SA Orthopaedic Journal
Print version ISSN 1681-150X
INTRODUCTION: The proximal thoracic spine is difficult to visualise on X-ray investigation with up to 22% of proximal fractures being missed. This is a major concern, especially in environments such as South Africa where trauma is endemic. AIM: To review the challenges of diagnosis and management in patients with proximal thoracic fractures. METHODS: Thirty-three patients with proximal thoracic fractures in the T1-T4 area managed in a spinal unit were identified. There were 21 males and 12 females with a median age of 31.8 years. A retrospective review of medical records and radiology was undertaken. Demographic data, mechanism of injury, diagnostic modalities, diagnostic delay, fracture characteristics, neurological status, associated injuries, hospital stay, management, complications and outcomes were recorded. RESULTS: The aetiology was 21 MVA passengers, eight drivers, one pedestrian, one assault, one bicycle and one hangglider accident. Eight had a one-day diagnostic delay, two between 2 to 5 days and five greater than 2 weeks. The fractures were A1 in seven, A3 in 14, B1 in seven, C1 in two and C2 in two. Twenty-three patients had neurological compromise, 13 being complete. Twentythree had associated chest and head injuries. Hospital stay was a mean of 27 days (max of 246). ICU median was 14 (max of 115) days. Twenty-six patients underwent surgery, posterior instrumented fusion being the commonest procedure. Although the surgery did not change the median kyphosis (25º pre-op to 20º at 1 year and 21º at 2 years), most kyphotic patients were improved (55º to 45º). CONCLUSION: Proximal thoracic fractures are most commonly encountered following motor vehicle accidents. There is a risk of delayed diagnosis due to poor visualisation with X-ray investigation. There is a high risk of associated spinal cord injury, chest, limb and abdomino-pelvic injuries that result in prolonged hospital stay. These fractures can be managed successfully by posterior pedicle screw fixation and fusion, only if unstable. A high index of suspicion for proximal thoracic fractures should be maintained in all patients involved in high impact accidents and with chest injuries, and CT should be employed if X-rays are unclear.
Keywords : Thoracic; spine; trauma; fracture; delay.