Pterion Prep CraniPro VUMC Case Prep
2026-06-27

Case Prep: Flexion-Distraction (Chance) Injury Fixation

Case / Approach Snapshot

One-Liner

[Age]yo [M/F] with a [T_/L_] flexion-distraction (Chance) injury [bony / ligamentous / combined] following [MVC with lap belt / fall] [± neurological deficit / ± intra-abdominal injury] planned for posterior instrumented fusion.

Figures, Imaging & Video

🎥 Operative video — search operative video on YouTube ▸ · The Neurosurgical Atlas ▸

🧭 Operative approach: Posterior thoracolumbar approach — detailed corridor setup, step-by-step technique & figures

Neurosurgical Atlas · AO Spine / Surgery Reference · Radiopaedia · PubMed Central — operative figures © linked; see media-sources.md

High-Yield Literature

Curated Image Set

Open-access figures are embedded from PubMed Central articles and kept unique to this guide.

Flexion-Distraction Injury Fixation — Fig. 4 Fig. 4. A 19‐year‐old male who presented with an AO Type B2 fracture at L1‐L2 and severe back pain. (A, B) CT scan of the lumbar spine showed an L2 fracture involving the vertebral body and… Source: Comparison of the Outcomes between AO Type B2 Thoracolumbar Fracture with and without Disc Injury after Posterior Surgery — Orthopaedic Surgery 2022; CC BY-NC-ND.

Flexion-Distraction Injury Fixation — Fig. 5 Fig. 5. A 64‐year‐old male with a T12 chance fracture (AO B2) caused by a fall from height. (A) Preoperative sagittal CT images show transosseous failure of the posterior column at T12 with an… Source: Comparison of the Outcomes between AO Type B2 Thoracolumbar Fracture with and without Disc Injury after Posterior Surgery — Orthopaedic Surgery 2022; CC BY-NC-ND.

Flexion-Distraction Injury Fixation — Fig. 6 Fig. 6. A 46‐year‐old female patient who had a fall from a height. She suffered a L1 B2 with L1 A3 fracture according to the AO Classification. (A) Sagittal CT scans show the flexion‐distraction… Source: Comparison of the Outcomes between AO Type B2 Thoracolumbar Fracture with and without Disc Injury after Posterior Surgery — Orthopaedic Surgery 2022; CC BY-NC-ND.

Flexion-Distraction Injury Fixation — Figure 4 Figure 4. Source: Comparison of the Outcomes between AO Type B2 Thoracolumbar Fracture with and without Disc Injury after Posterior Surgery — Orthop Surg. 2022 Aug 5;14(9):2119–31. doi: 10.1111/os.13400; CC BY-NC-ND.

Flexion-Distraction Injury Fixation — Fig. 1 Fig. 1. Classification of traumatic intervertebral disc lesions in B2 injuries: Photographs of discs showing (A) grade 0 (cranial), (B) grade 1 (cranial), (C) grade 2 (caudal), and (D) grade 3… Source: Comparison of the Outcomes between AO Type B2 Thoracolumbar Fracture with and without Disc Injury after Posterior Surgery — Orthopaedic Surgery 2022; CC BY-NC-ND.

Flexion-Distraction Injury Fixation — Fig. 2 Fig. 2. Radiological measurement using plain lateral radiography. AVBH = [2AVH0/(AVH1 + AVH2) × 100]. UIDH = (a1 + a2 + a3)/3, LIDH = (b1 + b2 + b3)/3. CA, Cobb angle; LK, Local kyphosis; AVBH,… Source: Comparison of the Outcomes between AO Type B2 Thoracolumbar Fracture with and without Disc Injury after Posterior Surgery — Orthopaedic Surgery 2022; CC BY-NC-ND.

Flexion-Distraction Injury Fixation — Fig. 7 Fig. 7. A 48‐year‐old male patient who had a vehicle accident. He suffered a L1‐L2 B2 with L2 A4 fracture according to the AO Classification. (A) Preoperative MRI showing abnormal shapes in the… Source: Comparison of the Outcomes between AO Type B2 Thoracolumbar Fracture with and without Disc Injury after Posterior Surgery — Orthopaedic Surgery 2022; CC BY-NC-ND.

Flexion-Distraction Injury Fixation — Fig. 2 Fig. 2. Three-phase validation process for fracture classification systems as proposed by Audigé et al. [7], reprinted with permission Source: What should an ideal spinal injury classification system consist of? A methodological review and conceptual proposal for future classifications — European Spine Journal 2010; CC BY-NC.

Flexion-Distraction Injury Fixation — Figure 1 Figure 1. Sagittal computed tomography scan showing an enlargement of T11 and T12 spinous processes, which suggests a ligament injury Source: Thoracolumbar Chance fracture during a professional female soccer game: case report — Einstein 2016; CC BY.

History of Present Illness

Past Medical History

Imaging Review

CT (spine + abdomen/pelvis)

Labs

Neurological Examination

Surgical Planning

Case Logistics, OR Needs & Orders

Diagnosis & Indication

Position

Key Surgical Steps

  1. Level localization, posterior midline exposure
  2. Pedicle screw instrumentation above and below the injury (often short-segment for distraction injuries with good bone)
  3. Reduce the distraction/kyphosis by compression across the construct (restore the posterior tension band) — extension/compression maneuver
  4. Decompression only if neural compression/deficit (often not needed — distraction, not retropulsion)
  5. Decorticate and graft (posterolateral fusion), confirm alignment/hardware (fluoroscopy)
  6. Closure
    • (Mostly a compression construct restoring the posterior tension band — contrast with burst fractures which need anterior column support)

Critical Anatomy & Structures at Risk

  1. Conus medullaris / cauda equina (thoracolumbar junction)
  2. Pedicle walls (screw placement)
  3. Alignment restoration; associated abdominal viscera (non-spine but critical)

Equipment

Monitoring

Anesthesia

Potential Complications

  1. Missed intra-abdominal injury (the key associated danger)
  2. Neurological injury, hardware failure, loss of reduction, pseudarthrosis
  3. Infection, DVT

Operative Note Template

Preoperative Diagnosis: [T_/L_] flexion-distraction (Chance) injury [bony/ligamentous/combined — unstable]

Postoperative Diagnosis: Same

Procedure: [T_/L_] posterior instrumented fusion for flexion-distraction (Chance) injury

Surgeon / Assistant: Anesthesia: General endotracheal EBL / Fluids: Adjuncts: Fluoroscopy/navigation; SSEP/MEP/EMG Implants: Pedicle screws and rods, bone graft Complications: None

Indications: [Age]yo [M/F] with an unstable flexion-distraction injury at [T_/L_] (PLC disruption on MRI) after a [lap-belt MVC/fall]. Associated intra-abdominal injury was [evaluated/excluded] with the trauma service. Surgery was indicated for the unstable distraction injury. Risks discussed.

Description of Procedure: After consent and time-out, general anesthesia was induced and neuromonitoring established. The patient was carefully log-rolled prone onto a Jackson table (allowing extension/reduction of the kyphosis), with signals re-confirmed. A posterior midline exposure was performed over [levels] and pedicle screws placed above and below the injury under fluoroscopy.

The distraction/kyphotic deformity was reduced by compression across the construct, restoring the posterior tension band. [Decompression was performed for neural compression.] The decorticated surfaces were grafted for posterolateral arthrodesis, and alignment/hardware confirmed on fluoroscopy. Neuromonitoring remained stable.

Hemostasis was obtained, a drain placed, and the wound closed in layers. The patient was transferred to the [ICU/floor] with serial neuro and abdominal exams (coordinated with trauma).

Postoperative Plan

Chief-Level Case Review

Use these as the senior-level mental model for Flexion-Distraction (Chance) Injury Fixation:

Common Pimp Questions

Use these to pressure-test preparation for Flexion-Distraction (Chance) Injury Fixation:

  1. What neurologic level and root are responsible for the presenting deficit?
  2. What is the decompression target and how will you know it is adequately decompressed?
  3. What instability, deformity, bone-quality, or fusion variable changes the construct?
  4. What vascular, visceral, dural, or neural structure is the main structure at risk?
  5. What postop brace, drain, mobilization, MAP, antibiotic, and DVT plan should be ordered?

Attending Preference Variables

Items that commonly vary by surgeon or institution: