Unlucky Back Pain

Author: BuMin Kong, MD; Susie Lee, BA

Peer-Reviewer: Mark Hopkins, MD

Final Editor: Alex Tomesch, MD

35yr old male BIBA after MVA. Patient was wearing a lap belt without a shoulder harness and is now complaining of abdominal and back pain. Physical exam shows an abdominal seatbelt sign with pain in the abdomen and upper lumbar spine. CT is shown below.

Image 1: Case  of Dr Gagandeep Singh, Radiopaedia.org, rID: 7770

1. What is your diagnosis? 

2. How does the mechanism specifically cause this injury?

3. What other injuries are associated with this diagnosis?

4. What is your management in the ED?

-- See below for answers --

1. What is your diagnosis?

Chance fracture, also called a seat belt fracture, is an unstable flexion-distraction fracture that most commonly affects the thoracolumbar junction

Image 1: Case courtesy of Dr Gagandeep Singh, Radiopaedia.org, rID: 7770. Annotation by authors

• Pearl: A distraction injury is a fracture that causes a separation of the two fracture fragments

2. How does the mechanism specifically cause this injury?

A Chance fracture occurs when the spine flexes over a fulcrum (commonly a lap seat belt) and causes a wedge fracture of the anterior column and a distraction fracture of the middle and posterior column. [1]

Image 2: Case courtesy of Dr Bruno Di Muzio, Radiopaedia.org, rID: 46533. Annotation by authors

3. What other injuries are associated with this diagnosis?

Given the mechanism of injury, up to 50% of Chance fractures are associated with gastrointestinal injuries such as bowel perforation, bladder perforation, and mesenteric laceration. [1-2]

• Pearl: Although less likely than GI injuries, neurologic deficits can also occur if there is retropulsion of the posterior column into the spinal canal

4. What is your management in the ED?

The patient should be maintained in strict spinal precautions and a spine surgeon should be consulted as guided by institutional protocols. MRI can better dictate treatment by assessing for spinal stability and posterior longitudinal ligament (PLL) injury. Along with additional trauma workup, patients should likely be admitted for further management. 

• Pearl: Neurologic deficits or PLL injury are generally managed surgically, while immobilization with a cast or TSLO brace may occur in their absence. Nonoperative treatment has an increased risk for scoliosis, kyphosis, and nonunion, making good follow-up vital. [3]

Reference

1. AlJallaf M, AlDelail H, Hussein L. Let's review Chance fracture. BMJ Case Rep. 2015 Feb 19;2015:bcr2014206924. doi: 10.1136/bcr-2014-206924. PMID: 25697298; PMCID: PMC4336891

2. Koay J, Davis DD, Hogg JP. Chance Fractures. 2020 Dec 2. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan–. PMID: 30725611.

3. Egol K, Koval, KJ, Zuckerman JD. Handbook of Fractures. Lippincott Williams & Wilkins. 2010 ISBN: 160547760

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