Chance Fracture

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Patients complaining of back pain after motor vehicle accidents or falls from significant heights should be considered to have spinal injuries until proved otherwise. With flexion-distraction mechanisms such as those observed in passengers restrained with lap seatbelts, a progression of injury from the posterior column of the thoracolumbar spine is observed anteriorly. ^[1] When this involves only the osseous structures, a Chance injury exists.

First described in 1948, the Chance fracture represents a pure bony injury extending from posterior to anterior through the spinous process, pedicles, and vertebral body, respectively. ^[2] The Chance fracture most commonly is found in the upper lumbar spine, but it may be observed in the midlumbar region in children. The fracture occurs at a lower level in children because of their lower center of gravity. ^[3]  Rare cases of Chance fracture of the cervical spine have been reported. ^[4]

Flexion-distraction forces are responsible for the Chance fracture, which is one of the three injuries resulting from this mechanism. Usually related to lap seatbelt use, this mechanism can result in complete ligamentous injury or a combination of bony, ligament, and disk involvement. ^{[1, 3, 5]}

The diagnosis is best made on good quality radiographs obtained in two planes (anteroposterior [AP] and lateral). Prompt recognition followed by appropriate reduction and immobilization usually results in a good clinical outcome. Associated intra-abdominal injuries are common, ^{[6, 7, 8]} especially in the pediatric age group, ^{[9, 10, 11]} where the incidence approaches 50%. Thus, intra-abdominal trauma should always be excluded at the time of presentation.

Surgery generally has not been used to treat this injury. Because Chance fracture is a pure bony lesion and reduction is readily obtainable with extension, closed management of this injury has been the treatment of choice.

The usual location for Chance fractures is at the thoracolumbar junction (T10-L2) in adults or the midlumbar spine in the pediatric age group. The fracture lines are found to propagate from the spinous process posteriorly through the lamina, pedicles, and vertebral body anteriorly.

Conceptually, the thoracolumbar spine may be visualized as comprising three columns, as described by Denis. ^[12] The anterior column is represented by the anterior half of the vertebral body, disk, and anterior longitudinal ligament. The middle column consists of the posterior half of the vertebral body, its associated disk, and posterior longitudinal ligament. The posterior column includes the pedicles, facet joints, lamina, and spinous and transverse processes, as well as the ligamentous complex, including the ligamentum flavum.

The anterior and middle columns both are primarily involved in resisting axial loading of the spine. The added importance of the middle column relates to its proximity to the spinal canal and neural elements. Displacement of the middle column can result in neurologic compression and deficits. The posterior column primarily resists tensile forces, such as those encountered in flexion-distraction injuries. In Chance fractures, the bony elements involved fail, with the ligamentous components remaining intact. (See the image below.)

The thoracolumbar spinal junction represents a transitional area from the rigid thoracic spine to the more mobile lumbar region. The thoracic spine’s intrinsic stability is a result of the ribs and their articulation with the spine, the smaller disk spaces, and the frontal orientation of its facet joints. As the lower two thoracic vertebrae (T11-12) lose the anterior rib articulations (floating ribs), the facet joints also change orientation to become more oblique or sagittal, allowing an increase in mobility. ^[13]

Flexion-distraction forces are responsible for the Chance fracture. Usually related to lap seatbelt wear, this mechanism can result in complete ligamentous injury or a combination of bony, ligament, and disk involvement. (See the image below.)

The most common history is that of a back-seat passenger who was involved in a motor vehicle accident while restrained by a lap seatbelt ^[3] or that of a person who fell from a height.

Hu and Lieberman reported a case in which a 67-year-old woman with osteoporosis and thoracic kyphosis experienced a proximal vertebral body Chance fracture after pedicle screw instrumentation and fusion. ^[14]  Pitta et al described a case in which a patient with ankylosing spondylitis experienced a lumbar Chance fracture after undergoing total hip arthroplasty via the direct anterior approach. ^[15]

Fewer than 10% of fractures involving the lumbar spine are a result of flexion-distraction forces. These injuries tend to occur between T12 and L4, with the highest incidence at L2.

With proper recognition and early management of a Chance fracture, near-anatomic reduction and healing can be expected. After 3 months of immobilization in a cast or thoracolumbosacral orthosis (TLSO), a rehabilitation exercise program with emphasis on the extensor muscles of the thoracolumbar spine can assist the return to preinjury activity levels. The ultimate result may not be determined for a year after the injury, with long-term back pain being the major complaint. ^[16]

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 flexion fracture of the spine. Br J Radiol. 1948. 21:452-3.

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. 2016 Dec 23. [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].

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].

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].

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, Nuvasive<br/>Received consulting fee from Nuvasive for speaking and teaching; Received royalty from Globus for consulting.

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.

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.

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

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