Technique for reduction and percutaneous fixation of U- and H-shaped sacral fractures

Traumatic lumbosacral instability: part 2-indications and techniques for surgical management

Traumatic lumbosacral instability (TLSI) refers to a traumatic disruption of the axial skeleton at the level of the lumbosacral motion segment and/or sacrum, resulting in mechanical separation of the caudal spinal column from the posterior pelvic ring. Managing TLSI and its four underlying conditions poses unique challenges among spinal and pelvic injuries. This second part of a two-part series focuses on treatment strategies and decision making in TLSI, with an emphasis on surgical stabilization techniques. The primary objectives of this article are to: (1) elucidate factors influencing clinical decision-making, (2) synthesize current treatment options for the injury patterns underlying TLSI, and (3) briefly outline expected outcomes and complications.

Lumbopelvic Stabilization with Two Methods of Triangular Osteosynthesis: A Biomechanical Study

(1) Background: Pelvic fractures, and particularly instabilities of the dorsal pelvic ring, are becoming increasingly prevalent, particularly in orthogeriatric patients. Spino-pelvic triangular osteosynthesis is an effective approach to achieve sufficient stabilization in vertically unstable fractures. This study compares two types of osteosynthesis: the conventional one and a novel instrumentation where the iliosacral screw is placed through a fenestrated iliac screw. (2) Methods: Sixteen artificial osteoporotic L5+pelvis models with an unstable sacral fracture have been instrumented with either an iliac screw connected with a rod to a L5 pedicle screw and an iliosacral screw (TF) or a fenestrated ilium screw connected with a rod to a L5 pedicle screw and an iliosacral screw passing through the fenestra of the iliac screw (TFS). Biomechanical testing was performed using cyclic loading until failure. (3) Results: Both configurations yielded comparable results with regard to initial stiffness, implant loosening, and cycles to failure. The TFS exhibited markedly higher values for cycles to failure and markedly lower values for loosening. However, due to the characteristics of the artificial bone model, these findings were not significant. (4) Conclusions: The novel triangular fixation systems demonstrated comparable results to the standard triangular osteosynthesis configuration.

Fluoroscopy guided teardrop technique for open trans-muscular iliac screw placement and open reduction maneuvers during modified triangular spinopelvic fixation for unstable U-shaped sacral and tile C pelvic traumas: technical note

Unstable traumas of the spinopelvic junction, which include displaced U-shaped sacral fractures (Roy-Camille type 2 and type 3) and Tile C vertical shear pelvic ring disruptions, occur in severe traumas patients following high speed traffic accident or fall from a height. These unstable traumas of the spinopelvic junction jeopardize one's ability to stand and to walk by disrupting the biomechanical arches of the pelvis, and may also cause cauda equina syndrome. Historically, such patients were treated with bed rest and could suffer a life-long burden of orthopedic and neurological disability. Since Schildhauer pioneer work back in 2003, triangular spinopelvic fixation, whether it is performed in a percutaneous fashion or by open reduction and internal fixation, allows to realign bone fragments of the spinopelvic junction and to resume walking within three weeks. Nevertheless, such procedure remains highly technical and it not encountered very often, even for spine surgeons working in high-volume level 1 trauma centers. Hence, this visual technical note aims to provide a few tips to guide less experience surgeons to complete this procedure safely.

Surgical Management of Unstable U-Shaped Sacral Fractures and Tile C Pelvic Ring Disruptions: Institutional Experience in Light of a Narrative Literature Review

Unstable U-shaped sacral fractures and vertical shear Tile C pelvic ring disruptions are characterized by rare lesions occurring in patients with severe trauma. Because the initial damage-control resuscitation primarily aims to stop life-threatening bleeding, emergency treatment often includes an anterior external pelvic fixator. Delayed surgery is mandatory to allow early mobilization, reduce mortality, and improve functional outcomes. Regarding U-shaped sacral fractures, although Roy-Camille type 1 U-shaped sacral fractures can be treated with iliosacral screws, types 2 (posteriorly displaced, equivalent to AO Spine C3) and 3 (anteriorly displaced, equivalent to AO Spine C3) fractures require spinopelvic triangular fixation. Besides, proper reduction of type 2 and some type 3 sacral fractures is mandatory to prevent wound complications. In patients with neurological deficits, the need for sacral laminectomy is left at the discretion of the surgeon, given the indirect decompression already obtained with fracture reduction. Tile C pelvic disruptions with posterior ring injury located lateral to the sacral foramen can be treated with either iliosacral screws or triangular spinopelvic fixation, combined with anterior pelvic fixation. Conversely, Tile C pelvic disruptions with posterior ring injury located at, or medial, to the sacral foramen (Denis zone II or III) induce vertical lumbosacral instability and thus require spinopelvic triangular fixation with anterior pelvic osteosynthesis. Although minimally invasive techniques have been developed, open surgeries are still required for inexperienced operators and in case of major displacement. The complication rate reaches approximately 33.33% of the cases, and complications include hardware malposition, wound infection or dehiscence, hardware prominence, and sometimes hardware failure.

Consensus for management of sacral fractures: from the diagnosis to the treatment, with a focus on the role of decompression in sacral fractures

BACKGROUND

There is no evidence in the current literature about the best treatment option in sacral fracture with or without neurological impairment.

MATERIALS AND METHODS

The Italian Pelvic Trauma Association (A.I.P.) decided to organize a consensus to define the best treatment for traumatic and insufficiency fractures according to neurological impairment.

RESULTS

Consensus has been reached for the following statements: When complete neurological examination cannot be performed, pelvic X-rays, CT scan, hip and pelvis MRI, lumbosacral MRI, and lower extremities evoked potentials are useful. Lower extremities EMG should not be used in an acute setting; a patient with cauda equina syndrome associated with a sacral fracture represents an absolute indication for sacral reduction and the correct timing for reduction is "as early as possible". An isolated and incomplete radicular neurological deficit of the lower limbs does not represent an indication for laminectomy after reduction in the case of a displaced sacral fracture in a high-energy trauma, while a worsening and progressive radicular neurological deficit represents an indication. In the case of a displaced sacral fracture and neurological deficit with imaging showing no evidence of nerve root compression, a laminectomy after reduction is not indicated. In a patient who was not initially investigated from a neurological point of view, if a clinical investigation conducted after 72 h identifies a neurological deficit in the presence of a displaced sacral fracture with nerve compression on MRI, a laminectomy after reduction may be indicated. In the case of an indication to perform a sacral decompression, a first attempt with closed reduction through external manoeuvres is not mandatory. Transcondylar traction does not represent a valid method for performing a closed decompression. Following a sacral decompression, a sacral fixation (e.g. sacroiliac screw, triangular osteosynthesis, lumbopelvic fixation) should be performed. An isolated and complete radicular neurological deficit of the lower limbs represents an indication for laminectomy after reduction in the case of a displaced sacral fracture in a low-energy trauma associated with imaging suggestive of root compression. An isolated and incomplete radicular neurological deficit of the lower limbs does not represent an absolute indication. A worsening and progressive radicular neurological deficit of the lower limbs represents an indication for laminectomy after reduction in the case of a displaced sacral fracture in a low-energy trauma associated with imaging suggestive of root compression. In the case of a displaced sacral fracture and neurological deficit in a low-energy trauma, sacral decompression followed by surgical fixation is indicated.

CONCLUSIONS

This consensus collects expert opinion about this topic and may guide the surgeon in choosing the best treatment for these patients.

LEVEL OF EVIDENCE

IV.

TRIAL REGISTRATION

not applicable (consensus paper).

Sacroiliac screws fixation navigated with three-dimensional printing personalized guide template for the treatment of posterior pelvic ring injury: A case report

Objective

Pelvic injuries refer to the disruption of the inherent structural and mechanical integrity of the pelvic ring. Sacroiliac screw fixation technique is often used for the treatment of posterior pelvic ring injury, which is prone to the iatrogenic injury. Various attempts were proposed to avoid iatrogenic injuries, while the executing processes are usually too cumbersome. The patient-personalized guide template based on 3D printing technology has been considered as a promising method, which can achieve lower deviation and higher accuracy in a simple and convenient way. We reported the first case of posterior pelvic ring injury using 3D printing personalized guide template with the verification of intraoperative CT.

Methods

The subject was a 74-year-old female with posterior pelvic ring injury. Two patient-specific guide templates were customized based on 3D printing technology, one for S1 and the other for S2. We used the guide templates for navigation to place the sacroiliac screws. The placement of screws was verified by intraoperative CT. Intraoperative and postoperative variables were collected.

Results

The technique helped us successfully insert the sacroiliac screws into the safe zone. The intraoperative blood loss was 23.03 ml, and the duration of operation was 62 min. The exposure dose during CT scanning was 7.025 mSv. The assessment of screws position was excellent. Furthermore, there was no sign of any functional impairment postoperatively.

Conclusion

Sacroiliac screws fixation with the assistance of 3D printing personalized guide template under the verification of intraoperative CT may be a promising method to treat posterior pelvic ring injuries.

Distal sacral nerve roots severed by a fragility fracture of the sacrum: a case report

Background

Owing to the aging population, fragility fractures of the pelvis are occurring more frequently. Fixation of the fracture and stabilization of the pelvic ring usually provide good clinical results. A case of distal sacral nerve roots severed by a fragility fracture of the sacrum is presented.

Case presentation

A 62-year-old Japanese woman with schizophrenia with low back pain, gait disorder, dysuria, and fecal incontinence presented to an emergency department, and plain X-rays showed no findings. She also complained of dysuria, and neurogenic bladder and cystitis were diagnosed. One month later, she was admitted to a psychiatric hospital for exacerbation of schizophrenia. In hospital, she had a urethral catheter inserted and spent 3 months in bed. She was referred to our orthopedic department because a gait disorder was discovered after her mental condition improved and she was permitted to walk. On examination, she could not walk and had decreased sensation from the buttocks to both posterior thighs and around the anus and perineum. Manual muscle testing of her lower limbs showed mild weakness of about 4 in bilateral flexor hallucis longus and gastrocnemius, and bilateral Achilles tendon reflexes were lost. Her anal sphincter did not contract, and urinary retention continued after urethral catheter removal. Imaging examinations showed an H-shaped sacral fracture consisting of a transverse fracture with displacement of the third sacral vertebra and vertical fractures of the bilateral sacral wings, with severe stenosis of the spinal canal at the site of the transverse fracture. The patient was diagnosed as having bladder and rectal dysfunction due to a displaced, unstable sacral fracture. First to third sacral laminectomy and alar–iliac fixation using percutaneous pedicle screws and sacral alar–iliac screws were then performed. The bilateral distal sacral nerve roots (S3, S4, S5) were completely severed at the second to third sacral levels, but bilateral second sacral nerve roots were not compressed from the bifurcation to the sacral foramen. Postoperatively, bladder and rectal dysfunction remained, but the low back pain was alleviated. Two weeks postoperatively, she could walk with a walker and was discharged. Three months after the operation, bone fusion of the fracture was observed.

Conclusions

In cases of bladder–rectal dysfunction with low back pain, the possibility of sacral fracture should be considered, and computed tomography, magnetic resonance imaging, and X-ray examinations should be performed. Even sacral fractures without displacement require attention because they can cause serious injury in the event of a nerve root being severed if not diagnosed early and given appropriate treatment.

Percutaneous posterior transiliac plate versus iliosacral screw fixation for posterior fixation of Tile C-type pelvic fractures: a retrospective comparative study

BACKGROUND

This study aimed to compare the clinical outcomes and complications between two minimally invasive surgical techniques: percutaneous transiliac plate fixation and iliosacral (IS) screw fixation for the treatment of Tile C-type pelvic bone fractures.

METHODS

We retrospectively reviewed the data of 77 consecutive patients with Tile C pelvic ring injuries who underwent either percutaneous transiliac plate fixation or IS screw fixation in a single academic center between November 2007 and January 2018. We recorded patients' demographics, surgery-related data, and postoperative surgical outcomes and compared the incidence of complications and revision surgery rates between the two groups.

RESULTS

Overall, 14 patients were included in the plate group, while 63 were included in the IS screw fixation group. No significant differences were observed in the patients' demographics between the two groups except for a longer interval from injury to surgery (13.5 days vs. 5.4 days, P = 0.001). Both groups acquired fracture union in all cases. There was one case of infection requiring surgical debridement in the plating group. Notably, nerve injury (n = 3) and implant loosening (n = 5) occurred in the IS screw group, but the difference was not significant.

CONCLUSIONS

Both percutaneous posterior transiliac plating and IS screw fixation in patients with Tile C-type pelvic bone fractures showed good results. We recommend IS screw fixation as the primary treatment and propose posterior plating as treatment for sacral dysmorphism and bilateral sacral alar fractures in patients with spinopelvic dissociation.

LEVEL OF EVIDENCE

III.

Screw misplacement in percutaneous posterior pelvic iliosacral screwing with and without navigation: A prospective clinical study of 174 screws in 127 patients

BACKGROUND

Recent studies of iliosacral screw fixation performed using intraoperative navigation systems have shown promising results. The Surgivisio Platform is a new-generation three-dimensional intraoperative navigation tool that has been used at our institution for 2years. The aim of this prospective study was to assess the contribution of navigation in terms of iliosacral screw positioning accuracy and of radiation exposure, by comparing outcomes with vs. without navigation.

HYPOTHESIS

Navigation allows more accurate percutaneous iliosacral screw positioning regardless of the type of screw fixation (with sacral dysmorphism and/or cemented screw fixation and/or multiple screw fixation).

MATERIALS AND METHODS

Between January 2018 and December 2019, consecutive patients who underwent percutaneous iliosacral screw fixation of pelvic ring fractures without vertical instability were included in this single-centre prospective study. Screw position accuracy was evaluated by postoperative high-resolution computed tomography (HRCT). Operative time, radiation dose, and complications were recorded.

RESULTS

We included 127 patients with 174 iliosacral screws, of which 129 were positioned under fluoroscopic guidance and 45 using navigation. According to the modified Gras classification, 7% (12/174) of the screws were incorrectly positioned and 2% (4/174) required repositioning. The frequency of screw malposition was not significantly different between the fluoroscopy and navigation groups (8.5%, 11/129 vs. 2.2%, 1/45, respectively; p=0.19). However, screw position in dysmorphic sacra was significantly better with navigation (p=0.04), whereas no significant difference in final screw position was found for cemented or multiple screw implantations. In the navigation group, the operative time was significantly longer (28.2min vs. 21.6min, p=0.003), and the mean dose-area product significantly greater (6.6Gy·cm² vs. 4.9Gy·cm², p=0.02). The complication rates were not different between the two groups.

CONCLUSION

In patients who have pelvic ring fractures without vertical instability, navigation of percutaneous iliosacral screw placement using the Surgivisio Platform improves screw positioning in dysmorphic sacra, at the cost of a longer operative time and greater radiation exposure of the patient.

LEVEL OF EVIDENCE

II, prospective study.

Clinical Outcome of Sacroiliac Rod Fixation for Fragility Fracture of the Pelvis Rommens and Hoffman Classification Type IVb: Case Series

Introduction

Fragility fracture of the pelvis (FFP), generally involving Rommens and Hoffman classification type IVb (H-shaped) requires spinopelvic fixation (SPF). We report the clinical outcome of sacroiliac rod fixation (SIRF) for FFP type IVb in a case series.

Materials and Methods

In this retrospective observational study, six patients (mean age, 80.3 years; range, 74-85 years) with FFP type IVb who underwent SIRF since October 2019 and could be followed up for ≥1 year postoperatively were included. All patients were injured in low-energy falls, a patient had a femoral neck fracture, and other had a humeral neck fracture and distal radius fracture.

Results

The mean (range) operative time was 135 (98-200) min, and mean blood loss was 103 (80-130) g. All patients achieved bone union in an average of 4.3 months. No implant failure or surgical site infection requiring reoperation occurred. No patient complained of iliac screw irritation or requested removal. One patient developed a T12 vertebral fracture at 3 weeks postoperatively. The mean final follow-up period was 17.8 months (13-22 months) and mean final modified Majeed Score (maximum 76 points as the items “work” and “sexual intercourse” were omitted for this study) was 71.7 (56-76).

Conclusions

SIRF is a less invasive surgical technique than SPF that uses only an S1 pedicle screw and iliac screw. SIRF using the “within ring” concept showed good clinical outcome in FFP type IVb.

Minimally invasive triangular lumboiliac and iliosacral fixation of posterior pelvic ring injuries with vertical instability: Technical note

To date, no strong consensus exists on the best way to treat posterior pelvic ring injuries when there is no neurological deficit. Various fixation methods have been described; more recently, constructs that combine lumboiliac and iliosacral fixation have been introduced. This type of fixation is mainly indicated in cases of spinopelvic dissociation with large displacement of fracture fragments in the sagittal plane. However, these techniques are associated with postoperative complications, particularly infections and severe skin complications. This led us to propose a minimally invasive lumboiliac and iliosacral fixation technique for posterior pelvic ring injuries. The procedure is done with the patient prone. It consists of pedicle screw insertion into L4 or L5 and screw fixation of the ilium with fluoroscopy guidance; intraoperative distraction can be done depending on the amount of displacement. An iliosacral screw is then inserted percutaneously to allow reduction in the transverse plane and yield a triangular construct. In the five patients that we have operated using this technique, the mean preoperative vertical displacement was 11.9±6.9mm (SD) (min 1.3, max 19.7) versus 3.7±3.2mm (min 0.3, max 6.7) postoperatively and the mean preoperative frontal displacement was 7.5±3.7mm (min 4.2, max 12.4) versus 2.5±2.0mm (min 0.3, max 4.3) postoperatively. Minimally invasive iliosacral and lumboiliac fixation is an option for treating posterior pelvic ring fractures free of neurological deficit and especially spinopelvic dissociation.

Roy-Camille Type 3 suicidal jumper's fractures: Case series and review of the literature

Background:

Roy-Camille reported only three patients in their Type 3 posttraumatic transverse sacral fracture (TSF) classification. A modified Roy-Camille classification has been already proposed by other authors suggesting further categorization of the TSFs as partially displaced or completely displaced to predict the rate of neurological recovery following lumbopelvic fixation.

Materials and Methods:

We reported three adult cases of surgical fixation of fracture–dislocation (3A and 3B) of the sacrum due to traumatic injuries and submitted to lumbopelvic posterior reconstruction. A case of a 15-year-old male patient affected by Type 3C with vascular pelvic injury was also reported. A comprehensive literature search was performed on evaluation and management of Type 3 TSFs.

Results:

In Type 3A, there is a minimal anterior dislocation and the reduction is feasible with good chance of recovery. In Type 3B, the anterior dislocation is severe, neurological deficits are present, reduction is difficult, and there is a risk of vascular injury both at the trauma and during the surgical reduction. In Type 3C, the anterior dislocation is massive, and the risk of vascular injury is very high requiring prompt vascular or endovascular treatment. Open reduction and posterior instrumentation are technically feasible in patients affected by Type 3 high TSFs.

Conclusions:

In our opinion, a modified Roy-Camille classification could be useful in the assessment of prognostic and therapeutic aspects of such fractures, In our opinion, a modified Roy-Camille classification could help assess the prognostic and therapeutic aspects of such fractures, in which the severity of the dislocation affects the surgical technique, the chance of neurological recovery, and the patient's life expectancy.

Suicidal jumper's fracture reduced with hyperextension and the joystick method: A case report

Suicidal jumper's fractures are transversal fractures of the upper sacrum. The treatment for this type of fracture remains controversial. We present a case of a Roy-Camille type 2 suicidal jumper's fracture treated with reduction by hyperextension of the lumbosacral junction, the joystick method, and percutaneous fixation on the day of injury. After the operation, the sacral canal at the S2 level was enlarged and both lower extremities began to move gradually. At 19 days after the injury, direct decompression via sacral laminectomy was performed to promote further neurological improvement. At 10 months after the injury, cauda equina syndrome and radicular symptoms were completely resolved. Considering its minimal invasiveness, we recommend trying hyperextension and the joystick method to treat Roy-Camille type 2 suicidal jumper's fractures on the day of injury.

Spinopelvic Dissociation: A Systematic Review and Meta-analysis

INTRODUCTION

Spinopelvic dissociation is a rare type of injury which occurs in approximately 2.9% of pelvic disruptions and correlates with high-energy trauma.The purpose of this study was to systematically evaluate the incidence, demographics, treatment, clinical outcome, and complication rate associated with these injuries.

METHODS

A literature review on Medline, PubMed, and Google was performed. Overall, 216 abstracts were reviewed in English, German, and French, of which 50 articles were included.

RESULTS

Within the 50 studies, 19 publications were case reports and 16 were case series with low-level evidence. Overall, 379 patients with spinopelvic dissociation were identified at a mean age of 31.6 ± 11.6 years and an injury severity score of 23.1 ± 3.8 between 1969 and 2018. Most cases were related to fall from heights (55.7%), followed by road accidents (28.5%). Two hundred fifty-eight patients (68.1%) showed neurologic impairment at initial presentation, which improved in 65.1% after surgery. The treatment of choice was surgery in 93.1% of cases with triangular fixation in 68.8%. Regardless of the technique, the healing/fusion rate was 100% with a complication rate of 29.9% (n = 96/321).

CONCLUSION

Spinopelvic dissociation is a rare type of injury with limited data in the literature. Based on our review, it is possible that a streamlined, evidence-based algorithm may improve care for these difficult patients.

LEVEL OF EVIDENCE

II.

STUDY DESIGN

Systematic Review.

Posterior Stabilization of Unstable Sacral Fractures: A Single-Center Experience of Percutaneous Sacroiliac Screw and Lumbopelvic Fixation in 67 Cases

Study Design

This is a retrospective study.

Purpose

Recent advances in intraoperative imaging and closed reduction techniques have led to a shifting trend toward surgical management in every unstable sacral fracture. This study aimed to evaluate the clinicoradiological outcome of the sacroiliac (SI) screw and lumbopelvic fixation (LPF) techniques and thereby delineate the indications for each.

Overview of Literature

Optimal management guidelines for unstable sacral fractures are still lacking probably due to the rarity of these injuries and varying fixation trends.

Methods

Out of the 67 patients, 40 and 27 were in the SI and LPF groups, respectively. The electronic medical record for each patient was reviewed, including patient demographic data, mode of trauma, coexisting injuries, neurological status (Gibbon's four-grade system), Injury Severity Score, time from admission to operative stabilization, type of surgical stabilization, complications, return to the operating room, and treatment outcome measures using Majeed's functional grading system and Matta's radiological criteria. The minimum follow-up period was 2 years.

Results

Noncomminuted longitudinal injuries with normal neurology and acceptable closed reduction have undergone SI screw fixation (n=40). Irreducible, comminuted, or high transverse fractures associated with dysmorphic anatomy or neurodeficit were managed by LPF (n=27). Excellent and good Majeed and Matta scores at 86.57% and 92.54% of the patients, respectively, were postoperatively achieved.

Conclusions

Unstable sacral fractures can be effectively managed with percutaneous SI screw including vertically unstable injuries by paying strict attention to preoperative patient selection whereas LPF can be reserved for comminuted fractures, unacceptable closed reduction, associated neurodeficit, lumbosacral dysmorphism, and high transverse fractures.

Spinopelvic Dissociation: Assessment, Reduction Strategies, and Fixation Techniques

Spinopelvic dissociation is a rare injury associated with 2% to 3% of transverse sacral fractures and 3% of sacral fractures associated with pelvic ring injuries. When spinopelvic dissociation is expediently identified and treated appropriately, patient outcomes can be maximized, highlighting the importance of early diagnosis and treatment. Because of its rarity and complexity, there remains a paucity of high-level evidence-based guidance on treating this complex issue. No consensus exists on fixation techniques or reduction maneuvers to achieve stability, allowing for early functional rehabilitation. The purpose of this article is to review the current body of literature to better understand this injury pattern to help establish a treatment algorithm that appropriately guides the treating surgeons in the surgical planning and perioperative care of these patients.

Surgical Fixation of Sacral Fractures in the Elderly Population: Are There Predictors of Outcome? An Analysis of Return to Ambulation and Residential Living Status

Introduction:

Recent literature suggests that surgical fixation of elderly sacral fractures may reduce time to mobilization and ultimately self-sufficiency. However, it is unclear if predictors of success exist in this subpopulation. The objective of this study was to characterize relative change in ambulation and residential living statuses (pre-injury vs. post-surgery) of elderly patients who received surgical fixation of sacral fractures, as well as determine whether or not demographics and injury characteristics influence these findings.

Methods:

Fifty-four elderly patients (≥60 years old) receiving percutaneous screw fixation of sacral fractures were retrospectively reviewed. All fractures were traumatic in nature; insufficiency fractures were excluded. Patient and surgical demographic data, as well as 1-year mortality status, was reported. Primary study endpoints included relative change in patient ambulation and residential living statuses (pre-injury to post-surgery). Statistical analyses were performed to assess relative change in ambulation/living status from pre-injury to post-surgery and to determine if predictors of outcome existed.

Results:

Of the 54 patients who met inclusion criteria, 4 expired prior to discharge, 2 expired post-discharge, and 4 were lost to follow-up. Of those patients discharged, 95.7% regained some form of ambulation at last follow-up (mean: 22.4 ± 18.9 weeks). Of patients living independent pre-injury, 94.9% would eventually return to independent home living. Neither time-to-surgery, concomitant orthopaedic injury, Charlson Comorbidity Index, or injury mechanism were predictors of final ambulation or residential status (p ≥ 0.07). Mortality at 1-year was 11.1%.

Discussion:

Operative fixation supported a high rate of return to pre-injury ambulation and residential living status. However, there did not appear to be measures predictive of final functional status. Further efforts with larger, prospective cohorts are warranted.

Plate versus sacroiliac screw fixation for treating posterior pelvic ring fracture: a Systematic review and meta-analysis

BACKGROUND

Whether plate fixation or sacroiliac (SI) screw fixation is the better treatment for posterior pelvic ring disruption is controversial. The aim of this systematic review and meta-analysis was to compare the two fixation methods.

MATERIAL AND METHODS

The MEDLINE, Embase, and Cochrane Library databases were systematically searched for studies comparing plate and SI screw fixations in posterior pelvic ring injuries. Intraoperative variables, postoperative complications, and clinical/radiological scores were compared between the techniques.

RESULTS

Eleven studies were included in the qualitative synthesis, and nine in the meta-analysis. The meta-analysis included 202 patients who underwent plate fixation and 258 patients who underwent SI screw fixation. The incision length and mean blood loss were greater in the plate group than in the SI screw group (standard mean difference (SMD) = 7.29, 95% confidence interval (CI): 3.18-11.40; SMD = 5.09, 95% CI: 2.08-8.09, respectively). Patients in the SI screw group had more X-ray exposure than those in the plate group (SMD = -5.96, 95% CI: -7.95-3.97). There were no differences in operation time and intraoperative complications (SMD = -1.42, 95% CI: -3.90-1.05; OR = 0.92, 95% CI: 0.05-18.60, respectively). The duration of hospital stay was longer in the plate group (SMD = 2.21, 95% CI: 1.74-2.68). There were no differences in postoperative neurological complications, infection rate, and nonunion rate (OR = 1.62, 95% CI: 0.20-13.21; OR = 2.10, 95% CI: 0.74-5.94; OR = 1.12, 95% CI: 0.26-4.87, respectively), but implant loosening was more common in the SI screw group (OR = 0.18, 95% CI: 0.04-0.87). There was no difference in revision surgery (OR = 0.23, 95% CI: 0.02-2.14). The total excellent rating according to the postoperative Majeed functional and Matta scores was higher in the SI screw group (OR = 0.43, 95% CI: 0.20-0.91; OR = 0.24, 95% CI: 0.08-0.74, respectively).

CONCLUSIONS

SI screw fixation was superior to plate fixation in the functional and radiological scores, but implant loosening was more common for the treatment posterior pelvic ring injuries.

Sacral fractures: issues, challenges, solutions

Sacral fractures are a heterogeneous group of fractures occurring in young people following road traffic accidents and falls from height, or in the elderly with osteoporosis following trivial trauma.This heterogeneity, combined with the low incidence of sacral fractures, determines a lack of experience amongst physicians, often leading to misdiagnosis, underestimation and inadequate treatment. The diagnosis should be made by assessing specific features during the clinical presentation, while computed tomography (CT) scan continues to be the choice of investigation.Sacral fractures can be treated non-operatively or surgically. Non-operative treatment is based on rest, pain relief therapy and early mobilization as tolerated. Surgical techniques can be split into two main groups: posterior pelvic fixation techniques and lumbopelvic fixation techniques. Anterior pelvic fixation techniques should be considered when sacral fractures are associated with anterior pelvic ring injuries, in order to increase stability and reduce the risk of posterior implant failure. To improve fracture reduction, different solutions could be adopted, including special positioning of the patient, manipulation techniques and use of specific reduction tools. Patients suffering from spinopelvic dissociation with associated neurologic lesions hardly ever recover completely, with residual lower-limb neurologic sequelae, urinary problems and sexual disfunction.Herein, we present issues, challenges and solutions related to the management of sacral fractures. Cite this article: EFORT Open Rev 2020;5:299-311. DOI: 10.1302/2058-5241.5.190064.

Neurological Outcome After Traumatic Transverse Sacral Fractures: A Systematic Review of 521 Patients Reported in the Literature

BACKGROUND

The purpose of this study was to determine the neurological outcome after transverse sacral fractures in patients with neurological impairment.

METHODS

A systematic review of the English, French, German, and Dutch literature was conducted. All study designs, including retrospective cohort studies and case reports, describing transverse sacral fractures were included. Two authors independently extracted the predefined data and scored the neurological impairment according to the Gibbons classification after the trauma and at the time of follow-up. The neurological outcomes were pooled according to the Gibbons classification.

RESULTS

No randomized controlled trials or prospective case series were found. A total of 139 articles were included, consisting of 81 case reports and 58 retrospective case series involving 521 patients. Regardless of the type of management, neurological recovery of at least 1 Gibbons category was reported in 62% of these patients. A comparison of the neurological outcome of nonoperatively treated patients and surgically treated patients showed similar neurological recovery rates. For the surgically treated patients, fixation of the fracture resulted in a better neurological improvement compared with an isolated decompression.

CONCLUSIONS

This review could not provide evidence of improved neurological recovery after surgical treatment compared with nonoperative treatment. When surgical treatment was considered, there was a low level of evidence that fixation of the fracture results in better neurological improvement compared with isolated decompression.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Effectiveness of closed reduction and percutaneous fixation of isolated sacral fractures. Functional outcomes and sagittal alignment after 3.6 years in 20 patients

BACKGROUND

Displaced U- or H-shaped sacral fractures (Roy-Camille Grade II or III) are treated at our institution by early transcondylar traction and manual countertraction, hyperlordosis induced by a pad positioned under the lumbo-sacral junction, and percutaneous ilio-sacral screw fixation. The objective of this study was to evaluate the outcome of this technique used in a level 1 trauma centre. Hypothesis Our early reduction technique provides anatomical reduction of U- or H-shaped sacral fractures by correcting the sagittal malalignment due to the intra-sacral kyphosis, thereby obviating the need for decompression laminectomy and improving neurological outcomes.

MATERIAL AND METHODS

We retrospectively evaluated 20 patients treated for U- or H-shaped sacral fractures using our original reduction technique followed by percutaneous fixation only. Mean follow-up was 42.4 months. Mean displacement of the S1 posterior wall was measured on computed tomography scans obtained before and after surgery. Pelvic incidence (PI) and measured lumbar lordosis (LLm) were evaluated on standard radiographs before surgery and on stereoradiographs after surgery. Expected lumbar lordosis (LLe) was computed as LLe=PI+9°. A 25% or greater difference between LLe and LLm defined lumbo-pelvic mismatch. At last follow-up, functional outcomes were assessed based on the Majeed score and the Iowa Pelvic Score (IPS), and a neurological examination was performed.

RESULTS

Mean S1 posterior wall displacement in the sagittal and axial planes was 64% and 64.8%, respectively, before surgery versus 5.6% and 15.2%, respectively, after surgery. At last follow-up, LLm was 63.5° and the LLe-LLm difference was 11.2%; only 3 (15%) patients had lumbo-pelvic mismatch at last follow-up. The mean Majeed score and IPS values were 86.6 and 79, respectively, and lumbo-pelvic mismatch correlated significantly with a worse functional outcome defined as a Majeed score below 75 (p=0.0087). At last follow-up, the neurological dysfunctions were improved in 90% of patients, and 70% of patients had achieved a full neurological recovery.

DISCUSSION/CONCLUSION

Given these encouraging findings, we advocate early reduction and percutaneous fixation of U- or H-shaped sacral fractures. Although technically demanding, this method restores the normal pelvic parameters and improves neurological function.

LEVEL OF EVIDENCE

IV, retrospective observational study.

Lumbopelvic Fixation for Sacral Insufficiency Fracture Presenting with Sphincter Dysfunction

Sacral insufficiency fractures (SIFs) are common in the elderly. In patients with SIF, objective neurological abnormalities such as sphincter dysfunction or leg paresthesia are uncommon. We present a case of SIF accompanied by spinopelvic dissociation with late neurological compromise treated by spinopelvic fixation. A 61-year-old woman presented to our hospital with low back pain without obvious trauma history. She had a past history of eosinophilic granulomatosis with polyangiitis and treatment with steroids. Her low back pain became worse, and she started to have radiating left posterior thigh pain and motor weakness in the left ankle and both great toes with symptoms of stress urinary incontinence, constipation, and loss of anal sensation. Magnetic resonance imaging revealed an H-shaped sacrum fracture. We attributed the neurological symptoms to unstable SIF and performed lumbopelvic fixation. After the surgery, her leg pain and symptoms of stress urinary incontinence improved markedly, as did anal sensation. At a 6-month follow-up, the patient reported no low back pain and she was walking independently without pelvic complaints. CT showed bone union was achieved. Even minimally displaced SIF in patients with osteoporosis can be a cause of bowel and bladder disturbance. Lumbopelvic fixation is a treatment option for SIF with spinopelvic dissociation presenting neurological deficit.

Midline Longitudinal Sacral Fracture in an Anterior-Posterior Compression Pelvic Injury -A Surgical Decision-making and Outcome

INTRODUCTION

Anterior-posterior compression pelvic injuries occur from high-energy blunt trauma and can result in devastating outcomes. Often, widening of the pubic symphysis occurs with subsequent disruption of posterior pelvic ligamentous structures. Associated sacral fractures may increase the likelihood of neurologic injury and pelvic ring instability. The most common sacral fracture in this injury is an avulsion fracture of the sacral ala. Midline longitudinal sacral fractures into the spinal canal are an extremely rare variant of sacral injuries in conjunction with pelvic trauma. In contrast to traditional anterior-posterior pelvic ring injuries, those associated with this unique fracture type carry a decreased risk of neurologic injury. Only a small number of these cases exist in English literature. Given its rarity, further, investigation of the fracture mechanism and treatment protocol is warranted.

CASE REPORT

A 67-year-old Caucasian male presented with an anterior-posterior compression pelvic ring injury after he was struck by an oncoming vehicle on his motorcycle. Radiographs revealed pubic symphyseal widening of 4.7 cm. A pelvic binder was placed as a temporary measure to minimize intrapelvic hemorrhage. Advanced imaging revealed a complete, midline sagittal sacral fracture through the posterior sacral elements. During his hospital admission, the patient required multiple procedures for sustained upper extremity fractures and subsequently underwent surgical fixation of his anterior and posterior pelvic ring injuries 2 days after admission. Our patient to date has achieved sacral fracture union, minimal residual pubic diastasis, and has no evidence of neurologic injury. He has some persistent impotence and is ambulating without assistance. Despite his significant injuries, his outcome to date has been quite impressive.

CONCLUSION

It is critical to always examine the posterior pelvis and sacrum when examining anterior-posterior compression injuries. While most cases have reported fixation of only the anterior pelvis, we explain the need for additional posterior pelvic fixation to address the inherent instability of these unique sacral fractures and ultimately decrease patient morbidity. The surgical fixation technique of this patient's pelvic injuries is described, as well as his post-operative course and outcome to date.

Closed Reduction in a "Hyperextended Supine Position" with Percutaneous Transsacral-Transiliac and Iliosacral Screw Fixation for Denis Zone III Sacral Fractures

Background

Herein, we demonstrate the clinical results of closed reduction in a hyperextended supine position with transsacral-transiliac (TSTI) and iliosacral (IS) screw fixations for Denis zone III sacral fractures.

Patients and Methods

Sixteen consecutive patients with Denis zone III sacral fractures who were treated between January 2009 and September 2016 were evaluated. All patients were treated using percutaneous TSTI/IS screw fixation during closed reduction performed with patients placed in a hyperextended supine position with body manipulation. The clinical and radiological results were evaluated, and the neurological outcomes were retrospectively assessed using Gibbon's classification system. The clinical outcomes were evaluated using the German Multicenter Study Group Pelvic Outcome Scale (POS).

Results

The sacral kyphotic angle was reduced by 18.06° ± 15.26° (mean kyphotic angle: pre-OP, 39.44° ± 20.56°; post-OP, 21.38° ± 7.39°), and fracture translation was reduced by 5.93 ± 4.95 mm (mean fracture translation: pre-OP, 8.69 ± 8.03 mm; post-OP 2.75 ± 3.97 mm). The mean initial Gibbon's score was 3.00 ± 1.32. Among 15 patients with a follow-up duration of over 12 months, the mean reduction loss in the sacral kyphotic angle was 5.87° ± 10.40° and was 1.00 ± 3.00 mm for the fracture translation. The final Gibbon's score was 1.80 ± 1.21, and 73.3% of patients had good results based on the POS score.

Conclusions

Although closed reduction in a hyperextended supine position with percutaneous posterior screw fixation is associated with some surgical limitations and technical difficulties, the procedure is minimally invasive and highly effective for stabilizing Denis zone III sacral fractures.

SACRAL FRACTURE TREATMENT WITH A VARIATION OF THE LUMBOPELVIC FIXATION TECHNIQUE

ABSTRACT Spinopelvic instability is an uncommon injury that is caused by high-energy traumas. Surgical treatment is used, in the majority of cases, to restore stability and enable early mobilization. Various stabilization techniques have been used in the treatment of spinopelvic instability, and lumbopelvic fixation (LPF) is currently the technique of choice due to its biomechanical superiority. One of its limitations is the fact that the technique does not directly address the lower sacral segment, permitting a residual kyphotic deformity. This deformity has been attributed to unsatisfactory outcomes, including late development of pelvic floor muscle defects and complications during childbirth. We report a case of a patient with spinopelvic instability due to sacral fracture, which was treated using a variation of the LPF technique, in which rods and screws originally developed for cervicothoracic fixation were adapted to correct sacral deformity in the sagittal plane. The upper sacral segment was reduced indirectly using hip extension and femoral traction manoeuvres, associated with distraction manoeuvres via rods. Bone reduction forceps were used to reduce the kyphotic deviation in the lower sacral fragment, enabling its fixation to the lumbopelvic rod and screws system. There were no complications of infection, suture dehiscence, or breakage of the implants, and at the end of the first year of follow-up, the sacral kyphosis was normal and radiographic consolidation was confirmed. Our technique provides a viable and promising alternative to traditional LPF, making it especially useful in fractures with accentuated deviations of the lower sacral fragment. Level of Evidence: 4.Type of study: Case series

Reduction and temporary stabilization of Tile C pelvic ring injuries using a posteriorly based external fixation system

Tile C pelvic ring injuries are challenging to manage even in the most experienced hands. The majority of such injuries can be managed using percutaneous reduction techniques, and the posterior ring can be stabilized using percutaneous transiliac-transsacral screw fixation. However, a subgroup of patients present with inadequate bony corridors, significant sacral zone 2 comminution or significant lateral/vertical displacement of the hemipelvis through a complete sacral fracture. Percutaneous strategies in such circumstances can be dangerous. Those patients may benefit from prone positioning and open reduction of the sacral fracture with fixation through tension band plating or lumbo-pelvic fixation. Soft tissue handling is critical, and direct reduction techniques around the sacrum can be difficult due to the complex anatomy and the fragile nature of the sacrum making clamp placement and tightening a challenge. In this paper, we propose a mini-invasive technique of indirect reduction and temporary stabilization, which is soft tissue friendly and permits maintenance of reduction during definitive fixation surgical.

Current concepts in spondylopelvic dissociation

INTRODUCTION

Spondylopelvic dissociation is an uncommon and complex injury that results from high-energy trauma with axial overloading through the sacrum. Due to the life-threatening nature of these injuries, standard Advanced Trauma Life Support^® (ATLS) protocol must be used in the trauma setting as part of the initial management of these patients. The key to diagnosis is a good physical exam coupled with high level of suspicion. Radicular neurological deficits commonly are present in spondylopelvic dissociation (L5's roots) and should be documented for future evaluations. Radiographic views and CT-scan is preferred for the diagnosis.

BIOMECHANICS AND CLASSIFICATION

The authors briefly describe the anatomy and biomechanics of the pelvis, and present the main classifications used to define this rare lesion.

TREATMENT

Discussion about setting the boundaries of surgical stabilization, if there is still a role for conservative treatment, the importance of the initial treatment and the timing of intervention. Decompression is mandatory in the presence of canal compromise and progressive neurological deficit, regardless of biomechanical criteria for surgery. Kyphotic deformity occurs at the site of sacral transverse fracture and also reduces anteroposterior pelvis diameter. The technique of reduction and posterior surgical stabilization is emphasized. If residual kyphosis remains after bilateral lumbopelvic fixation by shifting of the lower sacral segment, we use S2 and/or S3 screws connected to transitional rods to additional reduction. An illustrated case is shown.

COMPLICATIONS

The infection of the wound and the failure of the implants are the most frequent complications of this surgical treatment.

CONCLUSION

Posterior stabilization is widely recognized as crucial in the treatment of pelvic disruptions. The concept of circumferential restoration of pelvic ring by bilateral lumbopelvic fixation and anterior fixation seems to be a nice option to increase stabilization and avoid bone misalignment.

Do Formal Laminectomy and Timing of Decompression for Patients With Sacral Fracture and Neurologic Deficit Affect Outcome?

OBJECTIVES

To identify whether formal sacral decompression provides improvement in outcome for patients with neurologic deficit after sacral fracture compared with patients treated with indirect decompression and whether the timing of surgical decompression influences neurologic outcome?

DATA SOURCES

MEDLINE was searched via PubMed using combinations of the following search terms: "Sacral fracture," "Traumatic Sacral fracture," "Sacral fracture decompression," "Sacral fracture time to decompression," "Sacral Decompression." Only clinical studies on human subjects and in the English language were included.

STUDY SELECTION

Studies that did not provide sufficient detail to confirm the nature of the sacral injury, treatment rendered, and neurologic outcome were excluded. Studies using subjects less than 18 years of age, cadavers, nonhuman subjects, or laboratory simulations were excluded. All other relevant studies were reviewed in detail.

DATA EXTRACTION

All studies were assigned a level of evidence using the grading tool described by the Centre for Evidence-Based Medicine and all studies were analyzed for bias. Both cohorts in articles comparing 2 groups of patients treated differently were included in the appropriate group. Early decompression was defined as before 72 hours.

DATA SYNTHESIS

The effect of decompression technique and timing of decompression surgery on partial and complete neurologic recovery was estimated using a generalized linear mixed model to implement a logistic regression with a study-level random effect.

CONCLUSIONS

There was no benefit to early decompression within 72 hours and no difference between formal laminectomy and indirect decompression with respect to neurologic recovery.

Longitudinal Midline Sacral Split Fracture - A Rare Entity

Fractures involving the central canal of the sacrum are rare injuries and can be transverse or longitudinal. Transverse fractures are by far common and associated with high incidence of neurological injuries. On the contrary, longitudinal midline split fracture is an extremely rare injury with minimal or no neurological injury. They are always associated with anterior pelvic ring fracture and are vertically stable needing only fixation of the anterior pelvic injury. Plating of the anterior pelvic ring in two planes would be beneficial than single plate to prevent gradual loss of reduction.

Chronic low back pain after lumbosacral fracture due to sagittal and frontal vertebral imbalance

PROBLEM AND HYPOTHESIS

Over time, some patients with unilateral or bilateral lumbosacral injuries experience chronic low back pain. We studied the sagittal and frontal balance in a population with these injuries to determine whether mismatch in the pelvic and lumbar angles are associated with chronic low back pain.

PATIENTS AND METHODS

Patients with posterior pelvic ring fractures (Tile C1, C2, C3 and A3.3) that had healed were included. Foreign patients and those with an associated spinal or acetabular fracture or nonunion were excluded. The review consisted of subjective questionnaires, a clinical examination, and standing A/P and lateral stereoradiographic views. The pelvic tilt (PT), sacral slope (SS), pelvic incidence (PI), measured lumbar lordosis (LLm), T9 sagittal offset, leg discrepancy (LD) and lateral curvature (LC). The expected lumbar lordosis (LLe) was calculated using the formula LLe=PI+9°. We defined lumbopelvic mismatch (LPM) as the difference between LLm and LLe being equal or greater than 25% of LLe.

RESULTS

Fifteen patients were reviewed after an average follow-up of 8.8 years [5.4-15]. There were four Tile C1, five Tile C2, five Tile C3 and one Tile A3.3 fracture. Ten of the 15 patients had low back pain. The mean angles were: LLm 49.6° and LLe 71.9° (P=0.002), PT 21.3°, SS 44.1°, PI 62.9° in patients with low back pain and LLm 57.4° and LLe 63.2° (P=0.55), PT 13°, SS 43.1°, PI 54.2° in those without. LPM was present in 9 patients, 8 of who had low back pain (P=0.02). Six patients, all of whom had low back pain, had a mean LC of 7.5° [4.5-23] (P=0.02). The mean LD was 0.77cm.

DISCUSSION

The findings of this small study suggest that patients who experience low back pain after their posterior arch of the pelvic ring fracture has healed, have a lumbopelvic mismatch. Early treatment of these patients should aim to reestablish the anatomy of the pelvic base relative to the frontal and sagittal balance.

LEVEL OF EVIDENCE

IV.

Open reduction internal fixation versus percutaneous iliosacral screw fixation for unstable posterior pelvic ring disruptions

BACKGROUND

Surgical stabilization of posterior pelvic ring fractures can be achieved by either open or closed methods. They all provide a comparable biomechanical stability. The aim of the present study is to compare the clinical results of both techniques for treating posterior pelvic ring injuries.

MATERIAL AND METHODS

Seventy patients operated for unstable posterior pelvic ring disruptions were retrospectively reviewed. We compared 35 patients treated by open reduction internal fixation (ORIF group) versus 35 patients stabilized by using closed reduction and percutaneous iliosacral screw fixation (CRIF group) under fluoroscopic guidance.

RESULTS

According to pelvic outcome scoring system of Pohlemann et al., 28 patients out of the ORIF group obtained good or excellent results (20 excellent and 8 good), five fair and two poor. In the CRIF group, 30 patients obtained good or excellent results (25 excellent and 5 good), four fair and one poor (P=0.64). The average intraoperative blood loss in the ORIF group was 500cc with average blood transfusion of 2units (1000cc) compared to blood loss 150cc in the CRIF group, with average blood transfusion of 1unit (500cc) (P=0.002). No intraoperative complications were reported in the ORIF group while operative guide wires were broken in two cases in the CRIF group (P=0.16). There were no neurological complications observed in the ORIF group, but one radiculopathy (L5 root palsy) occurred in the CRIF group (P=0.317). In the ORIF group, three patients had superficial wound infection and one patient had deep infection while in the CRIF group, we noted only one case of deep infection (P=0.083).

CONCLUSION

No difference was noticed between ORIF and CRIF. The technical decision is variable according to time of surgery, fracture types, patient general condition, skin condition, presence of ipsilateral fractures of the acetabulum and feasibility of the closed reduction. More studies are needed to identify prognostic factors related to quality of the reduction. We need for creation of decisional algorithm for ORIF versus CRIF.

LEVEL OF EVIDENCE

Level 4.

U-type bilateral sacral fracture with spino-pelvic dissociation caused by epileptic seizure

Sacral fracture with spino-pelvic  dissociation is a rare and unstable injury caused by high-energy trauma, often with serious haemodynamic and neurological implications. Diagnosis is easily delayed or missed as it is often masked by severe associated injuries. Here, we present an unusual case of spino-pelvic dissociation sustained during a seizure episode in a young epileptic patient on long-term anticonvulsant therapy with previous thoracolumbar spinal arthrodesis. This unique case brings to light the need for clinicians to consider sacral fractures in patients presenting with low back pain with no preceding trauma who otherwise may have risk factors for pathological fractures.

A Rare Case of Isolated Lower Segment Transverse Sacral Fracture in a 12-Year-Old Girl and Its Management by Fixation with K-Wire

BACKGROUND

Isolated lower segment sacral fracture is very rare. To the best of our knowledge, there is only one case report of S4 stable fracture that was treated conservatively.

CASE DESCRIPTION

Here, we report a 12-year-old girl who sustained an isolated S5 fracture with anterior displacement of S5 and coccyx on S4. The patient initially was managed conservatively 1 month and 25 days. On the failure of this treatment procedure, the patient was treated surgically by partial coccygectomy with S4-S5 fixation after reduction by 2 K-wires.

CONCLUSIONS

Sacral fracture is difficult to diagnose, especially when the patient has multiple injuries. This is because the emergency doctor may not perform a neurologic examination of the perineum and may miss its diagnosis. Another reason for its misdiagnosis is that the routine anteroposterior plain X-ray may not detect it. Trauma patients with sacrococcygeal pain and tenderness should raise concerns about sacral fracture, and a lateral plain X-ray and/or computed tomography of the sacrococcygeal spine should be performed. Neurologic deficit is rare in lower sacral segment fracture; hence, a trial of conservative management (same as for coccygeal fracture) should be tried first. If the patient does not respond and there is displacement, surgical intervention can be used, because it has a very good response from the patient. In the presence of a neurological deficit, however, surgical intervention should be attempted as soon as possible.

Osteosynthesis in sacral fracture and lumbosacral dislocation

Sacral fracture and lumbosacral hinge trauma are rare but serious lesions. Neurologic disorder is frequently associated, and nerve release may be required, with reduction and stabilization of the fracture. Management requires knowing the fracture lines and reduction maneuvers and the fixation techniques that may need to be associated. Three classifications allow these fractures to be well understood: the Roy-Camille classification identifies high transverse fractures and their displacement; the Denis classification identifies vertical fracture line location within the sacrum, which correlates with neurologic risk; and the Tile classification analyzes pelvic ring trauma when associated with the sacral fracture. Treatment, when surgical, requires careful patient positioning, sometimes on an orthopedic table. Reduction maneuvers are founded on the fracture classification. Isolated U-shaped fracture of the sacrum is to be distinguished from sacral fracture associated with pelvic ring lesion. Osteosynthesis may be lumbopelvic or restricted to the pelvic ring (sacroiliac or iliosacral). Open osteosynthesis allows reduction to be finalized by intraoperative maneuvers on the implant, while closed osteosynthesis requires perfect preoperative reduction. Complications are frequent and neurologic recovery is uncertain. Fatigue and osteoporotic fractures show little displacement and are good indications for cementoplasty, either isolated or associated to iliosacral screwing. In lumbosacral hinge trauma, and dislocation in particular, reduction surgery with fixation (usually 360°) is indicated. The present study details the analysis and classification of these fractures, the technical pitfalls of reduction and fixation, and treatment indications.