The sacrum is formed by the fusion of five sacral vertebrae, forming the posterior wall of the pelvis and transmitting all upper body loads to the ilia via the sacroiliac joints. The sacral foramina (S1-S4 anterior and posterior) transmit the sacral nerve roots forming the sacral plexus. The sacral hiatus (unfused S4-S5 arch) is the entry point for caudal epidural injections. The median sacral crest represents the fused spinous processes.
Sacral stress fractures (insufficiency fractures in osteoporotic patients and fatigue fractures in runners) present as bilateral or unilateral sacral pain reproduced by the seated flexion test. MRI confirms the H-pattern (Honda sign) of bilateral vertical sacral alar fractures with a horizontal connecting fracture. Treatment ranges from protected weight bearing to sacroplasty cement injection for refractory osteoporotic fractures.
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