Surgery for Unilateral Sacral Fractures: Are the Indications Clear?

Abstract

Objectives: To evaluate unilateral sacral fractures and compare those treated operatively versus nonoperatively to determine indications for surgery. Design: Prospective, multicenter, observational study. Setting: Sixteen trauma centers. Patients/Participants: Skeletally mature patients with pelvic ring injury and unilateral zone 1 or 2 sacral fractures and without anteroposterior compression injuries. Main Outcome Measurements: Injury plain anteroposterior, inlet, and outlet radiographs and computed tomography scans of the pelvis were evaluated for fracture displacement. Results: Three hundred thirty-three patients with unilateral sacral fractures and a mean age of 41 years with a mean Injury Severity Score of 15 were included. Ninety-two percent sustained lateral compression injuries, and 63% of all fractures were in zone 1. Thirty-three percent of patients were treated operatively, including all without lateral compression patterns. Operative patients were more likely to have zone 2 fractures (54%) and to have posterior cortical displacement (29% vs. 6.2%), both with P < 0.001. Over 60% of all patients had no posterior displacement. Mean rotational displacements comparing the injured side versus the intact side were no different for patients treated operatively compared with those treated nonoperatively. Conclusions: Most unilateral sacral fractures are minimally or nondisplaced. Many patients with radiographically similar fractures were treated operatively and nonoperatively by different surgeons. This suggests an opportunity to develop consistent indications for treatment. Level of Evidence: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Assessment of instability in type B pelvic ring fractures

“…Vallier et al's retrospective review looked at three hundred and thirty three unilateral sacral fractures treated at 16 different trauma centers. 25 Most patients who were treated operatively had less than 5 mm of sacral displacement. Zone 2 fractures were more commonly fixed.…”

Unilateral Sacral Fractures Demonstrate Slow Recovery of Patient-Reported Outcomes Irrespective of Treatment

“…The practical barrier to a large, multicenter randomized study is surgeons are not in relative agreement about indications, which may have negatively affected enrollment. 5 This likewise may have led to selection bias and inability to enroll a meaningful number of patients. Another weakness was the high loss to follow-up over time, which is consistent with treatment at academic medical centers.…”

Results of minimally invasive quick definitive fixation of unstable bony pelvic disruption by combined retrosacral transiliac rods and anterior external fixator during a critical national period

“…These findings support the need to develop consistent indications for surgical treatment of type-I and II sacral fractures. 16 Triangular osteosynthesis (TOS) for transforaminal sacral fractures is a technically demanding rigid fixation especially in cases of spinopelvic dissociation. Pain from prominence of the pedicular screws heads, L5-S1 facet joint distraction, iatrogenic L5 root injury from manipulation, wound problems, residual displacement and loosening of fixation are reported complications.…”

“…Pain from prominence of the pedicular screws heads, L5-S1 facet joint distraction, iatrogenic L5 root injury from manipulation, wound problems, residual displacement and loosening of fixation are reported complications. 16,17 This technique should be reserved as a salvage procedure for unstable sacral fractures if other fixation methods are not applicable. 18 Iliosacral screws (ISS) are commonly used to fix posterior injuries (SI joint dislocations, sacral fractures, type-III crescent fractures and combined injuries).…”