The sacral spine has received relatively little attention in the orthopedic and neurosurgical literature, in part because of the infrequency of developmental, degenerative, or neoplastic conditions of the sacrum requiring surgical intervention. This neglect is unwarranted in trauma, however, because sacral fracture and its associated neural deficit are both common and often complex problems. The sacrum and pelvis behave as a single functional unit; an understanding of the principles of sacropelvic stability has obvious relevance in planning the occasional resection of a sacral tumor and in dealing with the common problem of massive pelvic trauma. A classification of sacral fractures is reviewed along with the usual patterns of neurological involvement. Through analysis of an institutional series of cases, a specific attempt is made to correlate varying types of vertical sacral fractures with differing types of pelvic injury. The radiographic and physiological investigation of sacral fractures is reviewed, as are the various options for achieving the reduction, decompression, and stabilization of sacral fractures.