Traumatic lumbosacral fracture dislocation: a case report and review of the literature

Lumbosacral dislocation is uncommon. We report a case of traumatic lumbosacral dislocation which occurred in a 33-year-old pedestrian traffic accident victim. The posterior impact produced lumbar injury with diffuse pain exacerbated at the lumbosacral junction. Ecchymotic diffusion involving the entire lumbar region fluctuated due to the presence of a subcutaneous hematoma. The neurological examination revealed incomplete L5 paraplegia. Standard x-rays revealed L5-S1 spondylolisthesis and fracture of the L5 spinous process as well as fractures of the L3, L4, and L5 transverse processes. Computed tomography disclosed biarticular L5-S1 fracture dislocation and a voluminous herniation of the L5-S1 disc. Emergency surgery was performed and revealed subaponeurotic detachment from T4 to S1 and bald iliac pyramids. After L5 laminectomy and extraction of the voluminous herniation of the L5-S1 disc, a short L5-S1 posteriolateral fusion was achieved using pedicular screws and two rods on either side as well as a posterolateral iliac autograft. The clinical course was satisfactory with nearly complete neurological recovery (persistent levator ani paresis). This clinical case and a review of the literature illustrate the pathogenic, clinical, radiological and therapeutic aspects of lumbosacral fracture dislocation.     

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.     

Traumatic dislocation of the lumbosacral junction diagnosis, anatomical classification and surgical strategy

PURPOSE OF THE STUDY: Traumatic lumbosacral dislocation is a rare lesion often characterised by a fracture dislocation of L5-S1 articular facets associated with anterior L5 slipping. Because of its rarity, the surgical strategy of lumbosacral traumatic dislocation remains controversial. We report the most important series of traumatic lumbosacral dislocation. The cases of six men and five women are presented. We discuss the diagnosis and surgical treatment options regarding the different type of lesions. A moderate anterior slipping of L5 over S1 was present in eight cases. The lesion was a bilateral lumbosacral fracture dislocation in eight cases, a pure lateral dislocation in two cases and a unilateral rotatory dislocation in one case. Patients were multiple-trauma patients in eight cases. A radicular deficit was present in two cases. All patients were treated surgically with a posterior osteosynthesis and fusion. A circumferential fusion was made in six cases. In four cases, the anterior fusion was made during the posterior approach. The postoperative course was favorable in all the cases. One patient necessitated secondarily an iterative posterior lumbosacral fixation and anterior fibular bone graft because of a lumbosacral pseudarthrosis. Traumatic dislocation of the lumbosacral junction is a rare and severe spinal fracture which occurs in patients after high energy trauma and could be initially misdiagnosed. We devised a new classification based on anatomical lesions. Treatment is always surgical, requiring reduction, osteosynthesis, and fusion. In case of L5 anterior slipping, it is crucial to assess the L5S1 disc by MRI or surgical exploration for disc disruption. In such case, we recommend to perform circumferential fusion to prevent lumbosacral pseudarthrodesis.     

Unilateral lumbosacral facet joint dislocation associated with vertical shear sacral fracture.

An 18-year-old woman involved in a motor vehicle accident sustained a vertical shear fracture of the sacrum accompanied by unilateral dislocation of the L5-S1 joint. Evaluation of the patient's injuries was defined by computed axial tomography. Through a posterior midline incision, open reductions of the dislocated L5-S1 joint and of the sacral fracture were performed. Reduction was followed by anterior stabilization of the symphysis pubis. The patient remained neurologically intact after surgery.     

Traitement chirurgical mini-invasif des fractures de la jonction thoracolombaire en flexion distraction (type B Magerl) : à propos de trois cas

Background and purpose

Chance fractures are quite rare injuries that require surgical treatment in cases of spinal instability. Development of percutaneous and minimally invasive procedures can alter the management of such lesions, resulting in fewer related soft tissue lesions and morbidities.

Methods

We present our experience with three patients who underwent percutaneous posterior osteosynthesis associated with a minimally invasive anterior graft for discal lesion. The first two cases presented fracture through the disc and osteosynthesis was done on a single mobile level. In the third case with a bony Chance fracture, we performed a short-segment fixation one level above and below the fractured vertebra.

Results

In all three cases, operative blood loss was minimal and clinical outcomes were favorable, with tolerable postoperative pain. Fusion and consolidation were visible for all the patients without loss of correction or implant failure.

Conclusion

Percutaneous osteosynthesis and minimally invasive surgery can be an advantageous alternative for the management of Chance fractures. They allow early mobilization of the patient with less soft tissue trauma and morbidities associated with open procedures.     

Non-union after a vertical fracture of the sacral central zone with a conical dislocation of the pelvic ring

A longitudinal (vertical) fracture of the sacrum passing through the central sacral canal is a very rare injury, reported in the literature mostly as case reports. Out of 24 reference found, non-union associated with this fracture has been reported only once. A longitudinal fracture of the sacrum is always associated with injury to the anterior pelvic ring. Conical instability of the pelvis, little known so far, occurs if only the anterior ring of the pelvis is stabilised and early weight-bearing is established. It is demonstrated by opening of the distal part of a sacral fracture and, in the case of symphyseolysis, also by opening of the distal part of the symphysis. Therefore, in this type of fracture, both the anterior and posterior pelvic arches should be stabilised at the same time. Iliosacral screws applied percutaneously are optimal for osteosynthesis of sacral longitudinal fractures; sacral bars could be used as well. By means of this procedure, painful instability of the posterior pelvic segment and non-union in this area can be prevented. This case report describes the successful treatment of a 46-year-old male patient injured in a motorbike accident. Despite stabilisation of the pubic symphysis using a plate and locking screws, the patient developed a pseudoarthrosis of the sacrum with implant failure within 6 months of surgery. For that reason, the sacrum was stabilised by two iliosacral screws in a combination with a sacral bar at the S1-S2 level. The implants were introduced percutaneously using CT guidance. Stabilisation of the anterior part of the pelvis was performed by using a supra-acetabular external pelvic fixator; the original implant was left in situ. Consequently, the sacral non-union healed within one year.     

Isolated radial shaft fracture with unreducable posterior dislocation of the radial head and rupture of the lateral collateral ligament: A case report

Combined injuries associated with forearm shaft fractures and elbow dislocations are well recognized. We describe an uncommon case of an isolated radial shaft fracture with an unreducable posterior dislocation of the radial head and associated rupture of the lateral collateral ligament of the elbow.     

Transverse fracture of the upper sacrum. Suicidal jumper's fracture

Thirteen patients with transverse fractures of the upper sacrum were studied to determine fracture anatomy, clinical presentation, and therapeutic approaches. The injury results from falls from a height and is usually associated with suicidal attempts by jumping. The position of the lumbar spine in lordosis or kyphosis at the time of impact determines which of three types of morbid anatomy will result. Because of associated polytrauma, fracture of the upper sacrum is often not recognized in the acute stage, and awareness of the possibility of such injury, especially in the presence of perineal neurologic deficit should result in securing good quality radiographic study, including tomograms. Surgical treatment is often required.     

Operative management of displaced fractures of the sacrum

Displaced fractures of the sacrum are often asso-ciated with mechanical instability and neurologic deficits that cause late musculoskeletal problems and pain. We describe the radiologic and neurologic characteristics of 12 displaced fractures of the sacrum, (in 5 men and 7 women; age at injury, 17–61 years) as well as the management and results. Seven patients had unilateral longitudinal fractures (ULF), and 5 had bilateral longitudinal fractures (BLF) with a transverse fracture. All patients had mechanical instability (rotational and/or vertical). Seven (58%) had neurologic deficits. ULFs were stabilized with iliosacral screws. BLFs were stabilized with transiliac screws (for the longitudinal fractures), and with plates (for the transverse fractures). If neurologic deficits were present, a laminectomy was performed to explore and decompress nerve roots. The duration of follow-up ranged from 23 to 82 months (mean, 47 months). Eleven patients had no pain. Ten of the 12 patients were able to walk without any aids, while 2 patients needed foot apparatuses to walk. All patients showed union of the sacral fracture and a stable pelvis. Two patients did not recover neurologically; 1 patient with ULF had undergone late decompression for chronic radiculopathy and the other, with BLF, had had complete paralysis pre-operatively. Five patients with incomplete paralysis recovered both sensory and motor function. If a patient with a sacral fracture has instability, operative treatment with anatomical reduction is preferred. Received for publication on Nov. 12, 1998; accepted on March 1, 1999     

Transverse sacral fracture in children: a case report presenting with neurological injury and review of the literature

Transverse fractures of the sacrum are exceptional in children. We report a case in a 10-year-old girl. The patient presented an isolated flexion fracture of the sacrum in Denis zone III (transverse "U" fracture) of S1-S2 with neurological signs at the initial examination: sensorial deficit in the perineum and sphincter dysfunction. Treatment consisted in laminectomy and bone resection to relieve compression causing the neurological injury. Orthopedic treatment led to correct bone healing. Outcome was favorable with complete resolution of the neurological deficit and stability at three years. Eight cases of transverse sacral fracture before the age of 18 years have been reported in the literature. The diagnostic elements are similar to those in adults, but can be missed in children who rarely present sacral fracture. The therapeutic approach has varied, both for children and adults. We advocate surgical treatment in the event of neurological complications and orthopedic treatment of stable bone lesions.     

Lumbar plexus injury in an anterior fracture dislocation of sacroiliac joint: a case report and review of literature

Displaced unstable pelvic fractures are commonly associated with disruption of the osteoarticular junction of the sacroiliac joint. Posterior sacroiliac dislocation are commonly reported but there are only few reports the anterior type of sacroiliac dislocation where the iliac bone fractures and displaces anterior to sacrum, often in combination with fractures of pubic rami and symphyseal injuries. We present a case of an anterior type of sacroiliac fracture dislocation which was associated with a lumbar plexus injury involving both motor and sensory components. Preoperative neurological assessment was done by MRI scan. The tented nerve roots were explored and decompressed surgically, and sacroiliac fixation was done after reduction in the fracture and joint.     

Bilateral sacroiliac joint dislocation without associated fracture or anterior pelvic ring injuries

SI joint dislocations are serious injuries. They are often associated with posterior fractures or anterior ring disruptions. This case report documents the outcome of a patient with an uncommon injury involving bilateral SI joint dislocation without associated anterior pelvic injuries or posterior pelvic fracture.     

Bipolar fracture dislocation of clavicle: A report of osteosynthesis and early soft tissue reconstruction

IntroductionBipolar dislocation of the clavicle, also called bifocal or pan-articular dislocation or floating clavicle, is an uncommon traumatic injury. The injury of this case is also concomitant with distal third clavicle and coracoid fracture. This article aimed to report the experience of performing osteosynthesis and early soft tissue reconstruction on these injuries.Case reportWe reported a case of bipolar clavicle fracture-dislocation in concomitant with coracoid fracture in a man, aged 32 years old, successfully treated 24 days after accident by fixation of both fractures and early simultaneous reconstruction of sternoclavicular- acromioclavicular-coracoclavicular joints.DiscussionThese injuries are rare and capable of causing many complications if they are treated improperly. It is compulsory to carefully assess any fractured clavicle along its whole length, both clinically and radiologically. Various options, from non-operative to operative, have been reported to manage such of these cases. Early bony fixation and soft tissue reconstruction can correct the alignment of clavicle and recover the function of sterno-clavicular and acromio-clavicular- joints promptly.ConclusionFracture osteosynthesis and early soft tissue reconstruction can be regarded as an option treatment for bipolar fracture-dislocation of the clavicle to facilitate prompt treatment and early rehabilitation.     

Hip dislocation with femur head fracture

It is talked about the classification, the therapy and the late results of the traumatic dislocation of the hip joint with a fracture of the femoral head. Twelve patients with an average age of 36 years (from 18 to 77 years) were treated between the years 1972 and 1982. The rarer anterior dislocation of the hip including a fracture of the femoral head should be specifically classified, in order not to cause any errors for the therapeutic and prognostic assessment following the Pipkin classification. Type I and II with posterior dislocation justify a closed trial of reposition. The miscarried trial, and a continuing fragmental dislocation with a disturbance of the joint's function, or fragments participating in the load area of the femoral head necessitate an open reposition. Small fragments may be taken away, the larger ones require the screwing osteosynthesis. Smaller fragments from the load area must be sustained in an anterior dislocation ("IIb"). The type III injury gives primarily--in exceptional cases sometimes secondarily--an indication for an alloplastic false hip joint. Injuries of type IV should be restored operatively, respectively, it is necessary to perform a secondary operation to set in an endoprosthetic substitute. With the operative therapy--that is: 5 times extirpation of fragments, 4 times screwing osteosynthesis of the femoral head, twice screwing osteosynthesis of the acetabulum--we obtained good results in injuries of type I, II and IV. We performed 3 times a primary total false hip joint in type III injuries.     

Lumbosacral dislocation: A review of the literature and current aspects of management

Lumbosacral fracture dislocation is a very rare lesion and was first described by Watson-Jones in 1940. Two anatomical classifications are described in the literature, all other reports are case presentations.This fracture type is characterised by an antero- or retrolisthesis or a lateral translation of the 5th lumbar vertebra in relation to the sacrum. Biomechanics are discussed controversially. Most patients suffer from a high energy trauma with concomitant severe injuries. There is a high rate of additional neurological deficits. Fractures of the transverse process are thought to be sentinel fractures. MRI and CT scans are essential to detect the whole extent of the lesion. Circumferential fusion is recommended by several authors to regain stability at the lumbosacral junction.     

The anterior dislocation of the sacroiliac joint: a report of four cases and review of the literature and treatment algorism

Pelvic fractures are an uncommon injury in pediatric trauma patients, but the morbidity and mortality associated with these injuries can be profound. Of the posterior pelvic ring disruptions, the posterior dislocation of sacroiliac joint, which is the traditional dislocation of the sacroiliac joint, occurs in most incidences of pediatric trauma patients. There are few reports, however, on the “anterior” dislocation of sacroiliac joint, in which the ilium dislocates anterior to the sacrum and often combines with symphyseal diastasis and fractures of pubic rami and ilia. The distinct fracture-dislocation of sacroiliac joint is a subtype of completed posterior pelvic fracture. Literature review contains little information about such type of dislocation. We present four cases of pediatric trauma patients with the “anterior” dislocation of sacroiliac joint. After a thorough literature review of existing classification of pelvic fractures, we name it as the anterior dislocation of sacroiliac joint. Q. Zhang and W. Chen contributed equally to this work.     

Acute traumatic L5-S1 spondylolisthesis

Acute traumatic L5-S1 spondylolisthesis is a rare condition, almost exclusively the result of major trauma, frequently associated with L5 transverse process fracture and neurologic deficit. In recent years, open reduction and internal fixation with posterior stabilization has been the method of treatment most frequently reported. In the current case, the lesion was found in a victim of an automobile accident. Signs of a right L5 root deficit but no sphincter dysfunction were present. A computed tomography scan revealed several fractures in the posterior parts of L5 and anterior displacement of L5 on S1. A magnetic resonance imaging (MRI) scan verified that the lesion was indeed acute by showing the ruptured L5 disc and posterior ligaments, thereby demonstrating the importance of MRI in the planning of the treatment of these lesions. This case was successfully treated with an acute circumferential instrumented L4-S1 spondylodesis.     

Application of transforaminal lumbar interbody fusion in old thoracolumbar fracture and dislocation

Abstract

Background

The main indications for surgery for old thoracolumbar fractures are pain, progressive deformity, neurological damage, or increasing neurological deficit. These fractures have been one of the greatest therapeutic challenges in spinal surgery. Anterior, posterior, or combined anterior and posterior procedures have been successful to some extent. As far as we know, there is no report in the literature of transforaminal lumbar interbody fusion (TLIF) for old thoracolumbar fracture and dislocation.

Methods

Case report.

Results

A 26-year-old man with old fracture and dislocation of T12/L1 was treated with TLIF. At 12 months' follow-up, multi-slice computed tomography (CT) scans showed that solid fusion had been achieved between T12 and L1. Back pain had resolved completely at 2-year follow-up.

Conclusions

We performed TLIF for in a man with old fracture and dislocation of T12/L1, with good clinical outcome. TLIF might be an option in the treatment of old thoracolumbar fracture.     

Application of transforaminal lumbar interbody fusion in old thoracolumbar fracture and dislocation

Background

The main indications for surgery for old thoracolumbar fractures are pain, progressive deformity, neurological damage, or increasing neurological deficit. These fractures have been one of the greatest therapeutic challenges in spinal surgery. Anterior, posterior, or combined anterior and posterior procedures have been successful to some extent. As far as we know, there is no report in the literature of transforaminal lumbar interbody fusion (TLIF) for old thoracolumbar fracture and dislocation.

Methods

Case report.

Results

A 26-year-old man with old fracture and dislocation of T12/L1 was treated with TLIF. At 12 months'' follow-up, multi-slice computed tomography (CT) scans showed that solid fusion had been achieved between T12 and L1. Back pain had resolved completely at 2-year follow-up.

Conclusions

We performed TLIF for in a man with old fracture and dislocation of T12/L1, with good clinical outcome. TLIF might be an option in the treatment of old thoracolumbar fracture.     

An isolated sacral fracture and a fracture dislocation in two pediatric patients

Isolated sacral fractures are very rare in children. Two children, aged eight and 12 years, presented with an isolated sacral type III fracture and a fracture dislocation, respectively, both of which were not associated with any neurologic problems. Without any attempts for reduction, the fractures healed completely with conservative treatment. These cases demonstrated a high remodeling potential in children for spontaneous healing.