Treatment of Chance Fracture
The treatment of Chance fracture should be based on fracture stability, with surgical stabilization reserved for unstable fractures (types B, C, D) while stable fractures may be treated conservatively with bracing or casting. 1
Understanding Chance Fracture
Chance fractures are flexion-distraction injuries of the spine characterized by horizontal splitting of the vertebra, often involving the posterior elements, vertebral body, or both. These fractures are relatively rare, representing only about 0.6% of all spinal fractures 1.
Classification
Chance fractures can be categorized into four types based on stability:
- Type A: Stable fractures
- Types B, C, D: Unstable fractures requiring surgical intervention 1
Treatment Algorithm
1. Initial Assessment
- Evaluate fracture stability through radiographic imaging (AP and lateral views)
- Assess for associated injuries, particularly abdominal injuries which are common with Chance fractures
- Complete neurological examination
2. Treatment Options
Conservative Management (for stable fractures)
- Appropriate for Type A fractures with minimal displacement
- Treatment includes:
- Cast or brace immobilization
- Limited weight-bearing
- Pain management with appropriate analgesics
- Progressive mobilization as symptoms allow
Surgical Management (for unstable fractures)
- Indicated for Types B, C, and D fractures
- Surgical options include:
- Posterior spinal fusion with instrumentation
- Percutaneous cannulated pedicle screw fixation in selected cases 2
- Open reduction and internal fixation
3. Surgical Technique Considerations
- Percutaneous cannulated pedicle screws may be used in cases where bone grafting is not necessary, allowing early mobilization while minimizing morbidity 2
- For high thoracic Chance fractures, posterior spinal correction and fusion with instrumentation is recommended to prevent secondary kyphotic deformity 3
- In pediatric patients, specialized instrumentation systems (such as the cannulated NEON system) with CT-controlled positioning of guide wires may be employed 4
Post-Treatment Management
Follow-up Care
- Radiographic evaluation at regular intervals (6 weeks, 3 months, 6 months, and 1 year) to assess:
- Fracture healing
- Implant position
- Potential complications
Complications to Monitor
- Hardware failure
- Non-union
- Progressive kyphotic deformity
- Associated injuries (particularly abdominal injuries)
Important Considerations
Associated Injuries
- Always evaluate for abdominal injuries, even if the patient is asymptomatic
- Abdominal CT scan and MRI provide crucial information for management 5
- Common associated injuries include:
- Small bowel injuries
- Urinary tract disruptions
- Solid organ injuries (liver, spleen)
Special Populations
- Pediatric patients may require specialized instrumentation and techniques 4
- In cases with neurological deficits, early decompression and stabilization are critical
Pitfalls and Caveats
- Chance fractures are frequently not recognized initially, leading to delayed diagnosis 1
- Failure to identify and treat associated abdominal injuries can lead to significant morbidity and mortality
- Secondary kyphotic deformity may develop if unstable fractures are not properly managed, potentially requiring more aggressive treatment later 3
- In cases with implants, removal may be considered after solid fusion is achieved (typically 9-12 months post-surgery) 2