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Sacral Fracture, Emergency Medicine

Basics

Description

  • They occur in 45% of all pelvic fractures and are rarely isolated
  • They are defined by the orientation of the fracture line.
  • Mechanism:Axial compressionDirect posterior traumaMassive crush injuryInsufficiency fractures in elderly and osteoporotic patients

Fracture Classification

Transverse

  • Above S4:Neurologic injury commonCan see cauda equina syndrome (CES)
  • Below S4:Associated rectal tearsNeurologic injury is are

Vertical

  • Lateral to sacral foramina:SciaticaL5 root injuryNeurologic deficit infrequent
  • Foraminal (zone 2):Bowel/bladder dysfunctionL5, S1, S2 root injuryNeurologic deficit frequent
  • Canal (zone 3):Bowel/bladder dysfunctionSexual dysfunctionL5, S1 root injuryNeurologic deficit often present (>50%)

Etiology

  • Transverse: Fall from height, flexion injuries, direct blow
  • Vertical: Usually high-energy mechanism

Sacral insufficiency fractures should be considered in elderly patients with severe back pain

Diagnosis

Signs and Symptoms

  • Pain in buttocks, perirectal area, and posterior thigh
  • Swelling and ecchymosis over the sacral prominence
  • Possible sacral nerve dysfunction:Absent or diminished anal sphincter tone is an important finding.Bowel or bladder incontinence

Essential Workup

  • History and physical exam with attention to loss of anal sphincter tone, sensation in the perineum, and bowel and bladder sphincter control.
  • Sacral fractures rarely occur in isolation; look for associated injuries.
  • Rectal exam will elicit pain in the sacrum; blood in the rectum suggests an open fracture.

Diagnosis Tests & Interpretation

Imaging

  • Only 30% of sacral fractures are detected on plain radiograph.
  • CT provides optimal imaging to identify sacral fractures.
  • MRI is indicated when neurologic dysfunction is present.

Differential Diagnosis

  • Contusion
  • Lumbar spine fracture
  • Pelvic fractures

Treatment

Pre-Hospital

  • Sacral fractures are frequently associated with other spinal and intra-abdominal injuries.
  • Immobilize with backboard and C-spine collar.

Initial Stabilization/Therapy

  • Manage ABCs as needed.
  • Early immobilization in unstable pelvis or spine fractures
  • Pain control with NSAIDs or narcotic analgesics

Ed Treatment/Procedures

  • Vertical unstable fractures require a rapid and thorough assessment for life-threatening injuries as well as orthopedic consultation (see "Pelvic Fracture " ).
  • Nondisplaced isolated transverse sacral fractures are treated symptomatically with touch-down weight bearing on affected side and early orthopedic referral.
  • Surgery is often required for fractures associated with neurologic injury.

Medication

First Line

Analgesia as indicated

Follow-Up

Disposition

Admission Criteria

  • Critically injured trauma patient with unstable pelvic fracture
  • Neurologic impairment requires orthopedic consultation.

Discharge Criteria

  • Isolated nondisplaced sacral fractures
  • Consider intermediate or assisted-care setting for elderly patients.

Follow-Up Recommendations

  • Only nondisplaced, transverse fractures are appropriate for outpatient follow-up
  • Prompt surgical evaluation is indicated for displaced fractures.

Pearls and Pitfalls

  • Sacral fractures are rarely isolated; consider associated pelvic fractures.
  • Detailed neurologic exam, including rectal sphincter tone and perianal sensation, is indicated to assess for associated sacral nerve root injury.
  • Foley catheter in a trauma patient may mask voiding problems from sacral nerve root injury.

Additional Reading

  • Choi SB, Cwinn AA. Pelvic trauma. In: Rosen P, ed. Emergency Medicine: Concepts and Clinical Practice. 7th ed. Philadelphia, PA: Mosby-Elsevier; 2009.
  • Galbraith JG, Butler JS, Blake SP, et al. Sacral insufficiency fractures: An easily overlooked cause of back pain in the ED. Am J Emerg Med. 2011;29(3):359.e5 " e6.
  • Hak DJ, Baran S, Stahel P. Sacral fractures: Current strategies in diagnosis and management. Orthopedics. 2009;32:752 " 757.

See Also (Topic, Algorithm, Electronic Media Element)

Pelvic Fracture

Codes

ICD9

  • 733.13 Pathologic fracture of vertebrae
  • 805.6 Closed fracture of sacrum and coccyx without mention of spinal cord injury
  • 806.62 Closed fracture of sacrum and coccyx with other cauda equina injury
  • 806.69 Closed fracture of sacrum and coccyx with other spinal cord injury
  • 806.61 Closed fracture of sacrum and coccyx with complete cauda equina lesion

ICD10

  • M84.48XA Pathological fracture, other site, init encntr for fracture
  • S32.10XA Unsp fracture of sacrum, init encntr for closed fracture
  • S32.14XA Type 1 fracture of sacrum, init encntr for closed fracture
  • S32.119A Unsp Zone I fracture of sacrum, init for clos fx
  • S32.129A Unsp Zone II fracture of sacrum, init for clos fx
  • S32.139A Unsp Zone III fracture of sacrum, init for clos fx

SNOMED

  • 125872003 Fracture of sacrum (disorder)
  • 441881007 Stress fracture of sacrum (disorder)
  • 207974008 Closed fracture sacrum (disorder)
  • 208071000 Closed fracture of sacrum with complete cauda equina lesion (disorder)
  • 207975009 Closed compression fracture sacrum (disorder)
  • 207976005 Closed vertical fracture of sacrum (disorder)