Chance Fracture in an Unbelted Rear Seat Passenger

Okunlola, Abiodun Idowu; Adeolu, Augustine Abiodun · 2019 · Crossref

DOI: 10.4103/jnrp.jnrp_164_18

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Summary

This case report addresses the unusual occurrence of a Chance fracture in an unbelted rear seat passenger, challenging the conventional understanding that this injury is primarily associated with seat belt usage. Chance fractures are flexion-distraction injuries typically resulting from motor vehicle collisions where the lap belt acts as a fulcrum. While rare, such fractures can occur in unbelted individuals or following falls. The authors present a specific case to highlight the mechanism of injury in the absence of a seat belt and to demonstrate the efficacy of conservative management for bony Chance fractures without neurological deficits. The study details the clinical presentation of a 22-year-old female who was an unbelted passenger in an 18-seater bus involved in a lone accident. She presented with low back pain and difficulty lifting her lower limbs. Clinical examination revealed tenderness from T10 to L5, a positive pelvic compression and distraction test, and signs of right hip dislocation and left femoral shaft fracture. Diagnostic imaging via whole-body CT confirmed an L1 bony Chance fracture, fractures of L2 to L5 spinous processes, right hip fracture-dislocation, and a left femoral shaft fracture. Notably, there was no evidence of intra-abdominal injury, which is common in seatbelt-related Chance fractures. The patient underwent closed reduction for the hip and open reduction with internal fixation for the femoral fracture. The spinal injury was managed non-operatively; the patient was nursed flat on a water bed for eight weeks. The results indicated satisfactory bony union of the L1 fracture, confirmed by dynamic X-ray studies after the eight-week period. The patient experienced no neurological deterioration and was able to ambulate using a Zimmer’s frame before discharge. The authors note that the absence of internal fixation for the spine was due to the lack of appropriate screws and functional intraoperative fluoroscopy, as well as the presence of spinous process fractures which precluded specific stabilization techniques. The case underscores that unbalanced forces acting on the lower limbs can cause twisting of the thoracolumbar spine, leading to secondary spinal injury even without direct seatbelt restraint. The significance of this report lies in its demonstration that Chance fractures can result from mechanisms other than seatbelt restraint, specifically through twisting forces transmitted from lower limb injuries. It highlights the importance of a high index of suspicion and judicious use of imaging, particularly CT scans, for diagnosis. Furthermore, it supports the conclusion that conservative care can achieve satisfactory bone union in young patients with bony Chance fractures who lack neurological deficits, avoiding the need for internal or external fixation. This expands the clinical understanding of injury mechanisms and treatment options for spinal trauma in unbelted passengers.

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• seat belt use