Thoracic Spine Fracture

Definition/Description

T9-T10 chance fracture from MVA

Most thoracic fractures occur in the lower thoracic spine, with 60% to 70% of thoracolumbar fractures occurring in the T11 to L2 region, which is biomechanically less stressed. Most of these fractures occur without spinal cord injury. 20% to 40% of fractures are associated with Nerve damage.

Major (high energy) trauma, such as a fall from a height or a road traffic accident, is the most common cause of a chest fracture. [1] In people with conditions related to bone loss such as osteoporosis, minor trauma can also lead to thoracic spine fractures.

Etiology

1. Osteoporosis is the most common predisposing factor for vertebral fractures. However, trauma, cancer, chemotherapy, infection, long-term use of steroids, hyperthyroidism, and radiation therapy can also weaken bones, leading to compression fractures. Causes of low bone density may be Associated with smoking, alcohol abuse, decreased estrogen levels, anorexia, kidney disease, proton pump inhibitors, and other medications. Risk factors include female sex, osteoporosis, osteopenia, age >50, history of vertebral fractures, smoking, vitamin D deficiency, and long-term use Corticosteroids.
2. Trauma is the second most common cause of spinal fractures, and motor vehicle accidents are the number one cause of spinal cord injuries. [2]

Types of Fractures

There are four main types of thoracic spine fractures (by mechanism of injury) and a fifth rare type

1. Compression (wedge fracture) – Caused by isolated axial compression or flexion forces during forward bending of the spine or lateral flexion in trauma. It is a stable fracture and patients rarely have neurological deficits [3]. The most common causes in young patients are falls and motor vehicle accident. In older patients, the most common cause is a minor accident in daily life secondary to osteoporosis or metabolic bone disease. [4]
2. Burst – Similar to a compression fracture, except the entire vertebra is crushed evenly. This is a very serious fracture with backward impingement of bone fragments into the spinal canal. Nerve injury and posterior column injury occurred more frequently. A common cause of this fracture is due to Axial loads on the anterior spine, such as on the hips or lower extremities during a fall, concentrate the axial force at the thoracolumbar junction. [5][6][3]
3. Flexion-Distraction (Seatbelt Injury/Chance Fracture) – Involves separation (distraction) of the fractured vertebra. It is caused by major distraction forces on the spine. The axis of rotation is located within or in front of the anterior vertebral body. rear and middle failure The spine is in tension, usually from trauma caused by a sudden forward bending of the upper body while the lower body remains stationary (a seat belt injury). Often associated with abdominal trauma due to compression of the abdominal cavity at the time of injury. anterior column may be slight Affected but annulus fibrosis and anterior longitudinal ligament intact: prevent dislocation or subluxation. Gaps between spinous processes are usually present on palpation. [3]
4. Fracture-dislocation – combined with displacement of adjacent vertebrae. It is caused by a combination of forces. It is very unstable and can cause complete neurological dysfunction. All three spines failed under compression flexion rotation or shear forces. most Of all thoracolumbar injuries, unstable injuries are highly associated with neurological deficits. They can be caused by severe buckling forces similar to a seat belt injury or an object falling from the back. [3]
5. Clay-Shoveler Fracture – Rare fatigue fracture of the upper thoracic spinous process. Seen in weightlifters or people with high levels of physical exertion, resulting in shear forces or direct trauma to the spine that causes excessive curvature of the vertebrae. [7]

Characteristics/Clinical Presentation

Manifestations of symptomatic fractures include:[8][4][9][10][11][12]

• Chronic back pain in the thoracic and/or lumbar region
• Slower gait
• Reduced range of motion in the thoracic and lumbar spine
• Impaired pulmonary function
• Increased kyphosis – especially in osteoporotic patients with compression fractures
• Neurological deficit due to narrowing of the spinal canal – may occur within 1.5 years of injury

The duration of these symptoms can lead to decreased physical function and activities of daily living and increased risk of disability.

Spinal deformity is also associated with a significantly increased risk of future fractures, including hip fractures [8].

Patients with noncompression fractures are often polytraumatized and have various sources of injury and pain. Clinicians must use their best judgment and employ clinical screening criteria to determine if the thoracic spine is involved. [4]

Differential Diagnosis

Plain radiographs have historically been the gold standard for detecting thoracolumbar fractures, although fractures may be missed on radiographs due to the organs and soft tissues in the thoracic region. A CT scan is recommended to visualize thoracic fractures and an MRI to assess soft tissue damage. [13][9][10]

Multiple myeloma and other cancers may present with chest pain, but there are also other red flags, such as unexplained weight loss and fever.

Scheuermann’s disease manifests as exaggerated thoracic kyphosis with hyperextension anteriorly and schmorl nodules; it can be distinguished by the vertebral height parameters on radiographs. [14]

Examination

Screening for Fracture

Algorithms for screening patients with thoracic fractures and imaging needs have been developed but have not been adequately validated. [4]

The presence of one or more of the following 5 criteria in patients with blunt polytrauma is an indication for thoracolumbar imaging (Sn=0.99):

1. High Risk Mechanism of Injury (MOI):
   • Motor vehicle accident at speed >70 kph
   • Fall from height >3 m
   • ejection from a motor vehicle or motorcycle
   • Any injury outside of these criteria can result in a thoracolumbar fracture
2. Painful distracting injury: Painful trunk/long bone injury sufficient to distract patient from thoracolumbar injury pain
3. New neurologic signs or back pain/tenderness with clinical findings suspicious of a new fracture:
   • Back pain
   • Back tenderness on palpation
   • Palpable step in vertebral palpation
   • Midline bruising
   • Neurologic signs consistent with spinal cord injury
4. Cognitive Impairment:
   • Glasgow Coma Scale (GCS) < 15
   • Abnormal mental state
   • Clinical intoxication
5. Known cervical fractures: evidence for new traumatic cervical fractures. [4]

Other criteria for screening include:

1. X-ray film screening criteria for patients with blunt trauma thoracolumbar injury[11] (Sn=1.00 Sp=0.039)
2. Complaints of thoracolumbar spine pain
   • Thoracolumbar spine tenderness
   • Decreased level of consciousness
   • Intoxication with alcohol or drugs
   • Neurologic deficit
   • Painful distracting injury
3. Three predictors of thoracic fractures based on case-control studies [10] (Sp=0.93):
   • Fall > 2m
   • Thoracic pain
   • Intoxication

Medical Management

Operative

Advantages of surgery for thoracolumbar fractures compared with conservative treatment

• Avoid using orthoses in case of multiple injuries and skin injuries
• Immediate mobilization
• Earlier rehabilitation
• Better restoration of sagittal alignment [15].

Negatives of surgical intervention

• Surgical risks include those of general anesthesia.
• Traditional open surgical techniques may be accompanied by access-related muscle damage, increased infection rates, and higher blood loss.

There was no difference between surgical and nonsurgical treatments in terms of neurological recovery and long-term functional outcomes. [16]

Indications for surgery

• Neurologic involvement and/or progressive neurologic deterioration
• >50% spinal canal compromise
• >50% loss of anterior vertebral body height
• Kyphosis with >25° to 35° angle
• The posterior ligament complex (PLC) is damaged.

Surgical approaches can be combined anterior or posterior. [6] recently described a minimally invasive technique in thoracolumbar fractures.

Non-Operative

Patients with stable burst fractures and neurologically intact compression fractures can usually be treated nonoperatively:[6][15][16][17][18]

• Bed rest/activity restriction ranging from a few days to a few weeks
• Brace: Jewett or Cruciform Anterior Spine Hyperextension (CASH) 8 to 12 weeks
• Casting: 8 to 12 weeks
• Pain medication
• Physical therapy

There is no consensus on the exact duration of treatment.

Preventive treatments for osteoporosis-related fractures include bisphosphonates, calcium, vitamin D, and exercise. [7]

There were no significant long-term differences in pain disability and return to work among non-neurologically affected patients who underwent surgery compared with those who received a brace or cast. [19][16] This suggests that the higher surgical risks and costs may not be justified, and Bracing/casting will be the treatment of choice for this patient population. Bracing is a common part of postoperative and nonoperative thoracic fracture treatment protocols, but there is no evidence that bracing is effective in treating these fractures. .[18]

Physical Therapy Management

• The management of vertebral fractures remains controversial [6] [19] [20], and research has been limited to identifying physical therapy interventions.
• Until recently, conservative management of fractures included pain medication, rest and bracing to reduce spinal motion [21][19][22][16].
• Rehabilitation programs must be designed specifically for individuals based on their physical abilities and disabilities.
• With conservative treatment, most fractures heal within 8-12 weeks with significant pain relief. Significant pain reduction (5.9 cm above VAS) was observed 12-24 hours postoperatively [21].
• Interventions depend largely on whether the patient chooses surgery or conservative management.
• Interventions should always be prescribed and progressed according to patient tolerance.

Physical Therapy Exam

• Complete medical history including MOI and previous spinal fractures
• Neurological screen
• Assess the patient’s pain level and location
• Palpation of the thoracic spine
• Screen for thoracic fracture
• Identifying Impairments in ROM Strength Flexibility

Physical Therapy Goals

• Reduce pain
• Improve posture
• Improve thoracic mobility
• Strengthen trunk extensors
• Improve trunk control
• Provide education
• Lower extremity strengthening

Bennell et al. found that a multimodal treatment approach over 10 weeks was successful in reducing pain and improving function in patients with osteoporotic vertebral fractures [23]. However, since it is a multimodal approach, the effectiveness of each treatment is unknown.

General exercise recommendations [23][24]

• A major concern is refracture within a year of the initial injury.
• Strengthening the dorsi extensors can help reduce refracture rates or prolong the occurrence of refractures [22][23]
• Patients who exercised the posterior extensors reported improved pain levels and increased function. [22][25][26][23].
• Once the body is able, you should start strengthening the back extensors.
• When developing a plan of care, the therapist should consider the individual characteristics and possible secondary limitations of vertebral fractures.

Example Physical Therapy and Home Exercise Program Adapted from: Bennell et al (2010). [23] Progression within a tolerable pain-free range:

Technique/Exercise Dose Duration (Weeks) ImagePostural Taping – Performed by a Physiotherapist Starting at the front of each shoulder, leaning back to the opposite rib, worn throughout 1Soft Tissue Massage – Performed by a Physiotherapist Stroking circular friction petrissage Patient prone to erector spinae rhomboids and upper trapezius 5 minutes 1 – 10 Passive attachment Posterior anterior vertebral mobilization – Level 2-3 mobilization performed by physical therapist Descending from T1 to level 2 below the most painful vertebral region, patient prone 5 mobilizations Central level x 2 reps 1 – 10 Supine rolled towel Towel placed lengthwise along back to promote thoracic extension 5 – 10 minutes 1 (daily) Transversus abdominis (TA) Stable upright sitting forward Sitting on chair (no backrest), retract the chin, retract the scapula and TA contraction 10 sec hold x 5 reps 1 – 10 reps (daily) Seated with elbows back Hands behind head, elbows pointing sideways – use scapula retraction to press elbows back 5 sec hold x 5 reps 1 – 10 times (daily) Seated trunk range of motion Gently rotate hands on shoulders to two direction and lateral bends to each side 5 times each direction 1 – 10 (daily) Trunk mobility in seated position – extended Standing with head against wall, back and heels against wall, with a rolled up towel behind head – retracted Chin hold for 10 seconds x 5 times 1 – 10 (daily) standing angle stretch standing Facing a corner and place hands chest height on each side of wall – close to stretch chest 10 – 30 seconds hold x 3 repetitions 2 – 10 (daily) walk hands up while standing standing facing wall, hands up Walk until arms reach up – then lift hands off wall for 5 seconds x 5 reps 3 – 10 reps (daily) shoulders flexed while lying on back hold cane/towel straight – then arms overhead and held in end range 10 sec hold x 5 reps 3 – 10 reps (daily) Standing Wall Pushups Stand in front of you at shoulder height with your arms facing the wall – keep your body straight and bent Elbows straight 8 – 10 reps x 2 sets 1 – 10 (3 reps/week) Standing wall pushups Dumbbell seated rowing Sit upright – pull hands up toward chest by bending elbows, then lower 8 – 10 reps x 2 sets 1 – 10 (3 reps/week) Seated Overhead Dumbbell pressElbows Bend and Sideways – Push Dumbbells Straight up until arms are extended overhead 8 – 10 reps 2 sets of 3 – 10 (3 reps/week) Supine bridge with knees bent, feet flat on floor – push back and pelvis off floor through feet 5 – 10 second hold x 5 reps 1 – 2 (3x/week) Supine Bridge to Prone Hip Extension Lift one leg off the floor Then another 8 – 10 reps x 2 sets of 3 – 10 (3 reps/week) Prone Hip Extension Half Squat – progress to standing in front of chair with dumbbells, squat down to touch chair with hips – then stand up for 8 – 10 reps x 2 sets of 1 – 2 (3 reps/week) Weightlifting – Gradually master dumbbell lifts and lowers 10 cm steps – alternate legs 8 – 10 reps x 2 sets 3 – 10 (3 reps/week) seated scapula retraction hold theraband with both hands, elbows tucked in at sides – then wrist extension, forearm supination, shoulder out Rotation and retraction of the scapula 8 – 10 reps x 2 sets of 1 – 10 (3 times/week) Shoulder girdle contracted, chin tightened, TA maintains four-point kneeling, transversus abdominis pushes to the floor with hands, knees and feet – then pulls navel upwards, holds for 5 seconds x 8-10 times, repeats 2 Group 2 (3 times/week) Four-point kneeling, single-arm leg-lifting action as above—— Then lift one arm off the ground while lifting the other leg off the ground 8 – 10 times x 2 sets of 3 – 10 (3 times/week) 4 points Kneel TA Keep prone, arms raised, arms at shoulder level tall, elbows bent – engage in scapular retraction, then Lift arms off floor for 5 – 10 seconds Hold x 5 reps 2 – 3 (3 reps/week) Prone Trunk Extension Lift head and shoulders off floor while keeping chin retracted Hold for 5 – 10 seconds Hold x 5 reps 4 – 10 (3 times/week)

Complications to consider [6][20][22]

• Cardiorespiratory compromise
• Additional Fractures
• Refractures
• Osteoporosis
• Prolonged Pain
• Limited Range of Motion
• Limited Strength
• Neurological Compromise
• Postural Dysfunction
• General Deconditioning
• Gait/Ambulation Abnormalities
• Loss of Balance

Clinical Bottom Line

• There is a lack of high-quality evidence for the treatment of thoracic fractures.
• Physiotherapists should be familiar with screening for thoracic fractures and employing an injury-based approach when treating postoperative or nonsurgical patients.

Resources

1. Thoracolumbar fracture. Kerenman DS
2. Fracture of the thoracic spine (without spinal cord injury). MD’s Guide.
3. Fracture and dislocation of the thoracic spine. Medical scene reference.