CASE REPORT
U-shaped Sacral Fracture With Iliac Crest Apophyseal
Avulsion in a Young Child
Mohamed Kenawey, MB BCh, MSc, MRCS, PhD and Ahmad Addosooki, MB BCh, MSc, PhD
Background: U-shaped sacral fractures or Jumpers fractures are
rare injuries in adults and are even rarer in the pediatric population.
These fractures share a common pathoanatomy where the pelvis as
a unit together with the bilateral alar parts and the lower part of the
sacrum, loses its skeletal and soft tissue connections to the re-
maining axial skeleton and hence the term spinopelvic dissociation.
This report describes an unusual pattern of spinopelvic dissociation
in a young child where the transverse process of the fth lumbar
vertebra was avulsed on one side (spinal side avulsion), whereas on
the other side, complete iliac crest apophyseal avulsion took place
(pelvic sided avulsion). To our knowledge, this combination of
injuries was not reported before. The available literature describing
pediatric U-shaped sacral fractures were also reviewed to help ex-
plain the pathoanatomic basis of this association.
Methods: An 8-year-old boy sustained a U-shaped sacral frac-
ture with avulsion of the left iliac crest apophysis. A search in
the English literature was performed for all reports of U-shaped
sacral fractures in pediatric patients (r18 y of age), as well as the
relevant literature, which describes the pathoanatomy, possible
radiologic ndings, and current classication systems and
treatment options.
Results: Fixation using a 7.3 mm percutaneous iliosacral screw
was performed. At the latest follow-up, the child had no pain,
was fully bearing weight on lower extremities, and was neuro-
logically intact. The literature review yielded 6 other pediatric
patients with U-shaped sacral fractures in 4 articles.
Conclusions: In young children with immature pelvis, the iliac
apophysis may be avulsed instead of the transverse process of
the fth lumbar vertebra by forces transmitted through the
iliolumbar ligament. The apophysis will therefore keep its at-
tachment to the abdominal and trunk muscles, whereas the bony
iliac wing and the pelvis would be dissociated from the axial
skeleton. Otherwise, the pathoanatomy of these injuries is the
same as described in adults.
Level of Evidence: Level IV.
Key Words: U-shaped sacral fractures, jumpers fracture, spino-
pelvic dissociation, spinopelvic instability, pediatric sacral fractures
(J Pediatr Orthop 2014;34:e6e11)
From the Orthopaedic Department, Faculty of Medicine, Sohag Uni-
versity, Sohag, Egypt.
The authors declare no conicts of interest.
Reprints: Mohamed Kenawey, MB BCh, MSc, MRCS, PhD, Ortho-
paedic Department, Faculty of Medicine, Sohag University, Sohag
82524, Egypt. E-mail: mohamed.kenawey@gmail.com.
Copyright r 2013 by Lippincott Williams & Wilkins
e6 | www.pedorthopaedics.com
P ediatric pelvic injuries are not common injuries, ac-
counting for almost 1% to 2% of all pediatric skeletal
trauma.1,2 The sacrum together with the 2 iliac bones
joined at the sacroiliac joints and its supporting ligaments
is the cornerstone of the posterior pelvic ring stability.
Sacral fractures are estimated to accompany 45% of all
adult pelvic fractures; however, <5% of all sacral frac-
tures are isolated injuries.24 In contrast, pediatric sacral
fractures are quite rare injuries representing almost 0.16%
of the pediatric trauma, 8 children of the 4876 cases over
a 7-year period in a childrens hospital.5
Sacral fractures can be simply classied into either
transverse or vertical fractures.6 Transverse sacral frac-
tures account for 5% to 16% of all sacral fractures and
only 28% of them are associated with pelvic ring in-
juries.79 A transverse sacral fracture can be a part of
more complex sacral injury, which is called traumatic
spinopelvic instability or dissociation or the Jumpers
fracture.10,11 U-shaped sacral fractures or traumatic spi-
nopelvic dissociation are even rarer injuries and most of
reports in the literature are case reports or small case
series.11 According to the study of Nork et al,12 2.9% of
adult patients with pelvic ring disruptions have U-shaped
sacral fracture.
U-shaped sacral fractures or traumatic spinopelvic
dissociation were not reported in the literature in a young
child with an immature pelvis. Children with immature
pelvis and open triradiate cartilage have characteristic
patterns of pelvic ring injuries.2,13 All reports of U-shaped
or transverse sacral fractures in young patients were in
adolescents, 13 to 18 years of age.3,9,14,15
In the present report, the authors describe an
extremely rare injury in an 8-year-old boy with U-shaped
sacral fracture or Jumpers fracture (spinopelvic dis-
sociation). A novel association with iliac crest apophyseal
avulsion was found in this child. A review of the literature
was conducted to explain the possible pathoanatomic
basis of this association.
CASE PRESENTATION
An 8-year-old boy presented to our emergency department
with a history of a falling wall onto his back. The child was fully
conscious with stable general condition. General examination
was unremarkable. Local abdominal and pelvic examination
revealed the presence of large parietal hematoma on the left side
of the trunk extending from the level of the iliac crest upward.
Signicant tenderness was evident over the lower back and sac-
J Pediatr Orthop  Volume 34, Number 5, July/August 2014
J Pediatr Orthop  Volume 34, Number 5, July/August 2014
rum, as well as the area of posterior-superior iliac spines bi-
laterally and the left iliac crest. Movements of the lumbar spine
were painful and restricted, and the patient could not sit or bear
weight. Distal neurovascular status was intact, and abdominal
visceral injuries were excluded.
Plain radiographs of the pelvis (anteroposterior, outlet,
and inlet views) and anteroposterior and lateral radiographs for
the lumbosacral area were ordered. Lateral lumbosacral radio-
graph showed a transverse sacral fracture at the level of S1-S2
junction, Roy-Camille type 2 injury, and anterior wedging of L3
vertebral body (Fig. 1). The anteroposterior pelvic lm showed
paradoxical inlet view of the upper sacrum and the avulsed and
widely displaced right transverse process of the fth lumbar
vertebra, whereas the left transverse process was intact. On the
outlet view, there was a continuous ick of the bone, which
appeared to be avulsed all the way from the iliac crest starting
from the posterior-superior iliac spine to nearly the junction of
the middle and anterior thirds of the iliac crest. The rst and
second sacral foramina on the right side were irregular in shape
with a fracture line crossing their contour on the anteroposterior
and outlet views. In the inlet view, there was a fracture line
extending across the right sacral ala in addition to irregularity of
the shape of the left sacral ala and sacroiliac joint (Fig. 2).
Computed tomography (CT) axial cuts and coronal re-
constructions claried the presence of bilateral vertical trans-
foraminal sacral fractures with overlapped S1 and S2 bodies and
compromised anteroposterior diameter of the central sacral ca-
nal. An avulsion fracture of the left iliac crest (Salter-Harris type
II avulsion of the iliac apophysis) could be seen on the axial
views together with the avulsed right transverse process of the
fth lumbar vertebra. In the sagittal reconstruction, transverse
fracture dislocation at the level of S1-S2 with the exion de-
FIGURE 1. Plain radiographs for the lower dorsal, lumbar, and
sacral spine. A, Anteroposterior view showing avulsed and
widely displaced right transverse process of the fifth lumbar
vertebra (white arrow). B, Lateral view showing a transverse
fracture at the level between S1-S2 with flexion and slight
posterior translation and rotation, Roy-Camille type 2 (black
arrow). In addition, there was a mild anterior wedging of L3
vertebral body.
r 2013 Lippincott Williams & Wilkins
Sacral Fracture With Iliac Crest Apophyseal Avulsion
formity and posterior translation of S1 body and comminuted
upper end plate of S2 body were clearly identied (Fig. 3).
The patient was scheduled to the next operative list and
xation using single percutaneous 7.3 mm cannulated iliosacral
screw was performed (Fig. 4). The procedure was executed in the
prone position with some hyperextension of both hips and pelvis to
try to decrease the exion deformity between S1-S2 segments. Ex-
cellent pain relief was reported by the patient as early as the second
postoperative day and therefore he was allowed to sit on the bed
and the chair, although weight-bearing was not allowed for the next
8 weeks. He was discharged 2 days postoperatively and follow-up x-
rays were requested at 8 and 16 weeks. Healing was uneventful, and
at 8 weeks the patient was able to fully bear weight on both lower
limbs. At 16 weeks, the patient had full range of motion of lumbar
spine and both hip joints. His walking distance was unlimited and
he reported no diculty with walking or running.
With regard to the sacral kyphotic deformity and the
pelvic incidence, the pelvic incidence was 62 degrees with
a pelvic tilt of 22 degrees preoperatively, which was well main-
tained without change until the fourth month, with pelvic
incidence of 58 degrees and pelvic tilt of 25 degrees post-
operatively. Moreover, at the latest follow-up, wedging of the
L3 vertebral body and local kyphosis was not found to be
changed from the preoperative status, and the lumbar lordosis
was 24 degrees (Fig. 5).
DISCUSSION
Isolated sacral fractures are rare injuries in pediatric
trauma and transverse sacral fractures and the U-shaped
variety are even quite rarer injuries.5 To the best of our
knowledge, there are only 6 pediatric patients reported in
the literature with the diagnosis of U-shaped sacral frac-
ture.3,9,14,15 All of these patients were adolescents (13 to
18 y of age), and the pathoanatomy of their injuries was
not dierent from adults.
Sapkas et al15 reported 3 adolescent patients (14 to
15 y of age) with transverse sacral fractures due to a fall
from height in 2 and a work-related injury in the third
patient (squashed by an agricultural tractor). All of them
had neurologic abnormalities in the form of bowel and
bladder dysfunction with saddle anesthesia and incomplete
L5-S1 or L4-S1 injury. Laminectomy was performed in all
cases to decompress the neural elements with lumbopelvic
fusion using only bone grafting in 1 patient, Hartshill frame
in the second patient, and transpedicular screws in the
third. Neurology was completely recovered in one of them
and incompletely recovered in the other 2 cases.
Three other patients were separately described by
Bellabarba et al,3 Kim et al,9 and Avadhani et al.14 In the
series of Bellabarba et al,3 there was 1 adolescent patient
(15 y) of the 19 adult patients. The mechanism of injury
was a fall from height, and there was a cauda equina
lesion. Decompression and lumbopelvic xation was the
denitive treatment using transpedicular screws and rod
system (L5-S1 to 2 iliac wing screws). Another adolescent
patient was reported in the series of Kim et al9 of the
7 adults. This patient was 18 years of age and sustained a
motor vehicle accident (rear passenger ejected from a car).
There was bowel and bladder dysfunction and treatment
consisted of L5-S3 decompression without stabilization.
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Kenawey and Addosooki J Pediatr Orthop  Volume 34, Number 5, July/August 2014

FIGURE 2. Plain radiographic trauma series of the pelvis with their corresponding 3-dimensional computed tomography re-
constructions. A and B, Anteroposterior view of the pelvis and its 3D reconstruction showing a paradoxical inlet view for the upper
sacrum due to the flexion deformity of this cephalad sacral segment. C and D, Outlet pelvic views showing a fracture line
extending vertically on the right side through the right foramina of S1 and S2 (small black arrows) with a double-lined shadow
overlapping the contour of the S2 foramina due to the flexion deformity of S1 (white arrows). There is flick of bone avulsed from
the iliac crest on the left side starting posteriorly from the level of the posterior-superior iliac spine (thick black arrows). E and F,
Inlet views showing displaced transverse process of the fifth lumbar vertebra on the right side with fractured right sacral ala and
irregularity in the area of the left sacroiliac joint.

Neurology improved to normal at the nal follow-up.
The third patient was a 13-year-old girl described by
Avadhani et al.14 She had transverse sacral fracture, Roy-
Camille type 3 following a fall from height with asso-
ciated cauda equina syndrome. She underwent surgical
decompression with sacral laminectomy and xation
using sacrosacral plate xation.
The mechanics of this rare form of upper sacral
fracture dislocation or spinopelvic dissociation was de-
scribed in detail by Roy-Camille et al10 who called it the
suicidal jumpers fracture. In most cases, it is mainly an
axial loading of the spine with exion or extension moment.
This axial loading causes dissociation of the central part of
the sacrum from the lateral alar portions and the pelvis.

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J Pediatr Orthop  Volume 34, Number 5, July/August 2014 Sacral Fracture With Iliac Crest Apophyseal Avulsion

FIGURE 3. Computed tomography scan of the pelvis. A and B, Axial cuts at the level of the iliac crest showing avulsion of the right
transverse process of the fifth lumbar vertebra from its base and avulsion fracture of the left iliac crest (white arrows). C and D,
Axial cuts showing bilateral transforaminal sacral fractures together with overlapped bodies of S1 and S2, which is more evident in
(D) with narrowed anteroposterior diameter of the central sacral canal. E, A coronal reconstruction showing bilateral vertical sacral
fracture. F and G, Sagittal computed tomography reconstructions. The transverse component of the injury with fracture dis-
location at the level of S1-S2 junction is clearly evident. There is also flexion deformity together with slight rotation and translation
of S1 body and comminution of the upper end plate of S2 vertebra.

The lumbar spine and the upper sacral fragment are then
free to rotate in exion relative to the pelvis, which is in-
creased by the unopposed forces of the iliopsoas muscles
and the eect of gravity.11 Another proposed mechanism is
a high forward shearing force through car coalitions at high
speed or by direct hit on the lower back with heavy object,
while the hips are exed and knees extended.16 The strong
soft tissue attachments between the pelvis and the axial
spine would explain the associated avulsions of the L5
transverse process by the iliolumbar ligaments, whereas
avulsions of the transverse processes of the higher lumbar
vertebrae can be caused by the strong tendinous insertions
of iliopsoas and quadratus lumborum.16,17
Our child had a U-shaped sacral fracture with a
novel association of iliac crest apophyseal avulsion on
one side as opposed to the other side with the avulsed L5
transverse process. The outlet views as well as the axial
CT cuts showed an avulsion injury from the left iliac
crest, whereas the ipsilateral L5 transverse process was
intact; this injury is consistent with a type II Salter-Harris
avulsion of the left iliac apophysis or the Risser nu-
cleus.18,19 The combination of posterior ring instability
and iliac apophyseal avulsion is a new combination,
which changes our understanding for the pathoanatomy
of these lesions. In this scenario, the bony hemipelvis on
that side would lose its skeletal attachment with the
posterior pelvic ring through a break in the sacrum or
through sacroiliac fracture dislocation. As a second stage,
the attachment with the abdominal and trunk muscles
and the iliolumbar ligament connecting the pelvis to the
axial spine would be lost through the separation of
the iliac apophysis from the bony iliac wing, mostly by the

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Kenawey and Addosooki
FIGURE 4. Postoperative plain radiographs of the pelvis, anteroposterior (A), outlet (B), and inlet views (C), showing the position
of the iliosacral screw.
powerful traction of quadratus lumborum and therefore
the ipsilateral L5 transverse process would be intact
(pelvic side avulsion as opposed to the usual adult spinal
side avulsion through L5 transverse process).16,19,20
To the best of our knowledge, the study of Oransky
et al21 was the only study which described similar injuries
FIGURE 5. Preoperative (A) and postoperative (B) measure-
ments of the pelvic incidence and tilt.
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J Pediatr Orthop  Volume 34, Number 5, July/August 2014
of the Risser nuclei in 4 young children (5 to 9 y old) of
the 5 children with vertically unstable pelvic injuries and
displaced sacroiliac joint dislocations. During ORIF of
the posterior pelvic ring, they found that the whole bony
hemipelvis was avulsed and dislocated from its apophysis,
which was kept in place by its attached abdominal and
trunk muscles. These iliac apophyseal avulsions were 1
Salter-Harris type I injury, 1 type II, and 2 patients with
Salter-Harris type IV injuries.
Apophyseal avulsions around the pelvis are well
known injuries.22 The commonest of these apophyseal
avulsions are the ischial tuberosity, anterior inferior iliac
spine, and anterior superior iliac spine. Isolated iliac wing
apophyseal avulsions are quite rare injuries, and they
were reported previously in adolescent athletes.22,23 Rossi
and Dragoni22 reported only 3 iliac wing avulsions among
203 dierent apophyseal pelvic avulsions in competitive
adolescent athletes. The main mechanism of injury in-
volved powerful contraction of abdominal muscles during
violent twisting movements of the torso. These avulsion
injuries were almost exclusively observed in adolescents as
they might be related to the time of appearance of ossi-
cation of the apophyses and their fusion to the corre-
sponding pelvic tuberosities. In younger children with
nonossied iliac apophysis as those reported by Oransky
et al,21 as well as our current patient, it would be dicult
to diagnose any avulsion injury because we would not
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J Pediatr Orthop  Volume 34, Number 5, July/August 2014
usually see any clue for such lesion in our routine radio-
graphs. In fact, Oransky et al21 discovered those iliac
apophyseal avulsions by chance during open reduction of
the posterior pelvic ring. We were also lucky enough to
get this avulsed ick of bone from the iliac crest in the
outlet pelvic view, which was conrmed on the CT scans
and was consistent with the clinical presentation of the
patient. This may also explain why these injuries are al-
most always diagnosed in the adolescent age group.
Furthermore, it is always surprising how it is easy and
reproducible to surgically dislocate the iliac apophysis
from the bony iliac wing during dierent exposures of
pediatric hip, in particular for the treatment of devel-
opmental dysplasia in young children.24
Nork et al12 used percutaneous unilateral or bilateral
7.0 mm cannulated iliosacral screw xation for U-shaped
sacral fractures in adults. We have used the same techni-
que with a single unilateral 7.3 mm screw xation through
the small S1 body. We appreciate that there is a risk of
increased sacral kyphosis through the rotation of the sa-
cral body around single-screw xation; however, with the
compression provided by the partially threaded screw,
interlocking of the fracture fragments should increase
the rotational stability. The main advantage of this tech-
nique is the percutaneous insertion, which makes it
an appealing minimally invasive xation method with
decreased incidence of wound complications.
CONCLUSIONS
It is imperative to examine carefully every child with
an evidence of posterior pelvic ring instability or sacral
fracture for any tenderness or hematoma directly related
to the iliac crest. Careful review of the radiographs should
include all pelvic views and CT examination. Even if there
is no evidence of iliac apophyseal avulsion on the initial
radiographs (as in Salter-Harris type I avulsions), the
presence of intact transverse process of the fth lumbar
vertebra with clear signs of posterior ring instability
should raise the suspicion of the presence of such injury.
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