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Spinal Fractures Classification System an AOSpine Knowledge Forum initiative Cervical Spine Fractures Thoracolumbar Spine Fractures Sacral Spine Fractures

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Page 1: Spinal Fractures Classification System - spinetr.com · Spinal Fractures Classification System an AOSpine Knowledge Forum initiative. Cervical Spine Fractures Thoracolumbar Spine

Spinal Fractures Classification Systeman AOSpine Knowledge Forum initiative

Cervical Spine Fractures

Thoracolumbar Spine Fractures

Sacral Spine Fractures

Page 2: Spinal Fractures Classification System - spinetr.com · Spinal Fractures Classification System an AOSpine Knowledge Forum initiative. Cervical Spine Fractures Thoracolumbar Spine

AOSpine–the leading global academic community for innovative education and research in spine care, inspiring lifelong learning and improving patients’ lives.

Page 3: Spinal Fractures Classification System - spinetr.com · Spinal Fractures Classification System an AOSpine Knowledge Forum initiative. Cervical Spine Fractures Thoracolumbar Spine

Spinal Fractures Classification System 3

CONTENT Cervical Spine Fractures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 04

Thoracolumbar Spine Fractures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37

Sacral Spine Fractures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55

Spinal Fractures Classification Systeman AOSpine Knowledge Forum initiative

Project members(in alphabetic order)

Aarabi B, Bellabarba C, Chapman J, Dvorak M, Fehlings M, Kandziora F, Kepler C,Oner C, Radcliff K, Rajasekaran S, Reinhold M, Schnake K, Vialle L and Vaccaro A.

Endorsed by AOSpine International Board as the official AOSpine Classification.

Page 4: Spinal Fractures Classification System - spinetr.com · Spinal Fractures Classification System an AOSpine Knowledge Forum initiative. Cervical Spine Fractures Thoracolumbar Spine

Cervical Spine FracturesClassification System

AOSpine Knowledge Forum

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Cervical Spine Fractures Classification System 5

Compression injuriesType

AO

A1

A2

A3

A4

Description

No bony injury or minor injury such as an isolated lamina fracture or spinous process fracture

Compression fracture involving a single endplate without involvementof the posterior wall of the vertebral body

Coronal split or pincer fracture involving both endplates without involvementof the posterior wall of the vertebral body

Burst fracture involving a single endplate with involvement of the posterior vertebral wall

Burst fracture or sagittal split involving both endplates

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Cervical Spine Fractures Classification System6

Distraction injuriesType

B1

B2

B3

DescriptionSubtype

Physical separation through fractured bony structures onlyPosterior Tension BandInjury (bony)

Complete disruption of the posterior capsuloligamentousor bony capsuloligamentous structures together with a vertebral body, disk, and/or facet injury

Posterior Tension Band Injury (bony Capsuloligamentous, ligamentous)

Physical disruption or separation of the anterior structures(bone/disk) with tethering of the posterior elementsAnterior Tension Band Injury

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Cervical Spine Fractures Classification System 7

Translation injuriesType

C

Description

Translational injury in any axis-displacement or translationof one vertebral bodyrelative to another in any direction

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Cervical Spine Fractures Classification System8

Facet injuriesType

F1

F3

F2

F4

BL

Description

Nondisplaced Facet Fracture with fragment <1cm in height, <40% of lateral mass

Floating lateral mass

Facet fracture with fragment >1cm, > than 40% lateral mass, or displaced

Pathologic subluxation or perched/dislocated facet

Bilateral injury

Page 9: Spinal Fractures Classification System - spinetr.com · Spinal Fractures Classification System an AOSpine Knowledge Forum initiative. Cervical Spine Fractures Thoracolumbar Spine

Cervical Spine Fractures Classification System 9

NeurologyType

NO

N3

N1

N4

N2

NX

+

Description

Neurologically Intact

Incomplete spinal cord injury

Transient neurologic deficit

Complete spinal cord injury

Radiculopathy

Neurological status unknown

Ongoing cord compression in setting of incomplete neurologic deficit or nerve injury

Page 10: Spinal Fractures Classification System - spinetr.com · Spinal Fractures Classification System an AOSpine Knowledge Forum initiative. Cervical Spine Fractures Thoracolumbar Spine

Cervical Spine Fractures Classification System10

ModifiersType

M1

M4

M2

M3

Description

Posterior Capsuloligamentous Complex injury without complete disruption

Vertebral artery abnormality

Critical disk herniation

Stiffening/metabolic bone disease (ie.: DISH, AS, OPLL, OLF)

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Cervical Spine Fractures Classification System 11

Injuries are first classified by their level and primary injury type, either C, B, or A. If there are multiple levels, the most severe level is classified first. The secondary injuries are parenthesized.

For example, a C6-C7 translational injury (C) with a C7 compression fracture (A1) would be classified as:

C6-C7:C (C7:A1)

And a C5-C6 flexion distraction injury (B2) with a C6 compression fracture (A1) would be classified as:

C5-C6:B2 (C6:A1)

Classification

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Cervical Spine Fractures Classification System12

Included in parenthesis are the remaining subgroups in the order of: facet injuries, neurological status, and any modifiers.

For bilateral facet injuries, the “BL” modifier is added after the facet injury if the injuries are the same.

For example, a C6-C7 flexion distraction injury (B2) with bilateral facet dislocation (F4) would be classified as:

C6-C7:B2 (F4 BL)

When there are different facet injuries to the same level, the right side is listed first, then the left.

For example, a C6-C7 flexion distraction injury (B2) with right sided facet dislocation (F4) and a left sided displaced facet fracture (F2) would be classified as:

C6-C7:B2 (F4, F2)

If there are multiple injuries to the same facet (For example: small fracture (F1) and dislocation (F4),only the highest level facet injury is classified (F4).

If only facet injuries are identified (No A, B, or C injury), they are listed first after the level of injury.

Classification–Facet Injuries

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Cervical Spine Fractures Classification System 13

A0. No bony injury or minor injury such as an isolated laminafracture or spinous process fracture

Type A: Compression injuries

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Cervical Spine Fractures Classification System14

A1. Compression fracture involving a single endplate without involvement of the posterior wall of the vertebral body

Type A: Compression injuries

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Cervical Spine Fractures Classification System 15

A1. Compression fracture involving a single endplate without involvement of the posterior wall of the vertebral body

Type A: Compression injuries

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Cervical Spine Fractures Classification System16

A2. Coronal split or pincer fracture involving both endplates without involvement of the posterior wall of the vertebral body

Type A: Compression injuries

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Cervical Spine Fractures Classification System 17

A3. Burst fracture involving a single endplate with involvementof the posterior vertebral wall

Type A: Compression injuries

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Cervical Spine Fractures Classification System18

A3. Burst fracture involving a single endplate with involvementof the posterior vertebral wall

Type A: Compression injuries

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Cervical Spine Fractures Classification System 19

A4. Burst fracture or sagittal splitinvolving both endplates

Type A: Compression injuries

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Cervical Spine Fractures Classification System20

A4. Burst fracture or sagittal splitinvolving both endplates

Type A: Compression injuries

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Cervical Spine Fractures Classification System 21

A4. Burst fracture or sagittal splitinvolving both endplates

Type A: Compression injuries

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Cervical Spine Fractures Classification System22

B1. Posterior tension band injury (bony)

Type B: Distraction injuries

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Cervical Spine Fractures Classification System 23

B2. Posterior tension band injury(bony capsuloligamentous, ligamentous)

Type B: Distraction injuries

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Cervical Spine Fractures Classification System24

B3. Anterior tension band injury

Type B: Distraction injuries

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Cervical Spine Fractures Classification System 25

C. Translational injury

Type C: Translation injuries

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Cervical Spine Fractures Classification System26

F1. Nondisplaced facet fracture(Fragment <1cm, < 40% lateral mass)

Facet injuries

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Cervical Spine Fractures Classification System 27

F2. Facet fracture with fragment >1cm,> 40% lateral mass or displaced

Facet injuries

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Cervical Spine Fractures Classification System28

F3. Floating lateral mass

Facet injuries

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Cervical Spine Fractures Classification System 29

F4. Pathologic subluxation or perched/dislocated facet

Facet injuries

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Cervical Spine Fractures Classification System30

F4. Pathologic subluxation or perched/dislocated facet

Facet injuries

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Cervical Spine Fractures Classification System 31

F4. Pathologic subluxation or perched/dislocated facet

Facet injuries

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Cervical Spine Fractures Classification System32

BL. Bilateral injury

Facet injuries

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Cervical Spine Fractures Classification System 33

C7-T1: C(T1:A1; F4 BL; N4)

(assume bilateral)

Case Example 1.25 year old male involved in high speed MVA, complete SCI

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Cervical Spine Fractures Classification System34

C7-T1: C(T1:A1; F4 BL; N4)

Translational injury (C), with compression fracture at T1 (A1), bilateral facet dislocations (F4 BL), complete SCI (N4)

(assume bilateral)

Case Example 1.25 year old male involved in high speed MVA, complete SCI

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Cervical Spine Fractures Classification System 35

C5: F2, C6: F2(N2; M1)

Case Example 2.42 year old male involved in high speed MVA, radiculopathy

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Cervical Spine Fractures Classification System36

C5: F2, C6: F2(N2; M1)

C5 and C6 displaced facet fractures (F2), radiculopathy (N2), posterior capsuloligamentous complex injury without complete disruption (M1)

Case Example 2.42 year old male involved in high speed MVA, radiculopathy

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Thoracolumbar Spine FracturesClassification System

AOSpine Knowledge Forum

Page 38: Spinal Fractures Classification System - spinetr.com · Spinal Fractures Classification System an AOSpine Knowledge Forum initiative. Cervical Spine Fractures Thoracolumbar Spine

Thoracolumbar Spine Fractures Classification System38

Thoracolumbar Fractures–OverviewThis classification and injury severity system is basedon the evaluation of three basic parameters:

1. Morphologic classification of the fracture

2. Neurologic injury

3. Clinical modifiers

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Thoracolumbar Spine Fractures Classification System 39

1. Morphologic classification

A. B. C.

This is based on the Magerl classification modified by the AOSpine Classification Group.For this evaluation radiograms and CT scans with multiplanar reconstructions are essential.In some cases additional MR images might be necessary. Three basic types are identifiedon the basis of the mode of failure of the spinal column:

Type A: Compression injuries. Failure of anterior structures under compression.

Type B: Failure of the posterior or anterior tension band.

Type C: Failure of all elements leading to dislocation or displacement.

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Thoracolumbar Spine Fractures Classification System40

Type ADescribe injury to the vertebral body without tension band (PLC) involvement.There are five subtypes and no further sub-classification.These subtypes are also used as description of vertebral body fracture in B and C Types.

Type

A0

A2

A1

A3

A4

Description

Fractures, which do not compromise the structural integrity of the spinal columnsuch as transverse process or spinous process fractures.

Fracture of both endplates without involvement of the posterior wallof the vertebral body.

Fracture of a single endplate without involvement of the posterior wallof the vertebral body.

Fracture with any involvement of the posterior wall; only a single endplatefractured. Vertical fracture of the lamina is usually present and does not constitutea tension band failure.

Fracture with any involvement of the posterior wall and both endplates. Vertical fracture of the lamina is usually present and does not constitute a tension band failure.

Minor, nonstructural fractures

Split

Wedge-compression

Incomplete burst

Complete burst

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Thoracolumbar Spine Fractures Classification System 41

Type BDescribe the failure of posterior or anterior constraints (in case of TL this is the tension band orPLC / Posterior Ligamentary Complex or the anterior longitudinal ligament).Is to be combined with subtypes A when appropriate. There are three subtypes:

Type

B1

B3

B2

Description

Monosegmental pure osseous failure of the posterior tension band.The classical Chance fracture.

Injury through the disk or vertebral body leading to a hyperextended position of the spinal column. Commonly seen in ankylotic disorders. Anterior structures, especially the ALL are ruptured but there is a posterior hinge preventing further displacement.

Bony and/or ligamentary failure of the posterior tension band together witha Type A fracture. Type A fracture should be classified separately.

Transosseous tension band disruption / Chance fracture

Hyperextension

Posterior tensionband disruption

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Thoracolumbar Spine Fractures Classification System42

Type CDescribe displacement or dislocation.There are no subtypes as because of the dissociation between cranial andcaudal segments various configurations are possible in different images.Is combined with subtypes of A if necessary.

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Thoracolumbar Spine Fractures Classification System 43

A0. Minor, nonstructural fracturesFractures, which do not compromise the structural integrity of the spinal column such as transverse process or spinous process fractures.

Type A

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Thoracolumbar Spine Fractures Classification System44

A1. Wedge-compressionFracture of a single endplate without involvementof the posterior wall of the vertebral body.

Type A

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Thoracolumbar Spine Fractures Classification System 45

A2. SplitFracture of both endplates without involvementof the posterior wall of the vertebral body.

Type A

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Thoracolumbar Spine Fractures Classification System46

A3. Incomplete burstFracture with any involvement of the posterior wall; only a single endplate fractured. Vertical fracture of the lamina is usually present and does not constitute a tension band failure.

Type A

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Thoracolumbar Spine Fractures Classification System 47

A4. Complete burstFracture with any involvement of the posterior wall and both endplates. Vertical fracture of the lamina is usually present and does not constitute a tension band failure.

Type A

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Thoracolumbar Spine Fractures Classification System48

B1. Transosseous tension band disruption / Chance fractureMonosegmental pure osseous failure of the posterior tension band.The classical Chance fracture.

Type B

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Thoracolumbar Spine Fractures Classification System 49

B2. Posterior tension band disruptionBony and/or ligamentary failure of the posterior tension band together with a Type A fracture. Type A fracture should be classified separately.

Example: This should be classified as: T12-L1 Type B2 with T12 A4 according to the combination rules.

Type B

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Thoracolumbar Spine Fractures Classification System50

B3. HyperextensionInjury through the disk or vertebral body leading to a hyperextendedposition of the spinal column. Commonly seen in ankylotic disorders.Anterior structures, especially the ALL are ruptured but there is aposterior hinge preventing further displacement.

Type B

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Thoracolumbar Spine Fractures Classification System 51

C. Displacement or dislocationThere are no subtypes as because of the dissociation between cranial and caudal segments various configurations are possible in different images. Is combined with subtypes of A if necessary.

Type C

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Thoracolumbar Spine Fractures Classification System52

Algorithm for morphologic classificationSTART Yes

Yes

NoNo

No

No

No No injury

No

No

Yes

Yes

Yes

Yes

Yes

Translation

Insignificant injury

Complete burst

Hyperextension

Split/Pincer

Pure transosseous disruption

Wedge/Impaction

Incomplete burst

Osseoligamentous disruption

C

A0

A4

B3

A2

B1

A1

A3

B2

Displacement/Dislocation

Vertebral process fracture

Vertebral body fracture

Tension band injury

Both endplates involved

Mono-segmentalosseous disruption

Posterior wall involvement

Posterior

Anterior

Yes

Yes

Yes

Both endplates involved

Osseoligamentous disruption

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Thoracolumbar Spine Fractures Classification System 53

2. Neurologic injuryNeurologic status at the moment of admission should be scored according to the following scheme:

Type

N0

N2

N1

N3

N4

NX

Description

Neurologically intact

Radicular symptoms

Transient neurologic deficit, which is no longer present

Incomplete spinal cord injury or any degree of cauda equina injury

Complete spinal cord injury

Neurologic status is unknown due to sedation or head injury

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Thoracolumbar Spine Fractures Classification System54

3. ModifiersThere are two modifiers, which can be used in addition to ad 1 and 2:

Type

M1

M2

Description

This modifier is used to designate fractures with an indeterminate injury to the tension band based on spinal imaging with or without MRI. This modifier is important for designating those injuries with stable injuries from a bony standpoint for which ligamentous insufficiency may help determine whether operative stabilization is a consideration.

Is used to designate a patient-specific comorbidity, which might argue either for or against surgery for patients with relative surgical indications. Examples of an M2 modifier include ankylosing spondylitis or burns affecting the skin overlying the injured spine.

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Sacral Spine FracturesClassification System

AOSpine Knowledge Forum

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Sacral Spine Fractures Classification System56

Sacral Fractures–OverviewHierarchical system progressing from least to most unstable

Type A. Lower Sacro-coccygeal Injuries No impact on posterior pelvic or spino-pelvic instability

Type B. Posterior Pelvic Injuries Mimimal to no impact on spino-pelvic stability

Type C. Spino-Pelvic Injuries Spino-pelvic instability

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Sacral Spine Fractures Classification System 57

Type A: Sacrocccygeal FracturesDefinition:• Injuries below the S-I joint

• No impact on posterior pelvic stability

• No impact on spino-pelvic stability

• *May* have impact on neurology

Type

A1

A2

A3

Description

• Coccygeal or sacral compression vs ligamentous avulsion fractures

• Nondisplaced transverse injuries below S-I joint• Usually neuro intact

• Displaced transverse injuries below S-I joint• Often have cauda equina injuries

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Sacral Spine Fractures Classification System58

Type B: Posterior Pelvic InjuriesDefinition:• Unilateral longitudinal sacral fractures

• Primary impact is on posterior pelvic stability

• Mimimal to no impact on spino-pelvic stability* (*Except B4 – Injuries extending into facet)

• Framework is variation of Denis Zones I through III injuries

• Usually treated with sacroiliac screw fixation

Type

B1

Description

• Central Fracture that involves spinal canal, but with primarily longitudinal fracture pattern

• Longitudinal injuries only – rare type of Denis Zone III injuries

• Does not have the same impact on spino-pelvic stability nor same propensity for cauda equina injury as transverse fxs involving canal

• Very low likelihood of neurological injury

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Sacral Spine Fractures Classification System 59

Type

B2

B3

B4

Description

• Transalar fracture: Does not involve foramina or spinal canal

• Denis Zone I injury

• Approx 5% chance of neuro injury

• Transforaminal fracture: Involves foramina but not spinal canal

• Denis Zone II injury

• Approx 25% chance of neuro injury

• Any unilateral B-subtype that involves fracture of ipsilateral L5-S1 facet joint

• MAY IMPACT SPINO-PELVIC STABILITY (Isler), thus potentially most unstable of B-subtypes

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Sacral Spine Fractures Classification System60

Type C: Spino-Pelvic InjuriesDefinition:• Injuries resulting in spino-pelvic instability

Type

C1

C2

C3

Description

• Nondisplaced sacral U-type fracture

• Commonly seen as low-energy insufficiency fracture

• Bilateral Type B injuries without transverse fx

• More unstable and higher likelihood of neuro injury than C1, but lower than C3

• Displaced sacral U-type sacral fracture

• Worst combination of instability and likelihood of neuro injury

• Displaced transverse sacral fx = canal compromise

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A1. Coccygeal or compression vs ligamentous avulsion fractures

Type A: Sacrocccygeal Fractures

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A2. Non-displaced transverse fractures below the S-I joint• No implications on stability• Low likelihood of cauda equina injury

Type A: Sacrocccygeal Fractures

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A3. Displaced transverse fractures below the S-I joint• Higher likelihood of neuro injury than A1 or A2• May possibly benefit from reduction & stabilization

Type A: Sacrocccygeal Fractures

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B1. Central Fracture• Rare type of Denis Zone III injury–primary longitudinal pattern only

Type B: Posterior Pelvic Injuries

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B2. Transalar Fracture• 5% chance of neurological injury (primarily L5)

Type B: Posterior Pelvic Injuries

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B3. Transforaminal Fracture• Approx 25% chance of neuro injury

Type B: Posterior Pelvic Injuries

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B4. Any Unilateral B-subtype that involves L5-S1 facet joint• Usually B3• May impact spino-pelvic stability (Isler)

Type B: Posterior Pelvic Injuries

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C1. Nondisplaced sacral U-type variant• Commonly seen low-energy insufficiency fracture

Type C: Spino-Pelvic Injuries

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C1. (alternative)Sacral U-type variant without posterior pelvic instability• Either displaced or non-displaced• Spino-pelvic instability without posterior pelvic instability

Type C: Spino-Pelvic Injuries

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C2. Bilateral Type B injuries without transverse fracture• More unstable and higher likelihood of neuro injury than C1

Type C: Spino-Pelvic Injuries

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C3. Displaced U-type sacral fracture• Similar instability profile to C2, but higher likelihood of neuro injury due to transverse fracture displacement & canal compromise

Type C: Spino-Pelvic Injuries

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