Session II - Pediatrics/Spine

Suicidal Jumpers Fracture: Analysis of Treatment in 15 Patients

Axel Gänsslen, MD; Stefan Zech, MD; Markus Winny, MD; Tobias Hüfner, MD; Professor Tim Pohlemann, Unfallchirurgie, MHH, Hannover, Germany

Purpose: Unstable H-type fractures of the sacrum with bilateral transforaminal fracture lines are rare and difficult to manage. The purpose of this study was the evaluation of treatment and neurological course of this unusual injury.

Methods: Between 01.01.72 and 31.12.98 nearly 2500 patients with pelvic and acetabular fractures were treated at the authors' institution. Within this group 15 sustained a "suicidal jumpers fracture" as defined by Roy-Camille. Evaluation consisted of demographic data, mechanism of injury, type of pelvic fracture, Injury Severity Score (ISS), neurological evaluation, type of treatment and early complications.

Results: There were 7 male and 8 female patients, ranging in age from 17 to 65 years. In all cases mechanism of injury was a fall from a great height, including 10 suicide attempts. Two patients had isolated pelvic injury, five sustained a polytrauma. The mean ISS was 15.8 points (9-27). An initial neurological evaluation was possible in all but one patient, showing neurological deficits in all patients. In one patients evaluation was impossible due to polytrauma situation with severe head injury. The most common affected nerve roots were the L5 and S1 nerve roots and the lower sacral segments with involvement of bladder/rectal function in seven cases. Additional cephalad spinal fractures were present in 8 cases, three of these with additional spine-related neurological impairments. Primary radiological evaluation revealed H-type fractures of the sacrum in all cases, dominantly as bilateral transforaminal fractures with a transverse component of S1 or S2. All but one patient had a flexion type injury with a mean kyphosis of 60 degrees, one patient had an extension type injury of S1. Additional anterior pelvic ring injury was observed in four patients. According to the OTA classification all fractures were coded as 61-C 3.3. Treatment consisted of operative decompression of the central canal in two patients, closed reduction without additional measures in one and open reduction, posterior decompression and spinopelvic internal fixation in eight cases. In two patients no reduction was performed due to minimal displacement, and in two patients no reduction/decompression was performed due to polytrauma situation. One of the latter died as a result of the severe head injury. This was the only death in this group. Sacral kyphosis could be reduced after closed or open reduction to a mean of 30 degrees. Wound infections occured in three patients, all healed after surgical interventions. An increase of neurological function was observed in 5/11 patients after reduction, three of these (30%) after open reduction and decompression of the central canal. No iatrogenic nerve injury was observed. All fractures healed radiographically.

Discussion and Conclusion: Bilateral unstable factures of the sacrum with anterior/posterior displacement of the body of S1/S2 ("suicidal jumpers fracture") are rare injuries. In the literature management consists of closed reduction, operative decompression or internal fixation. The role of decompression and fracture reduction was not well defined. The present study recommends early reduction and operative decompression of the central canal for reduction of kyphosis and improvement of neurological deficits.