1 Introduction top
Transverse lower sacral fractures with displacement may injure sacral nerve roots. If perineal sensation or sphincter tone is abnormal, surgical decompression may be indicated. This could involve laminectomy, and if deformity is significant, reduction and fixation of the sacral fracture.
Otherwise, ORIF is indicated for correction of severe deformity or as part of management for open fractures.
Plate fixation of transverse sacral fractures must be performed posteriorly and typically involves the use of two small plates.
The exposure is obtained through a posterior midline sacral approach.
2 Preparation of the fracture site topenlarge
Expose the entire fracture line. Identify and remove small bony fragments from the fracture zone. They may be located in the transforaminal region and hinder fracture reduction.
Sacral nerve root decompression
The complete fracture line has to be cleaned out and inspected.
Enhance the exposure by using a lamina (bone) spreader, and carefully placed bone hooks.
Extract bone fragments that may compromise the sacral nerve roots. Fracture reduction may be required to realign the sacral vertebral canal and restore anterior clearance for the neural elements.
3 Reduction topenlarge
The typical displacement is flexion with possible anterior translation of the distal fragment.
The primary reduction maneuver typically involves the use of two pointed reduction forceps (Weber clamps).
The caudal fragment is grasped and pulled caudally to disimpact and permit reduction. Small elevators can be used to assist disimpaction.
Once reduced, the caudal fragment is clamped to the cranial fragment with pointed reduction forceps.
4 Planning of the internal fixation topenlarge
Safe placement of screws avoids the spinal canal and sacral foramina by using the illustrated lateral entry points proximal and distal to the fracture bilaterally. These are lateral to the sacral foramina and nerve roots, or between and in line with the sacral foramina.
5 Plate application topenlarge
Fixation is performed with two (bilateral) small fragment plates (4-6 holes). Locking plates may provide enhanced stability.