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Updated: Jan 10 2024

Chance Fracture (flexion-distraction injury)

Images xray_moved.jpg xray_moved.jpg
  • summary
    • Chance Fractures are traumatic fractures of the thoracic and lumbar spine that occur by a flexion-distraction injury mechanism and are associated with high rates of mechanical instability and gastrointestinal injuries.
    • Diagnosis of bony Chance fractures is made with radiographs or a CT scan. An MRI may be required to identify a ligamentous Chance injury with disruption of the PLC.
    • Treatment can be nonoperative or surgical spinal stabilization depending on the presence of mechanical instability and/or neurological deficits. 
  • Etiology
    • Mechanism
      • a flexion-distraction injury (seatbelt injury)
        • may be a bony injury
        • may be ligamentous injury (flexion-distraction injury)
          • more difficult to heal
        • middle and posterior columns fail under tension
        • anterior column fails under compression
    • Associated injuries
      • high rate of gastrointestinal injuries (50%)
  • Imaging
    • Radiographs
      • obtain AP and lateral
      • flexion-extension radiographs
    • MRI
      • important to evaluate for injury to the posterior elements
    • CT
      • important to evaluate degree of bone injury and retropulsion of posterior wall into canal
  • Treatment
    • Nonoperative
      • immobilization in cast or TLSO
        • indications
          • neurologically intact patients with
            • stable injury patterns with intact posterior elements
            • bony Chance fracture
        • technique
          • may cast or brace (TLSO) in extension
          • must be followed for non-union and kyphotic deformity
    • Operative
      • surgical decompression and stabilization
        • indications
          • patients with neurologic deficits
          • unstable spine with injury to the posterior ligaments (soft-tissue Chance fx)
        • techniques
          • anterior decompression and stabilization
            • usually with vertebrectomy and strut grafting followed by instrumentation
          • posterior indirect decompression and stabilization and compression fusion construct
            • historically three levels above and two levels below
            • modern pedicle screws have changed this to one level above and one level below
            • distraction construct in burst fractures
            • compression construct in Chance fractures
  • Complications
    • Pain
      • most common
    • Deformity
      • scoliosis
      • progressive kyphosis
        • common with unrecognized injury to PLL
      • flat back
        • leads to pain, a forward flexed posture, and easy fatigue
      • post-traumatic syringomyelia
    • Nonunion
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