SACRUM FRACTURES

1. SACRALSACRAL
FRACTURESFRACTURES

2. PELVIC ANATOMY ANTERIOR VIEWPELVIC ANATOMY ANTERIOR VIEW

3. PELVIC ANATOMY POSTERIOR VIEW

4. PELVIC ANATOMY INLET VIEW

5. SACRUM ANATOMY

6. SACRUM ANATOMY

7. POSTERIOR WALL OF PELVIS

8. LATERAL WALL OF PELVIS

9. SACRAL PLEXUS

10. SACRAL PLEXUS

11. SACRAL PLEXUS

12. SACRUM FRACTURES – NERVE ROOTS

14. SACRUM FRACTURES – DENIS CLASSIFICATIONSACRUM FRACTURES – DENIS CLASSIFICATION
ZONE I
Across sacral
Neurological injuries
•due to superior migration of fragments
•6% of the whole
•lumbrosacral plexus L5,S1 (24%)
•Femoral nerve

15. ZONE II
• Through the neuroforamina
• Neurological injuries → L5, S1 (50%)
• Unilateral sacral anesthesia
• Incontinence
• Flaccid bowel and bladder
• impotence
• Evaluation
• Achilles reflex
• Bulbocaverosus reflex
• Rectal tone
SACRUM FRACTURES – DENIS CLASSIFICATION

16. SACRUM FRACTURES – DENIS CLASSIFICATION
ZONE III
• through the body of the sacrum
• Neurological injuries
• 56% of the whole
• Cauda equina
• Neurogenic bladder
• Saddle anesthesia
• Loss of sphincter tone
• Bowel, bladder dysfunction 70%

17. MISCELLANEOUS FRACTURES
• Transverse fractures
• From landing on the
buttocks
• U shaped fractures

18. • One hand is placed on the iliac crest
• The other hand applies traction to the leg
→ Displacement in vertical plane
PHYSICAL EXAMINATION

19. RADIOGRAPHIC INVESTIGATION
• AP radiographs, inlet and outlet views
• Difficult – complex shape (50% are missed)
• Findings – low lumbar transverse process fractures
- asymmetrical sacral foramen
- irregular trabeculation of the lateral
masses
• Sacral arcuate lines → asymmetry: uncomplicated
sacral frx
→ disorganized: comminuted
sacral frx

21. RADIOGRAFIC INVESTIGATION

22. • The most accurateThe most accurate
• Especially for transverse fracturesEspecially for transverse fractures
• Useful for detecting large defects as tarlov cystsUseful for detecting large defects as tarlov cysts
• Diagnosis of coexisting malignant lesionsDiagnosis of coexisting malignant lesions
CT SCAN

26. CD SCAN

27. • The most sensitive
in detection of fractures
- soft tissue edema
- marrow changes
MRI

28. TREATMENT
ZONE I
• Without neurologic deficits and stable
• Symptom relief
• Bed rest (7-10 days)
• Log-rolled

29. TREATMENT
ZONE II and III
• Without neurologic deficits
• Bed rest for 4-8 weeks
• Weight bearing at 4-8 weeks on the fractured side

30. TREATMENT
ZONE III
• Without neurologic deficits
• Observation: neuropraxia that will resolve
• Symptoms beyond 6-8 weeks: foraminal decompression

31. TREATMENT
ZONE III
• With neurologic injury
• Aggressive radiologic examination
• Early posterior
decompression
for
Return of – bowel, bladder
control
Reserval of foot drop

32. COMPLICATIONS OF CONSERVATIVE
TREATMENT
• chronic pain
• sacroiliac joint arthritis
• changes in the alignment on the sacrum
• bowel, bladder disability

33. DETERMINATION OF FRACTURE STABILITY
• Stable fractures
• Impacted vertical fracture
• Nondisplaced fracture of posterior
sacroiliac complex
• Fracture of the upper sacrum

34. DETERMINATION OF FRACTURE STABILITY
• Unstable
• Fracture diastasis
of
more than 0,5 – 1cm along
with an anterior unstable
injury

35. SURGICAL INDICATION
• posterior or vertical displacement or both
(>1cm)
• Rotationally unstable pelvic ring injuries
• Sacral fractures with unstable pelvic ring
that requires mobilization
• Neurological injury

36. PROCEDURE
PRONE POSITION

37. PERCUTANEOUS ILIOSACRAL SCREW FIXATION
• For unilateral sacral fractures zone I or zone II
• Under fluoroscopic control the reduction is obtained and
held by iliac screws (cannulated)

38. OPEN REDUCTION AND INTERNAL FIXATION

39. MISCELLANEOUS CASES

40. CASE 4

43. CONCLUSION
• Neurological deficities
• Stable Fractures : conservative treatment
• Unstable Fractures : operative treatment
• Neurologic injury :posterior decompression