Sacral injuries

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2. PELVIC ANATOMY ANTERIOR VIEWPELVIC ANATOMY ANTERIOR VIEW 3. PELVIC ANATOMY POSTERIOR VIEW 4. PELVIC ANATOMY INLET VIEW 5. SACRUM ANATOMY 6. SACRUM ANATOMY 7. POSTERIOR WALL OF PELVIS 8. LATERAL WALL OF PELVIS 9. SACRAL PLEXUS 10. SACRAL PLEXUS 11. SACRAL PLEXUS 12. SACRUM FRACTURES NERVE ROOTS 13. SACRUM FRACTURES DENIS CLASSIFICATIONSACRUM FRACTURES DENIS CLASSIFICATION ZONE I Across sacral Neurological injuries due to superior migration of fragments 6% of the whole lumbrosacral plexus L5,S1 (24%) Femoral nerve 14. 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 15. 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% 16. MISCELLANEOUS FRACTURES Transverse fractures From landing on the buttocks U shaped fractures 17. One hand is placed on the iliac crest The other hand applies traction to the leg Displacement in vertical plane PHYSICAL EXAMINATION 18. 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 19. RADIOGRAFIC INVESTIGATION 20. 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 21. CD SCAN 22. The most sensitive in detection of fractures - soft tissue edema - marrow changes MRI 23. TREATMENT ZONE I Without neurologic deficits and stable Symptom relief Bed rest (7-10 days) Log-rolled 24. TREATMENT ZONE II and III Without neurologic deficits Bed rest for 4-8 weeks Weight bearing at 4-8 weeks on the fractured side 25. TREATMENT ZONE III Without neurologic deficits Observation: neuropraxia that will resolve Symptoms beyond 6-8 weeks: foraminal decompression 26. TREATMENT ZONE III With neurologic injury Aggressive radiologic examination Early posterior decompression for Return of bowel, bladder control Reserval of foot drop 27. COMPLICATIONS OF CONSERVATIVE TREATMENT chronic pain sacroiliac joint arthritis changes in the alignment on the sacrum bowel, bladder disability 28. DETERMINATION OF FRACTURE STABILITY Stable fractures Impacted vertical fracture Nondisplaced fracture of posterior sacroiliac complex Fracture of the upper sacrum 29. DETERMINATION OF FRACTURE STABILITY Unstable Fracture diastasis of more than 0,5 1cm along with an anterior unstable injury 30. 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 31. PROCEDURE PRONE POSITION 32. 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) 33. OPEN REDUCTION AND INTERNAL FIXATION 34. MISCELLANEOUS CASES 35. CASE 4 36. CONCLUSION Neurological deficities Stable Fractures : conservative treatment Unstable Fractures : operative treatment Neurologic injury :posterior decompression