Closed fracture of sacrum12/5/2023 ![]() ![]() CT is the most accurate and specific imaging modality, being able to differentiate between fractures, malignancy and osteomyelitis. MRI and isotope bone scans are more sensitive but may confuse fractures with malignancy and infection. Sacral fractures are difficult to diagnose on a PXR and are only seen after bony union and callus formation has begun. Neurological involvement in sacral fractures can occur but is uncommon, and vascular complications are rare but do happen. Urethral injury is much more common in men, and bladder neck injury usually only occurs in children. Koraitim reports that the risk of urethral injury in sacral fracture is influenced by the number of broken pubic rami as well as involvement of the sacro-iliac joint. However, it is a known complication of traumatic fractures. We could not find any published case reports of bladder rupture following closed osteoporotic pelvic fractures. Discharge, after a total of 168 days, was to her own home. She had a full physiotherapy assessment whilst in hospital, with education about prevention of falls. She was treated with ergocalciferol 300,000 IU intramuscularly, and was discharged on calcium, vitamin D and strontium ranelate. She also developed faecal incontinence, but MRI showed no evidence of cauda equina involvement. Once the urology team had opted for conservative treatment with urinary catheterisation and follow-up cystoscopy, the orthopaedic team advised we could begin to mobilise again within the limits of her pain. The orthopaedic team initially felt bed rest, rather than active rehabilitation, was the most appropriate management, pending urological input. X-ray image of pelvis before and after displacement. The haemodynamic instability was felt to have been caused primarily by the bladder tear, but was contributed to by blood loss at the fracture site. A pelvic MRI showed considerable haematoma formation and soft tissue oedema around the fractures with a displaced bone fragment from the pubic ramus lying posteriorly against the bladder wall. A cystogram identified an extra-peritoneal bladder leak on the right side close to the fracture site. A CT IVU showed an extra-vesical bladder injury thought to be caused by the pubic ramus fracture and a repeat PXR confirmed fracture displacement ( Figure 1). ![]() Views at cystoscopy were limited but suggested a haemorrhagic cystitis. A pelvic ultrasound scan revealed an intra-vesical mass, possibly a blood clot. Aspirin and tinzaparin were discontinued at this stage. Her haemoglobin dropped from 11 to 7.6 g/dL and she required blood transfusion. ![]() ![]() The haematuria then worsened and she became haemodynamically unstable. She then developed haematuria and urinary incontinence, which were initially diagnosed as urinary tract infections ( E scherichia coli and Enterococcus were isolated). Her pain was difficult to control, particularly in her left buttock, and pelvic MRI subsequently revealed bilateral sacral insufficiency fractures. She was managed conservatively with mobilisation as tolerated and transferred to a rehabilitation ward, where serious complications arose. Right superior and inferior pubic ramus fractures were diagnosed on a plain pelvic X-ray (PXR). She had a history of osteoporosis treated with bisphosphonates (risedronate 5 mg OD), but was not on calcium and vitamin D supplements prior to admission. Case reportĪn 86-year-old lady was admitted to an orthopaedic ward following a trip from standing height on an uneven path outside her house. Certain complications can happen, such as urinary bladder injury in multiple pubic ramus fractures, and sacral fractures can be associated with sacral nerve root damage and bleeding due inferior epigastric artery injury, particularly in those on oral anticoagulants. They often co-exist with pubic ramus fractures: 78% of those with sacral insufficiency fractures have concomitant pubic ramus fractures. The incidence of sacral insufficiency fractures in the elderly is increasing. Osteoporosis, sacral insufficiency fractures, pubic ramus fracture, elderly Introduction ![]()
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