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Chance Fracture Treatment & Management

  • Author: J Allan Goodrich, MD; Chief Editor: Jeffrey A Goldstein, MD  more...
 
Updated: Dec 18, 2014
 

Medical Therapy

Chance fractures can generally be reduced by placing the patient on a Risser table with hyperextension applied to the thoracolumbar junction. A fiberglass or plaster cast is then applied. Alternatively, a mold may be taken and a thoracolumbosacral orthosis (TLSO) made for stabilization. Patient selection is important to ensure compliance with orthosis use.

Once the flexion-distraction injury through the bony elements is approximated, and the kyphosis is reduced through extension of the thoracolumbar spine, the patient is maintained in the TLSO or hyperextension cast for 2-3 months. After immobilization, obtain an upright lateral radiograph to assess any residual deformity. The union rate is high and the results are good with closed management.

A rehabilitation program consisting of extension exercises can be instituted, and most individuals return to work within 6 months. Residual backache may be a problem for the first year after the injury.

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Surgical Therapy

If immobilization is impractical (eg, because of a large body habitus) or the patient has polytrauma, surgical management may be indicated.

A posterior approach to reconstruct the posterior tension band is preferred. This may be accomplished with either a rod-hook, a hook-pedicle screw-rod, or a pedicle screw-rod construct, depending on the individual patient's anatomy and the location of the injury. A similar operative approach may be used with ligamentous variants. Decompression usually is not a result of residual compression in this injury; realignment of the spine is of the utmost importance, followed by stabilization and arthrodesis.

Le et al emphasize the importance of defining the pattern of injury in the pediatric population to determine appropriate treatment.[17] Arkader et al concluded that surgical treatment in children provides the best results.[18]

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Preoperative Details

If operative intervention is selected, a computed tomography (CT) scan detailing the pedicle anatomy is helpful in selecting the appropriate fixation device. If a neurologic injury is present, magnetic resonance imaging (MRI) may be helpful as well.

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Intraoperative Details

Because a Chance fracture involves a flexion-distraction mechanism, placing the patient on rolls providing an extension moment or on the Jackson table prone frame aids in the reduction of this injury.

In a midline approach to the thoracolumbar junction, a level above and a level below the affected area should be dissected. Once the dissection has extended down to the tip of the spinous processes, subperiosteal dissection with Cobb elevators is carried out to the facet joints bilaterally. Further dissection around the facet joints to the transverse processes is performed to complete the exposure necessary for instrumentation.

Surgical gauze for packing the lateral gutters is invaluable in assisting with hemostasis. At each level, troublesome bleeding can be encountered from segmental vessels around the facets and pars interarticularis.

Instrumentation may involve as little as one level above and below the injured site, if pedicle screw fixation is possible. However, standard hook fixation may be used to incorporate two levels above and one or two levels below the zone of injury. A hybrid construct consisting of hooks above and pedicle screws below is also an option.

Closure in layers is performed after a standard posterior lateral arthrodesis is performed. Meticulous decortication of the transverse processes, pars, and lateral aspect of the facet joints should be completed before application of autologous bone grafting.

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Postoperative Details

With optimal surgical fixation, early mobilization should be possible. The usual postoperative concerns of bowel and bladder function and advancing diet should be addressed carefully and individually. Deep vein thrombosis prophylaxis can usually be provided by using compression hose and intermittent dynamic compressive devices, such as a foot pump or Venodyne boot. Other means of anticoagulation may be employed on a case-by-case basis, with care taken to weigh the risks of such therapy against its benefits.

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Follow-up

Arthrodesis usually is complete by 6 months, if not sooner, in younger patients. A rehabilitation program can be instituted as healing progresses and should include a walking routine and back exercises for mobilization and strengthening.

Follow-up radiographs should be obtained at monthly intervals to ensure progressive healing and maintenance of spinal alignment.

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Complications

The most common complications are residual kyphosis and chronic mechanical back pain. Pressure sores under a cast can be avoided with proper padding and cast application and with frequent turning of the patient. Pressure sores can also be avoided by early mobilization.[19]

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Outcome and Prognosis

With proper recognition and early management of a Chance fracture, near-anatomic reduction and healing can be expected. After 3 months of immobilization in a cast or TLSO, a rehabilitation exercise program with emphasis on the extensor muscles of the thoracolumbar spine can assist the return to preinjury activity levels. The ultimate result may not be determined for a year after the injury, with long-term back pain being the major complaint.[20]

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Future and Controversies

With the advent of percutaneous and minimally invasive techniques for pedicle screw insertion, these devices may be applied more easily in multiple-trauma patients and others in whom closed management would be impractical.[21, 22]

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Contributor Information and Disclosures
Author

J Allan Goodrich, MD Staff Physician, Orthopaedic Spine Surgeon, Doctor's Hospital

J Allan Goodrich, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, North American Spine Society, Society of Lateral Access Surgery

Disclosure: Received consulting fee from Nuvasive for speaking and teaching; Received royalty from Globus for consulting.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

William O Shaffer, MD Orthopedic Spine Surgeon, Northwest Iowa Bone, Joint, and Sports Surgeons

William O Shaffer, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Association, Kentucky Medical Association, North American Spine Society, Kentucky Orthopaedic Society, International Society for the Study of the Lumbar Spine, Southern Medical Association, Southern Orthopaedic Association

Disclosure: Received royalty from DePuySpine 1997-2007 (not presently) for consulting; Received grant/research funds from DePuySpine 2002-2007 (closed) for sacropelvic instrumentation biomechanical study; Received grant/research funds from DePuyBiologics 2005-2008 (closed) for healos study just closed; Received consulting fee from DePuySpine 2009 for design of offset modification of expedium.

Chief Editor

Jeffrey A Goldstein, MD Clinical Professor of Orthopedic Surgery, New York University School of Medicine; Director of Spine Service, Director of Spine Fellowship, Department of Orthopedic Surgery, NYU Hospital for Joint Diseases, NYU Langone Medical Center

Jeffrey A Goldstein, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American College of Surgeons, American Orthopaedic Association, North American Spine Society, Scoliosis Research Society, Cervical Spine Research Society, International Society for the Study of the Lumbar Spine, AOSpine, Society of Lateral Access Surgery, International Society for the Advancement of Spine Surgery, Lumbar Spine Research Society

Disclosure: Received consulting fee from Medtronic for consulting; Received consulting fee from NuVasive for consulting; Received royalty from Nuvasive for consulting; Received consulting fee from K2M for consulting; Received ownership interest from NuVasive for none.

Additional Contributors

James F Kellam, MD, FRCSC, FACS, FRCS(Ire) Professor, Department of Orthopedic Surgery, University of Texas Medical School at Houston

James F Kellam, MD, FRCSC, FACS, FRCS(Ire) is a member of the following medical societies: American Academy of Orthopaedic Surgeons, Orthopaedic Trauma Association, Royal College of Physicians and Surgeons of Canada

Disclosure: Nothing to disclose.

References
  1. Eismont FJ. Flexion-Distraction Injuries of the Thoracic and Lumbar Spine. In: Levine A, Eismont FJ, Garfin S, Zigler J, eds. Spine Trauma. Philadelphia, Pa: WB Saunders; 1998:. 402-14.

  2. Chance GQ. Note on a flexion fracture of the spine. Br J Radiol. 1948. 21:452-3.

  3. Gordon ZL, Gillespie RJ, Ponsky TA, Barksdale EM Jr, Thompson GH. Three siblings with Chance fractures: the importance of 3-point restraints. J Pediatr Orthop. 2009 Dec. 29(8):856-9. [Medline].

  4. LeGay DA, Petrie DP, Alexander DI. Flexion-distraction injuries of the lumbar spine and associated abdominal trauma. J Trauma. 1990 Apr. 30(4):436-44. [Medline].

  5. Triantafyllou SJ, Gertzbein SD. Flexion distraction injuries of the thoracolumbar spine: a review. Orthopedics. 1992 Mar. 15(3):357-64. [Medline].

  6. Tyroch AH, McGuire EL, McLean SF, Kozar RA, Gates KA, Kaups KL, et al. The association between Chance fractures and intra-abdominal injuries revisited: a multicenter review. Am Surg. 2005 May. 71(5):434-8. [Medline].

  7. Mulpuri K, Reilly CW, Perdios A, Tredwell SJ, Blair GK. The spectrum of abdominal injuries associated with Chance fractures in pediatric patients. Eur J Pediatr Surg. 2007 Oct. 17(5):322-7. [Medline].

  8. Reid AB, Letts RM, Black GB. Pediatric Chance fractures: association with intra-abdominal injuries and seatbelt use. J Trauma. 1990 Apr. 30(4):384-91. [Medline].

  9. Ragel BT, Allred CD, Brevard S, Davis RT, Frank EH. Fractures of the thoracolumbar spine sustained by soldiers in vehicles attacked by improvised explosive devices. Spine (Phila Pa 1976). 2009 Oct 15. 34(22):2400-5. [Medline].

  10. Schoenfeld AJ, Wood KB, Fisher CF, Fehlings M, Oner FC, Bouchard K, et al. Posttraumatic Kyphosis: Current State of Diagnosis and Treatment: Results of a Multinational Survey of Spine Trauma Surgeons. J Spinal Disord Tech. 2010 Jan 27. [Medline].

  11. Hu X, Lieberman IH. Proximal Instrumented Vertebral Body Chance Fracture after Pedicle Screw Instrumentation in a Thoracic Kyphosis Patient with Osteoporosis. J Spinal Disord Tech. 2012 Jul 19. [Medline].

  12. Smith WS, Kaufer H. Patterns and mechanisms of lumbar injuries associated with lap seat belts. J Bone Joint Surg Am. 1969 Mar. 51(2):239-54. [Medline].

  13. Denis F. The three column spine and its significance in the classification of acute thoracolumbar spinal injuries. Spine. 1983 Nov-Dec. 8(8):817-31. [Medline].

  14. Parizel PM, van der Zijden T, Gaudino S, Spaepen M, Voormolen MH, Venstermans C, et al. Trauma of the spine and spinal cord: imaging strategies. Eur Spine J. 2010 Mar. 19 Suppl 1:S8-17. [Medline].

  15. Bernstein MP, Mirvis SE, Shanmuganathan K. Chance-type fractures of the thoracolumbar spine: imaging analysis in 53 patients. AJR Am J Roentgenol. 2006 Oct. 187(4):859-68. [Medline].

  16. Groves CJ, Cassar-Pullicino VN, Tins BJ, Tyrrell PN, McCall IW. Chance-type flexion-distraction injuries in the thoracolumbar spine: MR imaging characteristics. Radiology. 2005 Aug. 236(2):601-8. [Medline].

  17. Le TV, Baaj AA, Deukmedjian A, Uribe JS, Vale FL. Chance fractures in the pediatric population. J Neurosurg Pediatr. 2011 Aug. 8(2):189-97. [Medline].

  18. Arkader A, Warner WC Jr, Tolo VT, Sponseller PD, Skaggs DL. Pediatric Chance fractures: a multicenter perspective. J Pediatr Orthop. 2011 Oct-Nov. 31(7):741-4. [Medline].

  19. Dimar JR, Fisher C, Vaccaro AR, Okonkwo DO, Dvorak M, Fehlings M, et al. Predictors of Complications After Spinal Stabilization of Thoracolumbar Spine Injuries. J Trauma. 2010 Apr 16. [Medline].

  20. Mulpuri K, Jawadi A, Perdios A, Choit RL, Tredwell SJ, Reilly CW. Outcome analysis of Chance fractures of the skeletally immature spine. Spine. 2007 Nov 15. 32(24):E702-7. [Medline].

  21. Beringer W, Potts E, Khairi S, Mobasser JP. Percutaneous pedicle screw instrumentation for temporary internal bracing of nondisplaced bony Chance fractures. J Spinal Disord Tech. 2007 May. 20(3):242-7. [Medline].

  22. Schizas C, Kosmopoulos V. Percutaneous surgical treatment of Chance fractures using cannulated pedicle screws. Report of two cases. J Neurosurg Spine. 2007 Jul. 7(1):71-4. [Medline].

 
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Chance fracture or modified compression fracture of upper lumbar spine may occur when weight of upper body moves forward (red arrow) while person's waist and upper body are fixed in position by seatbelt or steering wheel of automobile (pink arrows). Consequent fixed-position stress results in fracture.
Anterior view of Chance fracture of L2 vertebral body. Fracture line follows horizontal plane through L2 vertebral body and transverse processes (arrows).
Drawing of Chance fracture of thoracolumbar junction. Defect follows irregular horizontal plane (arrows), which results in disruption of anterior (black dotted line), middle (red dotted line), and posterior columns (blue dotted line).
 
 
 
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