Knowledge gaps in high-energy sacral fracture treatment and management

Ashraf N. El Naga; Marko H. Neva; Ahmed Abdelazim Hassan; Gregory D. Schroeder; Mohammad El-Sharkawi; Sebastian F. Bigdon; Andrei F. Joaquim; Klaus Schnake; Richard Bransford; Emre Yilmaz

doi:10.1016/j.jcot.2026.103455

Knowledge gaps in high-energy sacral fracture treatment and management

Ashraf N. El Naga
, Marko H. Neva
, Ahmed Abdelazim Hassan
, Gregory D. Schroeder
, Mohammad El-Sharkawi
, Sebastian F. Bigdon
, Andrei F. Joaquim
, Klaus Schnake
, Richard Bransford
, Emre Yilmaz^*

^*Corresponding author for this work

Research output: Contribution to journal › Review Article › peer-review

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Abstract

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.

Original language	English
Article number	103455
Journal	Journal of Clinical Orthopaedics and Trauma
Volume	78
DOIs	https://doi.org/10.1016/j.jcot.2026.103455
Publication status	Published - Jul 2026
Publication type	A2 Review article in a scientific journal

Funding

the authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was organized and funded by AO Spine through the AO Spine Knowledge Forum Trauma & Infection. Study support was provided directly through AO Innovation Translation Center, Network Clinical Research. This study was organized and funded by AOSpine through the AO Spine Knowledge Forum Trauma & Infection, a focused group of international experts. AO Spine is a clinical division of the AO Foundation which is an independent medically guided not-for-profit organization. Study support was provided directly through the AO Innovation Translation Center, Network Clinical Research . the authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was organized and funded by AO Spine through the AO Spine Knowledge Forum Trauma & Infection. Study support was provided directly through AO Innovation Translation Center, Network Clinical Research. This article is part of a special issue entitled: Gaps in Spinal Trauma and Infection Management published in Journal of Clinical Orthopaedics and Trauma.This article is part of the collection on Knowledge Gaps in the Treatment of Spine Trauma and Spine Infection. An exception to the journal's authorship policy has been granted, allowing more than six authors, as the article was collaboratively authored by team members and the Steering Committee of the AO Spine Knowledge Forum Trauma and Infections.This study was organized and funded by AOSpine through the AO Spine Knowledge Forum Trauma & Infection, a focused group of international experts. AO Spine is a clinical division of the AO Foundation which is an independent medically guided not-for-profit organization. Study support was provided directly through the AO Innovation Translation Center, Network Clinical Research.The authors would like to acknowledge the Copyrights, AO Spine, and the AO Spine Knowledge Forums.

Keywords

Knowledge gaps
Management
Pelvic injury
Sacral fractures
Spine trauma
Treatment

Publication forum classification

Other identified publication channels

ASJC Scopus subject areas

Orthopedics and Sports Medicine

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Knowledge gaps in high-energy sacral fracture treatment and managementFinal published version, 3.43 MBLicence: CC BY

https://urn.fi/URN:NBN:fi:tuni-202605286490Licence: CC BY

Cite this

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title = "Knowledge gaps in high-energy sacral fracture treatment and management",

abstract = "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.",

keywords = "Knowledge gaps, Management, Pelvic injury, Sacral fractures, Spine trauma, Treatment",

author = "\{El Naga\}, \{Ashraf N.\} and Neva, \{Marko H.\} and Hassan, \{Ahmed Abdelazim\} and Schroeder, \{Gregory D.\} and Mohammad El-Sharkawi and Bigdon, \{Sebastian F.\} and Joaquim, \{Andrei F.\} and Klaus Schnake and Richard Bransford and Emre Yilmaz",

note = "Publisher Copyright: {\textcopyright} 2026 The Authors. This is an open access article under the CC BY license. http://creativecommons.org/licenses/by/4.0/",

year = "2026",

month = jul,

doi = "10.1016/j.jcot.2026.103455",

language = "English",

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AU - El Naga, Ashraf N.

AU - Neva, Marko H.

AU - Hassan, Ahmed Abdelazim

AU - Schroeder, Gregory D.

AU - El-Sharkawi, Mohammad

AU - Bigdon, Sebastian F.

AU - Joaquim, Andrei F.

AU - Schnake, Klaus

AU - Bransford, Richard

AU - Yilmaz, Emre

PY - 2026/7

Y1 - 2026/7

N2 - 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.

AB - 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.

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KW - Pelvic injury

KW - Sacral fractures

KW - Spine trauma

KW - Treatment

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AN - SCOPUS:105039058772

SN - 0976-5662

VL - 78

JO - Journal of Clinical Orthopaedics and Trauma

JF - Journal of Clinical Orthopaedics and Trauma

M1 - 103455

ER -

Knowledge gaps in high-energy sacral fracture treatment and management

Abstract

Funding

Keywords

Publication forum classification

ASJC Scopus subject areas

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