Sacral Insufficiency Fracture Physical Therapy in Singapore

Table of Contents

• Introduction
• Diagnosis
• Tests
• Sacral Insufficiency Fracture Treatment in Singapore
• Follow-up
• Miscellaneous
• FAQ

• Sacral Insufficiency fractures occur in the sacral ala between the SI joints and the neural foramina (Denis Zone 1).
  • The fracture pattern adopts a characteristic H-shape, which is pathonemonic of the condition.
  • It is postulated that the vertical limbs of the H occur 1st, followed by the transverse fracture line.
  • In ~50% of cases, the fracture results from low-energy trauma such as a fall.
• Sacral insufficiency fractures often are associated with other insufficiency fractures around the pelvic girdle, most commonly the pubic rami.

• >90% occur in postmenopausal females
• Predominantly Caucasian females

• Osteoporosis
• Inflammatory arthritis
• Primary bone or metastatic neoplasms
• Radiotherapy
• Metabolic bone disease
• Corticosteroids
• Total hip replacement

• The mechanism of injury has yet to be defined, but theoretically:
  • During ambulation, load is transmitted from the spine through the sacrum around the pelvic rim to the lower limbs.
  • In people with osteoporosis, the tilting and rotation of the pelvis during ambulation or sudden load transmission during a fall creates shear forces that generate microfractures vertically in the sacral ala.
  • These fractures may be unilateral initially before progressing bilaterally.
  • Continued tilting and rotation of the pelvis around 2 cross-axes lead to microfracture transversely between the 2 vertical fracture lines.
• This theory explains the characteristic H or butterfly appearance on bone scintigraphy and why, in some sacral insufficiency fractures, only 1 or 2 vertical fractures are apparent, depending on how far the fracture has propagated before the diagnosis is made.

• Sometimes no antecedent trauma is apparent.
• Low-energy fall in up to 50%

• Other insufficiency fractures around the pelvic girdle
• Vertebral compression fractures
• Osteoporosis

• No clear set of symptoms that pinpoints the diagnosis
• Suspicion of a sacral insufficiency fracture should be raised in the presence of mechanical low back and buttock pain.
• Pain is exacerbated by sitting or mobilizing.

Tests

• Malignancy
• Infection

• Pain relief
• Bed rest

• In cases of prolonged and persistent pain resistant to analgesics, sacroplasty may be considered.
  • Percutaneous injection of small aliquots of bone cement into the fracture site to prevent micromotion at the fracture
  • Performed under regional or general anesthetic using CT guidance
  • The use of bone cement in this manner is not FDA approved.
• Operative internal fixation can improve pain in patients with established nonunion of the sacrum.

• Nonoperative treatment:
  • Delayed union
  • Recurrent Insufficiency fracture
• Operative treatment:
  • Damage to iliac vessels
  • Damage to lumbosacral nerve roots
  • Chronic pain

Miscellaneous

FAQ