The unusual chance fracture: case report & literature review

Endovascular Aortic Repair for Thoracic Aortic Compression Resulting From Chance Fracture of the Thoracic Spine

Blunt aortic injury is a serious condition with a high mortality rate. Although rare, blunt aortic injury associated with spinal fracture has also been reported, and appropriate management of aortic disease is key to a good outcome. This report is a case of a 78-year-old man who was found to have a transverse fracture (Chance fracture) in the ninth thoracic vertebra, with a sharp bone fragment compressing the thoracic aorta. Early spinal surgery was needed; however, there was concern about the possibility of bleeding from the aorta and surrounding small arteries associated with the bone fragment during spinal surgery. Therefore, thoracic endovascular aortic repair was performed before spinal surgery. The next day after thoracic endovascular aortic repair, posterior spinal instrumentation was performed, and the postoperative course was uneventful. Because aortic injury associated with vertebral fracture can lead to massive bleeding and spinal cord injury, endovascular repair before spinal surgery is reasonable.

Curiosity or Underdiagnosed? Injuries to Thoracolumbar Spine with Concomitant Trauma to Pancreas

The pancreas is at risk of damage as a consequence of thoracolumbar spine injury. However, there are no studies providing prevalence data to support this assumption. Data from European hospitals documented in the TraumaRegister DGU^® (TR-DGU) between 2008–2017 were analyzed to estimate the prevalence of this correlation and to determine the impact on clinical outcome. A total of 44,279 patients with significant thoracolumbar trauma, defined on Abbreviated Injury Scale (AIS) as ≥2, were included. Patients transferred to another hospital within 48 h were excluded to prevent double counting. A total of 135,567 patients without thoracolumbar injuries (AIS ≤ 1) were used as control group. Four-hundred patients with thoracolumbar trauma had a pancreatic injury. Pancreatic injuries were more common after thoracolumbar trauma (0.90% versus (vs.) 0.51%, odds ratio (OR) 1.78; 95% confidence intervals (CI), 1.57–2.01). Patients with pancreatic injuries were more likely to be male (68%) and had a higher mean Injury Severity Score (ISS) than those without (35.7 ± 16.0 vs. 23.8 ± 12.4). Mean length of stay (LOS) in intensive care unit (ICU) and hospital was longer with pancreatic injury. In-hospital mortality was 17.5% with and 9.7% without pancreatic injury, respectively. Although uncommon, concurrent pancreatic injury in the setting of thoracolumbar trauma can portend a much more serious injury.

Chance Fracture in an Unbelted Rear Seat Passenger

Chance fracture occurs from flexion-distraction injury in motor vehicle road crash usually when the patient is on a seat belt. It is often associated with intra-abdominal injuries. We managed a 22-year old female unbelted rear seat passenger of a bus which was involved in a lone accident. We highlighted the possible mechanism of chance fracture in an unbelted passenger and satisfactory spinal stability on conservative care with neither internal nor external fixation.

Utilizing a Cortical Bone Trajectory Pedicle Screw for Lumbar Flexion-Distraction Injury

Spinal flexion-distraction injuries (FDIs) are unstable fractures, commonly located at the thoracolumbar junction. Management of FDIs often necessitates the use of posterior instrumentation and fusion, but long-segment instrumentation surgery decreases postoperative spinal mobility and increases the risk of junctional kyphosis and fracture. We report the case of a patient with FDI showing an L2 vertebral fracture, unilateral L2 pedicle fracture, and disruptions of the posterior ligamentous complex between L1 and L2. After open reduction using L1 and L2 pedicle screws with a conventional trajectory on the right side, a cortical bone trajectory (CBT) pedicle screw was used as an osteosynthesis screw for the fractured left pedicle. This procedure enabled successful single-level fusion. Follow-up radiological examination revealed good reduction and complete bone union. To the best of our knowledge, utilizing a CBT technique as an osteosynthesis screw in FDIs has not previously been described.

Management of a high thoracic chance fracture

PURPOSE

Chance fracture of the high thoracic spine is rare, and its impact on the adjacent cervical spine can be important.

METHODS

We present the case of a 16-year-old male, who fell down from a 2 m height, in an unknown context as he has a mental retardation, and no witness saw the accident. Initial CT scan revealed a comminuted depressed fracture of the right parietal bone, associated with a chance fracture at the level of T3 with a kyphosis and bilateral lung contusion.

RESULTS

The patient underwent neurosurgical treatment for elevation and reconstruction of the parietal fracture; he also underwent, 2 days later, a posterior spinal correction and fusion with T1-to-T5 instrumentation. The patient returned to normal walking on day 7 with a satisfactory clinical and radiological result at 1 year.

CONCLUSION

Literature is sparse on the treatment of high thoracic chance fractures. The current case shows that early surgical management should prevent a secondary kyphotic deformity that may need a more aggressive treatment at a later stage.