From the Guidelines
Thoracic transverse process fractures are commonly associated with injuries to the thoracic aorta, intercostal arteries, and subclavian vessels, and patients with these fractures should undergo thorough vascular assessment, including CT angiography, to evaluate for potential vascular injuries, as recommended by the most recent guidelines 1.
Associated Vascular Injuries
The associated vascular injuries with thoracic transverse process fractures include:
- Thoracic aorta injuries, which can be detected using CT angiography with a high negative predictive value of up to 99% 1
- Intercostal artery injuries, which can be damaged directly by fractured bone fragments
- Subclavian vessel injuries, which can occur in upper thoracic transverse process fractures due to their proximity to the first and second thoracic vertebrae
Importance of Early Detection
Early detection of these vascular injuries is crucial, as unrecognized injuries can lead to life-threatening bleeding or ischemic complications. The use of CT angiography is recommended for evaluating potential vascular injuries in patients with thoracic transverse process fractures, especially those resulting from high-energy trauma 1.
Diagnostic Modalities
While other diagnostic modalities, such as transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE), can be used to evaluate great vessel disease and injury, CT angiography is the preferred method for detecting traumatic aortic rupture and other vascular injuries 1.
Clinical Implications
The clinical implications of thoracic transverse process fractures and associated vascular injuries are significant, and prompt recognition and treatment are essential to prevent morbidity and mortality. The use of CT angiography and other diagnostic modalities can help identify patients at risk for vascular injuries and guide management decisions 1.
From the Research
Associated Vascular Injuries with Thoracic Transverse Process Fractures
- The presence of thoracic transverse process fractures (TTPFs) can indicate the application of a strong force, leading to injuries that result in death at the scene of the event 2.
- Thoracic TPFs are predictive of associated thoracic non-spinal injuries (NSIs), including vascular injuries 3.
- Neck and chest pain are significantly associated with vascular injuries in patients with isolated transverse process fractures (ITPFs) 4.
- Vascular damage, such as rupture, intimal tear, and pseudoaneurysm, can occur in conjunction with thoraco-lumbar fractures, and comprehension of spinal biomechanics and vascular damages is crucial to avoid poor results or decrease mortality 5.
- The current practice of conservative management for isolated transverse process fractures (ITPFs) is supported by evidence, but identification of markers or scenarios where the diagnosis of ITPF is likely to be erroneous is necessary 6.
Types of Associated Vascular Injuries
- Rupture: the most common vascular damage, often requiring open or endovascular repair before spinal fixation 5.
- Intimal tear: a common vascular injury, which can be diagnosed using CT and angio-CT 5.
- Pseudoaneurysm: a type of vascular injury that can occur in conjunction with thoraco-lumbar fractures, particularly in cases of flexion-distraction lumbar artery injury 5.
- Laceration of collateral branches: a type of vascular injury that can occur in cases of rotation-torsion 5.
Diagnosis and Management
- CT and angio-CT are the investigations of choice for diagnosing vascular injuries associated with thoraco-lumbar fractures 5.
- Angiography may also be used to diagnose vascular injuries 5.
- Spine stabilization should always follow vascular repair 5.
- Conservative management, including unrestricted movement, bracing, and orthotics, is often used to manage ITPFs 6.