Open and Percutaneous Fixation of Traumatic Sacral Fracture–Dislocation with Spinopelvic Dissociation: Two Adolescent Cases and a Systematic Literature Review

Background: Spinopelvic dissociation secondary to sacral fracture–dislocation is a rare but severe injury, most often resulting from high-energy trauma. Management remains challenging, particularly in adolescents, and the optimal choice between open and percutaneous fixation is still debated. Methods: We present two adolescent cases of traumatic sacral fracture–dislocation with spinopelvic dissociation, one treated with percutaneous fixation and one with open lumbopelvic stabilization both with the use of navigation. The systematic literature review included 29 published studies. Together with the present two-patient case series, the overall analysis comprised 30 studies/series and 739 patients. Data on demographics, mechanisms of injury, neurological involvement, treatment strategies, and outcomes were extracted and analyzed. Results: Case 1 (18 years) was managed with closed reduction and percutaneous fixation, achieving complete neurological and functional recovery at 6 months. Case 2 (14 years) underwent open reduction, decompression, and lumbopelvic fixation, with favorable radiological outcomes but residual sphincter dysfunction at follow-up. In the literature, the weighted mean age was 40.6 years (range 5–91), with 48.6% presenting neurological deficits, most frequently cauda equina syndrome. Surgical management was performed in nearly all cases, with mean time to fixation ranging from 3.6 to 8.6 days. Open techniques were predominantly used in patients with severe displacement or neurological compromise, whereas percutaneous fixation was associated with reduced surgical morbidity and satisfactory neurological recovery in selected patients. Permanent bladder and bowel dysfunction persisted in up to 33% of cases. Conclusions: Spinopelvic dissociation following sacral fracture–dislocation remains a rare and highly unstable injury with frequent neurological impairment. Early surgical stabilization may be beneficial when the patient’s clinical condition permits, and the choice between open and percutaneous fixation should be individualized according to fracture morphology, neurological status, and the need for direct decompression. Our adolescent cases highlight both the potential for complete recovery and the risk of residual dysfunction, reflecting the complexity of these injuries.