The role of spine surgeons in the identification and treatment of sacral fractures will be outlined in this chapter. The focus will be on the sacral U-type fractures, transverse fractures, and vertical shear pelvic fractures. The remainder of pelvic fracture management will be deferred to the treatise on pelvic fractures. The distinction between insufficiency, osteoporotic fractures, and high-energy traumatic fractures will be highlighted. The means of evaluation, diagnosis, treatment decision-making, and fixation techniques will be discussed with the two distinct groups of patients in mind.