologic deficits

• Bed rest for 4-8 weeks

• Weight bearing at 4-8 weeks on the fractured side

Page 30: Sacral injuries

TREATMENT

ZONE III

• Without neurologic deficits

• Observation: neuropraxia that will resolve

• Symptoms beyond 6-8 weeks: foraminal decompression

Page 31: Sacral injuries

TREATMENT

ZONE III

• With neurologic injury

• Aggressive radiologic examination

• Early posterior

decompression

forReturn of – bowel, bladder

control

Reserval of foot drop

Page 32: Sacral injuries

COMPLICATIONS OF CONSERVATIVE

TREATMENT

• chronic pain

• sacroiliac joint arthritis

• changes in the alignment on the sacrum

• bowel, bladder disability

Page 33: Sacral injuries

DETERMINATION OF FRACTURE STABILITY

• Stable fractures

• Impacted vertical fracture

• Nondisplaced fracture of posterior sacroiliac complex

• Fracture of the upper sacrum

Page 34: Sacral injuries

DETERMINATION OF FRACTURE STABILITY

• Unstable

• Fracture diastasis of more than 0,5 – 1cm along with an anterior unstable injury

Page 35: Sacral injuries

SURGICAL INDICATION

• posterior or vertical displacement or both (>1cm)

• Rotationally unstable pelvic ring injuries

• Sacral fractures with unstable pelvic ring that requires mobilization

• Neurological injury

Page 36: Sacral injuries

PROCEDURE PRONE POSITION

Page 37: Sacral injuries

PERCUTANEOUS ILIOSACRAL SCREW FIXATION

• For unilateral sacral fractures zone I or zone II

• Under fluoroscopic control the reduction is obtained and

held by iliac screws (cannulated)

Page 38: Sacral injuries

OPEN REDUCTION AND INTERNAL FIXATION

Page 39: Sacral injuries

MISCELLANEOUS CASES

Page 40: Sacral injuries

CASE 4

Page 41: Sacral injuries
Page 42: Sacral injuries
Page 43: Sacral injuries

CONCLUSION

• Neurological deficities

• Stable Fractures : conservative treatment

• Unstable Fractures : operative treatment

• Neurologic injury :posterior decompression

Page 44: Sacral injuries