Rosen & Barkin's 5-Minute Emergency Medicine Consult (628 page)

• American Academy of Pediatrics.
  Report of the Committee on Infectious Diseases.
  29th ed. Elk Grove, IL: American Academy of Pediatrics; 2012.
  
• Banatvala JE, Brown DW.
  Rubella. Lancet.
  2004;363:1127–1137.
  
• Gerber JS, Offit PA. Vaccines and autism: A tale of shifting hypotheses.
  Clin Infect Dis
  . 2009;48:456–461.
  
• Mason WH. Rubella. In: Kliegman RM, Behrman RE, Jenson HB, et al., eds.
  Nelson Textbook of Pediatrics.
  18th ed. Philadelphia, PA: WB Saunders; 2007:1337–1340.
  

CODES

• 056.9 Rubella without mention of complication
  
• 647.50 Rubella in the mother, unspecified as to episode of care or not applicable
  
• 771.0 Congenital rubella
  

BASICS

• They occur in 45% of all pelvic fractures and are rarely isolated
  
• They are defined by the orientation of the fracture line.
  
• Mechanism:
  
  • Axial compression
    
  • Direct posterior trauma
    
  • Massive crush injury
    
  • Insufficiency fractures in elderly and osteoporotic patients
    

Transverse

• Above S4:
  
  • Neurologic injury common
    
  • Can see cauda equina syndrome (CES)
    
• Below S4:
  
  • Associated rectal tears
    
  • Neurologic injury is are
    

Vertical

• Lateral to sacral foramina
  :
  
  • Sciatica
    
  • L5 root injury
    
  • Neurologic deficit infrequent
    
• Foraminal
  (zone 2):
  
  • Bowel/bladder dysfunction
    
  • L5, S1, S2 root injury
    
  • Neurologic deficit frequent
    
• Canal
  (zone 3):
  
  • Bowel/bladder dysfunction
    
  • Sexual dysfunction
    
  • L5, S1 root injury
    
  • Neurologic deficit often present (>50%)
    

• Transverse: Fall from height, flexion injuries, direct blow
  
• Vertical: Usually high-energy mechanism
  

Sacral insufficiency fractures should be considered in elderly patients with severe back pain

DIAGNOSIS

• Pain in buttocks, perirectal area, and posterior thigh
  
• Swelling and ecchymosis over the sacral prominence
  
• Possible sacral nerve dysfunction:
  
  • Absent or diminished anal sphincter tone is an important finding.
    
  • Bowel or bladder incontinence
    

• History and physical exam with attention to loss of anal sphincter tone, sensation in the perineum, and bowel and bladder sphincter control.
  
• Sacral fractures rarely occur in isolation; look for associated injuries.
  
• Rectal exam will elicit pain in the sacrum; blood in the rectum suggests an open fracture.
  

• Only 30% of sacral fractures are detected on plain radiograph.
  
• CT provides optimal imaging to identify sacral fractures.
  
• MRI is indicated when neurologic dysfunction is present.
  

• Contusion
  
• Lumbar spine fracture
  
• Pelvic fractures
  

TREATMENT

• Sacral fractures are frequently associated with other spinal and intra-abdominal injuries.
  
• Immobilize with backboard and C-spine collar.
  

• Manage ABCs as needed.
  
• Early immobilization in unstable pelvis or spine fractures
  
• Pain control with NSAIDs or narcotic analgesics
  

• Vertical unstable fractures require a rapid and thorough assessment for life-threatening injuries as well as orthopedic consultation (see “Pelvic Fracture”).
  
• Nondisplaced isolated transverse sacral fractures are treated symptomatically with touch-down weight bearing on affected side and early orthopedic referral.
  
• Surgery is often required for fractures associated with neurologic injury.
  

Analgesia as indicated

FOLLOW-UP

• Critically injured trauma patient with unstable pelvic fracture
  
• Neurologic impairment requires orthopedic consultation.
  

• Isolated nondisplaced sacral fractures
  
• Consider intermediate or assisted-care setting for elderly patients.
  

• Only nondisplaced, transverse fractures are appropriate for outpatient follow-up
  
• Prompt surgical evaluation is indicated for displaced fractures.
  

• Sacral fractures are rarely isolated; consider associated pelvic fractures.
  
• Detailed neurologic exam, including rectal sphincter tone and perianal sensation, is indicated to assess for associated sacral nerve root injury.
  
• Foley catheter in a trauma patient may mask voiding problems from sacral nerve root injury.
  

• Choi SB,Cwinn AA. Pelvic trauma. In: RosenP, ed.
  Emergency Medicine: Concepts and Clinical Practice.
  7th ed. Philadelphia, PA:Mosby-Elsevier; 2009.
  
• Galbraith JG, Butler JS, Blake SP, et al. Sacral insufficiency fractures: An easily overlooked cause of back pain in the ED.
  Am J Emerg Med
  . 2011;29(3):359.e5–e6.
  
• Hak DJ, Baran S, Stahel P. Sacral fractures: Current strategies in diagnosis and management.
  Orthopedics
  . 2009;32:752–757.
  

See Also (Topic, Algorithm, Electronic Media Element)

Pelvic Fracture

CODES

• 733.13 Pathologic fracture of vertebrae
  
• 805.6 Closed fracture of sacrum and coccyx without mention of spinal cord injury
  
• 806.62 Closed fracture of sacrum and coccyx with other cauda equina injury