Chance Fracture of the Upper Thoracic Spine

Chance fracture: A case report and review of the literature

A Chance fracture, also known as a "seatbelt fracture," is "an unstable spinal injury that usually occurs at the thoracolumbar junction. Complications of a Chance fracture include spinal cord injury, neurological deficits, and long-term functional impairment if not promptly identified and treated. In this case report, we present the case of a 13-year-old patient who sustained a Chance fracture following a 30-foot vertical fall, an atypical mechanism of injury. Imaging revealed a vertebral body fracture with a horizontal break through the posterior elements and accompanying ligamentous tears. Management included surgical stabilization via pedicle screw fixation and laminectomy. This case highlights the importance of considering axial loading mechanisms in pediatric trauma patients and the role of timely surgical intervention in preventing long-term complications.

Occult thoracic disco-ligamentous Chance fracture in computed tomography: a case report

We report on a 46-year-old woman who was involved in a road traffic accident. Neurological examination demonstrated paraplegia, while initial CT showed bilateral pneumothorax and hemothorax, rib fractures, a C2 vertebral body fracture with C2-C3 dislocation and active arterial bleeding at the sacral level. Given the fact that her neurological status did not particularly correspond with what we observed on CT scan, MRI was obtained due to the suspicion that a much more severe occult injury could be present. MRI showed a complete rupture of the posterior ligamentous complex along with the intervertebral disk and the posterior longitudinal ligament at T8-T9 level. The patient underwent minimally invasive posterior fixation with pedicle screws. Chance fractures of the thoracic spine are uncommon. To our knowledge, this is the first report of a pure soft-tissue Chance fracture located in the thoracic spine. Given that the initial CT showed no fracture evidence or vertebral malalignment, a high index of suspicion, based on the mechanism of injury, clinical examination and/or concomitant lesions, is necessary to identify such extremely unstable injury. Early recognition is crucial for appropriate therapy and to minimize the extent of neurological deficit.

When a Child Dies Unexpectedly: No Truth Be Told

Sudden death of a child beyond infancy is a rare event. We report a child who presented to the emergency care system with asystole and the caregiver's report of an asthma attack as the preceding event. After unsuccessful attempts at resuscitation, an autopsy was performed by the medical examiner. Despite only scattered bruises with no clear-cut signs of abuse, aortic rupture and spinal fractures were found. This case highlights the crucial role of the medical examiner in evaluating sudden childhood death, even in the setting of underlying illness.

Sternal and Thoracic Spinal Fractures: Case Reports of Two in One Accident

Two restrained back-seat taxi passengers suffered from sternal fracture as a result of head-on collision with another car. They were wearing shoulder-lap seat belts at the time of the collision. Both of them also complained of upper back pain one day after admission. Computed tomography of the thorax showed fracture of the thoracic spine in both of them. We performed literature search, analysing the mechanism of sternal fracture and its association with spinal fracture. A management guideline in the emergency department is proposed to handle this injury.

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.

Trauma

Traumatic brain and spine injury (TBI/TSI) is a leading cause of death and lifelong disability in children. The biomechanical properties of the child's brain, skull, and spine, the size of the child, the age-specific activity pattern, and variance in trauma mechanisms result in a wide range of age-specific traumas and patterns of brain and spine injuries. A detailed knowledge about the various types of primary and secondary pediatric head and spine injuries is essential to better identify and understand pediatric TBI/TSI, which enhances sensitivity and specificity of diagnosis, will guide therapy, and may give important information about the prognosis. The purposes of this chapter are to: (1) discuss the unique epidemiology, mechanisms, and characteristics of TBI/TSI in children; (2) review the anatomic and functional imaging techniques that can be used to study common and rare pediatric TBI/TSI and their complications; (3) comprehensively review frequent primary and secondary brain injuries; and (4) to give a short overview of two special types of pediatric TBI/TSI: birth-related and nonaccidental injuries.

Compression Fractures in the Setting of Diffuse Idiopathic Skeletal Hyperostosis

Compression fractures are the most common vertebral fractures. They involve the anterior column of the spine, and are considered stable fractures due to the presence of intact posterior ligaments that aid in resisting further collapse and deformity. They are thus often managed conservatively. We describe a series of 3 cases that were initially diagnosed as compression fractures and managed conservatively. With the abundance of compression fractures and increase in preference for conservative management of compression fractures, it is of utmost importance to recognize the possibility of other spinal co-pathologies, especially that of hyperostosis of the spine, both by clinical judgment as well as radiological analysis before embarking on conservative management, should there be under-treatment and development of complications that could have otherwise been avoided, as in the cases presented in this series.

Pediatric spinal trauma

Pediatric spinal trauma is unique. The developing pediatric spinal column and spinal cord deal with direct impact and indirect acceleration/deceleration or shear forces very different compared to adult patients. In addition children are exposed to different kind of traumas. Moreover, each age group has its unique patterns of injury. Familiarity with the normal developing spinal anatomy and kind of traumas is essential to correctly diagnose injury. Various imaging modalities can be used. Ultrasound is limited to the neonatal time period; plain radiography and computer tomography are typically used in the acute work-up and give highly detailed information about the osseous lesions. Magnetic resonance imaging is more sensitive for disco-ligamentous and spinal cord injuries. Depending on the clinical presentation and timing of trauma the various imaging modalities will be employed. In the current review article, a summary of the epidemiology and distribution of posttraumatic lesions is discussed in the context of the normal anatomical variations due to progressing development of the child.

Unusual mechanism of injury resulting in a thoracic chance fracture in a rodeo athlete: a case report

OBJECTIVE

To introduce the characteristics of a Chance fracture and increase awareness of the mechanism of injury that may occur during athletic activity.

BACKGROUND

A T12 Chance fracture was diagnosed in an 18-year-old male rodeo athlete. The rider was forced into extreme lumbothoracic hyperflexion when the horse bucked within the chute, pinning the rider's legs to his chest.

DIFFERENTIAL DIAGNOSIS

Burst fracture, abdominal organ rupture, spinal dislocation, spinal cord injury, disk herniation, pars interarticularis fracture, spinal nerve injury, paralysis.

TREATMENT

The patient underwent an open reduction and fixation of the thoracic fracture. Posterior stabilization was obtained with nonsegmental instrumentation. Allograft and autografts were used for posterolateral arthrodesis at T11-T12 and T12-L1.

UNIQUENESS

Motor vehicle crashes with occupants wearing lap-type-only restraints account for nearly all previously reported Chance fractures. When only lap seatbelts are worn, the pelvis is stabilized, and the torso continues moving forward with impact. The stabilized body segment for this individual was reversed. Nearly 3 years after the initial surgery, fixation, and infection, the bareback rider has returned to full participation in rodeo.

CONCLUSIONS

To our knowledge, this is the first reported diagnosis of a T12 Chance fracture in a rodeo athlete. When animals buck, athletes can be forced into hyperflexion, exposing them to Chance fractures. Therefore, anyone treating rodeo athletes must suspect possible spinal fracture when this mechanism is present and must treat all athletes with early conservative management and hospital referral.

Chance fractures in the pediatric population

OBJECT

The pediatric Chance fracture (PCF) is an uncommon injury, but it has been increasingly reported. Knowledge is limited to few case reports and short series. To understand the various aspects of this injury, the authors reviewed the current literature.

METHODS

A literature search was conducted using the PubMed and Ovid online databases and relevant key words. All articles that were in English and provided information regarding PCF as a sole or part of the objective were retrieved.

RESULTS

Seventy-three articles were found to fulfill the inclusion criteria. Relevant information about PCF collected from these articles included: 1) mode of trauma, 2) associated injuries, 3) radiological classification, and 4) treatment.

CONCLUSIONS

Chance fractures in children are potentially devastating injuries largely caused by motor vehicle collisions, and these fractures may be more common than previously thought. Concomitant intraabdominal injuries are common and should be suspected, particularly when a seat belt sign is observed. Blunt abdominal aortic injuries are rarely associated, but should be evaluated for and treated appropriately. Magnetic resonance imaging is best for defining ligamentous injury, which aids in defining the pattern of injury, facilitating appropriate treatment regimens.

Thoracolumbar flexion-distraction injuries: associated morbidity and neurological outcomes

STUDY DESIGN

Retrospective study, prospectively gathered databases.

OBJECTIVE

To assess abdominal comorbidities, missed injuries, and complications associated with thoracolumbar flexion-distraction injuries (FDI).

SUMMARY OF BACKGROUND DATA

From 1989 to 2003, 153 patients with flexion-distraction type injuries were identified. Predominant injury mechanisms consisted of motor vehicle crashes, falls, and motorcycle crashes.

METHODS

Spinal injuries were categorized by region, injury pattern, American Spinal Injury Association grade, and motor score. Diagnostic methods, delayed diagnoses, and complications were recorded and compared with variables of spinal injury, abdominal injury, and neurologic outcome. Treatment variables included nonoperative care, posterior surgery alone, anterior surgery alone, or combination treatment. Primary outcomes were neurologic status, unintended secondary procedures, complications, and kyphosis angle.

RESULTS

Spinal cord injury (SCI) was found in 37 of 151 patients (25%). SCI was correlated with high-grade posterior element dissociation. Intra-abdominal injury (IAI) was found in 46 of 151 of patients (30%). There was a statistically significant correlation between presence of FDI and IAI in the lumbar (L2-L4) region. There was a 3.9% incidence of delayed diagnosis of FDI and a 0.9% incidence of delayed diagnosis of IAI. Presence of a "lapbelt-sign" had a positive predictive value of 0.69 and a negative predictive value of 0.91 for IAI. Presence of a lumbar injury due to a motor vehicle crash in the presence of a lapbelt sign was positively associated with IAI. There was no increase in complications in the subpopulation of patients with concurrent SCI and FDI.

CONCLUSION

Both IAI and SCI remain commonly associated with FDI of the thoracolumbar spinal column. The presence of an abdominal wall contusion (lapbelt sign) is a strong indicator of IAI. Adherence to an established trauma algorithm can minimize the risk of delayed diagnosis. Disruption of an established work-up paradigm, however, can lead to potentially life and spinal cord threatening complications.

Chance-Type Fractures of the Thoracolumbar Spine: Imaging Analysis in 53 Patients

OBJECTIVE

Chance-type fractures are subtle unstable injuries that are often associated with intraabdominal injuries. CT-based observations made during routine interpretations revealed involvement of a burst component to this fracture pattern and a clue on the transaxial images to its presence. The purpose of this review was to determine how often these features occurred in a retrospective study of a large sample because these findings influence diagnosis and management.

MATERIALS AND METHODS

A retrospective review of all patients identified from the University of Maryland Shock Trauma Center trauma registry and IDXRad system diagnosed with flexion-distraction injuries of the thoracolumbar spine over an 8-year period was performed. Three trauma radiologists assessed the admission spinal radiographs, CT studies with multiplanar images, and available MRI examinations. Imaging findings were confirmed by consensus. Abdominopelvic CT studies and surgical reports were reviewed for evidence and type of intraabdominal injury. A literature review of previous similar series was performed.

RESULTS

Fifty-three patients were identified for inclusion in the study. Associated intraabdominal injury occurred in 40% and most commonly involved the bowel and mesentery. A close examination of the fracture patterns on CT revealed that a burst-type fracture with posterior cortex buckling or retropulsion was a common finding (48%). Also, serial transaxial CT images often (76%) showed a gradual loss of definition of the pedicles that we refer to as the "dissolving pedicle" sign. The study showed that the horizontally oriented fracture planes through the posterior elements can often be recognized radiographically, but these fractures can be very subtle.

CONCLUSION

Intraabdominal injuries occurred in 40% of flexion-distraction thoracolumbar fractures in our study cohort, which is slightly lower than previously reported. About half of the patients with this injury displayed a burst-type component that could have a significant influence on surgical management. The dissolving pedicle sign can assist in recognition of this often subtle injury on transaxial CT.