Midthoracic Chance Fracture in a Morbidly Obese Polytrauma Patient
The patient is a morbidly obese 63-year-old male who presented as a polytrauma after a ground level fall onto hard concrete. He denies numbness or weakness in extremities, but elicits severe pain in his back and right hip.
Past Medical History
HTN, morbid obesity, gout, type 2 diabetes, diabetic neuropathy, CAD, OSA
The patient is alert and oriented.
He is obese (460 lbs).
Neurologic exam intact, but limited secondary to body habitus and right femur fracture.
The patient is ASIA E.
Figure 1: Image demonstrating patient’s body habitus
During the trauma survey, the patient was found to have DISH (diffuse idiopathic skeletal hyperostosis).
Figure 2: Pre-treatment cervical sagittal CT demonstrating flowing anterior ossification (DISH).
Figure 3: Pre-treatment thoracic sagittal CT demonstrating flowing anterior calcifications with “fish mouth” deformity at T7-T8
Figure 4: Pre-treatment thoracic sagittal CT demonstrating disruption of the inferior T7 endplate
Figure 5: Pre-treatment thoracic coronal CT demonstrating T7-T8 fracture
The patient was diagnosed with a flexion-distraction injury (Chance fracture) through the inferior endplate of T7 and a history of DISH (diffuse idiopathic skeletal hyperostosis).
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During the first 24 hours of being hospitalized, the patient underwent posterior single-stage T6-T9 percutaneous pedicle screw fixation with the goal of early mobilization and treatment of orthopedic injuries.
The EBL was < 50 cc; operating time 103 minutes.
Figure 6: Intraoperative image demonstrating patient positioning
Figure 7: Intraoperative image showing the pedicle screw towers and demonstrating depth of patient’s back
Figure 8: AP fluoro image showing percutaneous pedicle screw placement prior to placing rods
Figure 9: Post-operative sagittal CT showing instrumentation 2 levels above and below T7-T8 fracture
Figure 10: Post-operative axial CT image showing percutaneous pedicle screw placement
At 3-month follow-up after a short stay in rehab, the patient continues to be non-weight bearing from his right femur fracture but is full strength in his lower extremities. He was not braced due to his large size. Incisions are well healed, as seen in Figure 11.
Figure 11: Clinic image showing well-healed incisions
Figure 12: AP x-ray at 3-month follow-up
Figure 13: Lateral x-ray at 3-month follow-up
Dr. Uribe presents an interesting fracture in a very complicated patient. The fracture itself is routine in a DISH patient experiencing an extension trauma. However, in addition to the difficulties presented by the DISH itself, this patient has multiple other co-morbidities not the least of which is morbid obesity. A large literature exists demonstrating increased complications with open surgery in morbidly obese patients, suggesting that in this patient “less is more.” On the other hand, prolonged bed rest in this patient could be equally disastrous, so surgery a reasonable option.
That being said, none of the traditional options are ideal in this patient. We have already said that immobilization necessitated by non-operative therapy in this patient carries a high risk. On the other hand, open thoracotomy or open posterior fusion and stabilization also are associated with a high complication rate in this group. Dr. Uribe’s decision to proceed with a percutaneous stabilization in this patient is an excellent alternative. Because of the nature of the fracture, autograft or allograft fusion substrate is not necessary to achieve fusion in this patient. Thus, all is that needed is alignment and stabilization. Percutaneous instrumentation can be performed in minimal time, with minimal blood loss. It minimizes potential infection, and maximizes rapid entry into rehabilitation. Literature is currently developing which demonstrates that major spine procedures can be performed in morbidly obese patients with complication rates equivalent to non-obese patients. Thus, in this complicated patient, I believe this is the best available treatment option.