Download - Sacral fractures
Sacral Fractures
Hitesh Gopalan UIndia
SICOT Educational Day 2013SICOT Congress Hyderabad
Sacral fractures- Incidence
• 45% of all pelvic injuries
• Often Missed( Upto 50% in neurologically intact patients)
• Missed open fractures( in females)- PV Exam
Mehta S, J Amer Acad Orthop Surg.2006; 14(12):656-665.
Sacrum- Physiology
• S1-S5 nerve roots
• Inferior Hypogastric Plexus
• Bladder, Bowel, Sexual function
Mechanism
• Lateral compression- Stable
• Vertical Shear- Unstable
• Lumbopelvic instability- Dissociation
Neurological Injury
• Neuropraxia
• Incomplete
• Transection
• Cauda Equina
Basic Imaging
• Pelvis Xray- Series: Inlet/outlet views
• Lateral view: Sagittal displacement
• CT Scan
• MRI
Classification
• Denis Classification
• Descriptive: H type, U type, Lambda and T type
• Subclassification of Denis 3: Roy Camille et al.
• Isler class: Lumbosacral Junction
Denis
Denis F et al..Clin Orthop Relat Res. 1988; (227):67-81.
Roy Camille- Strange-Vognsen and Lebech: TRANSVERSE #
Roy Camillle et al..Spine. 1985; 10(9):838-845Strange-Vognsen HH, Lebech A. J Orthop Trauma. 1991; 5(2):200-203..
Predictor of Neurology
• Denis 3> Denis 2> Denis 1
• Transverse #: 97%(Robles et al..)
Robles et al..Spine J. 2009;9(1):60-69.
Lumbosacral Stability
Isler B et al..J Orthop Trauma. 1990;4:1-6.
Clinical Exam- Key
• L5 to S4 nerve roots exam
• Reflexes
• Sensation
• Anal spinchter tone
• Bulbocavernous, Cremasteric, Anal Wink reflexes
• Sensation
Clinical Exam
Treatment
Non operative• No pelvic ring disruption, • Fractures not involving the lumbosacralJunction• fractures without neurologic injury.
Displaced Fractures
• Initial Management with Skeletal Traction
• Optimum Time for intervention
• Nerve Root Decompression
Surgical
• Percutaneous Iliosacral Screws
• Posterior Tension Band plating
• Anterior plating
• Transsacral Rods/Transiliac Rods
• Lumbopelvic fixation
Nerve Root Decompression
• Controversial
• Early(24- 72 hours)
• Indirect reduction Vs Laminectomy
• Electrodiagnostic Testing
Percutaneous Iliosacral Screws
SAFE CORRIDOR
Percutaneous Screws
• Safe corridor
• Sacral Dysmorphisms
• Intraoperative Radiation Exposure
• Lumbopelvic instability
Iliosacral Screws: Nork et al..
• 13 patients
• Denis Zone II or III injuries
• No deterioration of sacral kyphosis
• Bilateral screws in H or U zone III fractures
Nork SE, Jones CB, Harding SP, Mirza SK, Routt ML Jr. Percutaneous stabilization of Ushaped sacral fractures using iliosacral screws: technique and early results. J Orthop Trauma. 2001;15:238-46.
Posterior SI Joint Tension Band Plating
Posterior Plating
• Exposure
• Hardware and Wound breakdown
• Anterior Injury should be treated first
Lumbopelvic fixation
• Lumbopelvic instability
• Isler 3
• H type and U type
Roy Camille 2- Transverse sacral
Lumbopelvic fixation- Triangular Osteosynthesis
Spino-Pelvic Fixation
Lumbopelvic Fixation
• Invasive• Fixation of lumbar pedicles• Spine Surgeon• Superior Biomechanics
Schildhauer TA, Ledoux WR, Chapman JR, Henley MB, Tencer AF, Routt ML Jr. Triangular osteosynthesis and iliosacral screw fixation for unstable sacral fractures. A cadaveric and biomechanical evaluation under cyclic loads. J Orthop Trauma. 2003;17:22-31.
Conclusion
• Good Physical Examination
• Evaluation of Motor and Sensory system
• Per Vaginal examination in females to avoid missing an open fracture
Conclusion
Decompression: No Level 1 Evidence.
• Level 4 evidence: No reporting of severity on pre and post surgery neural recovery
• Denis et al..: Operative
• 80% improvement regardless of treatment(Schmidek et al.. Neurosurgery 1984;15:735-746)
Conclusion
Fixation Methods:• Trend towards percutaneous iliosacral screws
• No level 1 Evidence
• Lumbopelvic fixation: Invasive
• Iliosacral screw Vs Lumbopelvic fixation
Conclusion
• Long term pain in 30% patients regardless of fixation
• Paucity of High Quality Evidence