The 100 most cited articles in sacral fracture: A bibliometric analysis

The human pelvis is a sturdy ring of bone that supports the weight of the upper body and connects the spine to the legs. Within this ring lies the sacrum, a large, triangular bone at the base of the spine that acts as a crucial bridge between the torso and the lower limbs. When this bone breaks, the consequences can be severe, but the nature of the injury depends entirely on the person involved. For a young person, a break in this area usually results from a high-energy crash, such as a car accident or a fall from a great height, often shattering the pelvic ring and tearing the connection between the spine and the pelvis. For an elderly person, the same bone can fracture from something as minor as a stumble or a simple step, a type of injury known as a fragility fracture, caused by bones that have become weak and porous with age. For decades, doctors treated these two very different scenarios as separate problems, but as medical imaging has improved and surgical tools have advanced, the field has learned to see the connections between them.

To understand how the medical community has learned to manage these complex injuries, a team of researchers at Ruhr University Bochum and St. Josef-Hospital in Germany decided to look back at the most influential work ever published on the subject. They did not simply count how many papers existed; instead, they sought out the one hundred articles that other scientists and doctors had cited the most. By reading these top hundred papers, the researchers could trace the history of the field, seeing how the focus shifted from simply recognizing the injury to developing sophisticated ways to fix it. This approach allowed them to map the evolution of treatment, revealing that the story of sacral fractures is actually a story of two converging paths: one dealing with violent trauma and the other with the fragility of aging.

The researchers began by searching a massive digital library of scientific literature, looking for any study that focused on breaks in the sacrum, including specific patterns like U-shaped or H-shaped fractures. They sorted the results by how often each paper had been referenced by others, a standard way to measure influence in science. After carefully reviewing the top candidates and removing a few that did not focus primarily on the fracture itself, they settled on a final list of one hundred articles. These papers, published between 1977 and 2022, had been read and referenced a total of nearly seven thousand times. The most cited paper alone had been referenced nearly four hundred times, highlighting its massive impact on how doctors think about these injuries.

When the team analyzed the content of these hundred papers, a clear timeline emerged. In the earlier decades, the literature was dominated by studies on diagnosis and classification. Doctors were still learning how to spot these fractures on X-rays and how to describe the different ways the bone could break. As time went on, the focus shifted dramatically toward solutions. The later papers were filled with discussions about how to hold the broken bone together. The researchers found that the most common topics in these influential works were diagnosis and imaging, the biomechanics of how the bone holds weight, and various methods of surgical fixation. One of the most significant trends was the rise of minimally invasive techniques, where surgeons use small incisions and specialized screws to stabilize the bone, rather than opening up large areas of the body.

The study also revealed that the field is built on two distinct but increasingly connected traditions. Roughly half of the most cited papers focused on high-energy, traumatic injuries, often involving young patients with severe pelvic instability and nerve damage. These studies pioneered concepts like lumbopelvic fixation, which involves connecting the spine directly to the pelvis to restore stability when the natural ring is broken. The other major group of papers focused on fragility fractures in the elderly. These studies addressed the growing problem of osteoporosis, where bones break easily, and explored treatments like sacroplasty, a procedure where bone cement is injected into the fracture to strengthen it and relieve pain. While these two groups of patients seem different, the researchers noted that the literature is beginning to bridge the gap, recognizing that elderly patients can sometimes suffer fracture patterns that look like traumatic injuries, requiring a careful balance between surgical strength and patient safety.

Geographically, the United States produced the majority of these influential papers, with Germany, the United Kingdom, and Switzerland also making significant contributions. The research came from a mix of disciplines, including orthopedic trauma, spine surgery, and radiology, reflecting the fact that treating these injuries requires a team of specialists. The most frequently cited journals were those dedicated to orthopedic trauma and spine surgery, indicating that the solutions to these problems are found at the intersection of these fields. The analysis showed that while many of the studies were based on reviewing past patient records or testing bone models in a lab, there was a strong emphasis on understanding the anatomy and mechanics of the injury before attempting to fix it.

Ultimately, this review of the most important literature shows that the field has matured from simply identifying the problem to mastering the solution. The landmark papers have guided doctors from a time when these fractures were often missed or poorly understood to an era where specialized screws, bone cement, and reconstruction techniques can restore stability and function. The research suggests that the future lies in refining these treatments further, particularly for the growing population of elderly patients who need care that addresses both their broken bones and their overall frailty. By understanding the history of these discoveries, current and future doctors can make better decisions about how to treat the next patient who walks through the door with a broken sacrum.