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Eur J Trauma Emerg Surg (2012) 38:517524

DOI 10.1007/s00068-012-0225-7

ORIGINAL ARTICLE

Management of traumatic spinopelvic dissociations: review


of the literature
W. Lehmann M. Hoffmann D. Briem
L. Grossterlinden J. P. Petersen M. Priemel
P. Pogoda A. Ruecker J. M. Rueger

Received: 2 May 2012 / Accepted: 27 August 2012 / Published online: 25 September 2012
Springer-Verlag 2012

Abstract
Purpose Spinopelvic dissociation is a rare high-energy
injury pattern in adults associated with high morbidity and
an increased rate of neurological deficits. The purpose of
this article is the conception of fracture type-associated
treatment recommendations.
Methods This article is based on our own experience with
spinopelvic dissociations and a review of the current
literature.
Results Bilateral vertical plus an optional transverse
fracture component configures spinopelvic dissociations as
U- or H-shaped, with the result of a spinopelvic dissociation. Y-, T- or II-shaped fractures do not
necessarily belong to this entity but can be subsumed to
this entity in a wider sense. The surgical treatment of these
injuries remains challenging. Initial haemodynamic stabilisation represents the main goal of primary care until
definitive treatment can be performed. Anatomical reduction is demanding and even more complex in fracture areas
with large comminution. Surgical treatment options depend
on the fracture type, including transsacral screws, sacral

This work is dedicated to the 60th anniversary of our mentor and


surgical teacher, Prof. Dr. Med. Johannes M. Rueger, to whom we
faithfully congratulate.
W. Lehmann and M. Hoffmann contributed equally to this manuscript
and, therefore, share the first authorship.
W. Lehmann (&)  M. Hoffmann  D. Briem 
L. Grossterlinden  J. P. Petersen  M. Priemel  P. Pogoda 
A. Ruecker  J. M. Rueger
Department of Trauma, Hand and Reconstructive Surgery,
University Medical Center Hamburg-Eppendorf,
Martinistrasse 52, 20246 Hamburg, Germany
e-mail: wlehmann@uke.de

banding and spinopelvic fixation, plus combinations of


these procedures.
Conclusions Spinopelvic dissociations remain highly
complex injuries. U- and H-shaped fractures usually
require triangular fixation, whereas II-, Y- and
T-shaped fractures might be sufficiently stabilised with
transsacral screws.
Keyword

Pelvic trauma

Introduction
Less than 10 % of sacral fractures occur solely, as they are
combined injury patterns with other fractures of the pelvic
ring. Spinopelvic dissociations are usually associated with
high-energy trauma in adults. They are also observed in
elderly patients with osteoporotic bone after low-energy
traumas. Due to its anatomical localisation and configuration, the sacrum encounters two major forces of opposite
direction [1]. The vertical stress causes a bilateral intraforaminal fracture, resulting in an instability, which, in turn,
provokes the sacrum to pivot out of the posterior pelvic
ring. This creates a horizontal fracture, normally in the S1
to S2 junction, known as a weak area in the bony structure
of the sacrum causing the spinopelvic dissociation. They
represent a heterotopic entity of different soft tissue and
bony injuries [2]. Therefore, the term traumatic spinopelvic dissociation was proposed by Bents et al. [3] to
differentiate this entity from lumbosacral fracture dislocations or bilateral sacroiliac joint dislocations. However,
fully bilateral transforaminal fractures might also be added
to that entity of spinopelvic dissociations, as they lack a
bony connection to the pelvis. Additionally, the sacrotuberous and the sacrospinous ligaments might be torn.

123

518

According to our own experiences and a review of the


current literature, this article aims to provide a road map
for fracture type-specific treatment options. Five cases with
spinopelvic dissociation were treated in our hospital in the
last 2 years. All patients showed combined injury pattern.
Except the U-shaped fracture, all patients were treated
with an external compression device during primary care.

Discussion
Classification system
The most simple classification for sacrum fractures was
developed by Denis et al. [4], which categorised fractures
into three types based on the anatomical relationship to the
sacral neural foramina. The vertical fracture line in spinopelvic dissociations occurs mostly in zone 2 according to
the Denis classification. Based on biomechanical considerations, Roy-Camille et al. [1] introduced the first classification for these fractures (Fig. 1). They distinguished
three different types of fractures: type 1 as a flexion fracture

W. Lehmann et al.

in which the upper fragment dislocates anteriorly, type 2 as


a flexion fracture in which the upper part dislocates posteriorly, and type 3 as an extension fracture in which the upper
fragment is vertical and displaced antero-inferiorly in front
of the lower fragment [2]. Strange-Vognsen and Lebech [5]
added a fourth type of fracture with a complete comminution of the upper sacrum without a distinct transverse
fracture or displacement from the lower sacrum. The fractures appear relatively heterogeneous based on this classification, and a variety of morphological variations exist in
the coronal plane of the sacrum. However, spinopelvic
dissociation occurs only in H-, U- and II-, T- and
Y-shaped sacral fracture patterns (Fig. 2). However, with
the sacrospinous and sacrotuberous ligaments being torn,
the II-fracture configuration can also be considered as a
spinopelvic dissociation. Other forms which have been
described are the T- and Y-type fractures [6].
Primary care
Primary care follows the standard rules of advanced trauma
life support (ATLS) [6]. In the early phase of primary care

Fig. 1 Schematic representation of the spinopelvic dissociation forms described by Roy Camille et al. [1] and extended by Strange-Vognsen and
Lebech [5]

Fig. 2 Spinopelvic dissociations can appear as U-, H-, II-,


T- and Y-types. While for the U and H forms the
spinopelvic, respectively, the triangular osteosynthesis seems to be

123

essential, other forms that are also attributed spinopelvic dissociations can be sufficiently addressed with alternative osteosyntheses

518

According to our own experiences and a review of the


current literature, this article aims to provide a road map
for fracture type-specific treatment options. Five cases with
spinopelvic dissociation were treated in our hospital in the
last 2 years. All patients showed combined injury pattern.
Except the U-shaped fracture, all patients were treated
with an external compression device during primary care.

Discussion
Classification system
The most simple classification for sacrum fractures was
developed by Denis et al. [4], which categorised fractures
into three types based on the anatomical relationship to the
sacral neural foramina. The vertical fracture line in spinopelvic dissociations occurs mostly in zone 2 according to
the Denis classification. Based on biomechanical considerations, Roy-Camille et al. [1] introduced the first classification for these fractures (Fig. 1). They distinguished
three different types of fractures: type 1 as a flexion fracture

W. Lehmann et al.

in which the upper fragment dislocates anteriorly, type 2 as


a flexion fracture in which the upper part dislocates posteriorly, and type 3 as an extension fracture in which the upper
fragment is vertical and displaced antero-inferiorly in front
of the lower fragment [2]. Strange-Vognsen and Lebech [5]
added a fourth type of fracture with a complete comminution of the upper sacrum without a distinct transverse
fracture or displacement from the lower sacrum. The fractures appear relatively heterogeneous based on this classification, and a variety of morphological variations exist in
the coronal plane of the sacrum. However, spinopelvic
dissociation occurs only in H-, U- and II-, T- and
Y-shaped sacral fracture patterns (Fig. 2). However, with
the sacrospinous and sacrotuberous ligaments being torn,
the II-fracture configuration can also be considered as a
spinopelvic dissociation. Other forms which have been
described are the T- and Y-type fractures [6].
Primary care
Primary care follows the standard rules of advanced trauma
life support (ATLS) [6]. In the early phase of primary care

Fig. 1 Schematic representation of the spinopelvic dissociation forms described by Roy Camille et al. [1] and extended by Strange-Vognsen and
Lebech [5]

Fig. 2 Spinopelvic dissociations can appear as U-, H-, II-,


T- and Y-types. While for the U and H forms the
spinopelvic, respectively, the triangular osteosynthesis seems to be

123

essential, other forms that are also attributed spinopelvic dissociations can be sufficiently addressed with alternative osteosyntheses

Management of traumatic spinopelvic dissociations

for a haemodynamically unstable patient with a suspected


unstable pelvic fracture, a pelvic compression device
should be appliedindependent of any detailed fracture
classification. The integration of whole-body computed
tomography (CT) scanning into early trauma care significantly increased the probability of survival in patients with
polytrauma [7]. Therefore, the timely acquisition of a
whole-body CT scan is mandatory in the early phase of
trauma care. Conventional pelvic X-rays should be avoided
in haemodynamically unstable patients, as fractures of the
dorsal pelvic ring are often prone to being left undetected
[8].
The stabilisation of unstable pelvic fractures can be
achieved with various compression devices. Pelvic circumferential compression devices are designed to stabilise
the pelvic ring according to the ATLS. Pelvic Binder, SAM
Sling and T-POD provide sufficient reduction in partially
stable and unstable (Tile type B1 and C) pelvic fractures. In
a biomechanical study by Knops et al. [9], no undesirable
over-reduction was reported. The pulling force needed to
attain complete reduction of the fracture parts varied
among the tested devices. However, a disruption of the
anterior pelvic ring structures can be obscured by a Pelvic
Binder and be noticed later, once the Pelvic Binder is
removed.
If no adequate control of pelvic haemorrhage can be
achieved using an external compression device, fixation
using a pelvic clamp, laparotomy and packing according to
the damage control algorithm are indicated [10]. Further
bleedings might also be addressed by radiographic coiling
(Fig. 3).
Decision-making, timing and treatment options
Decision-making for definitive surgical treatment requires
exact knowledge of the fracture morphology. X-ray diagnostics seems appropriate for primary care imaging.
However, as injuries of the posterior pelvic ring are often
inaccessible for X-ray diagnostics, exact fracture classification necessitates CT scans plus possibly further magnetic
resonance imaging (MRI) diagnostics [11, 12], if necessary. Furthermore, the patient needs to be examined carefully, including a special neurological survey and a digital
rectal examination to rule out occult open fractures with
perforation into the rectum. As these fractures are mainly
caused by high-energy trauma, the risk for major soft tissue
trauma is not negligible. Palpable subcutaneous fluid is
consistent with lumbosacral fascial degloving [6]. These
Morel-Lavellee lesions pose a high risk for infection, and
greater incisions for osteosynthesis through these areas
should be avoided [8, 13].
Reviewing the literature, more than 80 % of patients
presented neurological status abnormalities [2, 1423]

519

(Table 1). As spinopelvic dissociations are usually combined with other life-threatening injuries, the majority of
patients are sedated or intubated on hospital admission,
allowing no neurological status examination. Therefore,
the neurological status often remains unknown in the phase
of definitive treatment. However, if radiological imaging
reveals obliteration of the spinal canal or neural foramina,
timely intervention and decompression are mandatory.
Recent studies have shown that early fixation within
24 h is particularly important, because it reduces morbidity
and length of intensive care unit stay [24]. The definition
of the length of time of that early period has changed
within the last several years. While the damage control
orthopaedics principle should still be applied, we do not
continue to insist on a 3- to 4-day time period between
early care and definitive treatment, as earlier studies recommended [25].
Basically, we can distinguish between open and minimally invasive procedures. Reviewing the literature,
standard procedures are vertebropelvic fixation techniques
[16, 17, 19]: a dorsal tension band plate combined with
iliosacral screws and the distraction spondylodesis with or
without additional sacroiliacal screw, so called triangular
osteosynthesis. This technique of vertebropelvic fixation
was primarily described in 1994 by the groups of Kach
and Trentz (5 cases) and Josten et al. (8 cases) [26, 27].
Schildhauer et al. [19, 28, 29] reported excellent clinical
and biomechanical results. Compared to unlocked plating
of sacrum fractures, locked plating did not show relevant
advantages [3032]. In regards to minimally invasive
methods, iliosacral screw fixation can be performed as
percutaneous osteosynthesis, and either one or two screws
can be inserted unilaterally or bilaterally (Fig. 3). Furthermore, the technique of vertebropelvic fixation can be
carried out in a less invasive method, described as less
invasive lumbopelvic stabilisation (LILS) by Keel et al.
[33]. Sabourin et al. [23] reported a shortening osteotomy
and sacro-sacral plating in limited access surgery [2]. The
problems with the minimally invasive procedures are the
limited possibility for reduction and the impossibility of
decompressing neuronal structures. Konig et al. [34]
recently published a series of three patients in whom the
sacral fractures were reduced and fixed percutaneously
with iliosacral screws. In our experience, the use of isolated screws is indicated in cases of severe soft tissue
injury, which does not allow a standard open surgical
procedure. However, severely displaced fractures should
generally be treated by open reduction so as to allow
anatomical reduction. Based on current knowledge, triangular osteosynthesis seems to be the safest method [28].
Anatomical reduction and fixation of sacral fractures can
be challenging, especially when facing a large comminution zone.

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W. Lehmann et al.

Fig. 3 ac Computed
tomography (CT) scan of a type
II fracture. d Post-operative
AP view. Due to the severe soft
tissue trauma on the back, the
stabilisation on the dorsal side
was done minimally invasively
with percutaneous screws and
small incisions for the
reduction. e, f Digital
subtraction angiography
showing the bleeding out of the
arteria obturatoria (red arrow)
before and after coiling of the
vessel, respectively

Surgical techniques
Reviewing the biomechanical datasets, triangular stabilisation seems to be the most stable method of fixation.
In the early phase of treatment, closed reduction in the
prone position with hyperextension of the hip joint and
applied extension is worth a try [35]. Yet, the goal is an

123

anatomical reduction and decompression of neuronal


structures if necessary, which can only be addressed by
open procedures. In extended comminution in particular,
finding the right orientation on the sacrum can be difficult.
First, the approach must be chosen depending on the type
of fracture and the stabilisation method. The approaches
used most often are paravertebral, parailiacal or curved

MoI mechanism of injury, CS clinical series, RCS retrospective clinical study, CR case report, SA suicide attempt, F fall, CI crush injury, RTA road traffic accident, GS gun shot, N/A not
available, AB abnormal, N/M not mentioned, N normal, ND neurological deficit, IS iliosacral screws, SB sacral banding, TF triangular fixation, SPF spinopelvic fixation

SPF

SPF
AB (1)

N/M (1)
AB (1)

AB (1)
N/M

21
U-shape

U-shape
X-Ray

CT
CI (1)

RTA (1)

CR (1)
Rhee et al. [14]

26

CR (1)
Vilela et al. [16]

23

SPF (1), TF (1), IS (2)


Open reduction, laminectomy,
cast immobilisation

TF (3)
N/M

N(2), AB (2)
N (2)
N (2), AB (2)
AB (2)

AB (3)
9

N/M
3
U-shape
U-shape

U-shape
CT

X-ray
X-ray
SA (3), RTA (1)
AF (1), CI (1)

SA (2), CI (1)

CS (4)
CR (2)
Hunt et al. [17]
Hussin et al. [15]

30
18

CS (3)
Mouhsine et al. [18]

31

SPF (19)
N (10), ND (8),
1 lost FU
AB (19)
N/M
N/M
X-ray
F (10), RTA (7),
CI (2)
RCS (19)
Schildhauer et al. [19]

34

IS (13)

IS (2), SB (1), TF (5)


N (1), ND (7)

N (2), ND (11)
N (2), AB (9),
N/A (2)

AB (1), N/A (7)


7

4
U-shape

U-shape
X-ray

X-ray
SA (3), F(4),
RTA (6)

SA (7), F (1)
29
RCS (8)

RCS (13)
Nork et al. [20]

31

521

Gribnau et al. [21]

IS (3)
N (1), ND (2)
AB (2), N/A (1)
6
U-shape
CT
AF (1), RTA (1),
SA (1)
CS (3)
Konig et al. [2]

22

MoI (no.
of cases)
Mean age
(years)
Study type
(no. of cases)
Authors, references

Table 1 Baseline data of previously reported cases and studies

Primary
diagnostic
imaging

Fracture
type

Mean time to
surgery (days)

Neurostatus
pre-op.

Neurostatus
post-op.

Type of surgery

Management of traumatic spinopelvic dissociations

incision. The curved incision is for transsacral plating and


exposition of the whole sacrum [36]. This section runs
from the posterior superior iliac crest to the spinous process of L4 or L5, back to the posterior superior iliac crest.
The favourite approach is the paravertebral approach
starting 2 cm lateral from the spinous process of L4 parallel to the posterior iliac crest. This approach allows good
visualisation of the fracture and the possibility of spinopelvic stabilisation, especially if it is extended caudally to
the lateral side. For transiliacal plating, a bilateral longitudinal incision on both sides of the dorsal iliac crest is
useful (Figs. 4 and 5). In the next step, the fracture must
be exposed. The injury pattern separates the lumbar spine
and, in the U- and H-type fractures, the superiorcentral part of the sacrum from the lower part of the
sacrum and the pelvis through the sacral alae. In case of a
complete transforaminal fracture with disruption of the
sacrospinous and sacrotuberous ligaments, the lumbar
spine is separated with the mid-part of the sacrum from
the pelvis. Thus, this part can move in all three axes in the
three-dimensional space. The majority of the patients
with spinopelvic dissociations present kyphosis across the
fracture side [6]. The cranio-caudal shift needs to be
corrected, and the ventral-dorsal dislocation and the rotation of the sacrum needs to be addressed, which can be
achieved either by direct or indirect manipulation. For
direct manipulation, the angulated sacral body can be
secured by placing a Schanz screw in S1. To compensate
for the length offset, unilateral or bilateral femoral traction
is helpful. A distractor can even be placed between L5 and
the ilium. Konig et al. described a percutaneous technique
in which they first inserted a transpedicular Schanz pin in
L5 or S1 as a lever for the cephalad segment and a second
pair of pins into the posterior iliac spine. With the aid of
an external rod and a multi-directional connector, the
fracture was reduced and then fixed with two cannulated
7.3-mm iliosacral screws [34]. This technique seems to be
elegant, but no decompression is possible and percutaneous stabilisation with two iliosacral screws may be not
sufficient. In this study, at least one of the three patients
had a loss of reduction within a short time.
To obtain accurate orientation, exposing the caudal side
of the sacrum on the transition to the ilium is helpful. Sacral
reduction can be monitored by palpating the anterior side of
the sacrum. Here, one has to be careful to not injure the
nerve roots and the superior gluteal artery. In some cases of
difficult ventro-dorsal reduction, a coaxial clamp can be
used. The reduction can be achieved by simultaneously
pulling on the leg and a Schanz pin in the ilium to address
mal-rotation. Separation of the fragments in the frontal
plane, especially in bilateral transforaminal fracture lines
(type II), can usually be counteracted with pelvic clamps.
In highly obese patients with comminution of the upper

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W. Lehmann et al.

Fig. 4 Example of a typical


H-type fracture. The patient
was treated with triangular
osteosynthesis and resulted in
no neurological deficit.
a Computed tomography (CT)
scan, axial view. b CT scan,
coronal view. c CT scan, sagittal
view with the transverse
component. d Conventional
post-operative X-ray

Fig. 5 a, b Typical H-type


fracture in transversal and
sagittal planes. c A bone
spreader is used to open up the
fracture such that the nerve
roots can be freed from bone
fragments using a microsurgical
technique. d Post-operative
picture showing an example of
dorsal bending combined with
an iliosacral screw on the
left side

sacrum that makes it difficult to use small tongs for local


reduction, we used a pelvic C-clamp in the prone position to
achieve sufficient compression. However, compression of
the neural foramina with the nerve roots should be avoided.
To maintain the reduction, transiliosacral k-wires can be

123

inserted and used as guide rods for cannulated screw


insertion.
If a neurological examination reveals nerval palsy,
decompression is mandatory. However, the patients are
often polytraumatised and exact pre-operative neurological

Management of traumatic spinopelvic dissociations

examination is not feasible. Reviewing our own cases,


major bony destruction usually comprised nerve root
involvement and required microsurgical neurolysis prior to
reduction and fixation. In the literature, decompression and
laminectomy have been carried out in 32 % of patients
[14, 16, 17, 19, 37].
Special surgical procedures and fixation technique
depend on the fracture type and morphology. For unstable
U- and H-shaped fractures, triangular osteosynthesis
seems to be the safest way for stabilisation. For IIshaped fractures, this method is also suited but, due to the
different rotation centres in comparison to the transverse
fracture line in the upper sacrum, a bilateral iliosacral
screwing or dorsal bending with a tension plate seems to be
sufficient. The T- and Y-type fractures can also be
addressed with dorsal stabilisation using either plates or
screws. A spinopelvic or triangular stabilisation seems not
to be indispensable.
Outcome
As only small study series with heterogenic additional
injury patterns are available in the literature, comparing
outcomes is difficult. Reviewing the armament of neurological classification systems, the Gibbons et al. classification [38] seems straight forward: 1, no neurological deficit;
2, paresthesias only; 3, lower extremity motor deficit, and 4,
bowel/bladder dysfunction. Less than 45 % of the studies
reported complete recovery of the patients, meaning
Gibbons 1, but almost one-third suffered from remaining
bowel and bladder dysfunction, which is what we found in
two of our patients, who showed no improvement in their
voiding dysfunction. No sustainable data are available
regarding the surgical technique and correlating incidence
rates of post-operative palsy or nerval dysfunction. Furthermore, little information is available about the quality of
life after such severe sacral injuries. Borg et al. [39] showed
a low recurrence rate of suicidal behaviour in a group of
jumpers. In our hospital, psychiatrists were involved in all
cases from the early treatment phase onwards.

Summary
Spinopelvic dissociations are rare injuries commonly
associated with high-energy trauma in adults. They are also
described in elderly patients after low-energy trauma. The
most common method to address these injuries is spinopelvic fixation. The biomechanical data suggest that
spinopelvic stabilisation combined with iliosacral screw
placement, defined as triangular osteosynthesis, provides
the most fixation stability. However, spinopelvic injuries
are a heterogenic entity requiring fracture-defined fixation

523

methods. U- and H-type fracture configurations represent the most unstable forms of spinopelvic dissociations
and commonly require triangular fixation. II-, Y- and
T-type fractures usually provide more intrinsic fracture
stability and might be addressed by transsacral screws only.
In summary, these patients do not have a good prognosis
and suffer long-term physical and neurological impairment.
Conflict of interest

None.

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