Superior Endplate Fractures of T4 and T6 from Trauma: Emergency Assessment
Superior endplate fractures of T4 and T6 from trauma alone are not typically considered a medical emergency unless accompanied by neurological deficits, spinal instability, or other concerning features.
Assessment Algorithm
Initial Evaluation
- CT is the gold standard for identifying thoracic spine fractures with a reported sensitivity of 94-100% 1
- Superior endplate fractures are among the most common types of traumatic vertebral fractures, particularly involving the anterior portion of the endplate 2, 3
- Nondisplaced superior endplate fractures are among the fractures that may not alter clinical management 1
Red Flags Requiring Immediate Advanced Imaging
- Presence of neurological deficits requires immediate evaluation for potential spinal cord injury 1, 4
- Progressive neurological symptoms or signs of spinal cord injury warrant urgent MRI 4
- Suspected spinal instability based on fracture pattern or mechanism of injury requires prompt evaluation 4
Imaging Approach
- CT without contrast is recommended for suspected fracture from trauma 4
- Reformatted images from existing chest/abdomen/pelvis CT scans are effective and radiation-dose sparing for thoracolumbar trauma 1, 4
- MRI should be performed if there is clinical concern for spinal cord injury, nerve root compression, or ligamentous instability 1
Clinical Decision Making
Non-Emergency Scenarios (Most Common)
- Isolated superior endplate fractures without neurological deficits or instability can often be managed non-operatively 5
- Minor superior endplate fractures are commonly missed on routine body imaging protocols but typically do not alter clinical management 1
- Traumatic endplate fractures most commonly involve the anterior segments (a1, a2) of the superior endplate 2, 3
Emergency Scenarios
- Spinal cord injury with neurological deficits requires urgent evaluation and potential surgical intervention 1, 4
- Three-column injuries with ligamentous disruption represent unstable injuries requiring surgical stabilization 6
- Multiple trauma patients with thoracic fractures may require damage control approach with staged surgical procedures 1, 7
Important Considerations
- Thoracic spine fractures are commonly associated with other traumatic injuries that may take priority in management 5
- The presence of a single vertebral fracture requires assessment of the entire spine due to the risk of noncontiguous fractures 4
- Patients with ankylosing spondylitis are at higher risk for unstable fractures even with minor trauma 4
Pitfalls to Avoid
- Relying solely on plain radiographs may miss significant thoracic spine injuries, particularly in the upper thoracic region where visualization is limited 1, 4
- Failing to recognize that superior endplate fractures may be part of more complex injury patterns that could affect stability 6
- Overlooking the need for MRI when there is suspicion for ligamentous injury, which can result in delayed diagnosis of instability 1