Management of sacral fractures associated with spinal or pelvic ring injury. J Trauma Acute Care Surg. 2012;73:239-242. [PMID: 22743390 DOI: 10.1097/ta.0b013e31825a79d2]

Biomechanical effects of S1 sacroiliac screws versus S2 sacroiliac screws on sacroiliac screws combined with a lumbar iliac fixation in the treatment of vertical sacral fractures: a biomechanical finite element analysis

OBJECTIVE

To examine the impact of sacroiliac screw position and length on the biomechanical properties of triangular osteosynthesis in treating unilateral vertical sacral fractures and provide a clinical reference.

METHODS

Unilateral Denis type II sacral fractures were modelled using finite elements to represent Tile C pelvic ring injuries. Six sacroiliac screws were used with iliolumbar fixation patterns to fix the sacral fractures, and the sacral stability, maximum pressure, and stress distribution were compared among the internal fixation modalities.

RESULTS

The best vertical stability of the internal fixation model was achieved when the S1 segment was fixed with lengthened sacroiliac screws, followed by when the S1 segment was fixed using normal sacroiliac screws. There was no significant difference in vertical stability between the S1 + S2 dual-segment fixation model and the S1-segment fixation model. The maximum pressure under a vertical force of 600 N showed a trend of L5LS1 < L5NS1 < L5LS12 < L5LS2 < L5NS2 < L5NS12.

CONCLUSIONS

In unilateral vertical sacral fractures (Denis II) treated with triangular osteosynthesis using triangular jointing combined with unilateral iliolumbar + sacroiliac screw fixation, the use of a single lengthened sacroiliac screw for the S1 segment is recommended to achieve the best vertical stability of the sacrum with less maximum compression on the internal fixation components. If it is not possible to apply a lengthened sacroiliac screw, the use of a normal sacroiliac screw for the S1 segment is recommended. Adding an S2 screw does not significantly increase the vertical stability of the sacrum.

Technical Note on Placement of Low-Profile Triangular Osteosynthesis for Unstable Posterior Pelvic Ring Injuries

SUMMARY

Triangular osteosynthesis is a technique used to stabilize posterior pelvic ring injuries. Conventional triangular fixation can be problematic for several reasons, including the need for advanced skill sets to place instrumentation, difficulty with pelvic reduction and placing the connecting construct, and prominent instrumentation. The purpose of this study is 2-fold: (1) to describe in detail a technique for lumbopelvic fixation using implants that are easy to connect, allow distraction for complex lumbosacral displacements, and are placed in a location minimizing soft tissue prominence and (2) to present our initial case series using this technique. We present a retrospective review of 18 consecutively treated patients with this technique. Inclusion criteria were patients with complete disruption through the sacrum or sacroiliac joint from blunt trauma (OTA/AO type C injuries). Outcomes included pelvic reduction/malreduction, wound healing, and complications. Fourteen patients underwent unilateral fixation (81%), and 4 patients underwent bilateral fixation (19%). All patients (18 of the 18) had a well-reduced pelvis after fixation. No patient (0%) required a return trip to the operating room for loss of reduction/malreduction, wound breakdown, or implant failure. This study presents an updated technique for a low-profile triangular osteosynthesis construct with straightforward application for unstable posterior pelvic ring injuries. This technique does not require rod bending, results in a consistently more recessed iliac screw and connecting rod, and can be used in a wide variety of unstable posterior pelvic ring injuries, including comminuted sacral fractures, L5/S1 facet fractures, and vertical shear injuries.

[Closed reduction and minimally invasive fixation of a sacral avulsion fracture : Minimal invasiveness with maximum stability]

Surgical stabilization of high-energy sacral avulsion fractures with spinopelvic dissociation places high demands on the surgeon. The goal is to achieve maximum stability while minimizing invasiveness. The present case of a dislocated U‑type fracture in a 25-year-old motocross rider exemplifies how a reduction with the targeted application of closed reduction techniques through hyperextension of the hip joints and lordosis in the lumbosacral hinge and through a standardized procedure in intraoperative fluoroscopic imaging, a minimally invasive stabilization by means of transsacral screw fixation and spinopelvic fixation of lumbar vertebra 5 to the ilium in the sense of a bilateral triangular stabilization is possible without compromising the achieved stability of the osteosynthesis. The limitations of the described approach are also pointed out.

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.

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.

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.

Minimally invasive triangular osteosynthesis for highly unstable sacral fractures: Technical notes and preliminary clinical outcomes

Triangular osteosynthesis involves unilateral L5 iliac posterior instrumentation combined with an iliosacral screw fixation. The aim of this study was to describe this procedure and report the preliminary clinical results in patients with unstable sacral fractures treated with minimally invasive triangular osteosynthesis (MITO). Between 2012 and 2017, 10 patients (6 men and 3 women, mean age, 50 ± 23 years) with sacral fractures were treated with MITO and were followed up for a mean of 15.0 ± 8.5 months in our institution. Classification of sacral fracture, operative time, intraoperative bleeding, timing of full weight bearing, bone union, complications, and clinical outcomes were investigated. Two cases were classified as Denis zone 1, 2 cases as zone 2, and 6 as zone 3. Four patients had Roy-Camille type 1 fracture and 2 patients had type 2. All patients underwent MITO, which involved bilateral lumbopelvic fixation and a uni/bilateral iliosacral screw with stab incisions for percutaneous fixation or central longitudinal incision. The operative time was a mean of 182 ± 64 minutes, and the amount of intraoperative bleeding was a mean of 63 ± 74 g. Full-weight bearing was initiated at a mean of 8.2 ± 2.4 weeks. Eight fractures healed; 1 patient had pulmonary embolism and 1 had implant loosening. Based on Majeed score, 8 patients had "excellent" clinical outcomes, 1 patient had a "good" clinical outcome, and the other had a "fair" clinical outcome. MITO could be less invasive on the soft tissues and be a reliable procedure for bony union. It might provide sufficient stability to accelerate the commencement of post-operative rehabilitation, even in patients with highly unstable sacral fractures.

Isolated Decompression for Transverse Sacral Fractures with Cauda Equina Syndrome

BACKGROUND The purpose of this study was to evaluate the clinical outcomes of isolated decompression for patients with transverse sacral fractures and cauda equina syndrome, which have been rarely reported before. MATERIAL AND METHODS Twelve neurological impaired patients with transverse sacral fracture from January 2010 to March 2017 treated in our institution were evaluated. All patients went through isolated decompression and were followed for a minimum of 12 months. Fracture causes, classifications, associated injury, radiologic results, clinical outcomes using the Majeed index, and neurological outcomes using the Gibbons criteria were evaluated. RESULTS Motor vehicle accidents and falling injuries were the major causes of trauma. The average time from trauma to surgery was 89.8 days. Eleven patients underwent laminectomy with no more than 3 segments resected and 1 patient had S1-S4 excised. Three patients with fracture involving the lumbopelvic joint had L5 laminectomy. All patients achieved bony union, with 7 patients (63.6%) showing satisfactory pelvic outcome. Average Gibbons scores improved from 2.8 to 1.9 at 18-month average follow-up, but most patients were left with residual pain. No surgical-related complications were seen in any patients. CONCLUSIONS Isolated decompression can be considered for patients who present a stable sacrum with non-displaced fracture or an old fracture that shows fracture healing. Favorable pelvic outcomes and neurological recovery, along with acceptable stability, can be acquired.

Spinopelvic dissociation in patients suffering injuries from airborne sports

BACKGROUND

Spinopelvic dissociation which is also called U-type or referred to H-type sacral fractures with a transverse fracture line is an infrequent injury that results mainly from high-energy accidents. This results in an osseous dissociation of the upper central segment of the sacrum and the entire spine from the lower sacral segments. The purpose was to investigate the incidence of spinopelvic fracture in general among airborne injuries.

PATIENTS AND METHODS

Using our electronic patient records, we retrospectively investigated all sacral fractures related to airborne sports between 2010 and 2017. All injuries were classified according to the Roy-Camille, Denis, AOSpine and the Tile classification system.

RESULTS

During the period of interest, 44 patients (18.7%) were admitted with sacral fractures after accidents obtained from airborne sports, including 16 spinopelvic dissociations (36.4%). The majority of these injuries were obtained from paragliding (75.0%), followed by BASE jumping (21.4%) and parachuting (4%). The mean injury severity score (ISS) in the spinopelvic dissociation group was significantly higher compared with other sacral fracture group (38.1 vs. 20.0; p < 0.001). Six lambda-type, four T-type, four H-type and two U-type injuries were identified. In total, four patients (25%) were found to have neurological impairment. For treatment, 87.5% of patients underwent subsequent surgical stabilization.

CONCLUSION

Airborne sports have high potential for serious, life-threatening injuries with a high incidence of spinopelvic dissociation. In the literature, the prevalence of spinopelvic dissociation in sacral fractures is described to be between 3 and 5%. In our series, the prevalence is 36.4%. It is important to identify the potential injuries promptly for the further treatment. These slides can be retrieved under Electronic Supplementary Material.

Patient Weight-bearing after Pelvic Fracture Surgery-A Systematic Review of the Literature: What is the Modern Evidence Base?

Background

Little attention in the literature appears to have been paid to the issue of postoperative weight-bearing protocols for different injury patterns after pelvic fracture surgery. The primary aim of this study is to review the currently available literature to define the level of available evidence used to inform surgical decisions on weight-bearing after pelvic fracture surgery. Secondary aims are to assess the published methods of fracture classification, surgical management, and assessment or reporting of patient outcomes.

Methods

A systematic review of the English language literature from 1990 to 2016 was undertaken. Eligible papers were all papers reporting minimum 6-month outcomes following surgery for pelvic fractures in adults. Exclusion criteria included pathological fractures or those resulting from penetrating injury, solely osteoporotic fractures, or series with less than 6 months of follow-up data.

Results

There is very little published scientific data to inform the treating surgeon on postoperative weight-bearing protocols after pelvic fracture surgery, with no randomized trials and only 1 paper out of 122 stating this as a primary aim. More than half of the papers published did not state what postoperative protocol was employed. There is no standardization of outcome measures, with less than 20% of papers using the most common validated outcome scoring system; in contrast, there is good agreement on the use of either the Tile (75%) or Burgess and Young (20%) classification.

Limitations

Due to the lack of published studies looking at the topic of postoperative weight-bearing after pelvic fractures, no specific recommendations are possible. As large numbers of papers were included, they were not individually assessed for bias.

Conclusion

A review of postoperative weight-bearing regimes reveals a nonexistent scientific evidence base from which to make recommendations, although a consensus strategy has been identified. Future research needs to be directed at this topic, as has already been the case in numerous other fracture areas, since the advantages of early mobility are potentially significant. The reported methodology for assessing and reporting patient outcomes after pelvic fracture surgery reveals no consistent standards, and the majority of papers use no specific outcome scoring system.

How to cite this article

Rickman M, Link B-C, Solomon LB. Patient Weight-bearing after Pelvic Fracture Surgery-A Systematic Review of the Literature: What is the Modern Evidence Base? Strategies Trauma Limb Reconstr 2019;14(1):45-52.

Biomechanical Study of Posterior Pelvic Fixations in Vertically Unstable Sacral Fractures: An Alternative to Triangular Osteosynthesis

Study Design

Biomechanical study.

Purpose

To investigate the relative stiffness of a new posterior pelvic fixation for unstable vertical fractures of the sacrum.

Overview of Literature

The reported operative fixation techniques for vertical sacral fractures include iliosacral screw, sacral bar fixations, transiliac plating, and local plate osteosynthesis. Clinical as well as biomechanical studies have demonstrated that these conventional techniques are insufficient to stabilize the vertically unstable sacral fractures.

Methods

To simulate a vertically unstable fractured sacrum, 12 synthetic pelvic models were prepared. In each model, a 5-mm gap was created through the left transforaminal zone (Denis zone II). The pubic symphysis was completely separated and then stabilized using a 3.5-mm reconstruction plate. Four each of the unstable pelvic models were then fixed with two iliosacral screws, a tension band plate, or a transiliac fixation plus one iliosacral screw. The left hemipelvis of these specimens was docked to a rigid base plate and loaded on an S1 endplate by using the Zwick Roell z010 material testing machine. Then, the vertical displacement and coronal tilt of the right hemipelves and the applied force were measured.

Results

The transiliac fixation plus one iliosacral screw constructions could withstand a force at 5 mm of vertical displacement greater than the two iliosacral screw constructions (p=0.012) and the tension band plate constructions (p=0.003). The tension band plate constructions could withstand a force at 5° of coronal tilt less than the two iliosacral screw constructions (p=0.027) and the transiliac fixation plus one iliosacral screw constructions (p=0.049).

Conclusions

This study proposes the use of transiliac fixation in addition to an iliosacral screw to stabilize vertically unstable sacral fractures. Our biomechanical data demonstrated the superiority of adding transiliac fixation to withstand vertical displacement forces.

Suicidal jumper's fracture - sacral fractures and spinopelvic instability: a case series

BACKGROUND

Sacral fractures with spinopelvic dissociation are rare, and hard to diagnose and treat. Fractures with a H- or U-shaped line are severely unstable, due to a dissociation of the spine and of the upper body of the sacrum from the pelvis. They are commonly due to high-energy trauma events, with severe neurological injuries in 80% of cases.

CASES PRESENTATION

Five polytraumatized Caucasian patients, three women and two men (mean age: 34 years old) with spinopelvic dissociation were selected. All patients underwent level I-II examinations with radiographs and computed tomography total-body scans; all patients needed damage-control procedures. Sacral fractures were classified according to Denis and Roy-Camille classifications, and neurologic injuries of cauda equina according to Gibbons classification. Patients' outcome was analyzed with the Majeed score. Definitive surgical treatment was appropriate for two patients (lumbar-pelvic fixation or transverse bar). Clinical and radiographic outcomes were analyzed periodically. Four patients survived, all of them suffered severe neurologic deficits. One case of osteomyelitis was treated with the removal of the fixation implants 23 months after the accident.

CONCLUSIONS

Diagnosis of spinopelvic dissociation is frequently overlooked due to the severe associated injuries affecting these patients. In cases of a fall from high height, this lesion should be investigated with a lateral sacral radiographic view and computed tomography scan of the pelvis. If untreated, it can lead to severe and progressive neurologic deficit with muskuloskeletal deformities and persistent pain. Early decompression treatment is controversial, but an early lumbopelvic fixation is recommended. A correct diagnosis and early treatment can reduce morbidity and strongly improve the outcome of these patients.

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.

Pelvic ring injuries: Surgical management and long-term outcomes

Pelvic ring injuries present a therapeutic challenge to the orthopedic surgeon. Management is based on the patient's physiological status, fracture classification, and associated injuries. Surgical stabilization is indicated in unstable injury patterns and those that fail nonsurgical management. The optimal timing for definitive fixation is not clearly defined, but early stabilization is recommended. Surgical techniques include external fixation, open reduction and internal fixation, and minimally invasive percutaneous osteosynthesis. Special considerations are required for concomitant acetabular fractures, sacral fractures, and those occurring in skeletally immature patients. Long-term outcomes are limited by lack of pelvis-specific outcome measures and burden of associated injuries.

Isolated sacral injuries: Postoperative length of stay, complications, and readmission

AIM: To investigate inpatient length of stay (LOS), complication rates, and readmission rates for sacral fracture patients based on operative approach.

METHODS: All patients who presented to a large tertiary care center with isolated sacral fractures in an 11-year period were included in a retrospective chart review. Operative approach (open reduction internal fixation vs percutaneous) was noted, as well as age, gender, race, and American Society of Anesthesiologists’ score. Complications included infection, nonunion and malunion, deep venous thrombosis, and hardware problems; 90-d readmissions were broken down into infection, surgical revision of the sacral fracture, and medical complications. LOS was collected for the initial admission and readmission visits if applicable. Fisher’s exact and non-parametric t-tests (Mann-Whitney U tests) were employed to compare LOS, complications, and readmissions between open and percutaneous approaches.

RESULTS: Ninety-four patients with isolated sacral fractures were identified: 31 (30.4%) who underwent open reduction and internal fixation (ORIF) vs 63 (67.0%) who underwent percutaneous fixation. There was a significant difference in LOS based on operative approach: 9.1 d for ORIF patients vs 6.1 d for percutaneous patients (P = 0.043), amounting to a difference in cost of $13590. Ten patients in the study developed complications, with no significant difference in complication rates or reasons for complications between the two groups (19.4% for ORIF patients vs 6.3% for percutaneous patients). Eight patients were readmitted, with no significant difference in readmission rates or reasons for readmission between the two groups (9.5% percutaneous vs 6.5% ORIF).

CONCLUSION: There is a significant difference in LOS based on operative approach for sacral fracture patients. Given similar complications and readmission rates, we recommend a percutaneous approach.

Anterior sacral pseudomeningocele following minimal trauma

Sacral fractures are rare and seldom result in formation of a sacral pseudomeningocele. Treatment of these pseudomeningoceles usually consists of conservative management with flat bedrest or open operative management. The authors describe the case of a 55-year-old woman with an anterior sacral pseudomeningocele that was successfully treated using a lumbar drain for temporary continuous CSF drainage. The patient first presented to an outside institution several days after sacral trauma from an ice skating fall. Initial symptoms included throbbing headaches relieved by lying flat. Head and cervical spine CT demonstrated no abnormality. As symptoms worsened, she presented to another institution where MRI of the lumbar spine indicated sacral fracture with pseudomeningocele. The patient subsequently transferred to the authors' facility, where symptoms included headaches and occasional mild sacral pain. Given her headaches and the authors' concern for CSF leak, another head CT scan was performed. This revealed no subdural hematoma or other abnormality. A subsequent CT myelogram revealed an anterior sacral pseudomeningocele at S3–4 with an anterior irregular linear filling defect, likely representing torn dura. Treatment included placement of a lumbar drain (10 ml/hr) and flat bedrest. Resolution of the CSF leak occurred on postprocedure Day 9. At the 4-week follow-up visit, the patient had no clinical symptoms of CSF leak and no neurological complaints. To our knowledge, this is the first description of temporary continuous CSF drainage used to treat a posttraumatic sacral pseudomeningocele. This technique may reduce the need for potentially complicated surgical repair of sacral fractures associated with CSF leak in select patients.