THORACAL FRACTURE OF

THE SPINE
Supervisor:
dr. Jainal Arifin, M.Kes, Sp.OT(K), Spine
Advisors:
dr Angga Anggriawan
dr Michael BW
FARANUR BINTI SABUDIN
C11111844

ANATOMY

Thompson JC. Netters Concise Orthopaedic Anatomy 2nd Edition.

ANATOMY

Thompson JC. Netters Concise Orthopaedic Anatomy

2nd Edition

ANATOMY

ANATOMY

Thompson JC. Netters Concise Orthopaedic Anatomy 2nd Edition

ANATOMY

Thompson JC. Netters Concise Orthopaedic Anatomy 2nd Edition

COMMON SPINAL CAUSE OF THORACIC

PAIN
DEGENERATIVE
DISORDERS

NEOPLASM

FRACTURE

INFECTION

DEFORMITY

METABOLIC

NEUROGENIC

Spine Secret PLUS Second Edition; Vincent J. Devlin, MD: Chapter 5: Evaluation of Thoracic and Lumbar Spine
Disorders

INTRODUCTION
Anatomic regions of injury:
thoracic spine (T2-T10)
o fractures from T2-T10 are rare due to increased stability of thoracic spine
o fractures include
1. traumatic burst fracture
2. osteoporotic compression fracture
3. fracture dislocation (rare but leads to paralysis in 80%)
. thoracolumbar region (T11 to L2)
o. more commonly affected by spine trauma due to fulcrum of motion (intersection
between stiff thoracic spine and increased motion of lumbar spine)
o. more than 50% of all thoracic and lumbar fractures occur in this region

www.orthobullets.com- thoracic and lumbar trauma

CLASSIFICATIO
N

DENIS
THEORY

Anterior : ALL + 2/3

of
vertebral
body/anulus
Middle : PLL + 1/3
of vertebral body
Posterior : Pedicles,
lamina,
spinous
process,
and
ligaments
Netters Concise Atlas of Orthopaedic; Atlas of Netter, 2nd ed

Specific Injury of Thoracolumbal

.

Compression

Burst

Flexion-distraction injury ( Chance Fractures)

Fracture-dislocation

Eisenstein S, Tuli S, Govender S. The Back. In: Solomon L, Warwick D, Nayagam S, editors. Apley's System of Orthopaedics
and Fractures. Ninth ed. London: Hodder Arnold an Hachette UK Company; 2010. p. 453-91.

Compression
.

Hyper flexion or compressive failure

Anterior column

Stable injury

Eisenstein S, Tuli S, Govender S. The Back. In: Solomon L, Warwick D, Nayagam S, editors. Apley's System of Orthopaedics and
Fractures. Ninth ed. London: Hodder Arnold an Hachette UK Company; 2010. p. 453-91.

Burst Fracture
.

Failure of anterior and middle columns

Predominantly axial load

No posterior column disruption

Stable injuries
.

< 50% retropulsion

<20 degrees kyphosis

Eisenstein S, Tuli S, Govender S. The Back. In: Solomon L, Warwick D, Nayagam S, editors. Apley's System of
Orthopaedics and Fractures. Ninth ed. London: Hodder Arnold an Hachette UK Company; 2010. p. 453-91.

Flexion-Distraction Injury
.

Due to distraction forces of middle and

posterior columns

Usually secondary to seat belt injuries

Boney, purely soft tissue, mixed

Visceral injuries common

Eisenstein S, Tuli S, Govender S. The Back. In: Solomon L, Warwick D, Nayagam S, editors. Apley's
System of Orthopaedics and Fractures. Ninth ed. London: Hodder Arnold an Hachette UK Company;
2010. p. 453-91.

Flexion-Dislocation Injury
.

Segmental displacement may occur with

various combinations of flexion,
compression, rotation and shear.

The injury most commonly occurs at the

thoracolumbar junction.

ATLS Student Course Manual 9th Edition: American College of Surgeons; Chapter 7: Spine and Spinal
Cord Trauma: Pg 199-205

ATLS Student Course Manual 9th Edition: American College of Surgeons; Chapter 7: Spine and Spinal Cord
Trauma: Pg 199-205

HISTORY
TAKING
ANAMNES
IS

RED
FLAGS

Examiner must identify the nature, onset, duration, and course of the
primary complaint; history of previous injury; character and distribution of
symptoms; prior diagnostic testing and treatment; other circumstances
surrounding an injury , and the degree of pain and disability perceived by
the patient
Low back complaints- infection, tumor, fracture
1. Cancer (> 50 years old) :
Previous cancer history, unexplained weight loss, pain not relieved by
bed
rest
2. Infection (osteomyelitis,epidural abscess):
Diabetes and history of tuberculosis.
3. Fracture (> 50 years old):
Trauma, History of corticosteroid use or known osteopenia or
osteoporosis
are also at increase risk of fracture.

Rothman Simone: The Spine Volume 2, 6th Edition: Section II: Diagnosis: The Patient History and Physical Examination: Cervical,
Thoracic, and Lumbar

PHYSICAL
EXAMINATION

Inspection
Deformity, hematom, scar, or gibbus

Palpation
Tenderness, muscle spasm, step off

Reflexes Examination

Neurological Examination

Eisenstein S, Tuli S, Govender S. The Back. In: Solomon L, Warwick D, Nayagam S, editors. Apley's System
of Orthopaedics and Fractures. Ninth ed. London: Hodder Arnold an Hachette UK Company; 2010. p. 45391

PHYSICAL
EXAMINATION

Netters Concise Atlas of Orthopaedic; Atlas of Netter, 2nd ed

NEUROLOGICAL
EXAMINATION

Rothman Simone: The Spine Volume 2, 6th Edition: Chapter 78: thoracic and Lumbar Spinal
Injuries

NEUROLOGICAL
EXAMINATION

Spine Secret PLUS Second Edition; Vincent J. Devlin, MD: Chapter 6: Evaluation of The Spine Trauma Patient

IMAGING
X-RAYS
(ANTEROPOSTERIOR)
Loss of height or splaying of the vertebral body with a crush fracture.
Widening of the distance between the pedicles at one level.
Increased distance between two adjacent spinous processes, is associated with
posterior column damage.
X-RAYS (LATERAL)
Examined for alignment, bone outline, structural integrity, disc space defects and
soft-tissue shadow abnormalities.
Always look carefully for evidence of fragment retropulsion towards the spinal canal.
CT AND MRI
CT showing structural damage to individual vertebrae and displacement of bone
fragments into the vertebral canal.
MRI is the method of choice for displaying the intervertebral discs, ligamentum
flavum and neural structures, and is indicated for all patients with neurological signs
and those who are considered for surgery.

Eisenstein S, Tuli S, Govender S. The Back. In: Solomon L, Warwick D, Nayagam S, editors. Apley's System of
Orthopaedics and Fractures. Ninth ed. London: Hodder Arnold an Hachette UK Company; 2010. p. 453-91

IMAGING

Spine Secret PLUS Second Edition; Vincent J. Devlin, MD: Chapter 10: Radiographic Assessment of The Spine
Pg70-9

IMAGING
Radiograph

Technique

Findings

Clinical
application

THORACIC SPINE
AP (anteroposterior)

Supine, beam to
mid
T-spine

Vertebral bodies

Alignment, scoliosis
(Cobb angle)

Lateral

Lateral, beam to Tspine

Bodies & posterior

elements

Alignment,
kyphosis, scoliosis,
fx

Bending films

AP or lateral w/
bending

Thoracic vertebrae

Access fl exibility of
scoliosis curves

C7, T1, and T2

Used if lateral does

not show C7
Used to rule out
cervical fractures

Swimmers view

Prone, one arm

above
head, beam into
axilla

Netters Concise Atlas of Orthopaedic; Atlas of Netter, 2nd ed

PRINCIPLE OF TREATMENT

To preserve neurological function

To minimize a perceived threat of neurological compression

To stabilize the spine

To rehabilitate the patient

Eisenstein S, Tuli S, Govender S. The Back. In: Solomon L, Warwick D, Nayagam S, editors. Apley's
System of Orthopaedics and Fractures. Ninth ed. London: Hodder Arnold an Hachette UK Company;
2010. p. 805-28

TREATMENT
Without
neurological
injury

With
neurological
injury

Stable

Stable

Unstable

Unstable

Eisenstein S, Tuli S, Govender S. The Back. In: Solomon L, Warwick D, Nayagam S, editors. Apley's System of
Orthopaedics and Fractures. Ninth ed. London: Hodder Arnold an Hachette UK Company; 2010. p. 805-28

TREATMENT
.

Beds: Special beds are used in the management of spinal injuries. They are designed
to avoid pressure sores (with special mattresses or the facility to turn the patient
frequently). Some beds allow postural reduction of fractures.

Brace: A thoracolumbar brace avoids flexion by threepoint fixation. It is suitable for

some burst fractures, seat-belt injuries and compression fractures.

Decompression and stabilization: The aim of surgery is to reduce the fracture, hold the
reduction and decompress the neural elements. The surgical approach can be either
anterior or posterior.

Eisenstein S, Tuli S, Govender S. The Back. In: Solomon L, Warwick D, Nayagam S, editors. Apley's System of Orthopaedics
and Fractures. Ninth ed. London: Hodder Arnold an Hachette UK Company; 2010. p. 805-28

TREATMENT

. Methylprednisolone has been advocated based on its antioxidant and

cell membrane stabilizing properties. A loading dose of 30 mg/kg is
followed by 5.4 mg/kg for 23 hours if administered within 3 hours of
injury or for 48 hours if administered between 3 and 8 hours after
injury. Use of methylprednisolone remains controversial due to
complications, such as infection, gastrointestinal bleeding, pulmonary
and endocrine problems, and an adverse effect on healing of spinal
fusions. Research regarding alternative pharmacologic agents is
currently under way.
Spine Secret PLUS Second Edition; Vincent J. Devlin, MD: Chapter 33: Post0operative Management and
Complications After Spine Surgery