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Spine Injury: Thoracic

Spine Injury: Thoracic is a topic covered in the 5-Minute Emergency Consult.

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Basics

Description

  • The following forces account for most thoracic fractures and dislocations:
    • Axial compression
    • Flexion–rotation
    • Shear
    • Flexion–distraction
    • Extension
  • 3 anatomically distinct columns; if 2 of the 3 columns are disrupted, the spinal column is unstable:
    • Posterior column: Posterior bony arch and interconnecting ligamentous structures
    • Middle column: Posterior aspects of the vertebral bodies, posterior annulus fibrosis, and posterior longitudinal ligament
    • Anterior column: Anterior longitudinal ligament, anterior annulus fibrosis, and anterior vertebral body
  • Major vs. minor fractures:
    • Minor:
      • Isolated articular fracture
      • Transverse process fracture
      • Spinous process fracture
      • Pars interarticularis fracture
    • Major:
      • Compression fracture
      • Burst fracture
      • Seat belt injury
      • Fracture–dislocation
  • Compression fracture (anterior or lateral flexion):
    • Fracture of anterior portion of vertebral body with intact middle column
    • May be posterior column disruption
    • Type A: Fracture through both end plates
    • Type B: Fracture through superior end plate
    • Type C: Fracture through inferior end plate
    • Type D: Both end plates intact
  • Burst fracture (axial loading):
    • Fracture through middle column of spine
    • May have spreading of posterior elements and laminar fractures with possible retropulsion into the spinal canal and potential neurologic compromise
    • Type A: Fracture through both end plates
    • Type B: Fracture through superior end plate
    • Type C: Fracture through inferior end plate
    • Type D: Burst in middle column with rotational injury leading to subluxation
    • Type E: Burst in middle column with asymmetric compression of anterior column
  • Seat belt injury (flexion–distraction):
    • Distraction of posterior and middle columns with anterior column intact
    • Typically caused by lap belts used without shoulder harness
    • Type A: Through bone
    • Type B: Primarily ligamentous
    • Type C: Disruption of bone through middle column
    • Type D: Through ligaments and disc with no middle column fracture
  • Fracture dislocations:
    • Failure of all 3 columns following compression, tension, rotation, or shear forces
    • Type A: Flexion–rotation; fall from height
    • Type B: Shear-violent force across long axis of trunk
    • Type C: Flexion–distraction; bilateral facet dislocation

Etiology

  • Thoracic spine is rigid owing to the support of the rib cage and the costovertebral articulations:
    • The spinal canal is narrowest in the thoracic spine
  • Traumatic thoracic spine fractures require enormous forces. Motor vehicle and motorcycle collisions, pedestrian's struck, and falls (particularly from height >10 ft) account for most fractures:
    • A small percentage are caused by penetrating injuries (see “Spinal Cord Syndromes”)
    • 50% of all spinal fractures and 40% of all spinal cord injuries occur at the thoracolumbar junction (T11–L2)

Pediatric Considerations
  • Suspect child abuse if thoracic spine injury without clear history of motor vehicle trauma.
  • Posterior rib fractures raise index of suspicion for abuse and require closer survey of thoracic spine and entire body for occult injury.


Geriatric Considerations
Increased brittleness of bones in elderly (>65 yr) predispose to fractures with less severe mechanism, falls from lesser height.

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Citation

Rosen, Peter, et al., editors. "Spine Injury: Thoracic." 5-Minute Emergency Consult, 5th ed., Lippincott Williams & Wilkins, 2016. Emergency Central, emergency.unboundmedicine.com/emergency/view/5-Minute_Emergency_Consult/307625/all/Spine_Injury:_Thoracic.
Spine Injury: Thoracic. In: Rosen P, Shayne P, Barkin AZ, et al, eds. 5-Minute Emergency Consult. 5th ed. Lippincott Williams & Wilkins; 2016. https://emergency.unboundmedicine.com/emergency/view/5-Minute_Emergency_Consult/307625/all/Spine_Injury:_Thoracic. Accessed June 18, 2019.
Spine Injury: Thoracic. (2016). In Rosen, P., Shayne, P., Barkin, A. Z., Wolfe, R. E., Hayden, S. R., Barkin, R. M., & Schaider, J. J. (Eds.), 5-Minute Emergency Consult. Available from https://emergency.unboundmedicine.com/emergency/view/5-Minute_Emergency_Consult/307625/all/Spine_Injury:_Thoracic
Spine Injury: Thoracic [Internet]. In: Rosen P, Shayne P, Barkin AZ, Wolfe RE, Hayden SR, Barkin RM, Schaider JJ, editors. 5-Minute Emergency Consult. Lippincott Williams & Wilkins; 2016. [cited 2019 June 18]. Available from: https://emergency.unboundmedicine.com/emergency/view/5-Minute_Emergency_Consult/307625/all/Spine_Injury:_Thoracic.
* Article titles in AMA citation format should be in sentence-case
TY - ELEC T1 - Spine Injury: Thoracic ID - 307625 ED - Rosen,Peter, ED - Shayne,Philip, ED - Barkin,Adam Z, ED - Wolfe,Richard E, ED - Hayden,Stephen R, ED - Barkin,Roger M, ED - Schaider,Jeffrey J, BT - 5-Minute Emergency Consult UR - https://emergency.unboundmedicine.com/emergency/view/5-Minute_Emergency_Consult/307625/all/Spine_Injury:_Thoracic PB - Lippincott Williams & Wilkins ET - 5 DB - Emergency Central DP - Unbound Medicine ER -