Surgical management strategies for unstable sacral fractures: Case series and surgical guideline.

introductionUnstable sacral fractures usually have posterior pelvic and spinopelvic instability, which usually be classified as AO type C. There are many controversial points concerning the management of these fractures due to their rarity. Herein, we retrospectively review cases of this injury and propose a surgical guideline. CASE PRESENTATION: A 37-year-old female experienced back pain after a motor vehicle accident. Diagnostic imaging revealed an AO type C1 sacral fracture, Isler subtype 2a (case No. 7). Preoperative CT scan and CT reconstruction images showed a longitudinal fracture with a simple intraarticular fracture of the left S1 superior facet. Although the patient sustains a lumbosacral facet joint injury, the lumbosacral motion seems preservable after healing. The triangular osteosynthesis was chosen because it provides both transverse plane and vertical plane stability. The patient was allowed to continue weight-bearing ambulation after the operation. To maintain lumbosacral motion, the spinopelvic rod was removed in the postoperative seventh month. DISCUSSION: The unstable sacral fracture might have instability in both the vertical and transverse planes. The fixation construct should provide both vertical and transverse stability. Regarding vertical fixation, it might cost a loss of lumbosacral motion, which the treating surgeon has to consider. The lumbosacral injury is sometimes trivial, and long-term lumbosacral motion is expectable. So, permanent spinopelvic fixation is not necessary. The patient's character is also an important factor. Whether the patient needs or does not need early progressive weight bearing after the operation determines the fixation method.

conclusionUnstable sacral fractures are rare conditions usually resulting from a high-energy injury. We have proposed a surgical management strategy for this group of fractures with an optimal fixation method based on three factors: 1) fracture morphology, 2) lumbosacral integrity, and 3) concomitant injury.