Midline sagittal sacral fractures in anterior-posterior compression pelvic ring injuries

OBJECTIVE: To evaluate the outcome of an uncommon variant of the anterior-posterior compression pelvic injury, in which the posterior ring injury is a midline sagittal sacral fracture extending into the spinal canal. DESIGN: Prospective, consecutive series.SETTING Two regional trauma centers. PATIENTS: A consecutive series of 10 patients with rotationally displaced, vertically stable anterior-posterior compression pelvic ring fractures (OTA type 61-B1) in which the posterior ring injury is a midline sagittally oriented sacral fracture involving the spinal canal (Denis zone III). This injury pattern comprised 0.6% of pelvic fractures and 1.4% of sacral fractures treated at these two institutions during a 10-year period. INTERVENTION: Patients were treated according to the same principles used in more commonly seen types of anterior-posterior compression pelvic ring injuries. Nine patients were treated with reduction and anterior pelvic stabilization at an average of 5 days after injury, 8 of whom were treated with open reduction and internal fixation and 1 with external fixation. No posterior pelvic fixation was used. One patient with nondisplaced bilateral pubic ramus fractures was treated nonoperatively. Immediate weight bearing was allowed as tolerated. MAIN OUTCOME MEASUREMENTS: Prospectively collected clinical follow-up data emphasized a detailed neurologic examination, whereas radiographic evaluation involved anteroposterior, inlet, and outlet plain radiographic views of the pelvis. RESULTS: An anatomical or near-anatomical reduction of the pelvis was achieved and maintained in all patients. Fractures healed at an average of 10 weeks. At an average follow-up of 31 months (range 20-46 months), there were no objective neurologic deficits that could be attributed to sacral root injury and no significant residual pain or gait disturbance related to the pelvic fracture. Loss of bowel or bladder function, loss of perianal sensation or sphincter tone, and lumbosacral radicular pain or sensorimotor deficit were specifically absent in all patients. Three patients, however, complained of sexual dysfunction at final follow-up. None of these patients had clinical evidence of sacral root/plexus injury secondary to the fracture. One additional patient, who sustained a urethral tear, required a chronic suprapubic catheter because of stricture. Six patients, one of whom had needed repair of a retroperitoneal bladder tear, had no urogenital sequelae. DISCUSSION AND CONCLUSION: Patients who sustain sagittally oriented midline fractures of the sacrum that extend into the spinal canal (Denis zone III) as part of displaced, vertically stable anterior-posterior compression pelvic injuries, have a low incidence of neurologic deficit attributable to sacral root or plexus injury. This is in contrast to the high rate of neurologic deficit (>50%) otherwise reported in zone III sacral fractures, particularly in those associated with a displaced transverse component. In the midline sagittal fracture variant, simultaneous lateral displacement of both bony and neural elements through the midline may protect the sacral roots and plexi from significant traction or shear injury by maintaining the spatial orientation between the sacral foramina and sciatic notch. Long-term sequelae were related to urogenital complaints rather than to musculoskeletal problems, as 4 of the 10 patients in this series had either sexual or urologic dysfunction.     

Fixation of fractures of the sacrum

Fractures of the sacrum are infrequent injuries; however, they comprise a wide spectrum of injury types.Classification of the injuries are predominantly by fracture line direction (vertical, transverse, and oblique). The direction of the fracture line dictates both the most effective type of surgical management as well as the biologic consequences of the fracture. Most vertical fractures are associated with pelvic injuries and rarely have severe neural conpromise. Fixation of the sacral fracture is often a part of the more complex restoration of pelvic stability. Transverse and oblique sacral fractures are less often part of a pelvic injury complex; and they more often have associated neural deficits. Surgical treatment is most often indicated for neural decompression and stabilization for optimal recovery.     

Neurological injury and patterns of sacral fractures

To evaluate the morphological and neurological findings in sacral spine injuries, a retrospective study was conducted of all patients admitted to Erie County Medical Center over a 2-year period with the diagnosis of pelvic or sacral injury. Of these 253 patients, 44 were found to have sacral fractures and form the basis of this study. The type of fracture, neurological deficit, treatment, and outcome in these patients were analyzed. The patient population consisted of 25 males and 19 females, with a mean age of 34 years (range 15 to 80 years). The fractures were classified by the degree of involvement of the foramina and central canal. Fractures through the ala sacralis only (Zone I, 25 cases) or involving the foramina but not the central canal (Zone II, seven cases) were less likely to cause nerve injury (24% and 29%, respectively). Fractures involving the central canal (Zone III), both vertical (five cases) and transverse (seven cases), were more likely to cause neurological injury (60% and 57%, respectively). Neurological deficits in Zone I and II injuries were usually unilateral lumbar and sacral radiculopathies. Zone III deficits were usually bilateral and severe; bowel and/or bladder incontinence was present in six of the 12 patients in this group. Deficits generally improved with time; however, operative reduction and internal fixation may have been useful, particularly in patients with unilateral root symptoms. The treatment options are discussed, and previously published series of sacral fractures are reviewed. The authors conclude that the classification of sacral fractures described is useful in predicting the incidence and severity of neurological deficit.     

骶骨骨折与骨盆骨折

目的：探讨骶骨骨折与骨盆骨折的关系及其治疗。方法：对29例骶骨骨折合并骨盆损伤病例作回顾性分析。25例行保守治疗，4例行手术治疗。结果：除1例死于多器官衰竭外，其余28例骨折均愈合，其中有3例为骨盆骨折畸形愈合。随访6个月－21年，28例中有24例神经功能已恢复正常，另5例功能明显改善。结论；骶骨骨折常合并骨盆损伤，对于骨盆骨折尤其是高能量损伤所致骨盆骨折，应注意是否同时存在骶骨骨折。骶骨骨折治疗方案的选择应考虑骨盆的稳定性和神经系统受累程度。对骨盆稳定性受到严重破坏、存在神经系统损害的患者，均应施行积极的治疗以使移位的骨折断端获得复位，并重建骨盆的稳定性。     

骶骨骨折的诊断与治疗方法选择

目的探讨骶骨骨折的临床表现特点及治疗方法的选择。方法３９例骶骨骨折,３７例行保守治疗,２例行手术治疗。结果除１例死于多发伤外,其余３８例随访３个月－１９年,有３３例已恢复正常,４例功能明显改善,１例无改善,结论骶骨骨折治疗方案的选择主要考虑两个因素,即骨盆的稳定性和神经系统受累程度。对于骨盆稳定性受到严重破坏,存在神经系统损害的患者应施行积极的治疗以使移位的骨折获得复位,并重建骨盆的稳定性。而对于     

Outcome of operatively treated type-C injuries of the pelvic ring

BACKGROUND: Internal fixation has become the preferred treatment for type-C pelvic ring injuries, but controversies persist regarding surgical approach and surgical technique. PATIENTS: We evaluated 101 consecutive patients with type C1-C3 pelvic ring injuries who had been treated with standardized reduction and internal fixation techniques. RESULTS: Our findings suggest a correlation between excellent reduction followed by sufficient fixation of the pelvic ring and functional outcome. Unsatisfactory reduction (displacement > 5 mm), failure of fixation, loss of reduction and a permanent lumbosacral plexus injury were the commonest reasons for an unsatisfactory functional result. All 40 patients with an associated lumbosacral plexus injury showed at least some evidence of neurological recovery. 14 underwent complete neurologic recovery. 8 had only sensory deficits and the remaining 18 also had motor deficits at the final followup. Complications were rare, but some of them were severe: loss of reduction in 8%, malunion in 10%, deep wound infection in 2%, and a lesion of the L5 nerve root in 1%. INTERPRETATION: Our results suggest that special attention should be paid to preoperative planning, reduction of the fracture, decompression of the nerve roots, and fixation of the most severe sacral fractures. Our results seem to favor internal fixation of displaced (> 10 mm) and unstable rami fractures and symphyseal disruptions in conjunction with posterior fixation, to achieve better stability of the whole pelvic ring.     

Vertically unstable sacral fractures with neurological insult: outcomes of surgical decompression and reconstruction plate internal fixation

During a 4-year period, 32 patients with type C unstable sacral fractures were treated in our university hospital. All patients had neurological deficits as a result of their sacral fracture. The average age was 31.2 (range 22-54) years and the average Hannover Polytrauma Score (PTS) was 24 (range 19-40) points. Twelve patients had zone I fracture, ten had zone II fracture and ten patients had comminuted fractures involving both zones. All patients underwent surgical decompression and reconstruction plate internal fixation. The average follow up period was 24.4 (range 19-47) months. Twenty-one patients (65.6%) had complete neurological recovery, eight patients (25%) had partial recovery and three patients (9.4%) had no recovery. The relationship between radiological and functional scores was evident but insignificant (P = 0.434). Significantly, the neurological recovery was less favourable in older age groups, pedestrian trauma, vertical shear injuries, comminuted fractures, fifth lumbar root involvement, very low motor power grades and in patients presenting late. Concerning complications, four patients (12.5%) had early infection and five patients (15.6%) had late urological problems and heterotopic ossification. Consequently, we conclude that patients undergoing very early surgical decompression and only reconstruction plate internal fixation can achieve safe early ambulation and better neurological, functional and radiological results.     

Begleitverletzungen beim schweren Beckentrauma

There has been a marked increase in the incidence of pelvic fractures over the last few years. Associated injuries to the urogenital and vascular system as well as nerve injuries worsen the prognosis. Over a five year period 126 patients with severe pelvic trauma were treated. Out of these 39 (30.9%) sustained additional peripelvic injuries and represent the study sample. Type B injuries according to the AO classification occurred in 16 (41%) patients, type C fractures in 23 (59%) patients. The spleen, liver and kidney were the most frequently injured organs (58.9%), followed by urogenital lesions (46.6%), nerve injuries (25.6%) and vascular lesions (15.3%). The most common extrapelvic lesions were thoracic injuries in 56.4% and severe head injuries (GCS < 8) in 33.3%. The mean Hannover Polytrauma score was 35.6 points, the mean Injury Severity Score 27.6 points. Osteosynthesis was performed in 21 pelvic ring fractures (53%), eight procedures (50%) in type B fractures and 13 (56%) in type C fractures. In type B injuries the anterior pelvic ring was stabilized with a tension band wiring in four cases, in two patients with an external fixator and with plate osteosynthesis in one case. In type C injuries the external fixator was applied as the only stabilizing procedure in six patients. In four cases the anterior ring was fixed with tension band wiring or plates and the dorsal aspect of the pelvic ring with sacral bars. Three patients had their additional acetabular fracture plated through a anterior approach. All surviving 28 patients were followed up for an average of 18 months (range 7-59 months) after the trauma. The patients were classified using the pelvic outcome score proposed by the German Society of Trauma Surgery. 53.4% of the type B fractures showed a good clinical outcome, 47.6% a poor outcome. 15.4% with type C fractures presented with a good outcome, 84.6% with a poor outcome. 80% of the type B and 23% of the type C fractures had a good radiological outcome. 20% of type B and 77% of type C injuries had a poor radiological outcome. Five patients (12.8%) sustained persistent urological symptoms. Three of these had urinary dysfunction, two used permanent cystotomies due to their severe neurological deficit after a head injury. Ten patients with nerve injuries at the time of trauma suffered long term neurological dysfunction of the lumbosacral plexus. The mortality rate was 28%. Seven patients died in the emergency room due to uncontrollable bleeding, four in the intensive care unit from multi-organ failure. The management of complex pelvic trauma consists of fracture treatment and interdisciplinary treatment of the associated injury. Lesions of the abdominal organs or of major vessels must be addressed first if hemodynamic instability is present. Injuries to smaller vessels can be embolized percutaneously. Urinary bladder ruptures are treated as an emergency, urethral lesions electively after four to six weeks. We recommend external fixation of the pelvis in the acute phase for control of both the osseous instability and control of haemorrhage through external compression. The treatment of choice for the anterior pelvic ring is tension band wiring or plating. If this is contraindicated due to an open fracture external fixation is the treatment of choice. Type C fractures require posterior ring stabilization which should be postponed until four days post admission.     

Outcome of operatively treated type-C injuries of the pelvic ring

Background?Internal fixation has become the preferred treatment for type-C pelvic ring injuries, but controversies persist regarding surgical approach and surgical technique.

Patients?We evaluated 101 consecutive patients with type C1-C3 pelvic ring injuries who had been treated with standardized reduction and internal fixation techniques.

Results?Our findings suggest a correlation between excellent reduction followed by sufficient fixation of the pelvic ring and functional outcome. Unsatisfactory reduction (displacement > 5 mm), failure of fixation, loss of reduction and a permanent lumbosacral plexus injury were the commonest reasons for an unsatisfactory functional result. All 40 patients with an associated lumbosacral plexus injury showed at least some evidence of neurological recovery. 14 underwent complete neurologic recovery. 8 had only sensory deficits and the remaining 18 also had motor deficits at the final followup. Complications were rare, but some of them were severe: loss of reduction in 8%, malunion in 10%, deep wound infection in 2%, and a lesion of the L5 nerve root in 1%.

Interpretation?Our results suggest that special attention should be paid to preoperative planning, reduction of the fracture, decompression of the nerve roots, and fixation of the most severe sacral fractures. Our results seem to favor internal fixation of displaced (> 10 mm) and unstable rami fractures and symphyseal disruptions in conjunction with posterior fixation, to achieve better stability of the whole pelvic ring.     

Determining indications and osteosynthesis techniques for the pelvic girdle]

1566 patients with fractures of the pelvis were treated at the Department of Traumatology of the Hannover Medical School between 1972 and 1990: 1350 patients had fractures of the pelvic ring, 216 isolated acetabulum fractures, 398 combinations of pelvic ring fractures and acetabular involvement; 718 of these patients were admitted with severe polytrauma. For 1254 patients a complete file was available for clinical and radiological evaluation of fracture distribution, classification (Tile and anatomical location) and concomitant injuries. During the observation period, significant increase in the severity of the trauma, the severity of the pelvic fractures and the rate of internal stabilization, especially of the posterior pelvic ring was observed. The overall mortality after pelvic fractures was 18.1%. This mortality depended significantly on the Hannover Polytrauma Score (PTS) and the associated pelvic and extrapelvic blunt trauma. Internal fixation of pelvic fractures was performed in 195 patients. This experience has now led to standardized procedures for the different fracture locations. With the task of minimizing soft tissue trauma and reducing the implant size, more differentiated treatment of sacral fractures is now applied. Adapted small fragment implants ("local osteosyntheses") can be applied, with an unilateral longitudinal dorsal incision providing an excellent overview over the fracture line. For internal fixation of sacral fractures, involvement (penetration by screws, transfixation) of the sacroiliac joint is avoided whenever possible. In our experience early open reduction and internal fixation of pelvic fractures facilitates the management of these severely injured patients.     

骶前静脉的解剖及在骨盆骨折大出血中的临床意义

目的探讨骶前区静脉的解剖和骨盆骨折大出血的关系。方法结合50例骨盆骨折伴盆腔内血管损伤出血临床病例救治，选成年尸体标本5具，研究骶前区静脉走行，骶骨的解剖学特点，骨折部位与出血的关系。结果骶前区静脉由骶前静脉丛和骶椎椎体静脉组成，有广泛的侧支循环，骶骨C区骨折及严重的B区骨折易损伤骶前静脉丛。临床骶前静脉出血者经剖腹探查证实、止血。结论骶骨C区骨折及严重的B区骨折易引起骶前静脉丛损伤。一旦确诊应立即恢复骨盆环的完整性，腹外加压止血，非必要时不能行剖腹探查止血。     

Influence of sacral fracture on the long-term outcome of pelvic ring injuries

Initial treatment of pelvic ring fractures with involvement of the iliosacral complex is directed at bleeding control and fixation of the pelvic ring. However, long-term outcome is determined by persisting neurological deficits, malunion of the posterior pelvic ring with low back pain, and urological lesions. Between 1991 and 2000, 173 patients with sacral fractures were treated at our institution. Sacral fractures as part of type B2 ("lateral compression") or type C ("vertical shear") pelvic ring fractures were treated conservatively, if dislocation was less than 1 cm. Fractures with a dislocation of more than 1 cm were treated operatively (n=33, 19%). A total of 112 patients were examined after an average of 4.9 years. Of the 39 patients with primary neurological deficits (35%) only 4 showed complete neurological recovery. Chronic low back pain was rarely observed (n=8, 7%) and only in type C injuries. The low incidence of chronic low back pain justifies conservative treatment of minimally (<1 cm) displaced sacral fractures. Long-term outcome is largely determined by neurological deficits, which persist in 30% of all patients with sacral fractures.     

Sacral fracture with compression of cauda equina: surgical treatment

Fractures of the sacrum are rare and generally accompany fractures of the pelvis. Isolated transverse sacral fractures are even less frequent, and extensive neurologic deficits may accompany these injuries. This report describes an unusual case of extradural hemorrhage accompanying a complex fracture of the sacrum. The reversal of a serious neurologic deficit was notably aided by sacral laminectomy.     

Sacral fractures

Sacral fractures most commonly occur after pelvic ring injuries but occasionally in isolation. Although the true incidence of sacral fractures is unknown, an estimated 30% are identified late. Sequelae of inappropriately treated or untreated sacral fractures include persistent pain, decreased mobility, and neurologic compromise. Because these fractures often result from high-energy trauma, concomitant injuries should be suspected. A thorough physical examination, including a detailed neurologic assessment and radiographic evaluation, is necessary to determine treatment. Computed tomography of the pelvis/sacrum can provide significant information about fracture pattern. Surgical intervention, often as a combination of neural decompression and stabilization, is indicated in patients with neurologic deficits, significant soft-tissue compromise, and lumbosacral instability. Patient satisfaction with surgical intervention has not been definitively documented, although neurologic improvement with timely intervention has been noted.     

Beckenfrakturen in der unfallchirurgischen Klinik Kiel

48 injuries to the pelvis were treated from January 1991 through December 1991. We found 45 fractures of the pelvic ring with associated acetabular fractures in 15 cases and three isolated acetabular lesions. 19 injuries were caused by car accidents, 18 fractures resulted from a fall, especially in older patients. Isolated fractures of the pelvis occurred in 18 cases. The average total severity of the injuries was 19.7 points according to the Hannover Polytrauma Score (PTS). Every fracture was classified using the Tile-classification. There were 15 (33%) Tile A lesions, 18 (40%) Tile B fractures and twelve (27%) type C pelvic ring injuries. In 18 cases surgery was the method of treatment. Seven out of 18 injuries to the acetabulum were treated with open reduction and internal fixation. In ten patients the unstable pelvic ring was fixed by means of an external fixator. To do so, a pair of 6 mm diameter pins were placed on both sides in the supraacetabular region of the iliac bone directed towards the sacroiliac joints. We used a triangular form of external fixation. An open reduction and internal fixation (ORIF) was necessary in five cases, one injury required a combination of external and internal procedures. There were 14 cases in which we found sacral fractures as an additional dorsal lesions. Nine of 14 sacral fractures were recognized only by CT examination. In elevent cases the conventional radiographs showed simple anterior pelvic ring fractures while the CT examination revealed an additional lesion of the sacroiliac joint in nine of these cases. A CT examination of every pelvic fracture is therefore indispensable. Complications occurred in eight of 18 patients treated surgically, a further operation was necessary in three of these cases.     

骨盆损伤中移位骶骨骨折的手术治疗

目的 探讨不稳定型骨盆损伤中移位骶骨骨折的手术方法及治疗效果.方法 对2000年9月至2007年9月收治的33例伴有骶骨骨折的骨盆损伤患者行手术治疗.根据AO/OTA的分型方法,骨盆B型损伤5例,C型28例.根据Denis的分型方法,骶骨I型骨折13例、Ⅱ型11例、Ⅲ型9例.其中早期合并原发性神经损伤23例.骶骨骨折应用张力带钢板固定1例;脊柱椎弓根钉棒系统经骨盆后方沿双侧髂嵴横向固定10例,经L_(4,5)或L_5S_1及双侧髂嵴后方纵向固定16例;骶髂螺钉固定3例;骶骨棒固定2例;骶髂螺钉联合骶骨棒固定1例.术中间期行椎板切除、马尾神经减压11例,二期行神经松解、骶前孔扩大术2例.结果 术后随访12～82个月,平均27.3个月.根据Majeed疗效标准,优17例、良7例、可2例、差7例.骶骨I型骨折疗效优良率为92.3%、Ⅱ型为72.7%、Ⅲ型为44.4%.神经损伤恢复情况在手术治疗组中优6例、良4例、无变化3例;在非手术治疗组中优6例、良1例、无变化3例.术后并发症包括腰骶部切口深部感染2例,腰骶僵硬不适2例.神经损伤一过性加重4例,迟发性骶神经损伤3例.结论 手术治疗是改善骶骨骨折复位质量的重要途径,骨盆前、后环损伤的联合制动是提高骨折内同定强度的有效方法.对手术指征明确的骶神经损伤,早期定位减压有助于其功能恢复.     

Einfluss der Sakrumfraktur auf das funktionelle Langzeitergebnis von Beckenringverletzungen

Initial treatment of pelvic ring fractures with involvement of the iliosacral complex is directed at bleeding control and fixation of the pelvic ring. However, long-term outcome is determined by persisting neurological deficits, malunion of the posterior pelvic ring with low back pain, and urological lesions. Between 1991 and 2000, 173 patients with sacral fractures were treated at our institution. Sacral fractures as part of type B2 (“lateral compression”) or type C (“vertical shear”) pelvic ring fractures were treated conservatively, if dislocation was less than 1 cm. Fractures with a dislocation of more than 1 cm were treated operatively (n=33, 19%). A total of 112 patients were examined after an average of 4.9 years. Of the 39 patients with primary neurological deficits (35%) only 4 showed complete neurological recovery. Chronic low back pain was rarely observed (n=8, 7%) and only in type C injuries. The low incidence of chronic low back pain justifies conservative treatment of minimally (<1 cm) displaced sacral fractures. Long-term outcome is largely determined by neurological deficits, which persist in 30% of all patients with sacral fractures.     

Neurologic deficits associated with sacral wing fractures

Twelve of 96 patients with pelvic fractures suffered neurologic deficits. Four secondary to acetabular fractures were excluded from the study. Of the remaining eight, five were found by CT scan to be secondary to fractures of the sacral wing extending through the sacral foramina. On the basis of this study, it is believed that the neurologic injuries were due to sacral root injuries rather than lumbosacral plexus injuries. This concept potentially could lead to surgical approaches for decompression of sacral root trauma.     

Percutaneous stabilization of U-shaped sacral fractures using iliosacral screws: technique and early results

PURPOSE: To present the technique and early results of percutaneous stabilization of U-shaped sacral fractures with attention to neurologic recovery and maintenance of fracture reduction of the sacrum. DESIGN: Retrospective clinical study. SETTING: Level I trauma center. PATIENTS: During a thirty-eight-month period, 442 patients with pelvic ring disruptions were treated at a Level I trauma center. Thirteen (2.9 percent) of these patients had displaced U-shaped sacral fractures treated with percutaneous stabilization. INTERVENTION: Fracture stabilization was accomplished using fluoroscopically guided iliosacral screws inserted percutaneously with the patient positioned supine. Neurodiagnostic monitoring was not used during screw insertions. This technique was limited to patients with sacral kyphotic deformities, which allowed in situ fixation. Sacral neurologic decompression was not performed. MAIN OUTCOME MEASUREMENTS: Fracture healing and the stability of fixation were assessed on inlet and outlet radiographs and a lateral sacral view. Detailed neurologic examinations were performed at injury and at follow-up. RESULTS: The sacral fractures were classified based on plain pelvic radiographs and computed tomography scans and included one Type 1, eight Type 2, and four Type 3 fracture patterns. Twenty-five fully threaded cancellous 7.0-millimeter cannulated screws were used. Eleven patients had bilateral screw fixations; one patient had unilateral double screw fixation; and one patient had unilateral single screw fixation. Operative time for screw insertion averaged forty-eight minutes, with 2.1 minutes of fluoroscopy per screw. Accurate screw insertions without neuroforaminal or sacral spinal canal violations were confirmed in all patients with postoperative pelvic plain radiographs and computed tomography scans. A paradoxical inlet view of the upper sacral segments on the injury anteroposterior pelvis was seen in twelve of thirteen patients (92.3 percent), and the diagnosis was confirmed with the lateral sacral view in all thirteen (100 percent) patients. Preoperatively, sacral kyphosis averaged 29 degrees, whereas postoperative sacral kyphosis averaged 28 degrees. Screw disengagement occurred without a change in position of the sacral fracture in the only patient treated with a single unilateral screw. All fractures healed clinically and radiographically. Of the nine patients with preoperative neurologic abnormalities, two (22 percent) patients had residual neurologic deficits. Both patients had associated multiple level lumbar burst fractures, which required decompression and instrumented stabilization. CONCLUSIONS: These sacral fractures are rare and occur after significant spinal axial loading. A paradoxic inlet view of the upper sacrum on the anteroposterior plain pelvic radiograph heralds the diagnosis. Delayed diagnosis is avoided by a high clinical suspicion, early lateral sacral radiographs, and pelvic computed tomography scans. Surgical stabilization may assist in early mobilization of the patient from recumbency and prevents progressive deformity with associated nerve root injury. Percutaneous fixation diminishes potential blood loss and operative times, yet still allows subsequent sacral decompression of the local neural elements using open techniques when necessary. Early percutaneous iliosacral screw fixation is effective treatment for these injuries.     

Zone 2 sacral fractures managed with partially-threaded screws result in low risk of neurologic injury

BackgroundZone 2 sacral fractures account for 34% of sacral fractures with reported neurological deficit in 21−28% of patients. The purpose of this study was to examine the risk factors for neurological injury in zone 2 sacral fractures. The authors hypothesized that partially thread iliosacral screws did not increase incidence of neurologic injury.MethodsA retrospective review of consecutive patients admitted to a level 1 trauma center with zone 2 sacral fractures requiring surgery from September 2010 to September 2014 was performed. Patients were excluded if no neurologic exam was available after surgery. Fractures were classified according to Denis and presence/absence of comminution through the neural foramen was noted. Fixation schema was recorded (sacral screws or open reduction and internal fixation with posterior tension plate). Any change in post-operative neurological exam was documented as well as exam at last clinic encounter.Results90 patients met inclusion criteria, with zone 2 fractures and post-operative neurological exam. No patient with an intact pre-operative neurologic exam had a neurological deficit after surgery. 86 patients (95.6%) were neurologically intact at their last follow-up examination. Four patients (4.4%) had a neurological deficit at final follow-up, all of them had neurological deficit prior to surgery. 81 patients were treated with partially threaded screws of which 1 (1.2%) had neurological deficit at final follow-up.Fifty-seven fractures (63.3%) were simple fractures and 33 fractures (36.7%) were comminuted. All four patients with neurological deficit had comminuted fractures. The association between neurologic deficit in zone 2 sacral fracture and fracture comminution was found to be statistically significant (p-value = 0.016). No nonunion was observed in this cohort.ConclusionsThe use of partially threaded screws for zone 2 sacral fractures is associated with low risk for neurologic injury, suggesting that compression through the fracture does not cause iatrogenic nerve damage. The low rate of sacral nonunion can be attributed to compression induced by the use of partially threaded compression screws. There is a strong association between zone 2 comminution and neurologic injury.