PURPOSE OF THE STUDY The characteristics, diagnosis, classification and treatment options of rare fractures of the sacrum known as suicidal jumper's fractures are presented based on six illustrative cases. MATERIAL AND METHODS Jumper's fractures of the sacrum are characterised by an H- or U-shaped fracture line in the upper sacrum, usually involving the S1-S2 region. Typically, the anterior segment of the pelvic ring is not injured. In most cases this injury is associated with polytrauma and it is imperative that the patients undergo thorough neurological examination including that for perineal sensitivity and anal tone. RESULTS Between 1998 and 2007, 109 patients were treated for AO/OTA type C pelvic injuries at the Department of Orthopaedics and Traumatology. A bilateral fracture of the sacrum with a typical fracture line, i.e., suicidal jumper's fracture, was recorded in six patients (5.5 %), which accounts for 1.2 % of the total number of the pelvic fractures treated. Five patients underwent surgery, one was treated conservatively. Neurological deficit was recorded in five of the six patients. Surgery resulted in bone union and overall improvement in five patients, the patient treated conservatively showed lasting neurological deficit with no progression; she developed pseudoarthrosis. DISCUSSION Transverse fracture of the sacrum, in the literature referred to as suicidal jumper's fracture, is a rare injury. In 1985 Roy-Camille introduced a classification system for sacral fractures. In the classification proposed by Denis et al., transalar, transforaminal and central fractures are distinguished, with transverse fractures being included. For making exact diagnosis, the AO/OTA classification is necessary. There is a wide range of neurological features associated with displaced sacral fractures. It includes motor and sensory deficit in L5 and S1 dermatomes and myotomes, dysfunction of the sphincters, perineal insensitivity and possibly also sexual dysfunction. Based on the Denis classification, zone I fractures are responsible for 5.9 %, zone II fractures for 28.4 % and zone III fractures for 56.7 % of the neurological deficits associated with sacral injuries. In patients with zone III fractures, urinary bladder innervation and sexual dysfunction are recorded in 76 %, and neurological deficit in 41 %, of which two-thirds are motor neuron lesions. Motor deficits are most often due to L5 and S1 root lesions; sensory deficits result from S2-S5 and L5 root lesions. External rotation and vertical displacement produce a traction mechanism, comminution and impaction of the massa lateralis result in nerve compression. Sacral fractures can be treated conservatively or surgically. Conservative therapy, bed rest, traction and gradual physical therapy are indicated in children and adolescents with non-displaced or slightly displaced sacral fractures, either without or with minimal neurological symptoms. Surgical treatment involving nerve decompression, open reduction of the fracture and subsequent fixation of the fragments is indicated in all displaced fractures. When nerve structures are affected, the injury-surgery interval should not exceed six hour. CONCLUSIONS Sacral fractures known as suicidal jumper's fractures are rare but very serious injuries difficult to diagnose. All injured patients should undergo a thorough neurological examination, including perineal sensitivity and anal tone. The treatment includes nerve decompression, fragment reduction and the restoration of sacral and pelvic stability necessary for neurological recovery, early rehabilitation and good clinical outcome.

Klinika ortopedie a traumatologie pohybového ústrojí LF UK a FN Plzeň

Suicidal Jumper's Fracture

Lit.: 19