This 2006 JAAOS narrative review covers the full spectrum of sacral fractures, from high-energy pelvic ring injuries to low-energy insufficiency fractures. It addresses evaluation, imaging strategy, classification systems, and indications and timing for decompression and stabilization. The review synthesizes evidence on neurologic risk stratification, surgical decision thresholds, and expected outcomes.
Sacral fractures are a high-stakes diagnosis that is easy to miss: approximately 30% are identified late, and plain radiographs detect only 30% of injuries. Order CT with fine cuts for any significant pelvic trauma. Do not use the AP pelvis to rule out sacral injury.
When you identify a sacral fracture with neurologic deficit and foraminal or canal debris, the decompression window is 24-72 hours. Epineural fibrosis develops after fracture healing and makes later decompression less effective and neurologic recovery less predictable.
Use Denis zone immediately to stratify risk: zone 3 injuries mandate urgent MRI and spine or neurosurgery involvement given the 60% deficit rate and high rates of permanent bowel and bladder dysfunction.
For unstable fractures requiring fixation, operate within 5 days to preserve closed reduction accuracy. Optimize soft tissue before going to the OR — surgery through a Morel-Lavallee lesion is contraindicated, and the 5-50% infection range in published series reflects how much the soft-tissue envelope determines outcome.
This 2006 JAAOS narrative review covers the full spectrum of sacral fractures, from high-energy pelvic ring injuries to low-energy insufficiency fractures. It addresses evaluation, imaging strategy, classification systems, and indications and timing for decompression and stabilization. The review synthesizes evidence on neurologic risk stratification, surgical decision thresholds, and expected outcomes.
Sacral fractures are a high-stakes diagnosis that is easy to miss: approximately 30% are identified late, and plain radiographs detect only 30% of injuries. Order CT with fine cuts for any significant pelvic trauma. Do not use the AP pelvis to rule out sacral injury.
When you identify a sacral fracture with neurologic deficit and foraminal or canal debris, the decompression window is 24-72 hours. Epineural fibrosis develops after fracture healing and makes later decompression less effective and neurologic recovery less predictable.
Use Denis zone immediately to stratify risk: zone 3 injuries mandate urgent MRI and spine or neurosurgery involvement given the 60% deficit rate and high rates of permanent bowel and bladder dysfunction.
For unstable fractures requiring fixation, operate within 5 days to preserve closed reduction accuracy. Optimize soft tissue before going to the OR — surgery through a Morel-Lavallee lesion is contraindicated, and the 5-50% infection range in published series reflects how much the soft-tissue envelope determines outcome.