SACRAL SACRAL
FRACTURES FRACTURES
PELVIC ANATOMY ANTERIOR VIEW PELVIC ANATOMY ANTERIOR VIEW
PELVIC ANATOMY POSTERIOR VIEW
PELVIC ANATOMY INLET VIEW
SACRUM ANATOMY
SACRUM ANATOMY
POSTERIOR WALL OF PELVIS
LATERAL WALL OF PELVIS
SACRAL PLEXUS
SACRAL PLEXUS
SACRAL PLEXUS
SACRUM FRACTURES – NERVE ROOTS
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
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
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%
MISCELLANEOUS FRACTURES
• Transverse fractures
• From landing on the buttocks
• U shaped fractures
• One hand is placed on the iliac crest
• The other hand applies traction to the leg
Displacement in vertical plane
PHYSICAL EXAMINATION
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
RADIOGRAFIC INVESTIGATION
• 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
CD SCAN
• The most sensitive
in detection of fractures
- soft tissue edema
- marrow changes
MRI
TREATMENT
ZONE I
• Without neurologic deficits and stable
• Symptom relief
• Bed rest (7-10 days)
• Log-rolled
TREATMENT
ZONE II and III
• Without neurologic deficits
• Bed rest for 4-8 weeks
• Weight bearing at 4-8 weeks on the fractured side
TREATMENT
ZONE III
• Without neurologic deficits
• Observation: neuropraxia that will resolve
• Symptoms beyond 6-8 weeks: foraminal decompression
TREATMENT
ZONE III
• With neurologic injury
• Aggressive radiologic examination
• Early posterior
decompression
forReturn of – bowel, bladder
control
Reserval of foot drop
COMPLICATIONS OF CONSERVATIVE
TREATMENT
• chronic pain
• sacroiliac joint arthritis
• changes in the alignment on the sacrum
• bowel, bladder disability
DETERMINATION OF FRACTURE STABILITY
• Stable fractures
• Impacted vertical fracture
• Nondisplaced fracture of posterior sacroiliac complex
• Fracture of the upper sacrum
DETERMINATION OF FRACTURE STABILITY
• Unstable
• Fracture diastasis of more than 0,5 – 1cm along with an anterior unstable injury
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
PROCEDURE PRONE POSITION
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)
OPEN REDUCTION AND INTERNAL FIXATION
MISCELLANEOUS CASES
CASE 4
CONCLUSION
• Neurological deficities
• Stable Fractures : conservative treatment
• Unstable Fractures : operative treatment
• Neurologic injury :posterior decompression