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Friday, February 15, 2002

Sacrum fractures managed with early weight bearing

Most minimally displaced fractures of the sacrum may be safely managed nonoperatively with early weight bearing, said the authors of paper 177 on Thursday, particularly if the fracture is classified as a lateral compression (LC) injury.

Over 28 months, 477 patients with pelvic ring injuries were treated. All patients were evaluated with standard radiographs and computed tomography of the pelvis. All patients with sacral fractures displaced less than 10mm were treated with a prospectively established protocol that allowed weight bearing as tolerated unless associated injuries required restriction. Researchers also obtained serial radiographs until union occurred and compared initial and healed radiographs to document interval displacement.

Researchers found 73 minimally displaced fractures of the sacrum and followed them to union. Fractures were classified as lateral compression (LC) injuries (91%) or as anterior-posterior compression (APC) injuries (9%). All sacral fractures had less than 5mm of initial cranial displacement; 63% were impacted and 11% had multiple sites of anterior pelvic ring injury. The average age of patients was 60.4 years and follow-up averaged 4 months.

"Patients with nondisplaced factures of the sacrum are traditionally mobilized with weight bearing restrictions," noted the researchers. "This is largely motivated by a concern that fracture displacement may occur, leading to a need for operative intervention."

Because the placement of iliosacral screws for sacral fractures is not without substantial risks, investigators hoped to determine the likelihood that such fractures might displace. Their results showed that no patient with an internal rotation (LC pattern) sacral fracture developed fracture displacement during healing.

"This is the first information available to help surgeons decide whether displacement is probable. We hope this data can assist surgeons to identify fractures that are unlikely to displace and may be safely managed nonoperatively. It appears that sacral fractures with internal rotation (LC pattern) are resistant to displacement, even with weightbearing. The use of prophylactic internal fixation would, therefore, seem to be unjustified," concluded the authors.

Two patients with APC fractures displaced (9mm and 12mm cranial) prior to healing their sacral fractures. Both had segmental fractures of the ramus with wide displacement (>2cm). "This should be considered a high-energy injury," said the investigators, "and may be a significant risk factor in predicting posterior pelvic ring instability. Close follow-up is recommended and there may be a role for operative stabilization."

Co-authors included Mark C. Reilly, MD, William K. Accousti, MD, Susan G. Merritt, PA-C, Michael S. Sirkin, MD, and Fred F. Behrens, MD, all of Newark, N.J.

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Last modified 06/February/2002