Sacral Fractures

MANUAL MINORS

Sacral fractures are injuries to the sacral bone, located at the base of the spine, and are typically associated with high-energy trauma, such as falls from heights or car accidents. They can also occur in patients with bone fragility, such as those with osteoporosis.

These fractures can be classified as stable or unstable, depending on the involvement of pelvic joints, and pose a risk of affecting neurological structures due to the proximity of the sacral nerves.

Diagnosis

Diagnosis is based on clinical suspicion after pelvic or lower back trauma, presenting with localised pain in the sacral area, difficulty walking, and, in some cases, neurological symptoms such as incontinence or weakness in the lower extremities.

Simple X-rays may not be sufficient to detect these fractures, so a computed tomography (CT) scan or magnetic resonance imaging (MRI) is recommended for more detailed evaluation, especially to identify complex or displaced fractures.

Differential Diagnosis

Condition	Key Differentiation
Pelvic fracture	Involves the iliac, pubic, or ischial bones without direct sacral involvement
Coccyx fracture	Localised pain in the lower sacral region, without pelvic or neurological involvement
Lumbar disc herniation	Pain radiating to the legs without a history of acute trauma
Sacral plexus injury	Neurological pain or weakness without visible bone fracture on imaging
Pelvic contusion	Pain following trauma, but no visible fracture on imaging

Emergency Management

Initial management includes stabilising the patient, pain control with analgesics (NSAIDs, opioids if necessary), and immobilisation. If neurological injuries are suspected, urgent neuroimaging should be performed, and consultation with neurosurgery or trauma specialists is advised.

For unstable fractures or those with neurological involvement, the patient should be prepared for urgent surgical intervention. A comprehensive assessment for other associated injuries is necessary, as sacral fractures often accompany other pelvic fractures or visceral injuries.

Definitive Treatment

Definitive treatment depends on the type and stability of the fracture. Stable, non-displaced fractures are usually managed conservatively with relative rest, pain control, and gradual physiotherapy.

Unstable or displaced fractures, as well as those with neurological compromise, require surgical fixation, which may involve iliosacral screws or external fixation. In cases of severe neurological damage, surgical decompression may be needed.

Rehabilitation is crucial for recovery, particularly in patients with stable fractures. Patients should be closely monitored for complications such as chronic pain, pelvic instability, or neurological sequelae.