Sacral fractures in young and elderly patients. One fracture, two different clinical identities with many treatment options
Keywords:
Sacrum fracture, insufficient sacrum fracture, spinopelvic dissociation, fragility fractureAbstract
Sacral fractures have always been a challenging treatment pathology, as they mostly concerned high-energy traumata with several coexisting fractures and injuries. In recent years, however, as the population ages more but remains active, diagnostic options have become more popular and widely used, leading to the appearance of the terms sacral insufficiency fracture or low energy sacral fracture in clinical practice. Although the terms refer to the same bone, the injury mechanism, complications, and treatment options do not overlap with high energy sacral fractures. This article reviews the two different fracture identities and suggests treatment options.
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References
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4. Wagner, D., Ossendorf, C., Gruszka, D. et al. Fragility fractures of the sacrum: how to identify and when to treat surgically?. Eur J Trauma Emerg Surg 41, 349–362 (2015). https://doi.org/10.1007/s00068-015-0530-z
5. Rodrigues-Pinto R, Kurd MF, Schroeder GD, et al. Sacral Fractures and Associated Injuries. Global Spine J. 2017;7(7):609-616. doi:10.1177/2192568217701097
6. Lunsjo K, Tadros A, Hauggaard A, Blomgren R, Kopke J, Abu-Zidan FM. Associated injuries and not fracture instability predict mortality in pelvic fractures: a prospective study of 100 patients. J Trauma. 2007;62(3):687-691. doi:10.1097/01.ta.0000203591.96003.ee
7. Bakhshayesh P, Weidenhielm L, Enocson A. Factors affecting mortality and reoperations in high-energy pelvic fractures. Eur J Orthop Surg Traumatol. 2018;28(7):1273-1282. doi:10.1007/s00590-018-2203-1
8. Vaccaro AR, Kim DH, Brodke DS, et al. Diagnosis and management of sacral spine fractures. Instr Course Lect. 2004;53:375-385.
9. Henes FO, Nüchtern JV, Groth M, et al. Comparison of diagnostic accuracy of Magnetic Resonance Imaging and Multidetector Computed Tomography in the detection of pelvic fractures. Eur J Radiol. 2012;81(9):2337-2342. doi:10.1016/j.ejrad.2011.07.012
10. Tamaki Y, Nagamachi A, Inoue K, et al. Incidence and clinical features of sacral insufficiency fracture in the emergency department. Am J Emerg Med. 2017;35(9):1314-1316. doi:10.1016/j.ajem.2017.03.037
11. Kim YY, Chung BM, Kim WT. Lumbar spine MRI versus non-lumbar imaging modalities in the diagnosis of sacral insufficiency fracture: a retrospective observational study. BMC Musculoskelet Disord. 2018;19(1):257. Published 2018 Jul 25. doi:10.1186/s12891-018-2189-1
12. Park JW, Park SM, Lee HJ, Lee CK, Chang BS, Kim H. Mortality following benign sacral insufficiency fracture and associated risk factors. Arch Osteoporos. 2017;12(1):100. Published 2017 Nov 9. doi:10.1007/s11657-017-0395-3
13. Breuil V, Roux CH, Carle GF. Pelvic fractures: epidemiology, consequences, and medical management. Curr Opin Rheumatol. 2016;28(4):442-447. doi:10.1097/BOR.0000000000000293
14. Finiels PJ, Finiels H, Strubel D, Jacquot JM. Spontaneous osteoporotic fractures of the sacrum causing neurological damage. Report of three cases. J Neurosurg. 2002;97(3 Suppl):380-385. doi:10.3171/spi.2002.97.3.0380
15. Dietz SO, Hofmann A, Rommens PM. Haemorrhage in fragility fractures of the pelvis. Eur J Trauma Emerg Surg. 2015;41(4):363-367. doi:10.1007/s00068-014-0452-1
16. Scheyerer MJ, Osterhoff G, Wehrle S, Wanner GA, Simmen HP, Werner CM. Detection of posterior pelvic injuries in fractures of the pubic rami. Injury. 2012;43(8):1326-1329. doi:10.1016/j.injury.2012.05.016
17. Meinberg EG, Agel J, Roberts CS, Karam MD, Kellam JF. Fracture and Dislocation Classification Compendium-2018. J Orthop Trauma. 2018;32 Suppl 1:S1-S170. doi:10.1097/BOT.0000000000001063
18. Burgess AR, Eastridge BJ, Young JW, et al. Pelvic ring disruptions: effective classification system and treatment protocols. J Trauma. 1990;30(7):848-856.
19. Beckmann N, Cai C. CT characteristics of traumatic sacral fractures in association with pelvic ring injuries: correlation using the Young-Burgess classification system. Emerg Radiol. 2017;24(3):255-262. doi:10.1007/s10140-016-1476-0
20. Denis F, Davis S, Comfort T. Sacral fractures: an important problem. Retrospective analysis of 236 cases. Clin Orthop Relat Res. 1988;227:67-81.
21. Isler B. Lumbosacral lesions associated with pelvic ring injuries. J Orthop Trauma. 1990;4(1):1-6. doi:10.1097/00005131-199003000-00001
22. Katsuura Y, Chang E, Sabri SA, Gardner WE, Doty JF. Anatomic Parameters for Instrumentation of the Sacrum and Pelvis: A Systematic Review of the Literature. J Am Acad Orthop Surg Glob Res Rev. 2018;2(8):e034. Published 2018 Aug 2. doi:10.5435/JAAOSGlobal-D-18-00034
23. Strange-Vognsen HH, Lebech A. An unusual type of fracture in the upper sacrum. J Orthop Trauma. 1991;5(2):200-203. doi:10.1097/00005131-199105020-00014
24. Zeman J, Pavelka T, Matějka J. Suicidal Jumper’s Fracture [Suicidal jumper’s fracture]. Acta Chir Orthop Traumatol Cech. 2010;77(6):501-506.
25. Bäcker HC, Wu CH, Vosseller JT, et al. Spinopelvic dissociation in patients suffering injuries from airborne sports [published online ahead of print, 2019 Apr 29]. Eur Spine J. 2019;10.1007/s00586-019-05983-6. doi:10.1007/s00586-019-05983-6
26. Rommens PM, Arand C, Thomczyk S, Handrich K, Wagner D, Hofmann A. Fragilitätsfrakturen des Beckens [Fragility fractures of the pelvis]. Unfallchirurg. 2019;122(6):469-482. doi:10.1007/s00113-019-0643-7
27. Zhao XG. Emergency management of hemodynamically unstable pelvic fractures. Chin J Traumatol. 2011;14(6):363-366.
28. Scaglione M, Parchi P, Digrandi G, Latessa M, Guido G. External fixation in pelvic fractures. Musculoskelet Surg. 2010;94(2):63-70. doi:10.1007/s12306-010-0084-5
29. Pavelka T, Houcek P, Hora M, Hlavácová J, Linhart M. Urologické poranení pri zlomeninách pánevního kruhu [Urogenital trauma associated with pelvic ring fractures]. Acta Chir Orthop Traumatol Cech. 2010;77(1):18-23.
30. Lykomitros VA, Papavasiliou KA, Alzeer ZM, Sayegh FE, Kirkos JM, Kapetanos GA. Management of traumatic sacral fractures: a retrospective case-series study and review of the literature. Injury. 2010;41(3):266-272. doi:10.1016/j.injury.2009.09.008
31. Kasukawa Y, Miyakoshi N, Ebina T, et al. Enhanced bone healing and decreased pain in sacral insufficiency fractures after teriparatide treatment: retrospective clinical-based observational study. Clin Cases Miner Bone Metab. 2017;14(2):140-145. doi:10.11138/ccmbm/2017.14.1.140
32. Rommens PM, Arand C, Hofmann A, Wagner D. When and How to Operate Fragility Fractures of the Pelvis?. Indian J Orthop. 2019;53(1):128-137. doi:10.4103/ortho.IJOrtho_631_17
33. Hak DJ, Baran S, Stahel P. Sacral fractures: current strategies in diagnosis and management. Orthopedics. 2009;32(10):orthosupersite.com/view.asp?rID=44034. doi:10.3928/01477447-20090818-18
34. Halawi MJ. Pelvic ring injuries: Surgical management and long-term outcomes. J Clin Orthop Trauma. 2016;7(1):1-6. doi:10.1016/j.jcot.2015.08.001
35. Beckmann NM, Chinapuvvula NR. Sacral fractures: classification and management. Emerg Radiol. 2017;24(6):605-617. doi:10.1007/s10140-017-1533-3
36. Vialle R, Charosky S, Rillardon L, Levassor N, Court C. Traumatic dislocation of the lumbosacral junction diagnosis, anatomical classification and surgical strategy. Injury. 2007;38(2):169-181. doi:10.1016/j.injury.2006.06.015
37. Tsirikos AI, Saifuddin A, Noordeen MH, Tucker SK. Traumatic lumbosacral dislocation: report of two cases. Spine (Phila Pa 1976). 2004;29(8):E164-E168. doi:10.1097/00007632-200404150-00026
38. Pulley BR, Cotman SB, Fowler TT. Surgical Fixation of Geriatric Sacral U-Type Insufficiency Fractures: A Retrospective Analysis. J Orthop Trauma. 2018;32(12):617-622. doi:10.1097/BOT.0000000000001308
39. Zelle BA, Gruen GS, Hunt T, Speth SR. Sacral fractures with neurological injury: is early decompression beneficial?. Int Orthop. 2004;28(4):244-251. doi:10.1007/s00264-004-0557-y
40. Kepler CK, Schroeder GD, Hollern DA, et al. Do Formal Laminectomy and Timing of Decompression for Patients With Sacral Fracture and Neurologic Deficit Affect Outcome?. J Orthop Trauma. 2017;31 Suppl 4:S75-S80. doi:10.1097/BOT.0000000000000951
41. Rommens PM. Is there a role for percutaneous pelvic and acetabular reconstruction?. Injury. 2007;38(4):463-477. doi:10.1016/j.injury.2007.01.025
42. Frey ME, Depalma MJ, Cifu DX, Bhagia SM, Carne W, Daitch JS. Percutaneous sacroplasty for osteoporotic sacral insufficiency fractures: a prospective, multicenter, observational pilot study. Spine J. 2008;8(2):367-373. doi:10.1016/j.spinee.2007.05.011
43. Kortman K, Ortiz O, Miller T, et al. Multicenter study to assess the efficacy and safety of sacroplasty in patients with osteoporotic sacral insufficiency fractures or pathologic sacral lesions. J Neurointerv Surg. 2013;5(5):461-466. doi:10.1136/neurintsurg-2012-010347
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2021-04-26
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