Using longer screws may lead to bending of the fixation. It is not safe to perform iliosacral screw fixation with persistent fracture displacement. SI joint disruption can be fixed by either closed means or by percutaneous iliosacral screw fixation. If neurologic injuries are present, open reduction and foraminal decompression are indicated. Options include percutaneous iliosacral screws, posterior tension band plating, and transiliac sacral bars. Surgical treatment consists of surgical reduction or fixation if fracture is displaced 1 cm. Pelvic angiography can be used for the treatment of hemorrhage. Immediate treatment for sacral fractures consists of general resuscitation measures and temporary reduction of displaced pelvic ring fractures with skeletal traction or external fixation. Other injuries to consider include pelvic ring fracture, ligamentous, neurologic, genitourinary and gastrointestinal injuries. Differential Diagnosis/Associated Injuries MRI can be useful for imaging of genitourinary or pelvic vascular structures as well as for patients who experience sacral neurological deficits after trauma. CT is useful for assessing the sacrum and SI joints. This is useful for determining vertical displacement of the hemipelvis, widened SI joint, discontinuity of the sacral foramina. Pelvic outlet x-ray provides a true AP view of the sacrum. It can be useful in determining anterior or posterior displacement of the SI joint, sacrum, or iliac wing. X-ray of the pelvic inlet shows the sacral spinal canal and superior view of S1. Patients may also report low-back or buttock pain with walking.ĪP x-ray of the pelvis provides limited visualization of the sacrum. A digital rectal examination and a vaginal exam in women should be conducted to exclude an open fracture. It is important to do a functional assessment of the lower sacral nerve roots by checking spontaneous and voluntary rectal sphincter contraction, pinprick sensation in dermatomes of S2-S5, and reflexes - perianal wink, bulbocavernosus and cremasteric reflexes. Sacral injury should be suspected if patient presents with peripelvic pain, posterior sacral bony prominence, or palpable subcutaneous fluid. Presentation/Physical Exam/Radiographic Studes Although zone 3 fractures are seen less frequently, they have the highest rate of neurological deficits of the three zones. Zone 2 fractures involve one or more foramen and are usually due to vertical shear. Zone 1 fractures are usually caused by lateral compression of the pelvis, vertical shear fracture, or sacrotuberous avulsions.
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