Sacral injuries

SACRAL SACRAL

FRACTURES FRACTURES

PELVIC ANATOMY ANTERIOR VIEW PELVIC ANATOMY ANTERIOR VIEW

PELVIC ANATOMY POSTERIOR VIEW

PELVIC ANATOMY INLET VIEW

SACRUM ANATOMY

SACRUM ANATOMY

POSTERIOR WALL OF PELVIS

LATERAL WALL OF PELVIS

SACRAL PLEXUS

SACRAL PLEXUS

SACRAL PLEXUS

SACRUM FRACTURES – NERVE ROOTS

SACRUM FRACTURES – DENIS CLASSIFICATIONSACRUM FRACTURES – DENIS CLASSIFICATION

ZONE IAcross sacralNeurological injuries

•due to superior migration of fragments•6% of the whole•lumbrosacral plexus L5,S1 (24%)•Femoral nerve

ZONE II

• Through the neuroforamina

• Neurological injuries L5, S1 (50%)

• Unilateral sacral anesthesia• Incontinence• Flaccid bowel and bladder• impotence

• Evaluation • Achilles reflex• Bulbocaverosus reflex• Rectal tone

SACRUM FRACTURES – DENIS CLASSIFICATION

SACRUM FRACTURES – DENIS CLASSIFICATION

ZONE III

• through the body of the sacrum

• Neurological injuries

• 56% of the whole• Cauda equina• Neurogenic bladder• Saddle anesthesia• Loss of sphincter tone• Bowel, bladder dysfunction 70%

MISCELLANEOUS FRACTURES

• Transverse fractures

• From landing on the buttocks

• U shaped fractures

• One hand is placed on the iliac crest

• The other hand applies traction to the leg

Displacement in vertical plane

PHYSICAL EXAMINATION

RADIOGRAPHIC INVESTIGATION

• AP radiographs, inlet and outlet views

• Difficult – complex shape (50% are missed)

• Findings – low lumbar transverse process fractures

- asymmetrical sacral foramen

- irregular trabeculation of the lateral

masses

• Sacral arcuate lines asymmetry: uncomplicated

sacral frx

disorganized: comminuted

sacral frx

RADIOGRAFIC INVESTIGATION

• The most accurateThe most accurate

• Especially for transverse fracturesEspecially for transverse fractures

• Useful for detecting large defects as tarlov cystsUseful for detecting large defects as tarlov cysts

• Diagnosis of coexisting malignant lesionsDiagnosis of coexisting malignant lesions

CT SCAN

CD SCAN

• The most sensitive

in detection of fractures

- soft tissue edema

- marrow changes

MRI

TREATMENT

ZONE I

• Without neurologic deficits and stable

• Symptom relief

• Bed rest (7-10 days)

• Log-rolled

TREATMENT

ZONE II and III

• Without neurologic deficits

• Bed rest for 4-8 weeks

• Weight bearing at 4-8 weeks on the fractured side

TREATMENT

ZONE III

• Without neurologic deficits

• Observation: neuropraxia that will resolve

• Symptoms beyond 6-8 weeks: foraminal decompression

TREATMENT

ZONE III

• With neurologic injury

• Aggressive radiologic examination

• Early posterior

decompression

forReturn of – bowel, bladder

control

Reserval of foot drop

COMPLICATIONS OF CONSERVATIVE

TREATMENT

• chronic pain

• sacroiliac joint arthritis

• changes in the alignment on the sacrum

• bowel, bladder disability

DETERMINATION OF FRACTURE STABILITY

• Stable fractures

• Impacted vertical fracture

• Nondisplaced fracture of posterior sacroiliac complex

• Fracture of the upper sacrum

DETERMINATION OF FRACTURE STABILITY

• Unstable

• Fracture diastasis of more than 0,5 – 1cm along with an anterior unstable injury

SURGICAL INDICATION

• posterior or vertical displacement or both (>1cm)

• Rotationally unstable pelvic ring injuries

• Sacral fractures with unstable pelvic ring that requires mobilization

• Neurological injury

PROCEDURE PRONE POSITION

PERCUTANEOUS ILIOSACRAL SCREW FIXATION

• For unilateral sacral fractures zone I or zone II

• Under fluoroscopic control the reduction is obtained and

held by iliac screws (cannulated)

OPEN REDUCTION AND INTERNAL FIXATION

MISCELLANEOUS CASES

CASE 4

CONCLUSION

• Neurological deficities

• Stable Fractures : conservative treatment

• Unstable Fractures : operative treatment

• Neurologic injury :posterior decompression