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Chance Fractures in the Pediatric Population Are Often Misdiagnosed

Andras, Lindsay M., MD; Skaggs, Kira F., BA; Badkoobehi, Haleh, MD; Choi, Paul D., MD; Skaggs, David L., MD, MMM

Journal of Pediatric Orthopaedics: May/June 2019 - Volume 39 - Issue 5 - p 222–225
doi: 10.1097/BPO.0000000000000925

Background: Flexion injuries of the spine range from mild compression fractures to severe flexion-distraction injuries, that is, Chance fractures. Chance fractures are often unstable and Arkader and colleagues demonstrated improved outcomes when Chance fractures are treated operatively compared with those managed nonoperatively.

Methods: A retrospective review was conducted of all patients treated over a 5-year period (2008 to 2013) for a flexion injury, either a Chance or a compression fracture, of the thoracolumbar spine at our tertiary pediatric level I trauma center. Patients were excluded if they had prior spine surgery or had a pathologic fracture.

Results: Of the 26 patients who met the inclusion criteria, 27% (7/26 patients) had a Chance fracture and 73% (19/26) had compression fracture(s). The mean age of the 7 patients with Chance fractures was 14.6 years (range, 13 to 16 y). In total, 71% (5/7) of the patients with Chance fractures were initially misdiagnosed: (3 as compression fractures, 1 as a burst fracture, 1 as muscular pain) and 80% (4/5) of these misdiagnoses were made by a neurosurgeon or orthopaedic surgeon. Average delay to correct diagnosis was 95 days (range, 2 to 311 d), with 57% (4/7) of the patients having ≥1 month delay. These 4 patients with a Chance fracture and ≥1 month delay in correct diagnosis presented to our clinic electively with chronic back pain. None of the patients with Chance fractures had a neurological injury. Six patients with posterior ligamentous disruption were treated with surgical instrumentation and fusion. All Chance fractures occurred between the levels of T12 and L3.

Conclusions: The majority of pediatric Chance fractures in this series were initially misdiagnosed (71%; 5/7) or mistreated (14%; 1/7) by neurosurgeons or orthopaedic surgeons. Mean time to the correct diagnosis was 3 months for the Chance fractures in this series.

Level of Evidence: Level IV.

Children’s Orthopaedic Center, Children’s Hospital Los Angeles, Los Angeles, CA

All figures in this manuscript are reproduced with permission of the Children’s Orthopaedic Center, Los Angeles.

This study has been carried out with approval from the Institutional Review Board at Children’s Hospital Los Angeles.

None of the authors received financial support for this study.

The authors declare no conflicts of interest.

Reprints: David L. Skaggs, MD, MMM, Children’s Orthopaedic Center, Children’s Hospital Los Angeles, 4650 Sunset Boulevard, MS#69, Los Angeles, CA 90027. E-mail:

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