Chance fracture

Background

• Unstable spinal fracture
  • Extends horizontally posterior to anterior through the spinous process, pedicles, vertebral body
• Caused by flexion-distraction forces; ex. seatbelt use in MVC
  • Upon deceleration, the spine forcibly flexes over the seatbelt, distracting (pulling apart) the middle/posterior column of spine
  • Most common at T12-L2 due to spinal curvature and mechanism
• Incidence of concurrent intra-abdominal hollow viscus injuries is 50%
  • Ex. bowel perforations and mesenteric lacerations
  • Intra-abdominal injuries more commonly associated than neuro deficits
• May be misdiagnosed as anterior compression fracture (usually stable)

Vertebral fractures and dislocations types

Vertebral anatomy.

Numbering order of vertebrae.

• Cervical fractures and dislocations
  • Atlanto-occipital dissociation
  • C1
    • Jefferson fracture
    • C1 isolated anterior arch fracture
    • C1 isolated posterior arch fracture
  • C2
    • Odontoid fracture
    • Hangman's fracture
  • C3-C7
    • Cervical burst fracture
    • Cervical spinous process fracture
    • Extension cervical teardrop fracture
    • Flexion cervical teardrop fracture
    • Anterior cervical wedge fracture
  • Cervical facet dislocation
  • Isolated transverse process fracture
• Thoracic and lumbar fractures and dislocations
  • Chance fracture
  • Thoracic burst fracture
  • Lumbar burst fracture
  • Isolated transverse process fracture
  • Thoracic and lumbar compression fractures

Clinical Features

• Back pain and thoracolumbar midline spinal tenderness to palpation
• Seatbelt sign: ecchymosis across the abdominal wall in the location of a lap belt
• Abdominal pain
• Lower extremity neurological deficits

Differential Diagnosis

Lower Back Pain

• Spine related
  • Acute ligamentous injury
  • Acute muscle strain
  • Disk herniation (Sciatica)
  • Degenerative joint disease
  • Spondylolithesis
  • Epidural compression syndromes
    • Spinal cord compression (non-traumatic)
    • Cauda equina syndrome
    • Conus medullaris syndrome
    • Epidural abscess (spinal)
    • Epidural hematoma (spinal)
  • Thoracic and lumbar fractures and dislocations
  • Cancer metastasis
  • Spinal stenosis
  • Transverse myelitis
  • Vertebral osteomyelitis
  • Ankylosing spondylitis
  • Spondylolisthesis
  • Discitis
  • Spinal Infarct
• Renal disease
  • Kidney stone
  • Pyelonephritis
  • Nephrolithiasis
• Intra-abdominal
  • Abdominal aortic aneurysm
  • Ulcer perforation
  • Retrocecal appendicitis
  • Large bowel obstruction
  • Pancreatitis
• Pelvic disease
  • PID
• Other
  • Retroperitoneal hemorrhage/mass
  • Meningitis

Evaluation

Chance fracture of T10 and fracture of T9 due to a seatbelt during an MVC on xray.

Chance fracture of T10 and fracture of T9 due to a seatbelt during an MVC on CT.

Workup

• Obtain sagittally-reconstructed CT of thoracic and lumbar spines if suspect lap-belt mechanism or flexion-distraction
  • Evaluate for retropulsion of bony fragments
• Obtain MRI to evaluate for ligamentous injuries or spinal cord injuries
• Obtain CT chest/abdomen/pelvis if suspecting intra-abdominal injuries

Diagnosis

• Pure bony injury from posterior to anterior through:
  • Spinous process
  • Pedicles
  • Vertebral body

Management

• If no neurologic deficits present:
  • Non-operative immobilization with cast or TLSO
• If neurologic deficits present:
  • Surgical decompression and fixation/fusion

Disposition

• Admit

See Also

• Thoracic and lumbar fractures and dislocations