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Fixation Techniques for Complex Traumatic Transverse Sacral Fractures: A Systematic Review

Bederman, S. Samuel MD, PhD, FRCSC; Hassan, Jeffrey M. MA; Shah, Kalpit N. BSc; Kiester, P. Douglas MD; Bhatia, Nitin N. MD; Zamorano, David P. MD

doi: 10.1097/BRS.0b013e318297960a
Literature Review

Study Design. Systematic review.

Objective. To identify and describe reconstruction methods for the treatment of transverse sacral fracture (TSF) and to evaluate outcomes based on treatment interventions.

Summary of Background Data. A variety of surgical interventions for stabilization of TSFs exist, yet the optimal management remains unclear. Although there are many individual case reports and series describing techniques to stabilize TSF, prior reviews fail to provide a comprehensive summary of current and past surgical techniques and their individual outcomes.

Methods. Our systematic review searched the PubMed database using keywords identifying sacral fractures with a transverse component, requiring internal fixation for stabilization as well as a review of bibliographies and archives from meeting proceedings.

Results. Our search located 417 publications for abstract review, of which 27 (109 patients) with TSF were included. Average follow-up was 22 months (range, 0–82 mo). Thirty-eight patients (34%) underwent spinopelvic fixation (SPF), 53 (49%) underwent posterior pelvic ring fixation (PPRF), and 18 (17%) underwent both. PPRF included iliosacral screws (37 patients), transiliac screws (11 patients), transiliac screws with plating (3 patients), posterior plating (1 patient), and transiliac bar (1 patient). Additional injuries causing lumbosacral instability were seen in 8 patients (42%) who underwent SPF, 2 patients (18%) treated with PPRF, and 5 patients (45%) who were treated with both SPF and PPRF. Of those who presented with a neurological deficit, 5 patients (45%) with SPF, 9 (39%) with PPRF, and 3 (30%) with SPF and PPRF experienced full neurological recovery. Five patients (45%) with SPF, 7 (30%) with PPRF, and 5 (50%) with both regained partial neurological function. One patient (9%) with SPF, 7 (30%) with PPRF, and 2 (20%) with both experienced no neurological recovery.

Conclusion. PPRF seems to be effective for stabilization of TSF. However, in the setting of further injuries causing additional lumbosacral instability, SPF should be used to ensure effective stabilization.

Level of Evidence: 4

Supplemental Digital Content is Available in the Text.Transverse sacral fractures (TSFs) present a unique challenge to surgeons who manage these injuries. Our systematic review found that posterior pelvic ring fixation seems to be effective for stabilization of TSF, however, in the setting of significant spinopelvic instability, spinopelvic fixation should be used to ensure effective stabilization.

From the Department of Orthopaedic Surgery, University of California at Irvine, Orange, CA.

Address correspondence and reprint requests to S. Samuel Bederman, MD, PhD, FRCSC, Department of Orthopaedic Surgery, University of California at Irvine, 101 The City Drive South, Pavilion III, Orange, CA 92868; E-mail:

Acknowledgment date: December 10, 2102. First revision date: February 19, 2013. Acceptance date: April 10, 2013.

The device(s)/drug(s) is/are FDA-approved or approved by corresponding national agency for this indication.

No funds were received in support of this work.

Relevant financial activities outside the submitted work: consultancy, grants pending, expert testimony and royalties.

© 2013 by Lippincott Williams & Wilkins