Fragility fractures of the sacrum: how to identify and when to treat surgically?

Abstract

The increasing prevalence of fragility fractures of the sacrum (FFS) occurring predominantly in osteoporotic individuals poses a diagnostic and therapeutic challenge. The clinical presentation varies from longstanding low back pain without the patient remembering a traumatic event to immobilized patients after suffering a low-energy trauma. FFS are often combined with a fracture of the anterior pelvic ring; hence they are classified as a part of fragility fractures of the pelvis (FFP). If not displaced, the patients are treated with weight bearing as tolerated and analgesics; however, we advocate to treat displaced fractures surgically according to the fracture personality and the patient’s comorbidities. Surgical options include minimal invasive sacro-iliac screws, trans-sacral bar osteosynthesis, open reduction and internal fixation, or spinopelvic stabilization. In the light of the high complication rate associated with immobilized patients, an operative approach often is indicated to accelerate the patient’s mobility.

Posterior, Lateral, and Anterior Hip Pain Due to Musculoskeletal Origin: A Narrative Literature Review of History, Physical Examination, and Diagnostic Imaging

“…41,42 Despite a thorough history and physical examination, the diagnosis of sacral stress fractures is often delayed because their presentation is similar to other differentials of low back and buttock pain (including sciatica), and no single clinical test is accurate. 43 Positive fulcrum, pelvic shear, adductor squeeze, and flexion-abduction-external rotation tests or pain while standing on the affected limb might be present with sacral stress fractures. 43 Point tenderness may be elicited with direct palpation.…”

“…43 Positive fulcrum, pelvic shear, adductor squeeze, and flexion-abduction-external rotation tests or pain while standing on the affected limb might be present with sacral stress fractures. 43 Point tenderness may be elicited with direct palpation. 43 As such, diagnostic imaging should be sought when clinical suspicion arises.…”

“…43 Point tenderness may be elicited with direct palpation. 43 As such, diagnostic imaging should be sought when clinical suspicion arises. 43,44 Radiography is specific but insensitive for detection of sacral stress fractures.…”

“…43 As such, diagnostic imaging should be sought when clinical suspicion arises. 43,44 Radiography is specific but insensitive for detection of sacral stress fractures. However, radiography may demonstrate a horizontal or vertical sclerotic line indicative of fracture.…”

Focus on pelvis and acetabulum

“…In their comprehensive article, Wagner et al [3] review the characteristics of fragility fractures of the sacrum and present the typical distribution of bone density in the sacrum of elderly persons. As a consequence, the morphology of sacral fractures in the elderly is consistent, but stability varies from stable to highly unstable.…”