Clinical Presentation & Protocol
Patient Usually Complains Of
Patient presents following high-energy trauma/mechanical fall with localized sacral pain, exacerbated by weight-bearing and lumbar flexion. Denies bowel/bladder incontinence, saddle anesthesia, or lower extremity neurological deficits. Pain rated at [X]/10, non-radiating.
Clinical Examination Findings
Patient is alert and oriented. Sacral region demonstrates localized tenderness to palpation, swelling, and ecchymosis. No step-off deformity noted. Neurological exam: intact sensation in L4-S1 dermatomes, motor strength 5/5 in bilateral lower extremities, reflexes 2+ symmetrical, negative straight leg raise. Perianal sensation and rectal tone intact.
Treatment Protocol
Initial management includes strict activity modification, non-weight bearing or toe-touch weight bearing as tolerated, and pain management with scheduled NSAIDs/analgesics. Orthopedic consultation obtained for stabilization assessment. DVT prophylaxis initiated. Follow-up imaging and clinical reassessment scheduled.