Abstract
Introduction:
Trauma is endemic in South Africa. The upper thoracic spine is extremely difficult to image and assess clearly with frontline x-rays resulting in up to 22% of proximal fractures being missed.
Aim:
To review a series of 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. A retrospective review of medical records and radiology was undertaken.
Demographic data, mechanism of injury, diagnostic modalities, level and type of fracture, neurological status, associated injuries, hospital stay, management, complications and outcome was recorded.
Results:
There were 21 males and 12 females, with a median age of 31.8 years.
Aetiology was 21 MVA passengers, 8 drivers, 1 pedestrian, 1 assault, 1 bicycle and 1 hanglider accident. Delay in diagnosis was 1 day in 8, 2–5 days in 2 and greater than 2 weeks in 5.
The fractures were A1 in 7, A3 in 14, B1 in 7, C1 in 2 and C2 in 2. Twenty three patients had neurological compromise, 13 being complete. Twenty-three had associated chest and head injuries.
Hospital stay was a mean of 27 days (maximum 246) and ICU stay median 14 (maximum 115) days.
Twenty-six patients underwent surgery, posterior instrumented fusion being the commonest procedure.
Although the surgery did not change the median kyphosis (25° preop to 20°at 1 year and 21°at 2 years), the most kyphotic patients were improved (55°to 45°).
Conclusion:
A high index of suspicion for proximal thoracic fractures needs to be maintained in high energy injuries, especially MVA passengers, where there is chest injury.
Prompt exclusion by appropriate special investigations is mandatory. Once recognized, they can be adequately managed with posterior instrumented fusion, although these patients are resource intensive due to the associated neurological impairment and chest injuries.
