01Approach to the Critical Patient/attcp56

Immediate priorities

›Hemorrhagic shock recognition

›Unstable pelvic ring fracture with sacral involvement

›SBP <90 mmHg

›Tachycardia >100 beats/min

›Retroperitoneal hematoma risk

›Apply pelvic binder at greater trochanters immediately for suspected pelvic ring instability

›Class I recommendation

›Do not delay for imaging

›Massive transfusion protocol activation if hemodynamic instability persists

›Target 1:1:1 ratio packed red cells to fresh frozen plasma to platelets

›Tranexamic acid 1 g IV over 10 minutes within 3 hours of injury

›Neurologic emergency recognition

›Cauda equina syndrome screening

›Urinary retention — most sensitive indicator

›Saddle anesthesia (S2–S5 distribution)

›Fecal incontinence

›Bilateral lower extremity weakness

›If cauda equina features present, emergent MRI sacrum and lumbar spine

›Do not delay for plain radiograph

›Emergent spine surgery consultation

›Denis Zone III fractures — neurologic injury in 57–60% of cases

›Central sacral canal involvement

›Highest neurologic injury risk of all zones

Hemodynamic targets and monitoring

›Resuscitation targets

›MAP >65 mmHg

›SBP >90 mmHg as permissive minimum

02History/hx63

Mechanism and onset

›Injury mechanism

›High-energy trauma

›Motor vehicle collision

›Fall from height

›Axial compressive load

›Low-energy or atraumatic

›Ground-level fall in elderly patient

›Insidious onset without identified trauma

›Absence of antecedent trauma does not exclude fracture in at-risk patients

›Onset and progression

›Acute onset — traumatic fracture

›Insidious onset over days to weeks — insufficiency fracture

›Mean diagnostic delay in ED setting ~24 days for insufficiency fractures

Symptom characterization

›Pain location

›Low back

›Buttock or gluteal region

›Groin or coxalgia

›Often bilateral in insufficiency fractures

›Aggravating factors

›Weight-bearing

›Ambulation

›Transitional movements — sit-to-stand

›Neurologic symptoms

›Radiculopathy or sciatica

›Saddle area numbness or tingling

›Bowel or bladder dysfunction

03Physical Exam/exam42

Vital signs and general

›Hemodynamic assessment

›Blood pressure and heart rate

›Tachycardia may be blunted in elderly due to beta-blocker use or age-related catecholamine insensitivity

›SBP <90 mmHg indicates hemorrhagic shock

›Respiratory rate and oxygen saturation

›Level of consciousness and GCS

Musculoskeletal examination

›Inspection

›Bruising or contusion over sacrum

›Contusion or abrasion is the best clinical red flag for spinal fracture

›Perineal or scrotal hematoma suggesting pelvic ring injury

›Visible deformity

›Palpation

›Sacral tenderness

›Sacroiliac joint tenderness

›Posterior pelvic ring tenderness

›Pelvic stability assessment

›Pelvic compression and distraction testing — perform once only, gently

›Spring test over sacrum

›Rotational instability

Neurologic examination

›Lower extremity motor assessment

›Hip flexion — L2–L3 myotome

›Knee extension — L3–L4 myotome

›Ankle dorsiflexion — L4–L5 myotome

›Ankle plantar flexion — S1 myotome

›Sensory assessment

04Differential Diagnosis/ddx47

Sacral and pelvic pathology

›Sacral insufficiency fracture

›ICD-10: M84.352 (sacrum), M84.659

›Most common in osteoporotic elderly women

›Frequently misdiagnosed as lumbar disc disease or metastatic disease

›Traumatic sacral fracture

›ICD-10: S32.10 (sacrum fracture, unspecified)

›High-energy mechanism

›Pelvic ring disruption in 40–50%

›Pelvic ring fracture without sacral involvement

›ICD-10: S32.89

›Requires CT for differentiation

Spine pathology mimics

›Lumbar disc herniation or spinal stenosis

›ICD-10: M51.16, M48.06

›Overlapping radiculopathy symptom profile

›MRI differentiates — disc herniation vs. nerve root compression from fracture

›Lumbosacral degenerative spondylosis

›ICD-10: M47.816

›Chronic course without acute onset

›Tandem insufficiency fractures

›Thoracolumbar junction fractures co-occur in ~30% of sacral insufficiency fracture patients

Oncologic and inflammatory differentials

›Sacral metastatic disease

›ICD-10: C79.51

›Sacral insufficiency fractures frequently misdiagnosed as metastases on imaging

›Constitutional symptoms, known primary malignancy

›MRI diffusion-weighted imaging aids differentiation

05Laboratory Tests/lt42

Acute trauma labs

›Complete blood count

›Baseline hemoglobin and hematocrit for hemorrhage assessment

›Serial hemoglobin for retroperitoneal bleeding monitoring

›Platelet count for transfusion threshold planning

›Basic metabolic panel

›Renal function for contrast planning and medication dosing

›Serum calcium and phosphorus for metabolic bone disease context

›Glucose for elderly trauma (stress hyperglycemia)

›Coagulation studies

›PT/INR and PTT — especially if anticoagulant use

›Thromboelastography (TEG) if on DOACs with active bleeding

›Type and screen for hemorrhagic patients

Metabolic bone disease workup

›Vitamin D (25-OH vitamin D)

›Virtually all sacral insufficiency fracture patients are vitamin D deficient

›Target repletion to 75–125 nmol/l

›Serum calcium and phosphorus

›Hypocalcemia in vitamin D deficiency and malabsorption

›Phosphorus for secondary hyperparathyroidism

›Parathyroid hormone

›Elevated in secondary and tertiary hyperparathyroidism

›Guides osteoporosis therapy selection

Inflammatory and malignancy markers

›C-reactive protein and erythrocyte sedimentation rate

›Elevated in osteomyelitis, inflammatory sacroiliitis, metastatic disease

›Normal levels support insufficiency fracture over infection

›Serum protein electrophoresis

06Diagnostic Tests/dt88

Scoring Systems

›Denis Classification System

›Zone I (alar) — lateral to foramina

›Neurologic injury risk ~24%

›L5 radiculopathy pattern

›Zone II (foraminal) — through foramina

›Neurologic injury risk ~29%

›Sciatica pattern, rarely bladder dysfunction

›Zone III (central canal) — medial to foramina

›Neurologic injury risk 57–60%

›Saddle anesthesia and sphincter dysfunction

›Modern data suggest overall rate ~3.5% lower than originally reported

›AO Spine Sacral Injury Classification (AOSIS)

›Validated hierarchical system for operative decision-making

›AOSIS >=5 — generally indicates operative management

›AOSIS 3–4 with anterior pelvic ring injury — at surgeon's discretion

›Incorporates fracture morphology, neurologic status, and modifying factors

›Rommens and Hofmann FFP Classification (Fragility Fractures of the Pelvis)

›FFP I–II — stable, conservative management

›FFP I: isolated anterior ring

›FFP II: non-displaced posterior ring

›FFP III–IV — unstable, often require surgical intervention

›FFP III: displaced unilateral posterior ring

›FFP IV: bilateral posterior ring instability

MRI

›MRI sacrum and pelvis

›Most sensitive modality for sacral fractures

›Sensitivity 98.6–99%

›Specificity >95%

›Bone marrow edema pattern

›T1 hypointense signal in sacral ala

›T2/STIR hyperintense signal before fracture line visible on CT

›Primary indications

›Suspected insufficiency fracture with negative CT

›Neurologic deficit assessment

›Differentiating fracture from metastatic disease

›Cauda equina syndrome workup

›Protocol recommendations

›Coronal STIR sequence should be standard

›Modified protocol with dedicated sacrococcygeal sequences for TLJ fractures increases detection

›Honda sign on T1

›H-shaped hypointensity in bilateral sacral ala

›Pathognomonic for bilateral sacral insufficiency fracture

›Diffusion-weighted imaging

›Aids differentiation of insufficiency fracture from metastatic lesion

›Fractures show restricted diffusion in acute phase

›Limitations

›Availability and time constraints in acute trauma

›Contraindicated with certain implants

›Claustrophobia and patient cooperation required

CT

›CT pelvis without contrast (trauma)

›Standard of care for diagnosing sacral fractures in trauma

›Sensitivity ~94%

›Gold standard for evaluating fracture morphology

›Protocol

›Thin-slice axial with coronal and sagittal reconstructions

›Bone window essential for fracture characterization

›Classification application

›Denis zone identification

›AO Spine AOSIS scoring

›Spinopelvic dissociation detection — U-type and H-type patterns

›Findings

›Fracture line orientation (vertical, horizontal, oblique)

›Displacement and comminution

›Pelvic ring integrity

›Associated acetabular or pubic rami fractures

›Plain radiograph comparison

›Plain radiograph sensitivity ~28.5% — inadequate for clinical decisions

›Ferguson view (25° cephalad AP tilt) marginally improves visualization

›CT required whenever sacral fracture is suspected

›CT angiography pelvis

›Indicated for hemodynamically unstable patients with pelvic ring fracture

›Identifies arterial bleeding source for embolization

›Arterial and venous phase acquisition

›Combined with trauma CT (pan-scan) in polytrauma

Ultrasound

›Focused Assessment with Sonography in Trauma (FAST)

›Extended FAST for pneumothorax and hemothorax in polytrauma

›Not diagnostic for sacral fractures

›Identifies concomitant solid organ injury

›Pelvic free fluid assessment

›Retroperitoneal hematoma typically not visualized by US

›Bladder ultrasound

›Postvoid residual measurement

›PVR >300 mL indicates urinary retention

›Performed at bedside — rapid and noninvasive

›Essential in suspected cauda equina syndrome

›Diagnostic limitations for sacral fractures

›Ultrasound has no role in direct sacral fracture diagnosis

›Bony anatomy not assessable by US

›CT and MRI are required imaging modalities

07Disposition/dispo38

Admission criteria

›Mandatory admission indications

›Hemodynamic instability or significant hemorrhage

›ICU-level care for resuscitation

›Orthopedic and trauma surgery consultation

›Neurologic deficit — new or progressive

›Spine surgery or neurosurgery consultation

›Emergent MRI if not yet obtained

›Displaced or unstable fractures requiring surgical planning

›High-energy mechanism with polytrauma

›Trauma team activation

›Multi-system injury evaluation

›Elderly patients unable to safely ambulate or self-care

›Social work and case management involvement

›Fall risk and home safety assessment

Observation criteria

›Short stay observation indications

›Stable fracture with moderate pain pending advanced imaging

›Awaiting orthopedic or spine consultation

›Pain not adequately controlled for safe discharge

›Elderly patient with unclear functional status or social support

Discharge criteria

›Safe discharge parameters

›Nondisplaced stable fracture confirmed on CT

›Neurologically intact with documented exam

›Pain controlled with oral analgesics

›Able to ambulate — even with assistive device

›Safe home environment with caregiver support

08Treatment/t89

Immediate stabilization

›Hemorrhage control

›Pelvic binder application for pelvic ring instability

›Position at greater trochanters — not iliac crests

›Reduces pelvic volume and tamponades venous hemorrhage

›Massive transfusion protocol for ongoing hemorrhage

›Packed red cells, fresh frozen plasma, platelets 1:1:1

›Tranexamic acid

›1 g IV over 10 minutes

›Administer within 3 hours of injury

›Second dose 1 g IV over 8 hours

›Angioembolization via interventional radiology

›For persistent hemodynamic instability with identified arterial source

Analgesia

›Multimodal pain management

›Acetaminophen

›650–1000 mg PO/IV every 6–8 hours

›Maximum 4 g/day (3 g/day in elderly or hepatic impairment)

›First-line for all patients

›NSAIDs

›Ibuprofen 400–600 mg PO every 6–8 hours with food

›Caution — may impair fracture healing; use for limited duration

›Avoid in renal impairment, GI bleeding risk, dehydrated elderly patients

›Opioid analgesics

›Hydromorphone 0.2–0.4 mg IV every 3–4 hours PRN for severe pain

›Oxycodone 5–10 mg PO every 4–6 hours for moderate-severe pain

›Minimize in elderly — increased fall risk, delirium, constipation

›Adjuncts

›Pregabalin 75 mg PO twice daily for neuropathic pain component

›Lidocaine patch 5% over sacral region — topical option

›Regional nerve blocks — sacral nerve root blocks may reduce opioid requirement

DVT prophylaxis

›Venous thromboembolism prevention

›Enoxaparin (LMWH)

›40 mg SC daily (standard) or 30 mg SC every 12 hours (higher risk)

›Initiate after hemorrhage controlled and hemostasis assured

›Renally adjust: GFR <30 mL/min — use 30 mg SC daily

›Sequential compression devices

›Apply immediately at admission

›Continue until pharmacologic prophylaxis initiated

›Direct oral anticoagulants as alternative

›Rivaroxaban 10 mg PO daily after hemostasis secured

Osteoporosis treatment

›Calcium and vitamin D supplementation

›Calcium carbonate 500–600 mg PO twice daily with meals

›Vitamin D3 1000–2000 IU PO daily

›Higher dose repletion if 25-OH vitamin D <50 nmol/l

›Vitamin D3 50,000 IU weekly for 8 weeks then maintenance

›Antiresorptive therapy

›Alendronate 70 mg PO weekly (first-line bisphosphonate)

›Contraindicated if GFR <35 mL/min, esophageal motility disorder, inability to sit upright for 30 minutes

›Denosumab 60 mg SC every 6 months (alternative if bisphosphonate contraindicated)

›Hypocalcemia risk — ensure vitamin D replete before initiating

›Anabolic therapy

›Teriparatide 20 mcg SC daily for up to 24 months

›Consider as first-line for severe osteoporosis or sacroplasty-planned patients

›Improves fracture healing outcomes when combined with sacroplasty

›Romosozumab 210 mg SC monthly for 12 months

›Cardiovascular contraindication — avoid if recent MI or stroke

Mobilization and rehabilitation

›Weight-bearing and mobilization

›Stable nondisplaced insufficiency fractures — weight-bearing as tolerated

›Displaced fractures — non-weight-bearing until surgical stabilization

›Progressive mobilization with physical therapy

›Assistive devices — walker, rollator for gait support

›Physical therapy

›Early mobilization reduces DVT, pressure ulcer, and deconditioning risk

›Core strengthening and balance training for fall prevention

›Occupational therapy for ADL modification

Procedural interventions

›Sacroplasty

›Indicated for nondisplaced insufficiency fractures with persistent pain (VAS >5) despite conservative management

›Mean NRS reduction from 7.8 to 0.9 at 6 months (VASF Registry)

›Faster pain relief than conservative management

›Fluoroscopy or CT-guided percutaneous cement injection into sacral ala

›Contraindications

›Displaced fractures

›Spinal canal violation

›Coagulopathy uncorrected

›Best outcomes when combined with anabolic osteoporosis therapy

›Percutaneous iliosacral screw fixation

›Indicated for displaced sacral fractures or unstable pelvic ring injuries

›Minimally invasive technique

›Fluoroscopy or CT guidance

›Post-procedure weight-bearing restrictions per surgeon protocol

›Lumbopelvic fixation

›Indicated for spinopelvic dissociation

›U-type and H-type fractures

›Lumbopelvic instability confirmed

›Iliac screw instrumentation to L4–L5 pedicle screws

›High complication rate — experienced spine center preferred

›Sacral decompression

›Indicated for neurologic deficit from nerve root compression

›Especially Zone III fractures with foraminal impingement

›Timing: urgent within 24–72 hours for progressive deficit

09Special Populations/sp69

Pregnancy

›Pregnancy-specific considerations

›Rare but recognized cause of sacral fracture

›Risk factors: high birth-weight infant, excessive gestational weight gain, rapid vaginal delivery, nulliparity

›Pelvic girdle pain and transient osteoporosis of pregnancy in differential

›Biomechanical factors

›Relaxin-induced sacroiliac joint laxity increases pelvic stress loading

›Postpartum period: continued laxity with rapid weight change

›Imaging considerations

›MRI preferred — no ionizing radiation

›CT only if MRI unavailable and clinical urgency demands fracture characterization

›Abdominal shielding for plain films if unavoidable

›Analgesic considerations

›Acetaminophen — preferred in all trimesters

›NSAIDs — avoid after 20 weeks (premature ductus arteriosus closure, oligohydramnios)

›Opioids — short-term use with neonatal monitoring for withdrawal

›DVT prophylaxis

›LMWH preferred — enoxaparin 40 mg SC daily (adjust for weight and renal function)

›Warfarin contraindicated in first and third trimesters

›Osteoporosis treatment

›Bisphosphonates — avoid (placental transfer, fetal bone effects)

›Calcium 1000–1200 mg/day and vitamin D 600–800 IU/day safe

›Teriparatide — contraindicated in pregnancy

Geriatric

›Epidemiology and risk

›Sacral insufficiency fractures predominantly affect elderly osteoporotic patients

›Mean age ~70–80 years in most series

›1-year mortality 13–27% in elderly pelvic insufficiency fracture patients

›Loss of independence in 64–89% of cases

›Atypical presentations

›Blunted tachycardia due to beta-blockers or autonomic aging

›Confusion as presenting feature of pain in dementia patients

›Delayed diagnosis mean 24 days due to overlapping degenerative conditions

›Cardiovascular assessment

›ECG mandatory — AF in ~9.5%, ECG abnormalities predict 30-day mortality (OR 6.1)

›Serial troponin if surgery planned — perioperative MI in ~35–40%, often asymptomatic

›Cardiology consultation for preoperative optimization in high-risk patients

›Analgesic modifications

›Reduce opioid doses 25–50% from standard adult dosing

›Avoid long-acting opioids — delirium and fall risk

›Acetaminophen limit 3 g/day (hepatic considerations)

›Avoid NSAIDs — renal impairment, GI bleeding, fluid retention

›Fall prevention

›Home safety assessment prior to discharge

›Physical therapy for strength and balance

›Medication review — reduce polypharmacy, sedatives, antihypertensives

›Vision screening referral

›Fracture prevention

›71% of patients not receiving adequate secondary prevention at time of fracture

›DEXA scan if not recently performed

›Initiate bisphosphonate or anabolic therapy before discharge or at follow-up

Pediatrics

›Epidemiology

›Sacral fractures rare in children — high-energy mechanism predominant

›Child abuse must be considered in fractures without adequate mechanism

›Physeal injury possible given open growth plates

›Stress fractures in adolescent athletes

›Running sports and gymnastics — repetitive axial loading

›Often bilateral

›Anatomic considerations

›Sacrum more cartilaginous in young children — greater deformability

›Neuroforamina relatively larger — lower neurologic injury risk for given fracture zone

›Physis at S1–S5 may mimic fracture lines on imaging

›Imaging approach

›MRI preferred to avoid radiation

›CT only for acute trauma or when MRI not feasible

›Bone scan or SPECT in stress fractures not resolving on MRI

›Treatment modifications

›Non-weight-bearing and activity restriction for stress fractures — 6–12 weeks

›Surgical intervention thresholds lower for displaced fractures in growing skeleton

›Avoid bisphosphonates in children except in specific metabolic bone disease

›Calcium 1300 mg/day and vitamin D 600 IU/day recommended in adolescents

10Background/b70

Epidemiology

›Prevalence and incidence

›Sacral insufficiency fractures increasingly prevalent due to aging population

›Predominantly affect postmenopausal women over 55 years

›Exact incidence underestimated due to diagnostic delay of ~24 days mean

›Traumatic sacral fractures

›Associated with pelvic ring disruption in 40–50% of high-energy injuries

›MVC and falls from height are leading mechanisms

›Radiation-induced fractures

›7.1% incidence after chemoradiation for rectal carcinoma

›Cervical and endometrial cancer pelvic radiation also implicated

›Post-fusion sacral stress fractures

›SIF diagnosed at ~9.5 weeks post-fusion in 24.9% of patients in one series

›Outcomes and prognosis

›Neurologic injury rates 3.5–60% depending on Denis zone and displacement

›Displaced fractures OR 8.4 for neurologic injury

›Comminuted fractures OR 5.2 for neurologic injury

›1-year mortality 13–27% in elderly pelvic insufficiency fracture patients

›Loss of independence in 64–89% at 1 year

›Most insufficiency fractures heal in 8–12 weeks with conservative management

Pathophysiology

›Insufficiency fracture mechanism

›Abnormal bone subjected to normal physiologic stress

›Reduced bone mineral density — osteoporosis primary etiology

›Decreased bone quality impairs load distribution across sacrum

›Trabecular bone failure

›Vertical fracture lines through sacral ala — parallel to SI joints

›Axial loading from upright stance concentrates stress in alar regions

›Radiation-induced mechanism

›Avascular necrosis and bone devitalization from high-dose pelvic radiation

›Normal ambulatory loading causes fracture of devitalized bone

›Traumatic fracture mechanism

›High-energy axial loading transmitted through lumbopelvic junction

›Motor vehicle collision and falls from height

›Associated with anterior pelvic ring injury in unstable patterns

›Spinopelvic dissociation

›Transverse sacral fracture (U-type or H-type) combining vertical zones

›Severs connection between spine and pelvis

›Lumbopelvic instability — surgical emergency

›Neurologic injury mechanism

›Denis Zone III — central canal compression

›Displaced fragment impinges on sacral nerve roots S2–S4

›Cauda equina syndrome without visible MRI compression in some cases

›Zone I — L5 root tethering over sacral ala

›Zone II — foraminal narrowing compressing S1–S3 roots

Therapeutic Considerations

›Conservative management rationale

›Majority of stable nondisplaced fractures heal with protected weight-bearing

›Insufficiency fractures — 8–12 weeks typical healing time

›Multimodal analgesia essential for mobility and rehabilitation compliance

›Osteoporosis management is mandatory — fracture is a sentinel event

›Fracture liaison service involvement reduces secondary fracture risk

›Sacroplasty evidence

›Significant pain reduction demonstrated

›Mean NRS 7.8 to 0.9 at 6 months (VASF Registry, first 102 patients)

›Faster functional recovery vs. conservative management

›Patient selection

›Persistent pain (VAS >5) despite 4–6 weeks conservative management

›Nondisplaced fractures only — displaced fractures contraindicated

›Anabolic osteoporosis therapy prior to or concurrent with sacroplasty improves outcomes

›Surgical fixation evidence

›Percutaneous iliosacral screws for unstable fractures

›Minimally invasive — lower morbidity vs. open reduction

›Lumbopelvic fixation for spinopelvic dissociation

›High complexity — associated with significant complication rates

›Best performed at high-volume trauma centers

›AO Spine AOSIS guides operative threshold

›Score >=5 — operative management generally indicated

›Bone healing modifiers

›NSAIDs — impair prostaglandin-mediated fracture healing; limit to <2 weeks

›Teriparatide — accelerates fracture healing; evidence supporting use with sacroplasty

›Smoking cessation — nicotine impairs osteoblast function and fracture healing

›Vitamin D repletion — essential for mineralization of healing callus

11Patient Discharge Instructions/pdi30

copy discharge instructions

›Diagnosis and injury explanation

›A fracture of the sacrum (the triangular bone at the base of the spine) has been identified

›This may be due to a fall, injury, or weakening of bone from osteoporosis

›The fracture is expected to heal over 8–12 weeks with rest and proper care

›Activity instructions

›Weight-bearing as tolerated with walker or cane for support

›Avoid prolonged standing or walking until follow-up

›Sit-to-stand movements should be slow and deliberate — use armrests

›No lifting, bending, or twisting at the waist

›Driving should not occur while taking opioid pain medications

›Pain management at home

›Acetaminophen 650–1000 mg every 6–8 hours as needed — do not exceed 4 g/day

›Take scheduled rather than as-needed for first 1–2 weeks

›Ice pack over sacral region 15–20 minutes several times daily for first 48–72 hours

›Opioid medications if prescribed — take only as directed, no alcohol

›Bone health

›Calcium supplement 500–600 mg twice daily with meals

›Vitamin D supplement 1000–2000 IU daily

›Follow up with family doctor or bone specialist for DEXA scan and osteoporosis treatment

›Follow-up appointments

›Orthopedic or spine surgeon within 1–2 weeks

›Repeat imaging may be arranged at 6–12 weeks to confirm healing

›DEXA scan if not recently performed — to guide fracture prevention treatment

›Return to emergency immediately for

›New or worsening numbness in the saddle area (genitals, inner thighs, buttocks)

›Inability to urinate or loss of bladder control

›Loss of bowel control or new fecal incontinence

12References/r24

Guidelines and key sources

›Dreizin D, Smith EB. CT of Sacral Fractures: Classification Systems and Management. Radiographics 2022. PMID 36112523

›Comprehensive CT classification review including Denis and AO Spine systems

›Pelvic ring disruption association in 40–50% of high-energy sacral fractures

›Rickert MM, et al. Sacral Insufficiency Fractures. JBJS Reviews 2022. PMID 35849657

›Conservative management evidence and weight-bearing protocols

›Insufficiency fracture natural history and outcomes

›El Naga AN, Gendelberg D, Theologis AA. Injuries and Fractures of the Sacrum — A Comprehensive Review. JAAOS 2025. PMID 40623144

›Most current comprehensive review of sacral fractures

›Morrison WB, et al. ACR Appropriateness Criteria Stress (Fatigue-Insufficiency) Fracture Including Sacrum: 2024 Update. JACR 2024. DOI 10.1016/j.jacr.2024.08.019

›Imaging algorithm and modality selection for sacral insufficiency fractures

›Lee Y, et al. The Surgical Algorithm for the AO Spine Sacral Injury Classification System. Spine 2024. PMID 37970681

›AOSIS scoring and operative management thresholds

›Singh M, et al. Sacroplasty for Sacral Insufficiency Fractures. Journal of Clinical Medicine 2024. PMID 38398413

›Sacroplasty patient selection, technique, and outcomes

›Pain reduction NRS 7.8 to 0.9 at 6 months

›Andresen JR, et al. Comparative Outcome of Different Treatment Options for Fragility Fractures of the Sacrum. BMC Musculoskeletal Disorders 2022. PMID 36536363

›Conservative vs. sacroplasty vs. surgical fixation outcome comparison

›Long B, Koyfman A, Gottlieb M. Evaluation and Management of Cauda Equina Syndrome in the Emergency Department. Am J Emerg Med 2020. PMID 31471075

›Cauda equina syndrome diagnosis, imaging, and ED management

›Collins AP, et al. Sacral Insufficiency Fractures: Pathology, Management, and Outcomes. JBJS Am 2025. PMID 41335115

›Current outcomes and treatment algorithms

›ACS Best Practices Guidelines — Spine Injury (2022) and Geriatric Trauma Management (2023)

›Cauda equina syndrome management protocol

›Elderly trauma cardiovascular risk assessment

Evidence & Review

Evidence & Review