Lateral Compression Sacral Fractures Have Less Favourable Outcome Compared to Crescent Fractures in Patients Less Than 50 Years Old

Background. Lateral compression (LC) accounts for a wide spectrum of pelvic ring injuries (PRIs). The primary aim of this study was to assess the health-related quality of life outcomes of surgically fixed LC crescent versus sacral fractures in patients less than 50 years old after high energy trauma. Material and methods. We retrospectively reviewed the database for PRIs treated surgically from Decem­ber 2011 to January 2019 at our tertiary level trauma centre. The EuroQoL-5D (EQ5D5L) questionnaire was elec­tronically sent to all patients. Multiple linear regression was conducted to determine the predictors of quality-adjusted life-years (QALYs). Results. The study included 37 patients. The mean age was 26 SD 9.46 years. The mean duration of follow-up was 3.78 (r:1-9) years. Twenty-one (56.8%) and 16 (43.2%) patients sustained sacral fractures and crescent fractures, respectively. Multi-regression analysis showed that any patient with LC injury without a sacral fracture is expected to have a utility value of QALY= 0.876. A reduction of 0.072 units in QALYs is expected in the presence of sacral fracture. About 71% of patients with sacral fractures were able to return to work and this probability increased by 40% among patients with crescent fractures (RR=1.4, p=.015). Conclusions. 1. Younger patients with crescent fractures tend to have better quality of life (higher EQ5D and QALYs) compared to those with LC sacral fractures. 2. Moreover, patients with LC sacral fractures have less chan­ce to return to their pre-injury level of work compared to those with crescent fractures.

The Impact of Specific Fracture Characteristics of Low-energy Fractures of the Pelvis in the Elderly on Mortality

Background:Pelvic fractures in the elderly are associated with relevant morbidity and mortality. Both might be determined by fracture morphology and/or patient characteristics. The aim of this project is to investigate the prognostic value of specific fracture characteristics with respect to overall survival and to compare it with an established classification system. Methods:Retrospective analysis of patients ≥60 years, treated conservatively for a CT-scan verified, low-energy pelvic ring fracture between August 2006 and December 2018. Survival data was available from patients’ charts and cantonal or national registries. The prognostic value of fracture characteristic describing the anterior and posterior involvement of the pelvic ring was investigated. This analysis was repeated after patients were stratified into a high-risk vs a low-risk group according to patient characteristic (age, gender, comorbidities, mobility, living situation). This allowed to assess the impact of the different fracture morphologies on mortality in fit vs. frail senior patients separately Results:Overall, 428 patients (83.4% female) with a mean age of 83.7 years were included. Two thirds of patients were still living in their home and mobile without walking aid at baseline. In-hospital mortality was 0.7%, overall, one-year mortality 16.9%. An independent and significant association of age, gender and comorbidities to overall survival was found. Further, the occurrence of a horizontal sacral fracture as well as a ventral comminution or dislocation was associated with an increased mortality. The effect of a horizontal sacral fracture was more accentuated in low-risk patients while the ventral fracture components showed a larger effect on survival in high-risk patients.Conclusion:Specific fracture characteristics may indicate a higher risk of mortality in conservatively treated patients with a low-energy pelvic ring fracture. Hence, they should be taken into account in future treatment algorithms and decisions on patient management.

S2-alar-iliac screw and S1 pedicle screw fixation for the treatment of non-osteoporotic sacral fractures: a finite element study

Background Five different sacral fracture fixation methods were compared using finite element (FE) analysis to study their biomechanical characteristics. Methods Denis type I sacral fractures were created by FE modeling. Five different fixation methods for the posterior pelvic ring were simulated: sacroiliac screw (SIS), lumbopelvic fixation (LPF), transiliac internal fixator (TIFI), S2-alar-iliac (S2AI) screw and S1 pedicle screw fixation (S2AI-S1) and S2AI screw and contralateral S1 pedicle screw fixation (S2AI-CS1). Four different loading methods were implemented in sequence to simulate the force in standing, flexion, right bending and left twisting, respectively. Vertical stiffness, relative displacement and change in relative displacement were recorded and analyzed. Results As predicted by the FE model, the vertical stiffness of the five groups in descending order was S2AI-S1, SIS, S2AI-CS1, LPF and TIFI. In terms of relative displacement, groups S2AI-S1 and S2AI-CS1 displayed a lower mean relative displacement, although group S2AI-CS1 exhibited greater displacement in the upper sacrum than group S2AI-S1. Group SIS displayed a moderate mean relative displacement, although the displacement of the upper sacrum was smaller than the corresponding displacement in group S2AI-CS1, while groups LPF and TIFI displayed larger mean relative displacements. Finally, in terms of change in relative displacement, groups TIFI and LPF displayed the greatest fluctuations in their motion, while groups SIS, S2AI-S1 and S2AI-CS1 displayed smaller fluctuations. Conclusion Compared with SIS, unilateral LPF and TIFI, group S2AI-S1 displayed the greatest biomechanical stability of the Denis type I sacral fracture FE models. When the S1 pedicle screw insertion point on the affected side is damaged, S2AI-CS1 can be used as an appropriate alternative to S2AI-S1.

A Case Report of Spino-Pelvic Dissociation with Neurological Deficit in Pediatric Age Group

Transverse sacral fracture is a rare entity in the pediatric age group, primarily resulting from a fall from height. This case report stresses the importance of proper neurological assessment, adequate imaging and highlights different modalities of management of this fracture. We report a case of a 13-year-old child with type III Roy-Camille sacral fracture with associated bladder and bowel dysfunction. The patient underwent spinopelvic fixation and decompression of the sacral canal. The patient partially regained bowel and urinary function and had improved motor function after three months of follow-up. Operative management is generally advocated for such fractures. Keywords: Decompression; Bone fractures; Neural tube; Pediatrics; Sacrum

Erectile Dysfunction after Conservative Treatment of Sacral Fractures in Males without Injury to the Urinary System

Background This study aimed to determine the incidence of erectile dysfunction (ED) reported by patients, and to define the prognostic relationship between ED and conservatively treated sacral fracture without urethral injury. Methods Patients aged between 20 – 50 years who were sexually active and had no known sexual dysfunction prior to the trauma were included in the study. Seventy-seven patients (47 married, 30 single) treated conservatively for sacral fracture between April 2012 and February 2017 were retrospectively screened. Patients were compared in terms of age, marital status, body mass index (BMI), trauma mechanism, additional system injury, functional outcomes, and complications. Functional outcomes were assessed using the International Index of Erectile Function (IIEF-5) and the Majeed pelvic fracture functional assessment scale (MPS). Results No statistically significant difference was observed between fracture types with respect to age, BMI, follow-up, marital status, trauma mechanism, and accompanying injury. The incidence of ED was 27.3% for those that received conservative treatment after sacrum fracture. The mean score of IIEF-5 was 18.6 ± 6.6 and MPS was 77.2 ± 13.2. There was no significant relationship between the injury type of the patients and the IIEF-5 and MPS scores (p = 0.593 and p = 0.907, respectively). The lowest IIEF-5 score was found in Denis type 2 fractures (p = 0.020). Conclusion The frequency of ED was higher in Denis type 2 sacrum fractures. Sexual function should be questioned in the follow-up, especially in those fracture types.

Treatment of Unstable Sacral Fracture with Minimally Invasive Spinopelvic Posterior Fixation and an Internal Anterior Fixator in a 95-Year-Old Patient with Diffuse Idiopathic Skeletal Hyperostosis: A Case Report

Introduction:Spinal fractures related to diffuse idiopathic skeletal hyperostosis (DISH) are almost always caused by a long lever arm, so treatment of the fractures requires stabilization of long segments of the spine. Treatment of unstable sacral fractures in DISH patients with ankylosis of the sacroiliac joints requires a treatment strategy that includes a consideration of the condition of the spine. This article is the first report of an unstable sacral fracture in a patient with DISH. Case Report:A 95-year-old male fell and presented with severe low back pain. An X-ray and computed tomography showed unstable pelvic fracture (AO type C2) and ankylosis of the lumbar spine due to DISH. We performed minimally invasive spinopelvic posterior fixation and internal anterior fixation (INFIX) for stabilization of the pelvic fracture. Initially, due to the long lever arm created from the lumbar spine to the pelvis, we performed L2-iliac posterior stabilization while the patient was in a prone position. After that, we performed INFIX to stabilize the anterior pelvis while the patient was positioned supine. The postoperative clinical course of the patient was uneventful and bony fusion was achieved as seen on X-ray obtained 1 year postoperatively. Conclusion:This patient was ankylosed from spine to pelvis due to DISH and sacroiliac joint ankylosis and sustained bilateral sacral fractures which dissociated the sacrum from the rest of the pelvis. Therefore, this fracture required spinopelvic fixation from the ankylosing spine to the pelvis. Because this patient was so elderly and in poor general health, we performed minimally invasive spinopelvic posterior fixation using percutaneous pedicle screws. We considered that many screw insertions that would equivalently stabilize the spine several segments above and below the fracture would be needed to stabilize the sacral fractures in this patient with DISH. In this case, we stabilized the unstable right pelvis, in a patient with