Date: Mon, 12 Sep 2005 16:14:32 +0200

From: J.C. Goslings

Subject: Sacral fracture case

List members,

Please share your opinion on this case.

21-year old male, fall from height 8 days ago

• subdural hematoma (craniotomy)
• Le Fort II fracture
• Galeazzi fracture (ORIF)
• bilateral open comminuted calcaneus, Chopart and Lisfranc fractures (ex. fix. and K-wires)
• U-shaped sacral fracture with dislocation
• today back on the ward after ICU stay, alert, neurologically intact, intact soft tissues covering sacrum

Images attached (only CT since patient was referred to us and conventional X-rays were not digitalized).

Axial - Click to Magnify

Sagittal - Click to Magnify

We plan to do lumbopelvic stabilization and posterior transsacral plate fixation.

Questions:

1. (How) would you reduce the fracture-disclocation?

2. Would percutaneous bilateral SI-screws (as described by Nork et al. in J Orthop Trauma 2001) still be an option?

Thank you,

Carel Goslings and Kees Jan Ponsen

Trauma Unit AMC

Amsterdam, the Netherlands

Date: Mon, 12 Sep 2005 08:37:13 -0700

From: Chip Routt

There have been several discussions (case 1, case 2) of similar patients on this site over the past few years with special emphasis on lumbopelvic fixation/reduction/etc...maybe they can be accessed.

Responses:

1. The reduction is difficult and incomplete in patients with such comminution and displacement.

2. Screws alone are always an option, but are not a good one without reduction and if used alone...they'll have little (if any) function for this pattern/displacement. You can anesthetize him, place him supine, and image it to see if it improves with positioning +/- traction...if so and you choose screws alone, you should consider strongly a brace/cast  to support the "fixation".

The lumbopelvic fixation discussions previously noted on this site should be helpful to you.

In 1991, I treated an obese patient with similar "traumatic upper sacral spondyloptosis" and placed him into a spica cast for several reasons...over 6 weeks being supine or log-rolled in the cast, he reduced ~80+% normal (surprisingly) and maintained his neurological status...maybe he was/we were just lucky, but the reduction was impressive...I'll include his injury and follow up slides.

Example case - Click to Magnify

Thanks-

Chip

M.L. Chip Routt, Jr.,M.D.
Professor-Orthopedic Surgery
Harborview Medical Center
Seattle, WA 98104-2499