Thoracic and lumbar fractures and dislocations

Pearls

• Injury to thoracic spine necessitates severe force
  • When spinal cord injury occurs usually complete
• Stable if two or more of the spinal columns are intact:
  • Anterior (anterior longitudinal ligament, annulus fibrosus, ant. half of the vertebral body)
  • Middle (posterior longitudinal ligament, posterior annulus fibrous, and post. half of vertebral body
  • Posterior (supraspinous and interspinous ligaments, facet joint capsule)
• Unstable if:
  • 50% loss of vertebral height
  • Kyphotic angulation around the fx:
    • >30' for compression fx
    • > 25' for burst fx
  • Neurologic deficit

Classification

Compression (wedge)

• Only unstable if posterior ligament complex ruptures (requires a rotational force)
• Suspect instability and obtain CT if:
  • Severe compression (>50% loss of vertebral height)
  • Kyphosis >30deg
  • Rotational component to injury
  • Compression fx at multiple sites
  • Posterior cortex abnormality

Burst fracture

• Unstable
• Can occur with or without injury to posterior elements (posterior involvement increases risk for neuro deficits)
• Be certain not to mistakenly call a burst fracture a wedge fracture
  • Obtain CT if unsure

Flexion-Distraction Injuries (lap belt)

• Unstable
• Intra-abdominal injuries more commonly associated than neuro deficits
• Obtain sagittally reconstructed CT if suspect lap-belt mechanism or flexion-distraction

Chance Fracture

• most common at T12-L2 due to spinal curvature and mechanism
• Unstable
• Seat Belt Injury: lap belt worn above the pelvic bones without a shoulder harness
  • Forceful flexion at lap belt leads to compression fx of ant and middle columns
  • Associated with intra-abdominal injury (rectus sheath hematoma, intestinal perforation)
    • One or both articular processes fx > upper vertebrae anterior dislocates/subluxation

• Imaging
  • anterior vertebral body compression fx with extension through middle of vertebral body into posterior wall
  • Compression fx + increased posterior interspinous spaces caused by distraction

• Management
  • type and screen/cross, labs including pancreatic enzymes if thoraco-lumbar location
  • consult ortho or neurosurgery (institution dependent)
  • spinal precautions
  • emergency operative repair unless medically unstable

Translational

• Massive direct trauma to the back > failure of all 3 columns
• Almost invariably demonstrate neuro deficits

See Also

Spinal Cord Trauma

Source

• UpToDate
• Tintinalli's