SACRAL FRACTURES SACRAL FRACTURES

Dr. D. N. BidDr. D. N. BidSarvajanik College of Physiotherapy, Sarvajanik College of Physiotherapy, Rampura, SuratRampura, Surat

1-3-20161-3-2016

A blow from behind, or a fall onto the A blow from behind, or a fall onto the ‘tail’ may fracture the sacrum or coccyx, ‘tail’ may fracture the sacrum or coccyx, or sprain the joint between them. or sprain the joint between them.

Women seem to be affected more Women seem to be affected more commonly than men.commonly than men.

Bruising is considerable and tenderness is Bruising is considerable and tenderness is elicited when the sacrum or coccyx is elicited when the sacrum or coccyx is palpated from behind or per rectum. palpated from behind or per rectum.

Sensation may be lost over the distribution Sensation may be lost over the distribution of sacral nerves.of sacral nerves.

SACRAL PLEXUS

SACRUM FRACTURES – NERVE ROOTS

SACRUM FRACTURES – DENIS CLASSIFICATIONSACRUM FRACTURES – DENIS CLASSIFICATION

ZONE IAcross sacral wingNeurological injuries

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

ZONE II• Through the neural foramina• 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

X-rayX-ray X-raysX-rays may show: may show:

(1)(1) a transverse fracture of the sacrum, in rare cases a transverse fracture of the sacrum, in rare cases with the lower fragment pushed forwards; with the lower fragment pushed forwards;

(2) a fractured coccyx, sometimes with the lower (2) a fractured coccyx, sometimes with the lower fragment angulated forwards; or fragment angulated forwards; or

(3) a normal appearance if the injury was merely a (3) a normal appearance if the injury was merely a sprained sacrococcygeal joint. sprained sacrococcygeal joint.

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 fractures

disorganized: comminuted sacral

fractures.

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

• 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

TreatmentTreatment If the fracture is displaced, reduction is worth attempting. If the fracture is displaced, reduction is worth attempting.

The lower fragment may be pushed backwards by a finger in the The lower fragment may be pushed backwards by a finger in the rectum. The reduction is stable, which is fortunate. rectum. The reduction is stable, which is fortunate.

The patient is allowed to resume normal activity, but is advised The patient is allowed to resume normal activity, but is advised to use a rubber ring cushion when sitting. to use a rubber ring cushion when sitting.

Occasionally, sacral fractures are associated with urinary Occasionally, sacral fractures are associated with urinary problems, necessitating sacral laminectomy. problems, necessitating sacral laminectomy.

Persistent pain, especially on sitting, is Persistent pain, especially on sitting, is common after coccygeal injuries. common after coccygeal injuries.

If the pain is not relieved by the use of a If the pain is not relieved by the use of a cushion or by the injection of local cushion or by the injection of local anaesthetic into the tender area, excision anaesthetic into the tender area, excision of the coccyx may be considered.of the coccyx may be considered.

CONCLUSION

• Stable Fractures : conservative treatment

• Unstable Fractures : operative treatment

• Neurologic injury :posterior decompression

Fractures of the coccyxFractures of the coccyx

Fractures of the coccyx result from a direct blow to Fractures of the coccyx result from a direct blow to the bottom from a fall onto the coccyx. They are the bottom from a fall onto the coccyx. They are exceedingly painful.exceedingly painful.

TreatmentTreatmentNo specific treatment is required apart from No specific treatment is required apart from analgesics and a soft cushion. The pain may be very analgesics and a soft cushion. The pain may be very slow to resolve and can lead to lasting disability.slow to resolve and can lead to lasting disability.