Date: Wed, 2 Jun 2004 06:50:37 -0500
From: Greg Schmeling, Jeffrey Ralston
Subject: U-shaped sacral fracture
This case was sent to me for my opinion on what to do. He asked if I would forward it to this list serve for other opinions. Please reply to all (I copied him on this email) as he is not on the OTA forum list. The patient has no neuro deficits.
Greg Schmeling
Medical College of Wisconsin
From: Jeffrey Ralston
Sent: Sunday, May 30, 2004 1:56 AM
This is an 18 year old healthy women roll-over ATV with femur fracture now with an antegrade nail. Can I have your advice about this U-shaped pelvis fracture? Injury was pm 5/29.
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Date: Wed, 2 Jun 2004 07:52:06 -0500
From: "Adam J. Starr, M.D."
Chip published a series of these fractures (or presented? - I forget, but it was a good series). Hopefully he will offer his opinion. It's always better to listen to somebody who has looked at their track record critically.
That said :)....I would do my best to get an acceptable alignment of the posterior part of the ring, and then and place perc iliosacral screws all the way across, from one ilium to the other, at 2 levels. If I couldn't get screws all the way across, I'd use bilateral screws. The images provided don't show the anterior ring. If there are ramus fractures I would fix those, too, using perc screws.
Adam Starr
Dallas
Date: Wed, 02 Jun 2004 09:03:06 -0700
From: Chip Routt
This subject has been discussed before on the list.
It appears to be a U-shaped sacral fracture on the limited studies/images...the anterior ring is not shown.
Assuming no other injury in a neuro intact patient, we'd position the patient supine on a sacral support. The sacral support and supine position often improve the reduction...you can use neuro monitoring if you choose. With inlet/outlet/lateral fluoro imaging and according to our preop plan, we'd use bilateral long (130-150mm) iliosacral screws to stabilize the fracture. We'd consider an HTLSO postop.
With neuro deficit, the plan is different.
As Adam mentioned, our early experience with this treatment was published in JOT (J Orthop Trauma. 2001 May;15(4):238-46) several years ago.
A "2 levels" screw technique is not helpful in this patient since the injury is confined to the upper-most sacral segment, and is a more dangerous technique since the safe area at the second sacral level is quite small.
Thanks-
Chip
Date: Wed, 02 Jun 2004 13:36
From: Bill Burman
> This subject has been discussed before on the list.
see: Paul Koerner's case and Carlo Bellabarba's on-line OTA BFC Sacral Fx Lecture.
Date: Wed, 2 Jun 2004 10:16:15 -0700
From: John Ruth
The patient needs a careful exam for rectal tone (bladder function too but hard to test for with foley) as these injuries can cause compression of the sacral nerve roots. An MRI can help as well. If sacral nerve root compression is present then a sacral laminectomy with decompression is indicated. The sacral fracture is impacted and relatively stable but probably should be treated with in-situ bilateral iliosacral screws. I am not sure that the deformity (in this case) needs to be reduced as it will produce more instability which would then likely require spino-pelvic fixation. I have not seen problems with this amount of deformity once healed but I only have a small series. Certainly the deformity can cause the compression of the sacral nerve roots, but this can usually be tamped down from behind without realignment of the upper sacral segment. Since it was referred to as a "U" type fracture I am assuming there is no anterior ring injury. If an anterior ring injury is present then reduction and stabilization of that is also required.
There is an excellent discussion of this topic on the OTA website under case discussion, pelvic fractures, sacral fracture. A reference on sacral decompression from that discussion is helpful.