Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Job Classification

In most duration tables, five job classifications are displayed. These job classifications are based on the amount of physical effort required to perform the work. The classifications correspond to the Strength Factor classifications described in the United States Department of Labor's Dictionary of Occupational Titles. The following definitions are quoted directly from that publication.

Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Fracture, Sacrum


Related Terms

  • Os Sacrum Fracture
  • Spine Fracture

Differential Diagnosis

Specialists

  • Emergency Medicine Physician
  • Neurosurgeon
  • Orthopedic (Orthopaedic) Surgeon
  • Physiatrist (Physical Medicine and Rehabilitation Specialist)
  • Physical Therapist
  • Trauma Surgeon
  • Urologist

Comorbid Conditions

Factors Influencing Duration

Length of disability is influenced by age, type of fracture, presence or absence of neurologic deficit, and presence or absence of other injuries.

Medical Codes

ICD-9-CM:
805.6 - Closed Fracture of Sacrum and Coccyx without Mention of Spinal Cord Injury
805.7 - Open Fracture of Sacrum and Coccyx without Mention of Spinal Cord Injury
806.60 - Closed Fracture of Sacrum and Coccyx with Unspecified Spinal Cord Injury
806.61 - Closed Fracture of Sacrum and Coccyx with Complete Cauda Equina Lesion
806.62 - Closed Fracture of Sacrum and Coccyx with Other Cauda Equina Lesion
806.69 - Closed Fracture of Sacrum and Coccyx with Other Spinal Cord Injury
806.70 - Open Fracture of Sacrum and Coccyx with Unspecified Spinal Cord Injury
806.71 - Open Fracture of Sacrum and Coccyx with Complete Cauda Equina Lesion
806.72 - Open Fracture of Sacrum and Coccyx with Other Cauda Equina Lesion
806.79 - Open Fracture of Sacrum and Coccyx with Other Spinal Cord Injury

Overview

A sacral fracture is a complete or incomplete break in the sacrum. The sacrum is part of the spinal column and is made up of five fused vertebrae (the sacral vertebrae S1 to S5) located between the lumbar vertebrae of the lower back and the tailbone (coccyx). The sacrum anchors the spine to the pelvic girdle, a bony structure that sits between the two hip bones.

Vertical sacral fractures are classified according to their location (zone) in relation to tunnel-like openings in the sacrum that allow passage of nerves and blood vessels through the spinal column (neural foramina). Zone I fractures occur at the wing-like structures of the sacrum (sacral ala) lateral to the neural foramina; this type of fracture can cause lumbar L5 nerve root impingement. Approximately 6% of individuals with Zone I fractures experience neurological injuries (Wheeless). Zone II fractures occur directly through the neural foramina and can cause one-sided numbness in the sacral region. Zone III fractures occur through the body of the sacrum (medial to the neural foramina) and can result in a syndrome characterized by urinary and rectal dysfunction (cauda equina syndrome) or bladder dysfunction (neurogenic bladder); 56% of individuals with Zone III fractures will exhibit neurological injuries (Wheeless). Other classification systems for trauma to the pelvic ring include the Tile system, which focuses on pelvic stability, and the Young-Burgess system, which focuses on the degree of injury.

Transverse fractures commonly occur between S1 and S3 and frequently have associated bladder dysfunction. Osteoporotic fractures usually involve only the sacrum. Most other sacral fractures are the result of high-energy impact injuries with a high incidence of associated injuries. These usually involve injury not only to the sacrum but also to the hip joint (sacroiliac joint) and the soft tissue surrounding the fracture, (i.e., muscles, nerves, tendons, ligaments, blood vessels, and bone covering [periosteum]).

Traumatic fracture of the sacrum can occur from a direct blow to the back, which often results in additional pelvic injury. Traumatic fracture also can occur due to indirect stress caused by twisting or other injury. In the elderly, a sacral fracture can occur secondary to osteoporosis with minimal or no trauma (insufficiency fracture). Individuals with rheumatoid arthritis are at higher risk for stress fractures of the sacrum.

Incidence and Prevalence: Incidence of sacral stress fracture is 1% of women older than 55 years of age in the US; incidence of insufficiency fractures internationally is from 1% to 5% (Peh).

Source: Medical Disability Advisor



Causation and Known Risk Factors

Most traumatic sacral and pelvic fractures occur from motor vehicle accidents (50% to 60%), motorcycle accidents (10% to 20%), pedestrian vs. car accidents (10% to 20%), falls (8% to 10%), and crush injury (3% to 6%) (Mechem). Individuals who play contact sports are at increased risk of developing a traumatic sacral fracture.

The repetitive stress of running on hard surfaces can produce stress fractures of the sacrum. Individuals taking long-term corticosteroid treatments and those who have undergone radiation therapy also are at increased risk of sacral stress fractures.

Postmenopausal women are at increased risk for insufficiency fractures, with most of these occurring in individuals over 60 years of age. This most likely reflects the increased incidence of osteoporosis in this population (Peh).

Source: Medical Disability Advisor



Diagnosis

History: A complete medical history should be obtained including previous trauma, prior fractures or orthopedic surgery, underlying medical conditions (especially diabetes mellitus, rheumatoid, osteoarthritis, or gout), medications, allergies, and occupation. Individuals may report a traumatic event such as a motor vehicle accident or fall or a direct blow to the back. A description of the mechanism of injury including the magnitude, location, and direction of impact is helpful. The individual may report severe pain in the lower back, tenderness to the touch, and/or numbness. The physician should inquire about urinary and/or fecal incontinence and sexual difficulties.

Physical exam: Careful observation and examination of the entire pelvis and lower back is crucial in the detection of associated injuries. Deformity, swelling (edema), and bruising (ecchymosis) may be noted on observation. The exam may reveal bony tenderness to gentle touch (palpation) and an inability to bear weight. Limitations of active and passive range of motion of the spine and hips should be noted. A thorough neurological examination is essential. The genitalia and rectum should also be examined. Damage to the nerves that supply the rectum, bladder, and genitals may not be evident for several days after the injury.

Tests: Plain x-rays of the pelvis usually will identify a fracture of the sacrum. CT scans are useful for more severe trauma since they can identify hip dislocation as well as pelvic, retroperitoneal, or intraperitoneal bleeding. A bone scan may be necessary to detect stress fractures. Additional laboratory and imaging studies may be necessary if other injuries are suspected. For example, blood loss can be monitored by serial hemoglobin and hematocrit determinations, and urinalysis may reveal trauma to the ureters, bladder, or urethra.

Source: Medical Disability Advisor



Treatment

Stability of the sacral fractures determines the course of treatment. Most sacral fractures are stable, and bed rest is the prescribed treatment along with a sacral corset or brace for comfort while the fracture heals. Medications (analgesics) may be recommended for pain. Some individuals may receive medication to lessen the likelihood of formation of blood clots in the veins of the legs (deep vein thrombosis [DVT]) during the period of bed rest. For osteoporotic and/or stress fractures, walker ambulation and analgesics are appropriate.

For fractures where the bones have moved out of their anatomically normal position (displaced fracture) or that are unstable or complicated by neurologic deficit, surgery usually is necessary. Surgical treatment may entail open reduction, internal fixation (ORIF) of the sacrum or removal of part of a vertebra (sacral laminectomy). With ORIF, the bones are aligned in their proper position (reduced) and secured internally with hardware (internal fixation). In a sacral laminectomy, part of a sacral vertebra is removed (excision of the posterior arch of the vertebra).

Source: Medical Disability Advisor



Prognosis

Prognosis depends on the severity and location of the fracture. The average healing time for a nondisplaced sacral fracture is 6 to 8 weeks. The average healing time for a displaced sacral fracture requiring surgical intervention is 8 to 12 weeks. In both medically and surgically treated fractures, complete healing is expected. Physical signs of fracture union include pain-free fracture site and an x-ray showing complete bone union. Stress fractures of the sacrum may take up to 9 months to heal completely.

Source: Medical Disability Advisor



Rehabilitation

Rehabilitation for a stable, uncomplicated sacral fracture is usually minimal. When needed, the goal of rehabilitation is to decrease pain and increase function (Braddom). Decreased pain can be achieved utilizing various modalities including cold, heat, and hydrotherapy (Bucholz). Gait should be assessed to determine the need for assistive devices such as a walker or cane. Muscle spasm and low back discomfort may be associated with these fractures and can be treated as other low back pain conditions. Stretching and strengthening of the low back and trunk muscles may be beneficial (See Low Back Pain). The individual may experience discomfort while seated, in which case a soft cushion or donut pillow may provide relief.

FREQUENCY OF REHABILITATION VISITS
Nonsurgical
SpecialistFracture, Sacrum
Physical TherapistUp to 12 visits within 6 weeks
The table above represents a range of the usual acceptable number of visits for uncomplicated cases. It provides a framework based on the duration of tissue healing time and standard clinical practice.

Source: Medical Disability Advisor



Complications

Individuals may experience pain with prolonged sitting or standing. Some individuals develop chronic pelvic pain. About 60% of individuals who experience a sacral fracture will have a neurological complication (Wheeless). These include cauda equina syndrome, in which the individual experiences decreased sensation in the buttocks, genitalia, or thighs with urinary retention and loss of rectal tone, and bladder dysfunction caused by nerve injury (neurogenic bladder). Sexual, bladder, or bowel dysfunction may persist due to nerve damage. Other possible complications include death of the bone cells (avascular necrosis) due to inadequate blood supply, bleeding from injuries, infection, an unstable or arthritic spine following injury, and deep vein thrombosis (DVT).

Source: Medical Disability Advisor



Ability to Work (Return to Work Considerations)

Individuals may need to wear a corset or brace for support while healing, and will need to avoid physical labor such as lifting and carrying. Prolonged sitting or standing may need to be limited until healing is complete. Accommodation for frequent bathroom visits could be necessary. Company policy on medication usage should be reviewed to determine if pain medication use is compatible with job safety and function.

Source: Medical Disability Advisor



Failure to Recover

If an individual fails to recover within the expected maximum duration period, the reader may wish to consider the following questions to better understand the specifics of an individual's medical case.

Regarding diagnosis:

  • Did individual present with symptoms consistent with a sacral fracture?
  • Was diagnosis confirmed with x-ray?
  • If diagnosis was uncertain, were other conditions with similar symptoms ruled out?

Regarding treatment:

  • Was treatment appropriate for the type of fracture?
  • Did individual comply with bed rest as prescribed?
  • Did individual wear sacral corset/brace as prescribed?
  • Was surgery required?
  • Was individual's pain controlled with analgesics? If not, were alternative interventions attempted, such as relaxation, visualization adjustments in medication dose?
  • Did individual comply with treatment recommendations?
  • Would individual benefit from consultation with a specialist (orthopedic surgeon, physiatrist)?

Regarding prognosis:

  • Has adequate time elapsed for healing?
  • Has individual participated in rehabilitation therapy as recommended?
  • Does individual have any conditions that may affect ability to recover?
  • Has individual experienced any complications? Have any complications been addressed in the treatment and rehabilitation plan (e.g., bladder training for individuals with bladder dysfunction)?

Source: Medical Disability Advisor



References

Cited

Braddom, Randolph L. Physical Medicine and Rehabilitation. 3rd ed. Philadelphia: W.B. Saunders, 2006.

Bucholz, Robert, and James D. Heckman. Rockwood and Green's Fractures in Adults. 6th ed. Philadelphia: Lippincott, Williams & Wilkins, 2005.

Mechem, Crawford. "Fracture, Pelvic." eMedicine. Eds. Michelle Ervin, et al. 11 Aug. 2008. Medscape. 13 Mar. 2009 <http://emedicine.medscape.com/article/825869-overview>.

Peh, Wilfred C.G. "Pelvis, Insufficiency Fractures." eMedicine. Eds. Leon Lenchik, et al. 3 May. 2005. Medscape. 13 Mar. 2009 <http://emedicine.medscape.com/article/394406-overview>.

Wheeless, Clifford. "Sacrum and Sacral Fractures." Wheeless' Textbook of Orthopaedics. Wheeless' Textbook of Orthopaedics. Duke Orthopaedics. 13 Mar. 2009 <http://www.wheelessonline.com/ortho/sacrum_and_sacral_fractures>.

Source: Medical Disability Advisor






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