Knowledge gaps in high-energy sacral fracture treatment and management

High-energy sacral fractures (HESF) are often challenging injuries due to the location of the sacrum at the junction of the spine and pelvis, the complex biomechanics of the pelvic ring and the wide spectrum of injury patterns, which make treatment standardization challenging. Despite advances in classification systems - particularly the AOSpine Sacral Injury Classification - significant gaps remain in understanding optimal management. To review and discuss the management and identify knowledge gaps related to HESF. A narrative review of the literature was conducted, focusing on five domains: 1. Relative instability and biomechanics affected in different injury patterns; 2. The significance of concomitant pelvic ring disruption; 3. Reduction goals and options; 4. Optimal instrumentation construct for specific injuries and 5. The role and timing of neural element decompression. The evidence is limited by retrospective studies and heterogeneity. The instability criteria are poorly defined. The role of anterior pelvic fixation remains controversial, with conflicting evidence considering posterior-only versus combined approaches. Reduction goals lack consensus as well. Considering instrumentation techniques, different options were proposed, such as sacroiliac fixation, spinopelvic constructions, and triangular osteosynthesis - with insufficient data for comparison. Finally, evidence for guiding neural decompression is sparse and inconsistent. The management of HESF is extremely based on expert opinion, despite advancements in the classification system. Further prospective, multicenter, and well-designed trials are strongly necessary to define better treatment algorithms and answer the raised knowledge gaps.