Sacral fractures.pptx

sacral fractures

1. Sacral fractures DR ASIF JATOI SENIOR REGISTRAR CMH RAWALPINDI

2. The sacrum is an irregularly shaped bone, made up of a group of five fused vertebrae The sacrum plays a central role in the stability of both the pelvis and the spinal column. The important neurologic structures the lower sacral roots and autonomic nerves that are important for continence of the bowel and bladder and sexual function

3. ANATOMY

4. frequently missed at presentation because these associated with high-energy trauma and present with multiple injuries & hemodynamically unstable. The neurologic evaluation must include DRE to assess rectal tone maximal contraction of the anal sphincter and rectal tears and anterior perineal lacerations.

5. The L5 nerve is at risk at the anterior junction of the ala and the sacral promontory, and the S1 nerve root can be injured within the foramen. Extremity motor and sensory testing and rectal examination

6. IMAGING STUDIOS Plain radiographs have not proven sensitive . CT scan of the pelvis with 2-mm slices and sagittal and coronal reformatted images should be obtained When associated neurologic deficits with displaced fractures, MRI also may be of value,

7. DENIS CLASSIFCATION Zone 1-lateral to the foramina 50% of injuries with a 6% incidenceof L5 and S1 injuries Zone 2 -through the foramina 34% of injuries, and 28% with deficits unilaterally at the L5, S1, or S2 levels Zone 3- medial to the foramen and involve the spinal canal Remaining 16% of injuries

8. ROY-CAMILLE CLASSIFICATION

9. ISLER CLASSIFICATION

10. AO CLASSIFICATION The classification system describes injuries based on three criteria: morphology of the injury neurologic status case-specific modifiers

11. MORPHOLOGY OF THE INJURY TYPE A INJURIES are lower sacro-coccygeal fractures with no impact on the posterior pelvic or spino -pelvic stability . TYPE B INJURIES are unilateral longitudinal (vertical) sacral fractures which result in posterior pelvic instability but no impact on spino -pelvic stability. TYPE C INJURIES include unilateral B injuries with L5-S1 facet involvement, bilateral longitudinal (vertical) sacral fractures and U fracture variations resulting in spino -pelvic instability.

12. NEUROLOGY Neurological injuries are classified as follows: Nx : Cannot be examined N0: No neurological deficits N1: Transient neurological injury N2: Nerve root injury N3: Cauda Equina Syndrome/Incomplete SCI N4: Complete SCI*

13. MODIFIERS These modifiers are added to distinguish features that may impact treatment of a given fracture type. M1: Severe soft Tissue Injury M2: Metabolic Bone Disease M3: Anterior pelvic ring injury M4: Sacroiliac joint injury

14. TREATMENT Type A1 and A2 are managed conservatively Type A3, by sacral alar plating or laminectomy Type B1,B2, B3 are managed with illiosacral screws or spinopelvic fixation.

15. Type A3

16. C0 Nondisplaced U-fracture This is a nondisplaced sacral U-type fracture, result from low-energy injuries. commonly seen as insufficiency fractures in patients with metabolic bone disease. Treated conservatively or by Iliosacral screws (ISS)

17. TYPE C1 This is any unilateral B-type fracture involving a fracture of the ipsilateral L5-S1 joint. This fracture type may impact spino -pelvic instability and is therefore classified as a C fracture

18. TYPE C2 This is a bilateral B-type fracture without a transverse component. These fractures are more unstable and have a higher risk of neurological injury than C1.

19. TYPE C3 This is a displaced U-type fracture. It has a similar instability profile as C2, but due to the transverse fracture displacement it has a higher likelihood of neurological injury.

20. Type C1, C2 and C3 are treated surgically by spinopelvoc fixation and Fixation of associated pelvic ring injuries.

21. ILIOSACRAL SCREW (ISS) FIXATION  Iliosacral screw (ISS) fixation is a fluoroscopically guided, percutaneous procedure . Its primary use is for fixation of satisfactorily reduced sacral fractures or sacro -iliac joint disruptions. Anatomic reduction must be obtained before ISS insertion.

22. REDUCTION

23. entry point should be anterior in S1 and inferior to the iliac cortical density (ICD), which parallels the sacral alar slope, usually slightly caudal and posterior

24. INSERTION OF ILIAC SCREW There are two standard iliac screw starting points within the ilium and one within the sacrum.

25. THE TRADITIONAL ENTRY POINT The traditional entry point is in the posterior iliac crest and countersunk to prevent pressure ulcers over the implant . An oscillating drill (3.5 mm) or awl is used to penetrate between the two cortices in a ventral, caudal direction toward the anterior inferior iliac spine .

26. ILIAC STARTING POINT is referred to as anatomic starting point. It is more caudal and medial than the traditional starting point and aligns better with the lumbar pedicles . The more caudal position places this screw in a wider cross section of bone above the sciatic notch

27. SACRAL ENTRY POINT The third starting point is at the inferolateral aspect of the S1 foramen.