Chance Fractures in the Pediatric Population Are Often Misdiagnosed

Abstract

Background: Flexion injuries of the spine range from mild compression fractures to severe flexion-distraction injuries, that is, Chance fractures. Chance fractures are often unstable and Arkader and colleagues demonstrated improved outcomes when Chance fractures are treated operatively compared with those managed nonoperatively.

Methods: A retrospective review was conducted of all patients treated over a 5-year period (2008 to 2013) for a flexion injury, either a Chance or a compression fracture, of the thoracolumbar spine at our tertiary pediatric level I trauma center. Patients were excluded if they had prior spine surgery or had a pathologic fracture.

Results: Of the 26 patients who met the inclusion criteria, 27% (7/26 patients) had a Chance fracture and 73% (19/26) had compression fracture(s). The mean age of the 7 patients with Chance fractures was 14.6 years (range, 13 to 16 y). In total, 71% (5/7) of the patients with Chance fractures were initially misdiagnosed: (3 as compression fractures, 1 as a burst fracture, 1 as muscular pain) and 80% (4/5) of these misdiagnoses were made by a neurosurgeon or orthopaedic surgeon. Average delay to correct diagnosis was 95 days (range, 2 to 311 d), with 57% (4/7) of the patients having ≥1 month delay. These 4 patients with a Chance fracture and ≥1 month delay in correct diagnosis presented to our clinic electively with chronic back pain. None of the patients with Chance fractures had a neurological injury. Six patients with posterior ligamentous disruption were treated with surgical instrumentation and fusion. All Chance fractures occurred between the levels of T12 and L3.

Conclusions: The majority of pediatric Chance fractures in this series were initially misdiagnosed (71%; 5/7) or mistreated (14%; 1/7) by neurosurgeons or orthopaedic surgeons. Mean time to the correct diagnosis was 3 months for the Chance fractures in this series.

Level of evidence: Level IV.