Thoracic and lumbar fractures and dislocations: Difference between revisions
 
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**Neurologic deficit
**Neurologic deficit


{{Vertebral fractures and dislocations}}
{{Vertebral fractures and dislocations types}}


==Classification==
==Clinical Features==
===Compression (wedge)===
*Typically pain over site of injury
*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]]===
===[[Lumbar burst fracture]]===
*considered unstable
*Mechanism: axial load with failure of the anterior and middle columns
*Can cause cord damage
===Chance Fracture (Flexion-distraction injuries)===
*Common mechanism: seat belt serves as axis of rotation with failure of middle and posterior columns
*Most common at T12-L2 due to spinal curvature and mechanism
*Pure bony injury from posterior to anterior through:
**Spinous process
**Pedicles
**Vertebral body
*Unstable
*Seat Belt Injury: lap belt worn above the pelvic bones without a shoulder harness
*Mechanism: minor anterior vertebral compression with failure of the middle and posterior columns
*May be misdiagnosed as anterior compression fracture, which is usually stable
*Intra-abdominal injuries more commonly associated than neuro deficits
*Obtain sagittally reconstructed CT if suspect lap-belt mechanism or flexion-distraction
 
===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


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


===Minor Thoracic and Lumbar Spine Fractures===
==Evaluation==
*Transverse process fracture
[[File:T12compressionfracMark.png|thumb|[[Thoracic compression fracture]] of T12.]]
*Spinous process fracture
===Workup===
*Pars interarticularis fracture
*Type and screen/cross, labs including pancreatic enzymes if thoraco-lumbar location


==Imaging==
*Indications to Image Thoracic and Lumbar Spine after Trauma
*Indications to Image Thoracic and Lumbar Spine after Trauma
**Mechanism
**Mechanism
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*Compression fracture + increased posterior interspinous spaces caused by distraction
*Compression fracture + increased posterior interspinous spaces caused by distraction
10% of patients with a spine fracture have second fracture in a different segment
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==
{{Lower back pain DDX}}
==Management==
LUMBAR
*Stable Fractures - TLSO brace as directed by Neurosurg




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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==

Latest revision as of 17:13, 27 October 2020

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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