Thoracic and lumbar fractures and dislocations: Difference between revisions

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**Anterior (anterior longitudinal ligament, annulus fibrosus, ant. half of the vertebral body)
**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
**Middle (posterior longitudinal ligament, posterior annulus fibrous, and post. half of vertebral body
**Posterior (supraspinous and interspinous ligaments, facet joint capsule)
**Posterior (supraspinous and interspinous ligaments, ligamentum flavum, facet joint capsule)
*Unstable if:
*Unstable if:
**50% loss of vertebral height
**50% loss of vertebral height
**Kyphotic angulation around the fracture:
**Kyphotic angulation around the fracture:
***>30' for compression fracture
***>30' for compression fracture
***> 25' for burst fracture  
***>25' for burst fracture  
**Neurologic deficit
**Neurologic deficit


==Classification==
{{Vertebral fractures and dislocations types}}
===Compression (wedge)===
*Only unstable if posterior ligament complex ruptures (requires a rotational force)
*Mechanism: axial loading and flexion
*Unlikely to cause cord damage
*Suspect instability and obtain CT if:
**Severe compression (>50% loss of vertebral height)
**Kyphosis >30deg
**Rotational component to injury
**Compression fracture at multiple sites
**Posterior cortex abnormality


===[[Thoracic burst fracture]]===
==Clinical Features==
===[[Lumbar burst fracture]]===
*Typically pain over site of injury
*considered unstable
*Mechanism: axial load w/ failure of the anterior and middle columns
*Can cause cord damage
 
===Flexion-Distraction Injuries (lap belt)===
*Mechanism: seat belt serves as axis of rotation w/ failure of middle and posterior columns
*increased height of posterior vertebral body
factor of the posterior wall of the vertebral body
posterior opening of the disk space
*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
*Mechanism: minor anterior vertebral compression w/ failure of the middle and posterior columns
*usually missed diagnosed as anterior compression fracture- (which is usually stable) versus this fx is unstable.
**Associated with intra-abdominal injury (rectus sheath hematoma, intestinal perforation)
***One or both articular processes fracture > upper vertebrae anterior dislocates/subluxation
 
===fracture dislocations===
*Unstable
*Most damaging of all injuries
*Mechanism: multiple can be compression, flexion, distraction, rotation or shearing forces causing failure of anterior, middle and posterior columns
 
 
===Minor Thoracic and Lumbar Spine Fractures===
*Transverse process fracture
*Spinous process fracture
*Pars interarticularis fracture
 
 
 
*Imaging
**Indications to Image Thoracic and Lumbar Spine after Trauma
***Mechanism
****Gunshot, High energy trauma, Motor vehicle crash with rollover or ejection, Fall >10 ft or 3 m, Pedestrian hit by car
***Physical Exam
****Midline back pain, Midline focal tenderness, Evidence of spinal cord or nerve root deficit
***Associated injuries
****Cervical fracture, ribe fracture, aortic injuries, hollow viscus injuries
**Plain radiographs or CT scan to evaluate for body abnormality
**Can reformat Chest and Abdomen CT to look at thoracic, lumbar spine
**MRI is diagnostic test of choice to evaluate patients w/ nerve injury
**CT myelography alternative when MRI unavailable
**anterior vertebral body compression fracture with extension through middle of vertebral body into posterior wall
**Compression fracture + increased posterior interspinous spaces caused by distraction
*10% of patients with a spine fracture have second fracture in a different segment
 
*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


==Differential Diagnosis==
==Differential Diagnosis==
{{Thoracic trauma DDX}}
{{Lower back pain DDX}}
{{Lower back pain DDX}}


==Management==
==Evaluation==
LUMBAR
[[File:T12compressionfracMark.png|thumb|[[Thoracic compression fracture]] of T12.]]
===Workup===
*Type and screen/cross, labs including pancreatic enzymes if thoraco-lumbar location


*Stable Fractures - TLSO brace as directed by Neurosurg
*Indications to Image Thoracic and Lumbar Spine after Trauma
**Mechanism
***Gunshot, High energy trauma, Motor vehicle crash with rollover or ejection, Fall >10 ft or 3 m, Pedestrian hit by car
**Physical Exam
***Midline back pain, Midline focal tenderness, Evidence of spinal cord or nerve root deficit
**Associated injuries
***Cervical fracture, ribe fracture, aortic injuries, hollow viscus injuries
*Plain radiographs or CT scan to evaluate for body abnormality
*Can reformat Chest and Abdomen CT to look at thoracic, lumbar spine
*MRI is diagnostic test of choice to evaluate patients with nerve injury
*CT myelography alternative when MRI unavailable
*anterior vertebral body compression fracture with extension through middle of vertebral body into posterior wall
*Compression fracture + increased posterior interspinous spaces caused by distraction
10% of patients with a spine fracture have second fracture in a different segment




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*Wedge
*Wedge
*>50% height (rule out middle column & burst)
*>50% height (rule out middle column & burst)
===Diagnosis===
==Management==
*Spinal precautions
*Consult ortho or neurosurgery (institution dependent)
*Stable fractures
**TLSO brace in discussion with consulting service
*Unstable fractures
**Emergency operative repair unless medically unstable


==Disposition==
==Disposition==
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[[Category:Trauma]]
[[Category:Trauma]]
[[Category:Neurology]]
[[Category:Orthopedics]]

Latest revision as of 21:49, 13 August 2025

Background

  • Injury to thoracic spine necessitates severe force
    • thoracic spine has enhanced stiffness secondary to articulations with the rib cage
    • When spinal cord injury occurs usually complete
    • thoracic spinal canal is narrower than in other regions, increased risk of cord injury
  • Important to evaluate for thoracic spine injuries and aortic injuries in the setting of blunt chest trauma with mediastinlal widening
  • Follows the three column model - 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, ligamentum flavum, facet joint capsule)
  • Unstable if:
    • 50% loss of vertebral height
    • Kyphotic angulation around the fracture:
      • >30' for compression fracture
      • >25' for burst fracture
    • Neurologic deficit

Vertebral fractures and dislocations types

Vertebral anatomy.
Numbering order of vertebrae.

Clinical Features

  • Typically pain over site of injury

Differential Diagnosis

Thoracic Trauma

Lower Back Pain

Evaluation

Thoracic compression fracture of T12.

Workup

  • Type and screen/cross, labs including pancreatic enzymes if thoraco-lumbar location
  • Indications to Image Thoracic and Lumbar Spine after Trauma
    • Mechanism
      • Gunshot, High energy trauma, Motor vehicle crash with rollover or ejection, Fall >10 ft or 3 m, Pedestrian hit by car
    • Physical Exam
      • Midline back pain, Midline focal tenderness, Evidence of spinal cord or nerve root deficit
    • Associated injuries
      • Cervical fracture, ribe fracture, aortic injuries, hollow viscus injuries
  • Plain radiographs or CT scan to evaluate for body abnormality
  • Can reformat Chest and Abdomen CT to look at thoracic, lumbar spine
  • MRI is diagnostic test of choice to evaluate patients with nerve injury
  • CT myelography alternative when MRI unavailable
  • anterior vertebral body compression fracture with extension through middle of vertebral body into posterior wall
  • Compression fracture + increased posterior interspinous spaces caused by distraction

10% of patients with a spine fracture have second fracture in a different segment


CT IF:

  • Compression
  • Wedge
  • >50% height (rule out middle column & burst)

Diagnosis

Management

  • Spinal precautions
  • Consult ortho or neurosurgery (institution dependent)
  • Stable fractures
    • TLSO brace in discussion with consulting service
  • Unstable fractures
    • Emergency operative repair unless medically unstable

Disposition

See Also

External Links

References

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