History and Physical Examination

The patient has back pain and, on clinical examination, may have a lap seatbelt abrasion across the abdomen. It is vital to be mindful of the high incidence of associated intra-abdominal injuries, such as liver or spleen lacerations, bowel rupture, or pancreatic injury. Therefore, a thorough examination of the abdomen at the initial evaluation is of the utmost importance.

It is wise to ask for a general surgical consultation at this time to ensure that an occult bowel or other viscus injury is not overlooked. Although neurologic findings are uncommon with this injury, it is nonetheless important to perform a thorough neurologic examination that includes motor, sensory, and reflex evaluation. A rectal and bladder examination should also be performed, including evaluation of the residual urine after the patient has voided. Palpation of the thoracolumbar spine is performed to assess points of maximum tenderness and palpable defects.

Radiographic assessment should begin with anteroposterior (AP) and lateral radiographs of the thoracolumbar spine. A demonstrable fracture line may be detected extending through the spinous process, pedicles, and vertebral body. In general, the diagnosis may be determined on the basis of plain radiographs, but occasionally, computed tomography (CT) scans with frontal and sagittal reconstructions are beneficial.

Complications

If a Chance fracture goes unrecognized, it may result in progressive kyphosis with ensuing pain and deformity.^[19]Associated intra-abdominal injuries can result in increased morbidity and mortality. Ureteropelvic junction disruption associated with Chance fracture has been reported.^[20]Chance fracture leading to traumatic hemothorax has been described.^[21]

Workup

Eismont FJ, Cuartas E. Flexion-distraction injuries of the thoracic and lumbar spine. Zigler JE, Eismont FJ, Garfin SR, Vaccaro AR, eds. Spine Trauma. 2nd ed. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2011.
CHANCE GQ. Note on a type of flexion fracture of the spine. Br J Radiol. 1948 Sep. 21 (249):452. [Medline].
Koay J, Davis DD, Hogg JP. Chance Fractures. Treasure Island, FL: StatPearls; 2020. [Full Text].
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].
Eghbal K, Abdollahpour HR, Ghaffarpasand F. Traumatic Chance Fracture of Cervical Spine: A Rare Fracture Type and Surgical Management. Asian J Neurosurg. 2018 Jul-Sep. 13 (3):906-909. [Medline]. [Full Text].
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].
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].
Triantafyllou SJ, Gertzbein SD. Flexion distraction injuries of the thoracolumbar spine: a review. Orthopedics. 1992 Mar. 15 (3):357-64. [Medline].
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].
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].
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].
Andras LM, Skaggs KF, Badkoobehi H, Choi PD, Skaggs DL. Chance Fractures in the Pediatric Population Are Often Misdiagnosed. J Pediatr Orthop. 2019 May/Jun. 39 (5):222-225. [Medline].
Denis F. The three column spine and its significance in the classification of acute thoracolumbar spinal injuries. Spine (Phila Pa 1976). 1983 Nov-Dec. 8 (8):817-31. [Medline].
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].
Harman F, Guvenc Y, Coskun M, Baran O. Airplane Landing Accident: How Safe Is Use of Passenger Lap Seat Belts in Aircrafts?. World Neurosurg. 2020 Oct. 142:188-190. [Medline].
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. 2015 Feb. 28 (1):31-6. [Medline].
Pitta M, Wallach CJ, Bauk C, Hamilton WG. Lumbar chance fracture after direct anterior total hip arthroplasty. Arthroplast Today. 2017 Dec. 3 (4):247-250. [Medline]. [Full Text].
Mulpuri K, Jawadi A, Perdios A, Choit RL, Tredwell SJ, Reilly CW. Outcome analysis of chance fractures of the skeletally immature spine. Spine (Phila Pa 1976). 2007 Nov 15. 32 (24):E702-7. [Medline].
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 Oct. 23 (7):e1-8. [Medline].
Katagiri A, Yamazaki H, Matsumoto K. Ureteropelvic junction disruption associated with Chance fracture dislocation: A case of seat belt injury. Urol Case Rep. 2020 Jul. 31:101188. [Medline]. [Full Text].
Okamoto K, Ichinose M, Hanaoka J. Traumatic hemothorax due to chance fracture requiring emergency surgical management: A report of two cases. SAGE Open Med Case Rep. 2018. 6:2050313X18819617. [Medline]. [Full Text].
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].
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].
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].
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].
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].
McAnany SJ, Overley SC, Kim JS, Baird EO, Qureshi SA, Anderson PA. Open Versus Minimally Invasive Fixation Techniques for Thoracolumbar Trauma: A Meta-Analysis. Global Spine J. 2016 Mar. 6 (2):186-94. [Medline]. [Full Text].
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].
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].
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 Dec. 69 (6):1497-500. [Medline].

Media Gallery

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).

of 3

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 income in an amount equal to or greater than $250 from: Globus medical<br/>Intellectual property Globus.

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, AOSpine, Cervical Spine Research Society, International Society for the Advancement of Spine Surgery, International Society for the Study of the Lumbar Spine, Lumbar Spine Research Society, North American Spine Society, Scoliosis Research Society, Society of Lateral Access Surgery

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Medtronic, Nuvasive, NLT Spine, RTI, Magellan Health<br/>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.

Chance Fracture Clinical Presentation

History and Physical Examination

Complications

About

Membership

Apps

WebMD Network

Editions

Chance Fracture Clinical Presentation

History and Physical Examination

Complications

References

Tables

Contributor Information and Disclosures

What would you like to print?

Find Us On

About

Membership

Apps

WebMD Network

Editions