Elsevier

Injury

Volume 31, Issue 4, May 2000, Pages 219-223
Injury

Upper thoracic spinal fractures in trauma patients — a diagnostic pitfall

https://doi.org/10.1016/S0020-1383(99)00235-1Get rights and content

Abstract

The diagnosis of upper thoracic spinal fractures in multiple-trauma patients remains a challenge. The clinical findings are often difficult to detect, especially in the presence of other (extremity) fractures, head injuries or in patients on respiratory support.

The findings of chest radiographs and plain spinal films are described in a series of 23 patients with an upper thoracic spinal fracture. Radiographs were retrospectively reviewed by an orthopaedic surgeon and a skeletal radiologist. Fractures were classified according to Magerl and type A1 and A2 compression fractures were excluded. The neurological outcome was assessed using the Frankel scale.

Initially, the fracture was missed in 5 patients (22%), mainly due to concomitant life-threatening injuries. Fractures consisted of type A, B and C in one, 10 and 12 patients, respectively. The main findings were: loss of vertical height of vertebra with or without malalignment (21), widened paraspinal line (21), widened mediastinum (4) and no gross abnormalities (2). Neurological lesions were Frankel A, B, C and E in respectively 14, 1, 1 and 7 patients.

Upper thoracic spinal fractures are easily missed in patients with multiple injuries. In patients with neurological symptoms CT and/or MRI is required as soon as the general condition of the patient permits this.

Introduction

The diagnosis of (upper) thoracic spinal fractures in patients with multiple, often severe, injuries can be difficult. These patients often suffer from coexisting neurological symptoms or head injuries, have multiple (limb) fractures and are often sedated or on respiratory support when first seen in a casualty department. Hence, a neurological evaluation is often unreliable, if possible at all. Furthermore, the requirement of a quick diagnostic work-up and the difficult circumstances surrounding these patients lead to radiographs which are often difficult to interpret, especially by junior staff. The upper thoracic spine is difficult to visualize, even in ideal circumstances. Thus, the combination of clinical and imaging difficulties render upper thoracic spinal fractures liable to being overlooked. Additional diagnostic tests, such as computed tomography or magnetic resonance imaging may not be possible due to pressing interventions for life-threatening complications [1]. Hence, these fractures are frequently not detected until later, which may lead to worsening of the neurological deficit [2].

Although a recent article in this journal drew attention to fractures of the thoracolumbar spine [3], only sparse literature exists with respect to upper thoracic spinal injuries. The main findings which have been described are: dislocation of the spine, loss of height of a vertebra, widening of the para-spinal line, widening of the mediastinum, left apical cap and displacement of the naso-gastric tube [4]. Especially these last three findings may be confused with a traumatic aortic rupture [4], [5], [6]. To complicate matters further, the type of injury associated with upper thoracic spinal fractures is also associated with aortic rupture.

In this study, we assessed the imaging findings and the outcome of a consecutive series of patients with upper thoracic spinal fractures, which were more serious than simple (Magerl A1 or A2) compression type injuries.

Section snippets

Materials and methods

Between January 1983 and December 1998, a series of 26 patients with high thoracic spinal lesions, excluding compression fractures (Magerl types A1 and A2), were identified. Follow-up data were available for 23 (88%) of these patients. Of these patients, 10 were initially seen and investigated in another hospital and subsequently transferred, while the remaining patients were all directly managed in our own trauma unit.

The case records were evaluated to assess the a etiology of the fracture,

Results

The patients studied consisted of 21 male and 2 female patients, varying in age between 16 and 52 yrs (mean 30.3 yr). The causes of their fractures were a traffic related accident (16 patients), a fall from a great height (4 patients) or miscellaneous (3 patients).

At initial examination, 14 patients had a complete neurological lesion (Frankel A), two had incomplete neurological lesions (Frankel B and Frankel C), while 7 patients had no neurological symptoms (Frankel E).

The fractures according

Discussion

The initial diagnosis of upper thoracic spinal fractures remains based on plain films and clinical awareness. In patients who have undergone significant injuring forces, which result in flexion and twisting of the thoracic spine, the diagnosis should be actively sought. This should consist of a careful inspection and palpation of the back, where gaps between spinous processes may be felt within soft tissue swelling. In spite of this, great difficulty may be encountered in obtaining the correct

References (11)

  • M.J.C. Stanislas et al.

    A high risk group for thoracolumbar fractures

    Injury

    (1998)
  • S. Anderson et al.

    Delayed diagnosis of thoracolumbar fractures in multiple-trauma patients

    Academic Emergency Medicine

    (1996)
  • S.D. Gertzbein

    Neurologic deterioration in patients with thoracic and lumbar fractures after admission to the hospital

    Spine

    (1994)
  • L.N. Dennis et al.

    Superior mediastinal widening from spine fractures mimicking aortic rupture on chest radiographs

    American Journal of Roentgenology

    (1989)
  • M.J. Bolesta et al.

    Mediastinal widening associated with fractures of the upper thoracic spine

    Journal of Bone and Joint Surgery

    (1991)
There are more references available in the full text version of this article.

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