Skip to textbook content
Doctor’s PassportTextbook
TopicsAll topics

Loading topic navigation…

Textbook navigation
TopicsAll topics

Loading topic navigation…
← Musculoskeletal medicine and orthopaedics indexChapter sections
OverviewAetiologyPathophysiologyClinical features and red flagsInvestigationsDifferential diagnosisManagementComplicationsMonitoring and follow-upSpecial situationsCommon pitfallsQuestionsSources
Full textbook13 sectionsOpen only what you need
Educational draft · awaiting clinical reviewThe full textbook explains uncertainty but does not replace live national or local guidance, specialist advice, or current prescribing information.

Thoracolumbar fracture patterns

Musculoskeletal medicine and orthopaedics · UK scope · Sources checked 27 Aug 2026 · Clinical review pending

RapidFull
!
Unstable fracture with neurological compromise

Burst, distraction, translation and ankylosed-spine fractures can compress cord, conus or cauda equina and may deteriorate with shock, transfers or uncoordinated movement.

Action: Maintain the safest spinal alignment, run ABCDE, document motor, sensory and sacral function, treat haemorrhage, obtain urgent complete CT and MRI when neurology is attributable to spinal injury, and involve spinal surgery immediately for deficit, canal compromise or mechanical instability.

Overview

Recognise stable and unstable thoracolumbar injury patterns, examine cord and cauda equina function, select CT and MRI stepwise, and protect alignment while specialist operative or non-operative care is agreed.

The thoracolumbar junction is vulnerable because the rigid thoracic spine transitions to the mobile lumbar spine. Assessment begins with ABCDE and mechanism. Inspect and palpate the whole spine without repeated log rolling, and examine abdomen and pelvis. Record leg and sacral neurology before and after transfer. Shock is presumed haemorrhagic until sources are controlled; lower thoracic cord injury can also contribute neurogenic physiology.

Compression wedge fractures result from anterior loading and may be stable when posterior wall and ligament complex remain intact. Burst fractures result from greater axial load and involve the posterior vertebral wall, with retropulsed fragments in the canal. Canal appearance alone does not define neurological outcome, but deficit, progressive deformity and posterior tension-band damage increase urgency and instability.

Practice

Two practice questions

Your practice draft is saved in this browser.

Question 1 of 2
0 correct
Musculoskeletal medicine and orthopaedicsOriginal SBA

Chance fracture association

A restrained passenger has a horizontal flexion-distraction thoracolumbar fracture and a prominent lap-belt mark. Which associated injury deserves particular attention?

Choose one answer, then submit
← Rapid synopsisBack to overviewAll Musculoskeletal medicine and orthopaedics topics →
Sources and review status4 sources · checked 27 Aug 2026 · clinical review pending+
Sources

Sources and review status

National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 27 Aug 2026; clinical approval remains outstanding.

  • NICE NG41 Spinal injury: assessment and initial management
  • BOASt assessment of the spine in the trauma patient
  • BOASt the management of traumatic spinal cord injury
  • Paracetamol 500 mg tablets Summary of Product Characteristics

Editorial contact: Doctor’s Passport editorial team. Source-check date is separate from clinical approval. Report a content problem · Content changes

Authoring stateComplete draftClinical stateAwaiting reviewJurisdictionUnited Kingdom
Flexion-distraction injuries fail the posterior tension band. A bony horizontal Chance line may cross body, pedicles and posterior elements, while ligamentous forms can be subtle on CT. Seat-belt abdominal marks and this fracture pattern should trigger assessment for bowel, mesenteric and pancreatic injury. Translation and rotation injuries disrupt alignment across all columns and are highly unstable, often with severe neurological injury.

Extension fractures occur particularly in ankylosing spondylitis and DISH, where the fused spine acts as a long lever. A low-energy fall can produce a three-column fracture and epidural haematoma, and pain may be misattributed to chronic disease. Preserve the person's habitual alignment during transfer and CT. Image the whole spine because non-contiguous injuries occur and plain radiographs are easily obscured by shoulders, osteoporosis and deformity.

CT is the preferred acute adult study, using sagittal and coronal reformats and complete coverage of junctions. Review vertebral height, posterior wall, pedicles, facets, interspinous distance, translation and paraspinal haematoma. MRI is needed urgently for neurological abnormality attributable to the spine and selectively for suspected posterior-ligament, disc or epidural injury that will alter management. Imaging should be discussed with a spinal specialist, not classified in isolation.

Management is based on stability, neurology, deformity, pain, bone quality, associated injury and the person's function. Protect an unstable pattern and transfer with a coordinated plan. Stable compression injury without deficit may be managed with effective analgesia, early mobilisation and sometimes an orthosis after specialist review. Unstable distraction or translation, progressive deformity, significant canal compromise with deficit and many ankylosed-spine fractures need operative stabilisation, with decompression when neural compression is clinically relevant.

Follow-up assesses more than radiographic union. Recheck power, sensation, bladder and bowel, pain, posture, skin and mobility. Avoid prolonged bed rest where stability permits because respiratory, pressure and thrombotic harm appears quickly. Assess osteoporosis after fragility fracture and investigate cancer or infection when the pattern is pathological. Provide clear lifting, brace, work, driving and red-flag instructions with named spinal follow-up.

Key points

  • Use mechanism and full-spine examination: a single painful level does not exclude non-contiguous fracture, particularly with high energy or an ankylosed spine.
  • Document leg myotomes, dermatomes, reflexes and sacral sensation, deep anal pressure and voluntary contraction when cord, conus or cauda equina injury is possible.
  • Compression wedge affects mainly anterior body; burst includes posterior-wall failure and retropulsion; flexion-distraction fails the posterior tension band; translation or rotation is highly unstable.
  • CT with multiplanar reformats is the preferred acute test in adults when thoracolumbar imaging is indicated and defines bone, alignment and canal fragments.
  • MRI follows CT urgently for neurological abnormality attributable to spinal injury and helps define cord, conus, cauda equina, disc, epidural and posterior-ligament damage.
  • Maintain the patient's pre-injury alignment in ankylosing disease; forcing a kyphotic spine flat can displace an unstable extension fracture.
  • Stable compression patterns without neurology may receive analgesia and early specialist-guided mobilisation, while instability, deformity, canal compromise or deficit often requires surgical stabilisation or decompression.
  • Search for abdominal injury with Chance-type lap-belt fractures and for osteoporosis or malignancy after low-energy or pathological patterns.

Aetiology

01

Axial compression

Fall onto feet or buttocks and vertical loading compress vertebral body, producing wedge or burst injury depending on energy and posterior-wall involvement.

02

Flexion-distraction

Lap-belt and fulcrum mechanisms pull posterior and middle columns apart, causing Chance-type bone or ligament injury and associated abdominal trauma.

03

Translation and rotation

High-energy shear displaces one spinal segment relative to another, disrupting all columns and creating severe instability and neurological risk.

04

Fragility or pathology

Osteoporosis, ankylosis, metastasis and infection weaken the spine, producing fractures from low energy with non-contiguous or progressive collapse.

Pathophysiology

  1. 1
    Anterior wedge compression

    Failure of the vertebral anterior column creates height loss and kyphosis while the posterior wall and ligament complex may remain intact.

  2. 2
    Burst retropulsion

    Axial force fractures anterior and middle columns and pushes posterior-wall fragments into the canal, with neurological effect varying by level and fragment position.

  3. 3
    Posterior tension-band failure

    Bony Chance fracture or ligament rupture opens posterior elements and creates instability even when vertebral-body compression looks modest.

  4. 4
    Canal neural injury

    Cord above the conus, mixed conus injury and cauda equina roots can be compressed, contused or stretched, producing different motor, sensory and sphincter patterns.

Clinical features and red flags

Stable wedge pattern

Anterior height loss without posterior-wall, posterior-ligament or neurological abnormality may represent a stable compression injury after specialist review.

Burst pattern

Posterior vertebral-wall fragmentation, interpedicular widening and canal retropulsion after axial load identifies burst morphology and prompts detailed neurological assessment.

Flexion-distraction pattern

Horizontal posterior-element injury, widened interspinous distance, facet distraction or lap-belt mechanism indicates tension-band failure and possible abdominal injury.

Translation pattern

Facet dislocation and vertebral displacement in sagittal or coronal planes signals severe multi-column instability and urgent operative assessment.

Ankylosed-spine fracture

New focal pain, posture change or neurology after minor trauma in a rigid spine suggests an unstable long-lever injury until whole-spine CT proves otherwise.

Conus or cauda equina deficit

Saddle change, urinary retention, reduced anal contraction and mixed upper- or lower-motor-neuron leg signs require emergency MRI and decompression discussion.

Red flags requiring action

  • New leg weakness, sensory level, saddle anaesthesia, urinary retention, reduced anal tone or bilateral radicular pain indicates cord, conus or cauda equina compromise requiring emergency MRI and spinal review.
  • High-energy flexion-distraction, translation or axial-load mechanism, palpable step, widened interspinous gap or CT posterior-ligament concern suggests unstable multi-column injury.
  • Ankylosing spondylitis, DISH, osteoporosis, long-term steroids or cancer creates unstable or pathological fracture risk after minor force and warrants a low threshold for whole-spine CT.

Investigations

  1. 01
    Preferred CT thoracolumbar spineFirst stepPreferred
    Why
    Define acute bone morphology, alignment and canal compromise.
    Interpretation and limitations
    Use thin slices and multiplanar reformats with complete junction coverage; image the whole spine in ankylosed or high-risk non-contiguous patterns.
  2. 02
    MRI after CT
    Why
    Assess cord, conus, roots, disc, epidural blood and posterior ligament complex.
    Interpretation and limitations
    Obtain urgently when neurological abnormality could be spinal and selectively when ligament status will change stability classification or treatment.
  3. 03
    Full neurological examination
    Why
    Localise cord, conus or cauda equina dysfunction and establish baseline.
    Interpretation and limitations
    Record motor, sensory, reflex and sacral function with limitations, then repeat after movement, reduction and surgery.
  4. 04
    CT chest, abdomen and pelvis
    Why
    Identify associated visceral and haemorrhagic injury after high-energy or flexion-distraction trauma.
    Interpretation and limitations
    Bowel and mesenteric injury may accompany a lap-belt Chance fracture and can evolve despite initially subtle findings.
  5. 05
    Bone-health laboratory assessment
    Why
    Identify contributors after fragility vertebral fracture.
    Interpretation and limitations
    Use calcium, vitamin D, renal, thyroid and myeloma or other testing according to age and clinical context rather than a fixed panel for every fracture.
  6. 06
    Upright follow-up radiographs
    Why
    Assess alignment under load in selected conservatively managed stable injuries.
    Interpretation and limitations
    Use only after specialist approval; increasing kyphosis, collapse or pain changes the management discussion.

Differential diagnosis

01

Muscular back strain

Paraspinal pain without midline tenderness or high-risk mechanism may be soft tissue, but cannot be assumed in osteoporosis or unreliable examination.

02

Renal or retroperitoneal injury

Flank pain, haematuria and shock after torso trauma may arise from kidney or vascular damage alongside or instead of vertebral injury.

03

Pathological collapse

Night pain, weight loss, cancer, infection, steroid exposure or multiple atraumatic levels suggest weakened bone requiring oncological or infectious investigation.

04

Hip or pelvic fracture

Groin pain, inability to bear weight and sacral tenderness can refer to the back and need pelvic imaging, especially after frailty falls.

Management

01ImmediateProtect, examine and imageFirst stepThoracolumbar pain, high-risk mechanism or neurological symptoms follow trauma.+
  1. 1Run ABCDE, control haemorrhage and maintain the safest alignment using coordinated transfer, especially in ankylosing disease.
  2. 2Examine the whole spine and document motor, sensory and sacral function, bladder symptoms and abdominal signs.
  3. 3Obtain complete CT with multiplanar reformats and urgent MRI when neurology is attributable to cord, conus or cauda equina injury.
  4. 4Discuss instability, deficit, deformity and associated abdominal injury promptly with spinal and trauma specialists.
02DefinitiveChoose stable or unstable pathwayDefinitiveImaging and repeated examination define morphology, neurology and posterior-ligament concern.+
  1. 1For a stable compression pattern without deficit, provide analgesia and specialist-guided early mobilisation, with an orthosis only when it serves a defined purpose.
  2. 2For distraction, translation, unstable burst, progressive deformity or ankylosed-spine fracture, maintain protection and plan operative stabilisation.
  3. 3Use decompression when clinically relevant neural compression and deficit warrant it, coordinated with fixation and overall trauma physiology.
  4. 4Treat abdominal, chest, pelvic and pathological-bone causes in parallel rather than viewing the vertebra in isolation.
03Follow-upRestore function and detect collapseAcute stability and operative or non-operative plan are established.+
  1. 1Set explicit movement, lifting, brace, weight-bearing and therapy instructions and avoid unnecessary prolonged bed rest.
  2. 2Repeat neurological, bladder, bowel, skin, pain and function review and obtain load-bearing imaging only at the specialist interval.
  3. 3Investigate and treat osteoporosis after fragility fracture and pursue malignancy or infection where clinical and imaging features suggest pathology.
  4. 4EscalationEscalate new weakness, saddle symptoms, urinary retention, uncontrolled pain or progressive deformity urgently.
Key medicines and prescribing safety1 treatment · regimens, roles and cautions+
Provides regular non-sedating analgesia to support breathing, examination and mobilisation while stronger agents are titrated when needed.

Paracetamol as baseline fracture analgesia

Give 1 g orally four times daily at intervals of at least 4 hours, maximum 4 g in 24 hours; reduce the maximum for body weight below 50 kg, frailty, malnutrition, chronic alcohol excess or liver impairment.

Check all combination products and hepatic risk, and do not let pain suppression substitute for repeat neurological examination or investigation of worsening deformity.

Complications

01

Neurological deficit

Cord, conus and cauda equina damage causes weakness, sensory loss, neuropathic pain, bladder, bowel and sexual dysfunction.

02

Progressive deformity

Unrecognised posterior-ligament failure or poor bone quality permits increasing kyphosis, pain and sagittal imbalance during healing.

03

Pressure and thrombotic harm

Prolonged flat restriction and immobility cause pressure-related skin injury, chest complications, severe deconditioning and venous thromboembolism.

04

Nonunion or fixation failure

Mechanical instability, smoking, osteoporosis, infection and ankylosed long-lever biomechanics can compromise biological healing, alignment and implanted fixation.

Monitoring and follow-up

  • Repeat leg and sacral neurology, bladder function and respiratory status after every transfer, reduction, operation and new symptom.
  • Inspect pressure areas and review VTE measures daily during movement restriction or postoperative immobility.
  • Track pain, posture, mobility and opioid adverse effects, using analgesia to enable rather than replace examination and rehabilitation.
  • Review final CT and MRI reports for non-contiguous injury, posterior-ligament findings and pathological features.
  • At follow-up, assess alignment, union, neurological function and bone health with an urgent pathway for late deficit or sphincter change.

Special situations

Morphology predicts questions

A wedge prompts posterior-wall review, a burst prompts canal and neurology review, and distraction prompts ligament and abdominal review.

Chance means check abdomen

The same lap-belt flexion that opens the spine can injure bowel, mesentery and pancreas.

Ankylosis hides instability

Chronic stiffness and minor mechanism are falsely reassuring in a spine that behaves as one fragile long bone.

Canal narrowing is not the whole decision

Neurology, ligament integrity, deformity, pain, bone quality and progression determine treatment with morphology.

Early mobilisation needs permission

It benefits stable injuries but can be hazardous when posterior tension-band failure has not been excluded.

Common pitfalls

  1. 01

    Imaging only the painful level in a high-energy or ankylosed-spine injury.

  2. 02

    Calling every anterior wedge stable without reviewing posterior wall, ligaments and neurology.

  3. 03

    Missing bowel or mesenteric injury in a lap-belt flexion-distraction fracture.

  4. 04

    Forcing an ankylosed kyphotic spine flat on a trolley or scanner.

  5. 05

    Accepting normal CT as sufficient despite cord, conus or cauda equina signs.

  6. 06

    Prescribing prolonged bed rest for a stable injury without a mobilisation and VTE plan.