Sacral fractures are frequently missed with plain radiography. Delayed recognition and inadequate treatment of sacral fractures may lead to painful deformity and progressive loss of neurologic function. Neurologic injury is common, particularly in Denis zone III fractures. Whenever soft tissues permit, early surgical decompression should be considered in a stable patient when foraminal or central canal stenosis with neurological deficit is present. Because of the potential development of epineural fibrosis, early decompression (within the first 24 to 72 hours) may be more effective to minimize the chance of further injury. In most cases, early decompression should be accompanied by fracture stabilization to allow for mobilization, with less risk for secondary neurologic injury because of fracture displacement. Various forms of stabilization techniques provide comparable biomechanical stability, but lumbopelvic fixation likely affords the greatest stability. However, clinical results are highly variable, and patient treatment should be individualized to optimize outcomes.