Dr. Ebraheim’s educational animated video describes flexion / distraction injury of the lumbar spine.
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It is sometimes called a seat belt injury or “chance fracture”. Usually, the patient is restrained, back seat passenger that is involved in a car accident and the person is wearing only a lap seat belt. The chance fracture is a variant of the flexion/distraction injury. The terminology is sometimes confusing, but a chance fracture could indicate a bony injury. It may present itself with a minimal compression fracture of the vertebral body, however, in this case all three columns of the spine are injured from distraction and tension. When you deal with a traumatic compression fracture in a young patient that is involved in a car accident, rule out a seat belt injury or “chance fracture”. This condition could be misdiagnosed or not diagnosed. Bowel trauma occurs in these cases due to crushing of the bowel between the lap seat belt and the spinal column, which results in devascularization and acute bowel rupture. In flexion/distraction injury, there will be an anterior wedge fracture of the vertebral body plus horizontal fracture of the posterior elements or distraction of the facet and the spinous processes. If it goes unrecognized, it may lead to progressive kyphosis with pain and deformity. This injury usually occurs in the thoracolumbar junction or in the midlumbar are. The posterior column fails first because of the axis of rotation is anterior to the vertebral body. The flexion/distraction injury is unstable in flexion and usually needs surgery to restore the disrupted tension band and prevent progressive deficit and pain, as well as enhance the functional recovery of the patient. In patients with flexion/distraction injury of the lumbar spine, up to 50% of these patients have associated potential life threatening injures such as visceral and gastrointestinal injury. Look for transabdominal ecchymosis; you will probably need to consult a general surgeon, and this condition occurs more in children. The hallmark of this injury is the axial split of the pedicle which is seen on the sagittal CT scan. There will be little comminution and since the center of rotation is the anterior longitudinal ligament, the posterior ligaments will be disrupted or the posterior neural arch is fractured transversely. Flexion/distraction injury or seat belt injury can be purely bony, purely ligamentous, or mixed. The treatment of flexion/distraction injury, especially if the injury is ligamentous, is usually a posterior reconstruction of the tension part of the spine with short segment fusion with instrumentation. Ligamentous injuries of the spine do not heal (needs to be fused). The bony chance fracture can be stable in extension and the fracture can heal. The fracture could heal, but the fracture will probably need long term follow-up. The fracture could be treated in a TLSO (Thoracic Lumbar Sacral Orthosis) brace and watch the fracture for the development of kyphosis.
23 май 2019
