Management of sacral fragility fractures leading to spinopelvic dissociation: a scoping review

Fragility fractures affecting the sacrum present an increasing challenge to orthopaedic practice, due to limited comparative data and the absence of consensus on optimal management. U-Type and Rommens Type IVb fractures may result in a bilateral pattern of spinopelvic dissociation with possible neurological injury. This scoping review aims to summarise the current principles of care, indications for surgery, and outcomes of operative versus non-operative treatment for low-energy bilateral posterior sacral fractures (BPSFs).

This scoping review adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR). A systematic search of electronic databases identified studies including ≥ 10 patients with Bilateral Posterior Sacral Fractures (BPSFs) comparing operative and non-operative approaches. Two reviewers independently screened titles, abstracts, and full texts against predefined inclusion and exclusion criteria, resolving disagreements by consensus. Data were extracted using a standardised form and summarised narratively with reference to mobility, quality of life, and patient-reported outcome measures. From 421 studies screened, eight met inclusion criteria.

From 421 screened records, eight studies including 235 patients met inclusion criteria. Operative management resulted from failed non-operative care in most cases. Percutaneous screw fixation was the most common surgical technique utilised. Although one study reported improved outcomes with early fixation, considerable heterogeneity in surgical approach and timing was observed with a similar lack of consensus on non-operative regimes and their point of 'failure'.

Operative management may enhance pain relief, mobility, and function in selected patients with BPSFs, though with notable implant-related risks. Careful patient selection remains key, and further prospective studies are needed to establish optimal non-operative management and those who would benefit from early operative intervention.