BPT Lectures

1. SACRAL FRACTURESSACRAL FRACTURES
Dr. D. N. BidDr. D. N. Bid
Sarvajanik College of Physiotherapy,Sarvajanik College of Physiotherapy,
Rampura, SuratRampura, Surat
1-3-20161-3-2016

2.  A blow from behind, or a fall onto theA 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 moreWomen seem to be affected more
commonly than men.commonly than men.

3.  Bruising is considerable and tenderness isBruising is considerable and tenderness is
elicited when the sacrum or coccyx iselicited when the sacrum or coccyx is
palpated from behind or per rectum.palpated from behind or per rectum.
 Sensation may be lost over the distributionSensation may be lost over the distribution
of sacral nerves.of sacral nerves.

4. SACRAL PLEXUS

5. SACRUM FRACTURES – NERVE ROOTS

6. SACRUM FRACTURES – DENIS CLASSIFICATIONSACRUM FRACTURES – DENIS CLASSIFICATION
ZONE I
Across sacral wing
Neurological injuries
•due to superior migration of fragments
•6% of the whole
•lumbrosacral plexus L5,S1 (24%)
•Femoral nerve

7. 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

8. 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%

9. MISCELLANEOUS FRACTURES
• Transverse fractures
• From landing on the
buttocks
• U shaped fractures

10. • One hand is placed on the iliac crest
• The other hand applies traction to the leg
→ Displacement in vertical plane
PHYSICAL EXAMINATION

11. X-rayX-ray
 X-raysX-rays may show:may show:
(1)(1) a transverse fracture of the sacrum, in rarea transverse fracture of the sacrum, in rare
cases with the lower fragment pushedcases with the lower fragment pushed
forwards;forwards;
(2) a fractured coccyx, sometimes with the(2) a fractured coccyx, sometimes with the
lower fragment angulated forwards; orlower fragment angulated forwards; or
(3) a normal appearance if the injury was(3) a normal appearance if the injury was
merely a sprained sacrococcygeal joint.merely a sprained sacrococcygeal joint.

12. 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.

14. RADIOGRAFIC INVESTIGATION

15. • 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

16. • The most sensitive
in detection of fractures
- soft tissue edema
- marrow changes
MRI

17. TREATMENT
ZONE I
• Without neurologic deficits and stable
• Symptom relief
• Bed rest (7-10 days)
• Log-rolled

18. TREATMENT
ZONE II and III
• Without neurologic deficits
• Bed rest for 4-8 weeks
• Weight bearing at 4-8 weeks on the fractured side

19. TREATMENT
ZONE III
• Without neurologic deficits
• Observation: neuropraxia that will resolve
• Symptoms beyond 6-8 weeks: foraminal decompression

20. TREATMENT
ZONE III
• With neurologic injury
• Aggressive radiologic examination
• Early posterior
decompression
for
Return of – bowel, bladder
control
Reserval of foot drop

21. COMPLICATIONS OF CONSERVATIVE
TREATMENT
• chronic pain
• sacroiliac joint arthritis
• changes in the alignment on the sacrum
• bowel, bladder disability

22. DETERMINATION OF FRACTURE STABILITY
• Stable fractures
• Impacted vertical fracture
• Nondisplaced fracture of posterior
sacroiliac complex
• Fracture of the upper sacrum

23. DETERMINATION OF FRACTURE STABILITY
• Unstable
• Fracture diastasis
of
more than 0,5 – 1cm along
with an anterior unstable
injury

24. 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

25. PROCEDURE
PRONE POSITION

26. 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)

27. OPEN REDUCTION AND INTERNAL FIXATION

29. TreatmentTreatment
 If the fracture is displaced, reduction is worthIf the fracture is displaced, reduction is worth
attempting.attempting.
 The lower fragment may be pushed backwards by aThe lower fragment may be pushed backwards by a
finger in the rectum. The reduction is stable, which isfinger in the rectum. The reduction is stable, which is
fortunate.fortunate.
 The patient is allowed to resume normal activity, but isThe patient is allowed to resume normal activity, but is
advised to use a rubber ring cushion when sitting.advised to use a rubber ring cushion when sitting.
 Occasionally, sacral fractures are associated with urinaryOccasionally, sacral fractures are associated with urinary
problems, necessitating sacral laminectomy.problems, necessitating sacral laminectomy.


30.  Persistent pain, especially on sitting, isPersistent pain, especially on sitting, is
common after coccygeal injuries.common after coccygeal injuries.
 If the pain is not relieved by the use of aIf the pain is not relieved by the use of a
cushion or by the injection of localcushion or by the injection of local
anaesthetic into the tender area, excisionanaesthetic into the tender area, excision
of the coccyx may be considered.of the coccyx may be considered.

31. CONCLUSION
• Stable Fractures : conservative treatment
• Unstable Fractures : operative treatment
• Neurologic injury :posterior decompression

32. Fractures of the coccyxFractures of the coccyx
 Fractures of the coccyx result from a direct blowFractures of the coccyx result from a direct blow
to the bottom from a fall onto the coccyx. Theyto the bottom from a fall onto the coccyx. They
are exceedingly painful.are exceedingly painful.
 TreatmentTreatment
No specific treatment is required apart fromNo specific treatment is required apart from
analgesics and a soft cushion. The pain may beanalgesics and a soft cushion. The pain may be
very slow to resolve and can lead to lastingvery slow to resolve and can lead to lasting
disability.disability.