Bilateral Vertical Sacral Fracture, a Highly Unstable Pelvic Injury in a Case of Accidental Fall from Height

This report describes a rare and life-threatening presentation of bilateral vertical sacral fractures in a 54-year-old hypertensive female following a high-energy fall from a second-floor balcony. Such fractures are uncommon and inherently unstable, often associated with pelvic ring disruption, neurovascular compromise, and haemodynamic instability. The patient presented to the emergency department (ED) in a drowsy state with a Glasgow Coma Scale (GCS) score of 12, hypotension, tachycardia, and bilateral lower limb weakness, indicative of polytrauma involving the neurological and musculoskeletal systems. Initial management followed a systematic trauma approach, including prompt resuscitation with intravenous (IV) fluids, administration of tranexamic acid, continuous monitoring, and early application of a pelvic binder based on clinical suspicion of an unstable pelvic fracture. Adjunct investigations, including an electrocardiogram, arterial blood gas analysis, cross-matching, and bedside extended Focused Assessment with Sonography in Trauma (e-FAST), aided in ruling out immediate life-threatening conditions. Comprehensive imaging with computed tomography (CT) polytrauma protocol and X-rays revealed an acute subdural haematoma, bilateral vertical sacral fractures with pelvic ring disruption, retroperitoneal haemorrhage, and a right calcaneal fracture. The patient underwent multidisciplinary management involving emergency medicine, anaesthesia, critical care, spine surgery, and orthopaedics. Surgical interventions included L4–S2 lumbopelvic fixation, L5–S1 laminectomy for an S1 nerve root laceration, and calcaneal fixation via the sinus tarsi approach. Perioperative management included invasive haemodynamic monitoring and neuromonitoring. Postoperatively, the patient received intensive critical care support followed by structured rehabilitation, ultimately achieving recovery without residual neurological deficits. This case underscores the rarity and diagnostic challenges of bilateral vertical sacral fractures, which account for less than 1% of sacral injuries and are frequently overlooked in the presence of multiple traumatic insults. It highlights the critical role of early imaging, adherence to structured trauma protocols, and coordinated multidisciplinary care in improving outcomes in high- energy polytrauma patients.