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Midthoracic Chance Fracture in a Morbidly Obese Polytrauma Patient


The patient is a morbidly obese 63-year-old male who presented as a polytrauma after a ground level fall onto hard concrete. He denies numbness or weakness in extremities, but elicits severe pain in his back and right hip.

Past Medical History

HTN, morbid obesity, gout, type 2 diabetes, diabetic neuropathy, CAD, OSA


The patient is alert and oriented.

He is obese (460 lbs).

Neurologic exam intact, but limited secondary to body habitus and right femur fracture.

The patient is ASIA E.

Fig 1 Uribe Obese Chance Fx Body Habitus

 Figure 1: Image demonstrating patient’s body habitus

Pre-treatment Images

During the trauma survey, the patient was found to have DISH (diffuse idiopathic skeletal hyperostosis).

Fig 2 Uribe Obese Chance Fx Pre-op Sag CTFigure 2: Pre-treatment cervical sagittal CT demonstrating flowing anterior ossification (DISH).


Fig 3 Uribe Obese Chance Fx Pre-op Thoracic Sag CTFigure 3: Pre-treatment thoracic sagittal CT demonstrating flowing anterior calcifications with “fish mouth” deformity at T7-T8


Fig 4 Uribe Obese Chance Fx Pre-op Thoracic Sag CT Disruption T7Figure 4: Pre-treatment thoracic sagittal CT demonstrating disruption of the inferior T7 endplate


Fig 5 Uribe Obese Chance Fx Pre-op Thoracic Coronal CTFigure 5:   Pre-treatment thoracic coronal CT demonstrating T7-T8 fracture


The patient was diagnosed with a flexion-distraction injury (Chance fracture) through the inferior endplate of T7 and a history of DISH (diffuse idiopathic skeletal hyperostosis).

Suggest Treatment

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Selected Treatment 

During the first 24 hours of being hospitalized, the patient underwent posterior single-stage T6-T9 percutaneous pedicle screw fixation with the goal of early mobilization and treatment of orthopedic injuries.

The EBL was < 50 cc; operating time 103 minutes.

Intraoperative Images

Fig 6 Uribe Obese Chance Fx Intraop PositioningFigure 6: Intraoperative image demonstrating patient positioning


Fig 7 Uribe Obese Chance Fx Intraop Pedicle Screw TowersFigure 7:  Intraoperative image showing the pedicle screw towers and demonstrating depth of patient’s back


Fig 8 Uribe Obese Chance Fx Intraop AP FluoroFigure 8:   AP fluoro image showing percutaneous pedicle screw placement prior to placing rods 

Post-treatment Images

Fig 9 Uribe Obese Chance Fx Post-op Sag CTFigure 9:  Post-operative sagittal CT showing instrumentation 2 levels above and below T7-T8 fracture


Fig 10 Uribe Obese Chance Fx Post-op Axial CTFigure 10:  Post-operative axial CT image showing percutaneous pedicle screw placement 


At 3-month follow-up after a short stay in rehab, the patient continues to be non-weight bearing from his right femur fracture but is full strength in his lower extremities. He was not braced due to his large size. Incisions are well healed, as seen in Figure 11.

Follow-up Images


Fig 11 Uribe Obese Chance Fx Follow-up Clinical PhotoFigure 11:  Clinic image showing well-healed incisions


Fig 12 Uribe Obese Chance Fx 3-mo Post-op AP X-rayFigure 12:  AP x-ray at 3-month follow-up


Fig 13 Uribe Obese Chance Fx 3-mo Post-op Lat X-rayFigure 13:  Lateral x-ray at 3-month follow-up

Case Discussion

Dr. Uribe presents an interesting fracture in a very complicated patient.  The fracture itself is routine in a DISH patient experiencing an extension trauma. However, in addition to the difficulties presented by the DISH itself, this patient has multiple other co-morbidities not the least of which is morbid obesity.  A large literature exists demonstrating increased complications with open surgery in morbidly obese patients, suggesting that in this patient “less is more.”  On the other hand, prolonged bed rest in this patient could be equally disastrous, so surgery a reasonable option. 

That being said, none of the traditional options are ideal in this patient.  We have already said that immobilization necessitated by non-operative therapy in this patient carries a high risk.  On the other hand, open thoracotomy or open posterior fusion and stabilization also are associated with a high complication rate in this group.  Dr. Uribe’s decision to proceed with a percutaneous stabilization in this patient is an excellent alternative. Because of the nature of the fracture, autograft or allograft fusion substrate is not necessary to achieve fusion in this patient.  Thus, all is that needed is alignment and stabilization.  Percutaneous instrumentation can be performed in minimal time, with minimal blood loss.  It minimizes potential infection, and maximizes rapid entry into rehabilitation.  Literature is currently developing which demonstrates that major spine procedures can be performed in morbidly obese patients with complication rates equivalent to non-obese patients.  Thus, in this complicated patient, I believe this is the best available treatment option.

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