Please confirm topic selection

Are you sure you want to trigger topic in your Anconeus AI algorithm?

Please confirm action

You are done for today with this topic.

Would you like to start learning session with this topic items scheduled for future?

Updated: Jun 24 2021

Sacral Insufficiency Fracture

Images
https://upload.orthobullets.com/topic/12297/images/bcde64cf-736e-4aca-98a4-bd138ce742ec_deni_1..jpg
https://upload.orthobullets.com/topic/12297/images/69d678ed-dd65-497d-b555-a6d305ee90e2_deni_3..jpg
https://upload.orthobullets.com/topic/12297/images/scsandc201745-f3.jpg
https://upload.orthobullets.com/topic/12297/images/unilat.jpg
  • summary
    • Sacral Insufficiency Fractures are fragility fractures of the sacral spine that occur more commonly in elderly women with osteoporosis.
    • Diagnosis can be made with inlet and outlet radiographs of the pelvis. CT or MRI may be helpful for fracture characterization and operative planning. 
    • Treatment is usually observation and pain control.  Surgical management is indicated for patients with progressive pain and/or difficulty ambulating that fail nonoperative treatment.
  • Epidemiology
    • Incidence
      • 1% of women > 55 years old
        • increases with age
        • estimated to increase by 23% each year
    • Demographics
      • females more commonly affected 2:1
      • average age is 69 years old
    • Risk factors
      • osteoporosis
      • vitamin D deficiency
      • rheumatoid arthritis
      • prolonged immobilization
      • long-term steroid use
      • pelvic radiation
  • Etiology
    • Pathophysiology
      • mechanism of injury
        • low energy trauma (i.e. ground level fall)
    • Associated conditions
      • other fragility fractures (i.e. distal radius, vertebral, hip)
  • Anatomy
    • Osteology
      • formed by fusion of 5 sacral vertebrae
      • articulates with
        • 5th lumbar vertebra proximally
        • coccyx distally
        • ilium laterally at sacroiliac joints
      • contains 4 foramina which transmit sacral nerves
    • Nerves
      • L5 nerve root runs on top of sacral ala
      • S1-S4 nerve roots are transmitted through the sacral foramina
        • S1 and S2 nerve roots carry higher rate of injury
      • lower sacral nerve roots (S2-S5)
        • function
          • anal sphincter tone / voluntary contracture
          • bulbocavernosus reflex
          • perianal sensation
        • unilateral preservation of nerves is adequate for bowel and bladder control
    • Biomechanics
      • transmission of load distributed by first sacral segment through iliac wings to the acetabulum
  • Classification
      • Denis Classification
      • Zone 1
      • Fracture lateral to foramina
      • Zone 2
      • Fracture through foramina
      • Zone 3
      • Fracture medial to foramina into the spinal canal
  • Presentation
    • History
      • low-energy trauma (i.e. ground level fall)
    • Symptoms
      • pain
        • groin, low back, buttock
        • worse with weightbearing
    • Physical exam
      • limited hip motion
      • neurologic deficits are rare
  • Imaging
    • Radiographs
      • recommended views
        • AP
        • lateral
        • inlet view
          • best assessment of sacral spinal canal and superior view of S1
        • outlet view
          • provides true AP of sacrum
    • CT
      • indications
        • negative radiographs but high suspicion for fracture
        • confirmed fracture on radiographs
    • MRI
      • indications
        • negative radiographs and CT but high suspicion for occult fracture
    • Bone scan
      • indications
        • no longer used
      • findings
        • Honda or H sign
          • seen with H-type fractures
  • Studies
    • Serum labs
      • evaluate for causes of osteoporosis
  • Treatment
    • Nonoperative
      • observation, mobilization, analgesia, osteoporosis screening & treatment
        • indications
          • first line of treatment
    • Operative
      • sacroplasty
        • indications
          • minimally displaced zone 1 injuries after failed nonoperative treatment
      • ORIF
        • indications
          • displaced zone 1 injuries after failed nonoperative treatment
          • zone 2 or 3 injuries after failed nonoperative treatment
  • Techniques
    • Sacroplasty
      • technique
        • injection of polymethylmethacrylate cement
      • complications specific to this treatment
        • cement leakage
          • avoid sacroplasty in displaced fractures due to risk of symptomatic cement leakage
    • ORIF
      • technique
        • unilateral iliosacral screws
          • place 2 parallel 7-8mm cannulated screws perpendicular to the fracture plane
            • 2 screws have more stability than 1 screw
            • screws should cross midline
            • stability is dependent on the strength of the sacral cancellous bone
          • use washers to prevent penetration of the screw head through the lateral cortex of the posterior part of the ilium
        • trans-sacral screw
          • place 6mm screw through the sacral corridor of S1
        • posterior bridging plate
          • place plate against sacrum and posterior part of ilium
          • acts as tension band
      • complications specific to this treatment
        • implant loosening
        • hardware failure
  • Complications
    • Non-union
    • Persistent pain
Card
1 of 0
Private Note