Clinical Radiology (2003) 58: 914–921

doi:10.1016/S0009-9260(03)00270-8, available online at www.sciencedirect.com

Pictorial Review

Imaging of Sacral Fractures

J. H. WHITE, C. HAGUE, S. NICOLAOU, R. GEE, L. O. MARCHINKOW, P. L. MUNK

Department of Radiology, Vancouver General Hospital, University of British Columbia, Vancouver, Canada

Received: 20 September 2002 Revised: 28 May 2003 Accepted: 6 June 2003

The article discusses traumatic, insufficiency and pathological sacral fractures. Special attention is
paid to the biomechanics and subsequent classification of traumatic sacral fractures. White, J. H. et al.
(2003). Clinical Radiology 58: 914–921.
q 2003 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.

Key words: sacrum, fracture, trauma.

INTRODUCTION mechanisms of injury/force vectors to classify pelvic fractures:

Fractures of the sacrum are frequently difficult to appreciate
on conventional radiographs. Concurrent pathology elsewhere
in the pelvis may be distracting and overlying bowel gas often
obscures the sacrum. Knowledge of the range of radiological
appearances of sacral fractures and when to use the appropriate
imaging techniques will enable the radiologist to properly
assess the sacrum.
This review illustrates the various radiological appearances
of traumatic, insufficiency, and pathological sacral fractures on
conventional radiographs, computed tomography (CT), mag-
netic resonance (MR), and nuclear medicine. The biomechanics
of traumatic sacral fractures are reviewed and correlated with
radiographs and cross-sectional images. Also reviewed, is a
widely accepted fracture classification system for sacral
fractures.
BIOMECHANICS AND CLASSIFICATION OF
SACRAL FRACTURES
anteroposterior compression, lateral compression, vertical
shear and combined/mixed mechanisms [2]. The pattern of
sacral fracture in combination with other associated pelvic
injuries described by this classification system can yield clues
to causative force vectors and help to direct management.
Although there is no universal classification system
focussing solely on sacral fractures, Denis and colleagues
have proposed one that is widely accepted [3,4]. This
classification system divides the sacrum into three zones (Fig.
1). Zone I fractures involve the sacral ala, which are lateral to
the sacral foramina and are rarely associated with neurological
deficits. Zone II fractures involve the sacral foramina and are
often associated with neurological deficits that may present as
unilateral lumbar or sacral radiculopathies [4]. Fractures in
zone III involve the sacral canal and often present with
significant bilateral neurological damage [4]. The Denis system
classifies transverse sacral fractures as zone III fractures as they
involve the sacral canal and can be associated with significant
neurological deficit.

Fractures involving the pelvis and sacrum were traditionally TRAUMA

classified according to stability. As orthopaedic procedures
improved, classification systems using causative force vectors
There are two principle mechanisms that lead to sacral
became more appropriate as they directed fixation [1]. The
fractures. Most commonly, fractures result from a stress
commonly used Young –Burgess system uses the following
transmitted through the pelvic ring to the sacrum. Such injuries
are can be explained by the force vectors used in the Young–
Guarantor and correspondent: S. Nicolaou, Department of Radiology,
Vancouver General Hospital, 899 W. 12th Ave., Vancouver, BC V5Z 1M9, Burgess system. Lateral compression injuries are commonly
Canada. Tel: þ1-604-875-4111x63659; Fax: þ 1-604-875-4723; E-mail: seen in motor vehicle accidents [4]. The commonest sacral
snicolao@vanhosp.bc.ca fractures, resulting from lateral compression forces, involve a
0009-9260/03/$30.00/0 q 2003 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.
 IMAGING OF SACRAL FRACTURES 915

Fig. 3 – A 32-year-old man involved in a motor vehicle accident. Inclined

Fig. 1 – Schematic representation of the sacral fracture classification
system proposed by Denis et al. (a) Normal without fracture. (b) Zone I
fractures are lateral to the neural elements and most commonly involve the
sacral ala. (c) Zone II fractures transect the sacral foramina. (d) Zone III
fractures involve the central canal of the spinal column.
small fracture of the sacral lip or an impacted vertical fracture
(zone I) ipsilateral to the force vector and are clinically stable
(Fig. 2) [1,4]. Lateral compression forces can also lead to more
serious and unstable sacral fractures, corresponding to at least
Denis zone II (Fig. 3) [5]. Vertical shear injuries generally
result from a fall from height onto the lower limbs [1,4]. They
involve disruption of both anterior and posterior pelvic rims
and possible cephalad displacement of the fracture fragment
(Fig. 4). The corresponding sacral fracture will be vertical and
coronal, reformatted CT of the sacrum demonstrates a vertical fracture
extending through the left sacral foramina into the neural canal (arrows).
This is a Denis zone II –III fracture. This patient has fixation screws in the
left iliac wing.
may be of any Denis zone classification [1,2,5]. Anteroposter-
ior compression injuries are less likely to result in sacral
fractures. In severe cases lateral sacral avulsions may be noted
due to stress on the sacroiliac ligaments [2]. Complex or mixed
injures are predominantly a combination of lateral and
anteroposterior compression forces and are often seen in
multi-trauma (Fig. 5) [2].
The less common mechanism of traumatic sacral fracture
is a direct stress to the sacrum, which can result from a
high fall landing on the buttocks (Fig. 6). Force vectors used
to define the Young–Burgess system cannot describe this
isolated sacral fracture. Such isolated fractures of the sacrum

Fig. 2 – A 39-year-old male patient with multiple trauma. (a) There are no appreciable abnormalities seen on plain film. There is no disturbance of the pelvic
rings to suggest pelvic or sacral disruption and the arcuate lines appear intact. (b) Axial CT of the pelvis demonstrates cortical disruption in the anterior right
sacral ala lateral to the sacral foramina. This is a stable sacral lip fracture (Denis zone I), which was missed on plain film. Such a fracture is often associated
with lateral compressive forces. CT of the pelvis at our institution is performed with 5 mm slices. Reformats in the coronal and sagittal planes are performed
with 2.5 mm slices.
916 CLINICAL RADIOLOGY

Fig. 4 – A 64-year-old woman involved in a fall from height, landing on the lower limbs. (a) Plain film demonstrates a vertical shear fracture consistent with a
vertical compression force. Fractures of the right superior and inferior pubic rami (white arrowhead). The arcuate lines are poorly seen on the right, a clue that a
vertical sacral fracture may be present (white arrow). There is slight cephalad displacement of the right hemipelvis, consistent with a vertical force vector. (b)
CT demonstrates a vertical fracture through the right sacrum involving the sacral foramina (white arrow), thus explaining the poor visualization of the arcuate
lines on the right sacrum in the plain film.

represent 5–10% of all sacral fractures, and are character-
ized by transverse, rather than vertical fractures [6]. As
mentioned previously Denis classifies such fractures as zone
III. These fractures are often associated with thoracolumbar
burst fractures [4].
Conventional radiography of the sacrum is often difficult to
interpret as overlying bowel gas, bladder, and the normal
angulation of the sacrum make the diagnosis of injury
problematic. An adequate anteroposterior radiograph of the
sacrum will enable visualization of the sacral arcuate lines,
which outline the sacral foramen. Disruption of the arcuate
lines is clear indication of a sacral fracture (Figs 4a and 7).

Fig. 5 – A 68-year-old man who was involved in a motor vehicle accident. (a) Anteroposterior radiograph of the pelvis. No disruption of the arcuate lines is
appreciable, however, fracture of the sacrum should be suspected as there is diastasis of the pubis. (b) Axial CT of the pelvis demonstrates two fractures through
the sacrum. There is an undisplaced zone I fracture through the left sacral ala (thin arrows) and a mildly displaced zone II fracture though the right sacral
foramina (thick arrow). This is an example of a combination of anteroposterior and lateral compressive forces, termed a mixed fracture pattern in the Young
and Burgess system. The anteroposterior force likely accounts for the pubic diastasis, while severe lateral compressive forces transfer across the pelvis to injure
not only the ipsilateral sacrum (thick arrow) but the contralateral sacrum as well (thin arrows).
 IMAGING OF SACRAL FRACTURES
Fig. 6 – A 41-year-old man who fell from a ladder and landed directly on
the sacrum. Reformated axial CT of the sacrum demonstrates a transverse
fracture of the sacrum at the S4 –S5 level. Transverse fractures of the
sacrum predominate in isolated sacral injuries, such as this one. Note the
acetabular screws from previous fixation. Although these fractures are
generally stable, it is the designation of our institution to provide CT
imaging for transverse sacral fractures.
Even when plain radiographs are adequate, 35% of sacral
fractures are undetected [7]. Sacral lip fractures are
especially difficult to identify, missed on plain radiographs
in up to 52% of cases [8]. Cross-sectional imaging such as
CT and MR, provide excellent visualization of the sacrum
Fig. 7 – A 25-year-old man involved in a motor vehicle accident.
Anteroposterior radiograph of the sacrum and pelvis demonstrates a
vertical shear fracture extending through the left sacral foramina (thick
arrows). There is disruption of the arcuates lines, indicating a fracture of the
sacrum on plain film. The sacrum has to be carefully inspected, as the
fracture is present without obvious dislocation. There are concurrent
fractures of the superior pubic rami (thin arrow) and inferior pubic rami.
917
Fig. 8 – An 81-year-old patient complaining of lower back pain. Whole-
body bone scinitgraphy with 99M TC methylene disphosphonate is cropped
and magnified to isolate the sacrum. Bilateral insufficiency fractures of the
sacrum demonstrating the classic “H” or “Honda sign” are appreciable
(arrow). This sign, typical of insufficiency fractures, represents increased
accumulation of activity within both sacral alae and transversely across the
sacrum.
and represent a superior method of identifying and confirm-
ing traumatic sacral fractures [3,6,9]. However, the use of
plain films should not be completely discounted as retro-
spective review of vertical shear injuries of the sacrum has
been found to improve sensitivity to 93% [8]. Resnik et al.
[10] report that they missed only 16% of sacral fractures on
plain films and that none of these missed fractures would
have changed management. The authors state that experience
may play a role in decreasing missed sacral fractures on plain
films [10].
INSUFFICIENCY FRACTURES
Insufficiency fractures of the sacrum result from a normal
stress acting on bone with deficient elastic resistance. Reduced
bone integrity can result from many factors, the most common
being postmenopausal or corticosteroid-induced osteoporosis
and radiation therapy. As a result of the altered internal
architecture of the sacrum, insufficiency fractures may arise
either insidiously or as the result of minor trauma. The
biomechanics of insufficiency fractures are not completely
understood. A history of trauma may be minimal or non-
existent. It has been suggested by some researchers that, based
on the common pattern of sacral insufficiency fractures, it is
possible that they occur secondary to weight bearing trans-
mitted through the spine [11]. Patients with insufficiency
fractures often present with symptoms such as lower back,
groin, or pelvic pain [3,4]. These symptoms are non-specific
and may mimic other clinical conditions, such as disc disease,
recurrence of a local tumour, or metastatic disease [3]. A high
918 CLINICAL RADIOLOGY

Fig. 9 – A 75-year-old woman complaining of lower back and groin pain. (a) Anteroposterior radiograph of the pelvis is sub-optimal for visualizing the
sacrum. Bone scintigraphy is required to visualize the insufficiency fracture. (b) Whole-body bone scintigraphy with 99M TC methylene disphosphonate
demonstrates asymmetrical increased uptake in both sacral ala. These findings are non-specific and could represent either insufficiency fractures or malignancy.
CT correlation is required. (c) Axial CT of the pelvis demonstrates a well-corticated sagittal fracture extending posteriorly through the right sacral ala (arrow).
The sclerosis surrounding the fracture indicates that the fracture is sub-acute. There is significant de-mineralization of the opposite sacral wing. These findings
are consistent with an insufficiency fracture of the sacrum.

index of suspicion is required in order to identify fractures of
this nature.
Due to de-mineralization of the bone, radiographs are often
inadequate for visualizing these lesions. This is especially
relevant in the acute setting, before the development of reactive
sclerosis makes the fracture easier to see. When additional
imaging methods are required, radionuclide bone scans and CT
are most often used. On scintigraphy, bilateral insufficiency
fractures of the sacral ala show increased uptake in an “H”
distribution (Honda sign). This sign is virtually pathognomonic
of insufficiency fracture, but is present in only 20% of cases
(Fig. 8) [3,9]. If the fracture is unilateral or incomplete, the
pattern on bone scan may be patchy, mimicking a primary
malignancy or metastatic disease, and therefore requires CT for
confirmation (Figs 9 and 10) [3]. Distinguishing these fractures
from metastatic disease is especially important in patients with
previous malignancy to avoid unnecessary biopsy or
radiotherapy.
MR is as good as CT at detecting insufficiency fractures and
may be used instead, depending on availability. The benefit of
MR is that it is highly sensitive to the presence of oedema,
which is consistent with fractures, but may be confused with
metastatic disease (Fig. 11).
PATHOLOGICAL FRACTURES
Pathological fracture is a term reserved for fractures that
occur in bone that is rendered abnormally fragile by neoplastic
or other disease conditions. In contrast, insufficiency fractures
 IMAGING OF SACRAL FRACTURES 919

Fig. 10 – A 69-year-old woman previously treated with radiation for cervical carcinoma presenting with a 2 month history of back pain. (a) Anteroposterior
radiograph of the pelvis shows that there are no appreciable fractures of the sacrum. CT was performed as a fracture was suspected. (b) Axial CT of the pelvis
demonstrates bilateral, well-corticated fractures present on either side of the sacral promontory (thick arrows). There is considerable sclerosis surrounding the
fractures indicating that they are sub-acute. These findings, combined with the history, are consistent with radiation-induced insufficiency fractures.

can be thought of as a subset of pathological fractures occurring
only in bones with structural alterations due to osteopenia,
osteoporosis or disorders of calcium metabolism [12].
Examples of potentially destructive lesions include metastases,
which are common to the sacrum, giant cell tumour, chordoma,
Ewing’s sarcoma, multiple myeloma and non-malignant
conditions such as cysts or osteomyelitis (Fig. 12). Metastatic
lesions to the sacrum are far more common than primary
malignancies, likely due to the role the sacrum plays in
haematopoiesis in the adult [3]. Metastatic lesions are most
often osteolytic, although sclerotic lesions can be present
especially when the primary tumour originates from prostate or
breast tissue [3].
CT is the imaging technique of choice to identify
pathological fractures. It is useful for demonstrating the
presence of osteolytic lesions—common to bone metastases,
as well as primary tumours. A fracture line on CT associated
with a previous history of malignancy supports the diagnosis of
pathological fracture, particularly in the presence of a soft-
tissue mass (Figs 13 and 14). MR can be used in cases where
CT is non-diagnostic and may reveal bone marrow oedema and
discrete fracture lines.
Diagnosing sacral fractures can be challenging for a
number of reasons. In the case of trauma, more
prominent fractures of the pelvis may be distracting,
and can hinder identification of sacral fractures. Further-
more, technical factors, such as fracture orientation and
overlying soft tissue and bowel gas, can obscure subtle

Fig. 11 – A 72-year-old woman with a previous history of breast cancer, who complained of lower back pain. (a) Axial T1-weighted MRI of the sacrum reveals
markedly decreased signal intensity—consistent with oedema—in both sacral ala (arrows). Two low-signal lines in the left sacral ala are present, consistent
with a fracture (thick arrows). MRI was indicated as CT was non-diagnostic and metastases or a pathological fracture was suspected. (b) Coronal view on T1-
weighted MRI demonstrates a well-corticated fracture through the left sacral ala (thick arrows). A second fracture through the tip of the right sacral ala is
appreciable (thin arrow). No soft-tissue masses were seen. These finding are consistent with bilateral insufficiency fractures of the sacral alae.
920 CLINICAL RADIOLOGY
Fig. 12 – A 62-year-old man with myeloma who complained of pelvic pain.
(a) AP radiograph of the pelvis. The sacrum is sub-optimally visualized and
the abnormality is not well appreciated. (b) Axial CT of the pelvis shows
bilateral cortical breaches through the anterior aspects of both sacral ala
(arrows). Note the moth-eaten appearance of sacrum, consistent with
myeloma. (c) Reformatted CT through the same area. The fractures through
both sacral ala are visualized (arrows). There are no soft-tissue masses
present. These findings, in combination with the history, are consistent with
a pathological fracture through abnormal bone secondary to myeloma.
Fig. 13 – A 60-year-old man with a history of sacral pain for 11 months and
previous rectal carcinoma treated by resection and radiation therapy 3 years
prior. (a) Anteroposterior radiograph of the pelvis demonstrates a sclerotic
lesion involving the distal sacrum (arrows). This finding is compatible with
either a primary or metastatic lesion. There are no appreciable fracture lines
visible on the plain film. The clips anterior to the sacrum related to previous
bowel resection. (b) Axial CT pelvis demonstrates a discrete fracture line
extending through the centre of the sacrum medial to the neural elements
(arrows). This fracture may have resulted from either the malignancy or
from previous radiation therapy. However, as the findings on CT included
marked abnormality and sclerosis through the whole distal sacrum, this
suggests that this fracture is most in keeping with radiation-induced
osteonecrosis.
radiographic findings. Recognizing the difficulty involved
in diagnosis, identification of sacral fractures can best be
achieved by ensuring that the most suitable imaging
technique is used.
 IMAGING OF SACRAL FRACTURES 921

Fig. 14 – An 86-year-old woman with chronic lymphocytic leukaemia (CLL) presenting with lower back pain. (a) Whole-body bone scintigram is cropped and
magnified to isolate the sacrum. Diffuse bilateral uptake within the sacrum is demonstrated (black arrow). The more inferior area of uptake represents the
bladder. Further imaging is required to differentiate between insufficiency and pathological fractures. (b) CT demonstrates bilateral involvement of the sacrum
with undisplaced, poorly corticated fractures of the left sacral ala (white arrow), and the right sacral ala (white arrowhead). These findings in combination with
history are consistent with pathological fractures.

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