Orthopaedics & Traumatology: Surgery & Research (2013) 99, 625—629

Available online at

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TECHNICAL NOTE

Technique for reduction and percutaneousfixation of U- and H-shaped sacral fractures

S. Ruatti ∗, G. Kerschbaumer, E. Gay, M. Milaire,P. Merloz, J. Tonetti

Service d’orthopédie traumatologie, hôpital Michallon, CHU de Grenoble, BP 217, 38043 Grenoble cedex09, France

Accepted: 18 March 2013

KEYWORDSSacral fracture;Reduction;Ilio-sacral screwfixation;

Summary We describe an early reduction and percutaneous fixation technique for isolatedsacral fractures. Strong manual traction combined with manual counter-traction on the torso isused to disimpact the fracture. Transcondylar traction is then applied bilaterally and two ilio-sacral screws are inserted percutaneously on each side. Open reduction and fixation, with sacrallaminectomy in patients with neurological abnormalities, remains the reference standard. Early

Sacral fixation;Percutaneous

reduction and percutaneous fixation ensures restoration of the pelvic parameters while minimis-ing soft-tissue damage and the risk of infection. Decompression procedures can be performedeither during the same surgical procedure after changing the installation or after a few days.These complex fractures warrant patient referral to specialised reference centres.© 2013 Elsevier Masson SAS. All rights reserved.

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Introduction

Among the fractures that disrupt the posterior pelvic ring,15% to 45% involve the sacrum [1,2] and 2% to 5% of thesesacral fractures are isolated U- or H-shaped fractures [3,4].The work reported by Roy-Camille et al. in 1985 improvedthe understanding of the mechanisms underlying U- and

H-shaped sacral fractures. Typically, the fracture occurswhen the patient lands after falling from a considerableheight (e.g. suicide by defenestration) with the lumbar spine

∗ Corresponding author.E-mail address: sruatti@chu-grenoble.fr (S. Ruatti).

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n exaggerated lordosis and the hips extended [5]. Roy-amille et al. developed the first classification scheme withhree types, and Strange-Vognsen et al. subsequently addednother type characterised by a burst fracture of the bodyf S1 [6].

Surgical treatment involving lumbo-pelvic or trans-sacralxation has not consistently been found effective comparedo the conservative treatment [7—13]. Nevertheless, recenteta-analyses confirm the beneficial effects of surgical

reatment, most notably regarding restoration of satisfac-ory alignment in the sagittal plane [14]. Open surgery can

e followed by complications, such as disturbed wound heal-ng and infection [15—18]. Percutaneous ilio-sacral screwxation as described by Routt et al. in 1996 decreases theorbidity of surgical treatment for sacral fractures [19,20].

served.

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Here, we describe a technique of early reduction fol-owed by percutaneous screw fixation for U- and H-shapedractures of the sacrum.

eduction technique

he diagnosis should be obtained at the arrival of theatient. Disruption of the pelvic ring must be definitivelyuled out. Computed tomography with sagittal reconstruc-ion allows classification of the fracture according tooy-Camille et al. and Strange-Vognsen et al. A neurolog-cal evaluation is indispensable at the admission and shoulde repeated during the immediate postoperative periodhen during subsequent follow-up. The findings should beecorded in the patient’s medical file.

At the early phase, in the operating room, bilateralranscondylar traction is set up. The patient is supine on

table slightly inclined in the Trendelenburg. After intuba-ion and neuromuscular blockade, the surgeon applies rapidtrong traction to both transcondylar traction stirrups whilewo assistants apply counter-traction to both armpits. Ide-lly, a cracking sound indicating fracture disimpaction iseard and felt. The strongest predictor of successful reduc-ion is a short time to performance of the manoeuvre. Theeduction is maintained by applying 15% of the patient’sody weight to each traction pin (Fig. 1). It is then possibleo wait for the most appropriate time for performing thexation procedure, according to the damage-control princi-le.

When the patient’s general condition is stable, the defini-ive fixation procedure can be performed. The patient isupine on a transparent surgical table with both transcondy-ar traction devices in place. A hard pad made from foldedheets to the size appropriate for the patient is placed underhe lumbo-sacral junction (Fig. 2) to induce hyperlordosis,hich completes the reduction of the sacrum. A method of

ast resort consists in placing the upper part of the table inrendelenburg position and the lower part in proclivity. Theuality of the reduction is assessed on lateral fluoroscopic

iews. We believe the best criterion is good alignment of thenterior sacral cortex (Fig. 3).

In our institution, we use bilateral percutaneous ilio-acral screws to ensure fixation [19,20]. Ideally, two screws

igure 1 Diagram of the full reduction technique performedn an emergency basis.

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igure 2 Patient installation on the operating table. Padnder the lumbar region to reduce the fracture via ligamen-otaxis.

hould be inserted through each longitudinal fracture tonsure rotational stability of the central sacral fragment.he patient is allowed to sit with the torso inclined no fur-her than 45◦ starting on day 1. Weight bearing is resumedn day 45.

esults

e report the results obtained in three patients (2 femalesnd 1 male). The fracture was due to a 3-m fall from acaffolding (Fig. 3), a motorcycle accident (Fig. 4), and a-m fall while skiing (Fig. 5), respectively. All the threeatients had neurological signs, which consisted in caudaquine syndrome in two patients and left S1 radicular painn one patient. The first patient was managed with two-tage surgery involving early reduction and laminectomy inrocubitus by a neurosurgeon then, implantation of fourlio-sacral screws. The other two patients had the same-tage early reduction and strictly percutaneous fixation withlio-sacral screws (two and four screws, respectively). Inhese two patients, reduction of the fracture ensured com-lete decompression of the sacral canal, obviating the needor laminectomy. The neurological evaluation was normaln the first patient after 7 months. In the second patient,nal sphincter contraction remained slightly impaired after

months. Follow-up duration was only 15 days in the thirdatient, at which point, the S1 pain was slightly improved.

iscussion

eduction and fixation of isolated sacral fractures areften difficult procedures that must be performed onultiply injured patients who are usually vulnerable and

equire management in level I trauma centers, in par-icular to enable appropriate management of co-existingesions and, if needed, emergency embolisation [1,6,21,22].on-operative management via bed rest is often advocated4,7—14], based on the argument that neurological impair-ents due to sacral root avulsion or contusion result in a very

ow likelihood of functional recovery [4,10,11]. Kellam et al.uggested that non-operative treatment may be most usefuln centers with little experience of sacral fracture surgerys, when well conducted, this approach may produce better

Percutaneous fixation of U- and H-type sacral fractures 627

Figure 3 A 37-year-old man. A. Preoperative computed tomography (CT), sagittal slice, showing a Roy-Camille type II sacralfracture. On the standard radiograph, pelvic incidence was 71◦. B. Intra-operative lateral fluoroscopic view before reduction. C.Intra-operative lateral fluoroscopic view after reduction and placement of the lumbar pad: quality of the reduction is assessedbased on alignment of the anterior sacral cortex. D. Postoperative CT, sagittal slice. On the standard radiograph, pelvic incidencewas 63.6◦. E. Postoperative CT, axial slice.

Figure 4 A 17-year-old woman. A. Preoperative computed tomography (CT), sagittal slice, showing a Roy-Camille type II sacralfracture. On the standard radiograph, pelvic incidence was 72.4◦. B. Preoperative CT, axial slice: obstruction of the sacral canal dueto posterior displacement of the proximal fragment. C. Preoperative 3D CT. D. Postoperative CT, axial slice: note the two ilio-sacralscrews. E. Postoperative CT, sagittal slice: anatomic fracture reduction. F. Postoperative CT, axial slice: decompression of the sacralcanal due to the anatomic fracture reduction.

628 S. Ruatti et al.

Figure 5 A 22-year-old woman. A. Preoperative computed tomography (CT), sagittal slice, showing a U-shaped Roy-Camille typeII sacral fracture. B. Preoperative CT, axial slice: narrowing of the sacral canal due to displacement of the proximal fragment.C. Intra-operative lateral fluoroscopic view, after the reduction manoeuvre and placement of the lumbar pad: anatomic fracturereduction. D. Postoperative CT, sagittal section: anatomic fracture reduction and visibility of two of the four ilio-sacral screws. E.Postoperative CT, axial slice: decompression of the sacral canal due to the anatomic fracture reduction.

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esults than a difficult surgical procedure performed by annexperienced team [23].

However, the general consensus is that open surgicalxation is the best strategy [1,2,5,6,15—18]. The mainomplications are surgical-site infection and wound heal-ng disturbances, seen in 16% of the patients in a study byellabarba et al. [23]. Pohlemann et al. cautioned againsthe major risk of infection, as well as the complexity ofhe constructs, which requires considerable experience onhe part of the surgical team [24]. Percutaneous ilio-sacralcrew fixation helps to minimise these complications. Thedvantages include the absence of decompression of thentra-pelvic haematoma and decreased intra- and postop-rative bleeding [19,20]. This attractive technique, whichecreases iatrogenic morbidity, seems of value for theanagement of isolated sacral fractures. Its use remains

hallenging, however, in patients with lumbo-sacral tran-itional abnormalities, such as lumbarisation of S1 oracralisation of L5 [19,20]. König et al. described a verynteresting technique involving fracture site distractionetween four screws inserted percutaneously into the L5nd S1 pedicles, followed by trans-sacral fixation using twolio-sacral screws [25].

The technique described here is a percutaneous fixation

echnique that can easily be combined with decompres-ion sacral laminectomy, either during the same surgicalrocedure or later on depending on the patient’s condi-ion. A study by Kim et al. [21] and a meta-analysis by Yi

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t al. [17] confirm the usefulness of laminectomy, chiefly forelieving pressure on roots that are undamaged, stretched,r minimally contused. However, the likelihood of recov-ry after root avulsion is minuscule. Yi et al. advocatedame-stage laminectomy, before fracture reduction and sur-ical fixation, based on the argument that free fragmentseleased by the reduction manoeuvre might put pressuren the roots entrapped in the canal. In our experience,ood quality percutaneous reduction is usually sufficient tochieve decompression of the sacral roots (Figs. 4f and 5e).his strategy eliminates morbidity related to the posteriorpproach.

onclusion

solated sacral fractures are serious lesions that must beanaged in specialised centers. Displaced fractures require

surgical procedure, and additional sacral laminectomyay be required in patients with neurological deficits. Early

eduction and percutaneous fixation reliably restores thehysiological pelvic parameters, provided rigorous tech-ique is used, and can be combined with laminectomy if theeduction fails to provide nerve root decompression. The

ell-known infectious and wound-healing complications ofpen surgery are far less common with the percutaneousechnique, allowing early rehabilitation therapy and produc-ng lower morbidity and mortality rates.

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Percutaneous fixation of U- and H-type sacral fractures

Disclosure of interest

The authors declare that they have no conflicts of interestconcerning this article.

References

[1] Denis F, Davis S, Comfort T. Sacral fractures: an importantproblem: retrospective analysis of 236 cases. Clin Orthop1988;227:67—81.

[2] Taguchi T, Kawai S, Kaneko K, Yugue D. Operative manage-ment of displaced fractures of the sacrum. J Orthop Sci1999;4:347—52.

[3] Carl A, Delman A, Engler G. Displaced transverse sacral frac-tures: a case report, review of the literature, and the CT scanas an aid in management. Clin Orthop 1985;194:195—8.

[4] Phelan ST, Jones DA, Bishay M. Conservative management oftransverse fractures of the sacrum with neurological features:a report of four cases. J Bone Joint Surg Br 1991;73:969—71.

[5] Roy-Camille R, Saillant G, Gagna G, Mazel C. Transverse frac-ture of the upper sacrum suicidal jumper’s fracture. Spine1985;10:838—45.

[6] Strange-Vognsen HH, Lebech A. An unusual type of fracture inthe upper sacrum. J Orthop Trauma 1991;5:200—3.

[7] Wiesel SW, Zeide MS, Terry RL. Longitudinal fractures of thesacrum: case report. J Trauma 1979;19:70—1.

[8] Ferris B, Hutton P. Anteriorly displaced transverse fracture ofthe sacrum at the level of the sacro-iliac joint. A report of twocases. J Bone Joint Surg Am 1983;65:407—9.

[9] Dogra AS, Karkhanis AR, Asurlekar RV. Fracture sacrum. J Post-grad Med 1995;41:47—9.

[10] Ikada K, Wada E, Kodama N. Traction injury of the lumbosacralspinal nerve roots: report of a case. Spine 1991;16:368—71.

[11] Mouhsine E, Wettstein M, Schizas C, Borens O, Blanc CH,Leyvraz PF, et al. Modified triangular posterior osteosynthesisof unstable sacrum fracture. Eur Spine J 2006;15:857—63.

[12] Lykomitros VA, Papavasiliou KA, Alzeer ZM, Sayegh FE, KirkosJM, Kapetanos GA. Management of traumatic sacral fractures:a retrospective case-series study and review of the literature.Injury 2010;41:266—72.

[

629

13] Dogra AS, Karkhanis AR, Asurlekar RV. Fracture sacrum. J Post-grad Med 1995;41(2):47—9.

14] Hart RA, Badra MI, Madala A, et al. Use of pelvic incidence as aguide to reduction of H-type spino-pelvic dissociation injuries.J Orthop Trauma 2007;21:369—74.

15] Robles LA. Transverse sacral fractures. Spine J 2009;9:60—9.

16] Dussa CU, Soni BM. Influence of type of management oftransverse sacral fractures on neurological outcome. A caseseries and review of literature. Spinal Cord 2008;46(9):590—4, http://dx.doi.org/10.1038/sc.2008.59 [Epub 2008 Jun10].

17] Yi C, Hak DJ. Traumatic spinopelvic dissociation or U-shaped sacral fracture: a review of the literature. Injury2012;43(4):402—8, http://dx.doi.org/10.1016/j.injury.2010.12.011 [Epub 2011 Jan 13].

18] Hak DJ, Baran S, Stahel P. Sacral fractures: current strate-gies in diagnosis and management. Orthopedics 2009;32,doi:pii:orthosupersite.com.

19] Routt Jr ML, Simonian PT. Closed reduction and percutaneousskeletal fixation of sacral fractures. Clin Orthop Relat Res1996;329:121—8.

20] Routt Jr ML, Nork SE, Mills WJ. Percutaneous fixation of pelvicring disruptions. Clin Orthop Relat Res 2000;375:15—29.

21] Kim MY, Reidy DP, Nolan PC, Finkelstein JA. Transverse sacralfractures: case series and literature review. Can J Surg2001;44:359—63.

22] Kellam JF, McMurtry RY, Paley D, Tile M. The unstablepelvic fracture operative treatment. Orthop Clin North Am1987;18:25—41.

23] Bellabarba C, Schildhauer TA, Vaccaro AR, Chapman JR.Complications associated with surgical stabilization of high-grade sacral fracture dislocations with spino-pelvic instability.Spine 2006;31(15):S80—8.

24] Pohlemann T, Angst M, Schneider E, Ganz R, Tscherne H. Fixa-tion of transforaminal sacrum fractures: a biomechanical study.J Orthop Trauma 1993;7:107—17.

25] König MA, Seidel U, Heini P, Orler R, Quraishi NA, Boszczyk AA,et al. Minimal-invasive percutaneous reduction and transsacralscrew fixation for U-shaped fractures. J Spinal Disord Tech2013;26(1):48—54.