Chance Fracture
Other Names
- Seatbelt fractures
- Chance Fracture
Background
- This page describes Chance fracture
History
- Named after George Quentin Chance, a British radiologist, who first described them in 1948[1]
Epidemiology
- Needs to be updated
Introduction
Pathophysiology
- Flexion-distraction injuries
- Fulcrum is created by direct impact or force holding a portion of the body in place while the rest of the body moves (hence seatbelt fractures). Spine tears at this junction and creates a top and bottom portion that flex anteriorly and distract posteriorly.
- Can be both bony injuries or ligamentous injuries
- Most often occurs in the upper lumbar region (~50% at thoracolumbar junction). More common in lower lumbar spine in children.
- High association of intra-abdominal injuries (up to 50%)
- If unrecognized can lead to progressive kyphosis.
Risk Factors
- Lap belt only seat belt use. Lower incidence since shoulder strap became commonplace.
- Typical risk factors for spinal fractures still apply:
- History of osteoporosis
- Use of corticosteroids
- Female gender
- Older age (> 50 years old)
- History of spinal fractures
- Malignancy
Differential Diagnosis
Differential Diagnosis Back Pain
- Fractures
- Neurological
- Musculoskeletal
- Autoimmune
- Infectious
- Pediatric
Clinical Features
History
- Onset will follow high velocity event
- Back pain
- Neurologic complaints possible for severe injury with mechanical instability/cord injury
- Abdominal pain possible if there are associated intraabdominal injuries
Physical Exam: Physical Exam Back
- Follow the full ATLS evaluation/ exam
- Look for bruising/ evidence of abdominal trauma
- Palpate the spine for midline tenderness/ step offs/ deformity
- Perform a thorough lower extremity neurovascular exam
Special Tests
- No specific special tests
Evaluation
Radiographs
- Standard Radiographs[2]
- AP, lateral, flexion-extension
- Findings
- Anterior wedge fracture of the vertebral body with a horizontal fracture through posterior elements or distraction of facet joints and spinous processes.
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
Classification
- Osseous injuries
- Includes fractures of the spinous process, pedicles, and the vertebral body
- Ligamentous injuries
- Involve rupture of the interspinous ligament, posterior longitudinal ligament, ligamentum flavum, facet joint capsule, and intervertebral disc
- Osteoligamentous injuries
- Includes elements of both the osseous and ligamentous types
Management
Nonoperative
- Indications[3]
- Neurologically intact patients with stable injury patterns with intact posterior elements
- Isolated bony Chance fracture.
- technique
- May cast or brace (TLSO) in extension
- Must be followed for non-union and kyphotic deformity.
Operative
- Indications
- Patients with neurologic deficits
- Unstable spine with injury to the posterior ligaments (soft-tissue Chance fracture)
- technique
- Anterior decompression and stabilization
- Usually with vertebrectomy and strut grafting followed by instrumentation
- Posterior indirect decompression and stabilization and compression fusion construct.
Rehab and Return to Play
Rehabilitation
- Needs to be updated
Return to Play/ Work
- Needs to be updated
Prognosis and Complications
Prognosis
- Prognosis in a Chance fracture in adults depends on the degree of kyphosis caused by the injury. Those with less than 15 degrees of kyphosis can be treated successfully with an extension cast/orthosis with good to fair results and no neurologic deficit. Chance fractures with more kyphosis are stabilized surgically, with >90% having good results after one year. The degree of kyphosis correlates with the severity of injury in children, also.
- Unfortunately, in a significant number of people, low back pain may be a major complaint in the future.
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
See Also
References
- ↑ CHANCE GQ. Note on a type of flexion fracture of the spine. Br J Radiol. 1948 Sep;21(249):452. doi: 10.1259/0007-1285-21-249-452. PMID: 18878306.
- ↑ Jones J, Kogan J, Vadera S, et al. Chance fracture. Reference article, Radiopaedia.org (Accessed on 09 Jun 2024) https://doi.org/10.53347/rID-10186
- ↑ Koay J, Davis DD, Hogg JP. Chance Fractures. [Updated 2023 Aug 14]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK536926/