Transverse sacral fractures with anterior displacement

Transverse fractures of the sacrum with anterior displacement are the rarest type of transverse sacral fractures. They usually occur at the S1–S2 region in suicide jumpers. A clinical study was performed to evaluate the diagnosis, treatment and outcome of transverse sacral fractures with anterior displacement. We present six patients with a transverse fracture of the sacrum with anterior displacement. All patients presented with bowel and bladder dysfunction, perineal anesthesia, sensory and motor deficits at the lower extremities. Prompt diagnosis of the sacral fracture was obtained in five of the six patients. Operative treatment including lumbosacral laminectomies, spine instrumentation and fusion was done in all patients. Neurological recovery was almost complete in one patient, incomplete in four patients, and none in one patient. Although reduction of the fracture was not ideal in many of these patients, long-term clinical and radiographic follow-up, and neurological improvement were rewarding.     

Transverse fracture of the 2nd sacral vertebra with neurological signs. Apropos of a case

The authors report a case of transverse fracture of the second part of the sacrum with neurological signs. Whilst such a lesion would appear very rare, associated involvement of the sacral roots is very common. Recovery of the neurological deficit syndrome is hazardous. A review of the literature fails to provide the basis for a defined programme of management.     

Longitudinal fracture of the sacrum

A longitudinal fracture of the sacrum without an associated neurological deficit was described. A 47-year-old man was involved in a motor vehicle crash, suffering from multiple injures including a vertical displaced fracture of the sacrum unassociated with neurological deficit, fracture of the pelvis, and second lumbar burst fracture. A three-dimensional computed tomographic (CT) scanning was also discussed for proper clinical evaluation. The sacral nerve roots were pushed to either side of the fracture, there were no neurological problems in the present case.     

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.     

Pediatric transverse sacral fracture with cauda equina syndrome

Background contextTransverse sacral fracture in pediatric patients is extremely uncommon with only nine cases reported in literature so far.PurposeThe purpose of this study was to heighten awareness and treatment options of a rare injury of traumatic pediatric transverse sacral fracture with cauda equina syndrome.Study designThis is a clinical case report and literature review.MethodsWe report a case of a 13-year-old girl with a Type III Roy-Camille, Zone III Denis sacral fracture whose only neurological deficit was a cauda equina syndrome with bowel and bladder involvement. She underwent emergent sacral laminectomy and surgical stabilization to decompress the cauda equina.ResultsThe patient regained bowel and bladder function at 6-month follow-up.ConclusionsThis case is presented to highlight the rarity of a pediatric transverse sacral fracture, which requires a high index of suspicion as early decompression helps in reversing the neurological deficit.     

Transverse fracture-dislocation of the sacrum: a diagnostic pitfall and a surgical challenge

Transverse fracture-dislocations of the sacrum are rare. Associated lesions of the lumbosacral spine as well as neurological injuries are common. Conventional radiographs of the pelvis often fail to clearly visualize the fracture. Delayed diagnosis increases the risk of progressive neurological disfunction. True lateral sacral views and CT-scans with 3-dimensional reconstructions are very helpful in establishing the full extent of the injury. These examinations should be considered in all patients with a history of high energy trauma and clinical signs indicating lumbosacral injury, such as severe low back pain and neurological disturbances of the lower extremities. The management of transverse sacral fracture-dislocations with or without associated neurological damage is controversial. Conservative treatment is associated with a high rate of persistent deformity and residual neurological dysfunction. Surgical management allows for anatomical fracture reduction, stable fixation and revision of the spinal canal and lumbosacral nerve roots. The dorsal approach is preferred. Two patients with transverse sacral fracture-dislocations and neurological disturbances are presented. One patient had an additional fracture-dislocation of the lumbar spine at the L4L5 level with intrusion of the lumbosacral spine into the pelvis. Both lesions in this patient were successfully stabilized using an internal fixator system. The other patient presented with a bilateral transforaminal sacral fracture. The transverse component was not recognized on the initial radiographs, which resulted in loss of reduction and progressive neurological disfunction after sacroiliac screw fixation.     

Transverse Fracture-Dislocation of the Sacrum: a Diagnostic Pitfall and a Surgical Challenge

Transverse fracture-dislocations of the sacrum are rare. Associated lesions of the lumbosacral spine as well as neurological injuries are common. Conventional radiographs of the pelvis often fail to clearly visualize the fracture. Delayed diagnosis increases the risk of progressive neurological disfunction. True lateral sacral views and CT-scans with 3-dimensional reconstructions are very helpful in establishing the full extent of the injury. These examinations should be considered in all patients with a history of high energy trauma and clinical signs indicating lumbosacral injury, such as severe low back pain and neurological disturbances of the lower extremities.

The management of transverse sacral fracture-dislocations with or without associated neurological damage is controversial. Conservative treatment is associated with a high rate of persistent deformity and residual neurological dysfunction. Surgical management allows for anatomical fracture reduction, stable fixation and revision of the spinal canal and lumbosacral nerve roots. The dorsal approach is preferred.

Two patients with transverse sacral fracture-dislocations and neurological disturbances are presented. One patient had an additional fracture-dislocation of the lumbar spine at the L4L5 level with intrusion of the lumbosacral spine into the pelvis. Both lesions in this patient were successfully stabilized using an internal fixator system. The other patient presented with a bilateral transforaminal sacral fracture. The transverse component was not recognized on the initial radiographs, which resulted in loss of reduction and progressive neurological disfunction after sacroiliac screw fixation.     

Operative treatment of complex lombosacral fracture dislocation: L5 chance fracture with trans S1-S2 dislocation

Sacral fractures are uncommon injuries that are often diagnosed late, the transverse fracture dislocation of the sacrum at the S1-S2 level associated with a L5 Chance fracture has never been reported. The purpose of this report is to describe operative treatment of transverse fracture dislocation of the sacrum at the S1-S2 level associated with a L5 Chance fracture. A 17-year-old woman sustained multiple injuries in a road accident and presented with hypovolumic shock. Radiological assessment demonstrated transverse fracture dislocation of the sacrum at the S1-S2 level associated with a L5 Chance-fracture. Neurologic examination demonstrated L5 root deficit and perineal hypoesthesia. Operative treatment was undertaken. The procedure consisted of laminectomy of L5, S1, and S2 and osteosynthesis of L3-L4 - S3-S4 (in sacral alae). Attempts to reduce dislocation failed. Postoperative recovery was uneventful. One year after operative treatment the patient presented no neurologic deficit and had resumed normal activity. Follow-up radiological imaging demonstrated consolidation of fracture zones. Management for uncommon lumbrosacral junction injuries must take into account various parameters including hemodynamic condition, neurologic status, and stability of the spinal lesions. Decompression of neural impingement and stabilization of fractures by osteosynthesis appear to be a useful alternative that allows patients to stand again and begin rehabilitation quickly.     

Fractures of the sacrum with neurologic complications. A case

The fractures of sacrum are rare and the literature is poor on their etiopathological aspects and possible complications. According to a sacral transverse fracture with neurological complications by epidural hematoma we analyze the different mechanisms to obtain this one.     

The problem of the sacrum fracture. Clinical analysis of 377 cases]

Sacral fractures are rare injuries that are often neglected because of the general severity of the patient's injuries. They are typical injuries in patients with polytraumata. A "hidden" injury, they are often diagnosed late or are even missed. In a well-documented consecutive series of 1,350 patients with pelvic fractures treated in the trauma department of the Hannover Medical School between 1972 and 1991, a total of 377 sacrum fractures were evaluated in a retrospective study. The cause of the accident, mechanism of injury, concomitant injuries, diagnostic procedures, classification of the pelvic injury (TILE), as well as the classification of the sacrum injury (DENIS), treatment and outcome were analyzed in all cases. Observed complications with special attention to injuries to the lumbosacral plexus were correlated with the classification of the sacrum and pelvis, as well as with a detailed analysis of the fracture pattern and fracture characteristics. In 89.4% at least one additional body region was injured in these patients. PTS (Hannover Polytrauma Score) groups III and IV included 42.5% of the patients. With an improved diagnostic protocol (radiological a.p. views, oblique views and CT scan), the observed rate of sacrum fractures was 33%. Neurological deficits occurred in 15.1% of the patients. In contrast to the literature, the rate of neurological deficits was related more to the degree of pelvic instability (TILE) than to the specific fracture pattern in the sacrum. In stable injuries (TILE A) neurological deficits were only seen in exceptions. In type B injuries the maximum rate was 10%, whereas in unstable fractures (TILE C) the rate of neurological deficits was 32.6% in transalar fractures (DENIS zone I), 42.9% in transforaminal fractures (DENIS zone II), and 63.6% in central fracture types (DENIS zone III). Additional risk indicators for neurological impairment are avulsion fractures of the sacrum, comminuted and bilateral fracture lines. The fracture classification should thus be modified. Our own experience with operative therapy for sacral fractures (open revision of the sacral plexus together with internal stabilization of the fracture) is still limited, but based on the experience presented, further development of the treatment protocol for sacrum fractures should be considered.     

骶骨骨折合并骶神经损伤的MRI诊断及临床应用

目的 探讨骶骨骨折合并骶神经损伤的MRI诊断及其临床意义.方法 1999年10月-2007年10月,对20例Denis Ⅱ型骶骨骨折合并骶神经损伤患者采用显示骶神经全长的骶骨斜冠状位MRI扫描,观察神经走行及毗邻关系.其中男17例,女3例;年龄30～55岁.受伤至入院时间1 d～23个月.致伤原因:车祸伤10例,重物砸伤8例,挤压伤2例.合并耻骨骨折8例,尿道断裂4例.行常规骨盆X线片、CT、螺旋CT三维重建检查.X线片示骶骨外侧骨折块向后上方移位,骶孔线模糊、扭曲变形、左右不对称;CT示骶管于不同断面水平存在左右不对称及骨折侧结构紊乱、骶骨外侧骨折块向后上方移位,同时存在压缩且向骶骨中央突入.根据临床表现、美国国立脊髓损伤学会和国际截瘫学会1990年推荐的脊髓损伤神经分类标准、与MRI正常侧对比及Gierada等的研究结果进行临床及MRI诊断,并进行手术验证.结果 临床诊断S1神经根损伤17例,S:神经根损伤14例,S,神经根损伤7例,S4神经根损伤6例;MRI诊断s1神经根损伤17例,S2神经根损伤14例,S3神经根损伤3例,S4神经根损伤2例;手术证实S1神经根损伤17例,S2神经根损伤14例,S3神经根损伤7例,S4神经根损伤1例.骶骨斜冠状位MRI扫描示骶神经全长及周围毗邻关系,骶神经损伤时发现有骨块压迫、神经根走行改变5例,损伤处神经根周围脂肪消失19例,骶管狭窄17例,骶神经出现异常增粗11例.结论 骶骨斜冠状位MRI扫描对于骶神经损伤定位及定性诊断有重要价值.     

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.     

Fixation of transverse fractures of the sternum and sacrum with the locking compression plate system: two case reports

Transverse fractures of the sternum or sacrum each present specific surgical challenges. Here, we report the successful use of a locking compression plate system in a 69-year-old woman with a displaced segmental fracture of the sternum following a motor vehicle accident and a 15-year-old girl with a low transverse fracture of the sacrum (S3-S4) as a result of a snowboarding accident. In both cases, the system provided adequate fixation to allow healing in the 2 fractures, despite the poor bone quality (sternal case) and the thin bone stock (sacral case).     

Minor defects of the sacrum and neurogenic bladder dysfunction

Minor defects of the sacrum are common and often dismissed as normal. The radiographs of 100 patients with urinary incontinence revealed sacral abnormalities in 43. Sacral evoked responses were measured and compared independently with the radiological findings. Patients who had defective closure of the dorsal neural arches of S1 or S2 all had abnormal nerve studies. We suggest that incomplete development of the bones of the dorsal neural arches of the upper sacrum may be a marker of incomplete neurogenesis of the sacral nerves. The sacral neurological deficit is subtle and difficult to demonstrate, but it is real and may be important in the pathogenesis of incontinence.     

Modified triangular posterior osteosynthesis of unstable sacrum fracture

We report preliminary results for unstable sacral fractures treated with a modified posterior triangular osteosynthesis. Seven patients were admitted to our trauma center with an unstable sacral fracture. The average age was 31 years (22–41). There were four vertical shear lesions of the pelvis and three transverse fracture of the upper sacrum. The vertical shear injuries were initially treated with an anterior external fixator inserted at the time of admission. Definitive surgery was performed at a mean time of 9 days after trauma. The operation consisted in a posterior fixation combining a vertebropelvic distraction osteosynthesis with pedicle screws and a rod system, whereby the transverse fixation was obtained using a 6 mm rod as a cross-link between the two main rods. Late displacement of the posterior pelvis or fracture was measured on X-ray films according to the criteria of Henderson. The patients were followed-up for a minimum time of 12 months. Four patients who presented with a pre-operative perineal neurological impairment made a complete recovery. No iatrogenic nerve injury was reported. One case of deep infection was managed successfully with surgical debridement and local antibiotics. All patients complained of symptoms related to the prominence of the iliac screws. The metalwork was removed in all cases after healing of the fracture, at a mean time of 4.3 months after surgery. No loss of reduction of fracture was seen at final radiological follow-up. The preliminary results are promising. The fixation is sufficiently stable to allow an immediate progressive weight-bearing, and safe nursing care in polytrauma cases. The only problem seems to be related to prominent heads of the distal screws.     

Surgical treatment the sacral fracture in childhood: case report and literature overview

Fractures of the sacrum in children are rare. In the 17 cases described in the past 25 years, surgery was indicated only for treatment of the consequences of the primary injury. We present the case of a 10-year-old girl who sustained the following injuries as a result of a fall from a swing: posterior angulation of S2/3 with suspected injury of anterior ligamentous structures, fracture of the proximal part of the S4 body with a displacement by the bone width anteriorly and contraction of 5 mm, posterior angulation of S5/Co1 also with a suspected injury of anterior ligamentous structures. After an unsuccessful attempt at closed reduction, open reduction and fixation by two K-wires was indicated. The fracture healed in 8 weeks. Two years after the treatment, the patient is without complaints and limitations. The question is whether surgery was necessary for treatment of this fracture or whether spontaneous healing and subsequent remodelling of the sacral bone in such a young patient may be expected which would be also fully satisfactory. In our view, the described surgical treatment was appropriate and is definitely indicated for patients with a similar injury associated with a neural lesion.     

Study of the morphology and biomechanics of sacral fracture

Objective:To observe the morphological characteristics of sacral fracture under different impact loads. Method: Ten fresh pelvic specimens were loaded in dynamic or static state. A series of mechanical parameters including the pressure strain and velocity were recorded. Morphological characteristics were observed under scanning electron microscope. Results: The form of sacral fracture was related to the impact energy. Under low-energy impact loads, ilium fracture, acetabulum fracture and crista iliaca fracture were found. Under high-energy impact loads, three types of sacral fracture occurred according to the classification of Denis: sacral ala fracture, Type I fracture; sacral foramen cataclasm fracture, Type II fracture; central vertebral canal fracture, Type III fracture. Nerve injury of one or two sides was involved in all three types of sacral fracture. The fracture mechanism of sacrum between the dynamic impact and static compression was significantly different. When the impact energy was above 25 J, sacral foramen cataclasm fracture occurred, involving nerve root injury. When it was below 20 J, ilium and sacral fracture was most likely to occur. When it was 20 - 25 J, Type I fracture would occur. While in the static test, most of the fracture belonged to ilium or acetabulum fracture. The cross section of sacrum was crackly and the bone board of Haversian system was brittle, which could lead to separation of bone boards and malposition of a few of cross bone boards. Conclusions: In dynamic state, sacrum fracture mostly belongs to Type I and Type n , and usually involves the nerve roots. Sacrum fracture is relevant to the microstructures, the distribution of the bone trabecula, the osseous lacuna and the Haversian system of sacrum. The fracture of ilium and acetabulum more frequently appears in static state, with slight wound of peripheral tissues.     

Transverse sacral fractures: case series and literature review.

OBJECTIVES: To report experience with transverse sacral fracture, an uncommon injury frequently associated with neurologic deficit, and to perform a meta-analysis of the literature in order to define the role of decompression for the management of sacral fractures. DESIGN: A review of 7 cases. SETTING: A university-affiliated tertiary care centre. PATIENTS: Seven patients with transverse fractures of the sacrum. The mean follow-up was 13 months. INTERVENTIONS: A review of the clinical data and a search of the literature for studies that reported on 4 or more patients with a transverse sacral fracture. MAIN OUTCOME MEASURES: Mechanism of injury, type of neurologic deficit and its management. RESULTS: The most common mechanism in the 7 study patients was a fall from a height. Six patients had neurologic deficits, mostly in the form of bowel or bladder disturbance. Five of these were treated with surgical decompression, and 4 of them had an improvement in neurologic function. The 7 original studies from the literature dealt with a total of 55 patients. As in the study patients, falls from a height and motor vehicle accidents predominated as the mechanisms of injury. In contrast to patients in this study, 20 of 48 patients in the literature review with neurologic deficits were treated conservatively. CONCLUSIONS: The outcomes in this study are similar to those reported in the literature. The place of surgical decompression for patients with neurologic deficit cannot be clearly determined from the evidence currently available.     

Limitations of radiography and computed tomography in the diagnosis of transverse sacral fracture from a high fall. A case report

Transverse sacral fractures with sacral canal compression and neurologic deficit are rare sequelae of high falls. Nevertheless, a high index of suspicion is necessary as such an injury may present significant complications and may be missed on standard anteroposterior pelvic roentgenograms and pelvic computed tomography (CT) examinations obtained during the evaluation of multiple traumas. The saddle anesthesia, loss of bladder and sphincter function, and sexual dysfunction may be masked or unrecognized during the acute phase of polytrauma. Special attention must be directed to obtaining a lateral profile view of the sacrum, as this deformity may not be seen in any other view. Sagittal reconstruction images of the sacrum can be obtained during a pelvic CT examination if the initial lateral roentgenograms are technically inadequate because of the patient's obesity or limitations of portable radiographic equipment in the emergency department. The CT scoutview itself may show the acute sacral angulation if sufficient technique factors are employed. The roentgenographic suspicions can be confirmed with lateral multidirectional tomography or even with sagittal magnetic resonance imaging (MRI). Because this transverse sacral fracture is unstable in flexion, additional neurologic injury may result if the spine or hips are unwittingly manipulated in flexion.     

Treatment of aneurysmal bone cysts of the pelvis and sacrum.

BACKGROUND: Aneurysmal bone cysts are benign, non-neoplastic, highly vascular bone lesions. The purpose of this study was to describe the prevalence, the clinical presentation, and the recurrence rate of aneurysmal bone cysts of the pelvis and sacrum and to examine the diagnostic and therapeutic options and prognosis for patients with this condition. METHODS: Forty consecutive patients with an aneurysmal bone cyst of the pelvis and/or sacrum were treated from 1921 to 1996. Their medical records and radiographic and imaging studies were reviewed, and histological sections from the cysts were examined. Seventeen lesions were iliosacral, sixteen were acetabular, and seven were ischiopubic. Seven involved the hip joint, and two involved the sacroiliac joint. All twelve sacral lesions extended to more than one sacral segment and were associated with neurological signs and symptoms. Destructive acetabular lesions were associated with pathological fracture in five patients and with medial migration of the femoral head, hip subluxation, and hip dislocation in one patient each. The mean duration of follow-up was thirteen years (range, three to fifty-three years). RESULTS: Thirty-five patients who were initially treated for a primary lesion had surgical treatment (twenty-one had excision-curettage and fourteen had intralesional excision); two patients also had adjuvant radiation therapy. Of the thirty-five patients, five (14%) had a local recurrence noted less than eighteen months after the operation. Of five patients initially treated for a recurrent lesion, one had a local recurrence. At the latest follow-up examination, all forty patients were disease-free and twenty-eight (70%) were asymptomatic. There were two deep infections. CONCLUSION: Aneurysmal bone cysts of the pelvis and sacrum are usually aggressive lesions associated with substantial bone destruction, pathological fractures, and local recurrence. Current management recommendations include preoperative selective arterial embolization, excision-curettage, and bone-grafting.