The sacrum is the mechanical hub of the axial skeleton, serving as the base for the spinal column and keystone for the pelvic ring. Both surgical and nonsurgical options are available to treat sacral spine fractures; however, because these fractures are relatively rare and heterogeneous in nature and because there is little evidence-based literature, choosing the optimal treatment is challenging. The timing of intervention and the choice of surgical technique need to be determined on an individual basis, with the goal of producing the best outcome for the patient.