• Eur J Trauma Emerg Surg · Feb 2021

    Progressive instability of bilateral sacral fragility fractures in osteoporotic bone: a retrospective analysis of X-ray, CT, and MRI datasets from 78 cases.

    • Thomas Mendel, Bernhard Wilhelm Ullrich, HofmannGunther OlafGODepartment of Trauma and Reconstructive Surgery, BG Klinikum Bergmannstrost Halle gGmbH, Merseburger Strasse 165, 06120, Halle (Saale), Germany.Department of Trauma, Hand and Reconstructive Surgery, Universitätsklinikum Jena, Am Klini, Philipp Schenk, Felix Goehre, Stefan Schwan, and Friederike Klauke.
    • Department of Trauma and Reconstructive Surgery, BG Klinikum Bergmannstrost Halle gGmbH, Merseburger Strasse 165, 06120, Halle (Saale), Germany. dr.th.mendel@gmail.com.
    • Eur J Trauma Emerg Surg. 2021 Feb 1; 47 (1): 11-19.

    PurposeThe pathogenetic mechanism, progression, and instability in geriatric bilateral fragility fractures of the sacrum (BFFSs) remain poorly understood. This study investigated the hypothesis of sequential BFFS progression by analysing X-ray, computed tomography (CT), and magnetic resonance imaging (MRI) datasets.MethodsImaging data from 78 cases were retrospectively analysed. Fractures were categorized using the CT-based Fragility Fractures of the Pelvis classification. MRI datasets were analysed to detect relevant fracture location information. The longitudinal sacral fracture was graded as stage 1 (bone oedema) on MRI, stage 2 (recent fracture), stage 3 (healing fracture), or stage 4 (non-union) on CT. Ligamentous avulsions at the L5 transverse process and iliac crest were also captured.ResultsContralateral sacral lesions were only recognized by initial bone oedema on MRI in 17/78 (22%) cases. There were 22 cases without and 56 cases with an interconnecting transverse fracture component (TFC) [between S1/S2 (n = 39) or between S2/S3 (n = 17)]. With 30/78 patients showing bilateral fracture lines at different stages (1/2: n = 13, 2/3: n = 13, 1/3: n = 4) and 38 at similar stages, Wilcoxon tests showed a significant stage difference (p < 0.001). Forty cases had a coexistent L5 transverse process avulsion, consistent with a failing iliolumbar ligament. Analysis of variance revealed significant increases in ligamentous avulsions with higher fracture stages (p < 0.001).ConclusionOur results support the hypothesis of stagewise BFFS progression starting with unilateral sacral disruption followed by a contralateral lesion. Loss of sacral alar support leads to a TFC. Subsequent bone disruption causes iliolumbar ligament avulsion. MRI is recommended to detect bone oedema.

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