Sacral fractures most commonly occur after pelvic ring injuries but occasionally in isolation. Although the true incidence of sacral fractures is unknown, an estimated 30% are identified late. Sequelae of inappropriately treated or untreated sacral fractures include persistent pain, decreased mobility, and neurologic compromise. Because these fractures often result from high-energy trauma, concomitant injuries should be suspected. A thorough physical examination, including a detailed neurologic assessment and radiographic evaluation, is necessary to determine treatment. Computed tomography of the pelvis/sacrum can provide significant information about fracture pattern. Surgical intervention, often as a combination of neural decompression and stabilization, is indicated in patients with neurologic deficits, significant soft-tissue compromise, and lumbosacral instability. Patient satisfaction with surgical intervention has not been definitively documented, although neurologic improvement with timely intervention has been noted.