summary Chance fractures are traumatic fractures of the thoracic and lumbar spine that occur via 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 CT scan. An MRI may be necessary to identify a ligamentous Chance injury involving disruption of the PLC Treatment can be nonoperative or involve surgical spinal stabilization, depending on the presence of mechanical instability and/or neurologic deficits Etiology Mechanism a flexion-distraction injury (seatbelt injury) may be a bony injury may be a 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 AP and lateral flexion-extension radiographs CT evaluate the degree of bone injury and retropulsion of posterior wall into canal MRI evaluate for injury to the posterior elements Treatment Nonoperative immobilization in cast or TLSO indications neurologically intact patients with: stable injury patterns and intact posterior elements bony Chance fracture technique may cast or brace (TLSO) in extension patients must be followed closely for nonunion and kyphotic deformity Operative surgical decompression and stabilization indications patients with neurologic deficits unstable spine with injury to the posterior ligaments (soft tissue Chance fracture) techniques anterior decompression and stabilization usually with vertebrectomy and strut grafting, followed by instrumentation posterior indirect decompression and stabilization with compression fusion construct historically, fusion included three levels above and two levels below modern pedicle screw systems have permitted stable fusion constructs using 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 of the PLL flat back deformity leads to pain, a forward flexed posture, and easy fatigue posttraumatic syringomyelia Nonunion