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

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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).

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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

References

Tables

Contributor Information and Disclosures

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