The Spine Journal 7 (2007) 491–494

Case Reports

Open fracture dislocation of the thoracic spine: a case report

Joseph P. DeAngelis, MDa,*, Michelle Aubin, BSa, W. Jay Krompinger, MDb

aDepartment of Orthopedic Surgery, University of Connecticut School of Medicine, Farmington, Connecticut 06034bOrthopaedic Associates of Hartford, P.C., 85 Seymour Street, Suite 607, Hartford, Connecticut 06106

Received 5 April 2006; accepted 23 August 2006

Abstract BACKGROUND: This injury has not been reported previously in the thoracic spine. All previousopen fracture dislocations of the spine have been reported in the lumbosacral spine with threeposterior and two anterior dislocations.PURPOSE: To describe the treatment of an open thoracic fracture dislocation with primary openreduction, posterior stabilization, and fusion.STUDY DESIGN: Case report.METHODS: A 25-year-old male pedestrian was struck by a car sustaining an open fracture dis-location of T8 on T9 with complete transection of the spinal cord. The accident resulted in completeparalysis of both lower extremities, a paraspinal hematoma from T4 to T12, and bilateral pneumo-thoracies. After wound irrigation and debridement, an open posterior reduction and stabilizationwas completed. The wound was closed primarily.RESULTS: Two years after surgery, there was a solid fusion and no evidence of infection. Thepatient has persistent paralysis of both lower extremities.CONCLUSIONS: Open thoracic spinal fracture dislocations can be effectively treated with pri-mary open reduction and fusion with instrumentation. � 2007 Elsevier Inc. All rights reserved.

Keywords: Open fracture; Thoracic spine; Fracture dislocation; Open reduction; Fusion with instrumentation; Primary

closure

Introduction

Open fracture dislocations of the spine are extremelyrare injuries, and few reported cases are found in the liter-ature [1–4]. However, in all previously reported cases, theopen injury has been reported in the lumbosacral spine.This case presents an open fracture dislocation of the tho-racic spine and its treatment with open reduction, posteriorstabilization, and fusion.

Case report

A 25-year-old male pedestrian was struck from behindby a car and sustained an open fracture dislocation of T8on T9 with complete transection of the spinal cord. Theaccident resulted in complete paralysis of both lower

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* Corresponding author. 117 High Pine Circle, Wilbraham, MA 01095.

Tel.: (860) 679-6640; fax: (860) 679-6649.

E-mail address: jpdeangelis@yahoo.com (J.P. DeAngelis)

1529-9430/07/$ – see front matter � 2007 Elsevier Inc. All rights reserved.

doi:10.1016/j.spinee.2006.08.008

extremities, a paraspinal hematoma from T4 to T12, andbilateral pneumothoracies.

After the accident, the patient was carried into the emer-gency room by a friend where he was presented to the triage

Fig. 1. Thoracic wound at the time of initial presentation.

492 J.P. DeAngelis et al. / The Spine Journal 7 (2007) 491–494

desk. Subsequently, he was evaluated according to AdvancedTrauma Life Support protocol, and his injuries were identi-fied formally. Throughout his evaluation, the patient

Fig. 2. (Top and bottom) Preoperative anterior-posterior and lateral

X-rays.

remained hemodynamically stable and was cleared for oper-ative management by the trauma service (Figs. 1–3).

In surgery, the patient was positioned supine, and gen-eral endotracheal anesthesia was administered. A completeseries of X-rays was then completed to assist in surgical

Fig. 3. Sagittal reformatted computed tomography scan of the thoracic

spine at presentation.

Fig. 4. Anterior-posterior X-ray after open reduction and instrumentation.

493J.P. DeAngelis et al. / The Spine Journal 7 (2007) 491–494

planning. Using a Jackson table, the patient was positionedprone, and the posterior thorax was prepared and drapedsterilely. An ellipse of traumatized skin was removed withthe accompanying subcutaneous tissue to the level of thedeep fascia, and the incision was extended distally intothe lumbar spine. The posterior elements were then exposedfrom T7 to T12, and the T8–T9 fracture dislocation wasidentified. At this level, there was extensive comminutionthrough the posterior elements, but the facet dislocationevident on presentation had been reduced during surgicalpositioning. Two 5.5 mm�40 mm pedicle screws wereplaced at T7, and 6.25 mm�40 mm pedicle screws wereplaced bilaterally in T8, T10, and T11. A 6.25 mm�40mm pedicle screw was placed unilaterally at T9 becausecomminution prevented instrumentation of the left pedicle.Spinal rods were then contoured and placed into the poly-axial pedicle screws, and the locking mechanism was ap-plied and tightened. To augment the stabilization, 30 mLof bone marrow was aspirated from the iliac crest andmixed with Healos bone graft substitute (DePuy Spine,Raynham, MA, USA). The resulting mixture was intro-duced into the decorticated lateral gutters from T7 toT11. A thorough irrigation and debridement was com-pleted, and the wound was closed primarily in layers.The distal extent of the surgical wound was extended toallow for a tension-free wound closure (Fig. 4).

Postoperatively, the patient was transferred to the surgi-cal intensive care unit where a spinal cord injury steroidprotocol was implemented for 24 hours. For antibioticprophylaxis of the open fracture dislocation, the patientreceived cefazolin for 72 hours and gentamicin for 24hours. On postoperative day 4, the patient was transferredto the floor where he was fitted with a thoracolumbosacralorthosis, and acute spinal cord rehabilitation was initiated.

The patient was discharged 11 weeks after admission.Two years after his injury, he continues to have completeparalysis of both lower extremities but performs his own

Fig. 5. Thoracic wound 10 weeks after primary closure.

activities of daily living, including transfers, with minimalassistance and translocates using a wheelchair. He has hadno wound complications or signs of deep infection at thesite of his open fracture dislocation (Figs. 5–7).

Fig. 6. Seated anterior-posterior X-ray 24 months after surgery.

494 J.P. DeAngelis et al. / The Spine Journal 7 (2007) 491–494

Discussion

Prior case reports have shown that extreme trauma canresult in open anterior or posterior lumbosacral fracture dis-locations [3,4]. In one of the three reported cases of open

Fig. 7. Seated lateral X-ray 24 months after surgery.

posterior dislocations, an anterior approach was used ini-tially to achieve reduction and stabilization with anteriorplating until the wound was appropriate for a posteriordecompression and fusion [3]. Additionally, there are tworeports of open anterior fracture dislocations of the lumbo-sacral spine, both presented by Carlson [4]. In one case,bilateral laminectomies were performed to aid visualizationfor pedicle screws placement and clamp-assisted reductionof the L5–S1 dislocation. A delayed primary wound closurewas used because of excessive contamination and pro-longed exposure of the tissues. In a second case, Carlson[4] describes performing a delayed anterior fusion of L5–S1 by using a transfixing dowel and disc excision after per-forming an initial wound irrigation and debridement at thetime of presentation and completion of a 6-week course ofantibiotic therapy and bed rest to stabilize the wound.

In this case, a pedestrian struck by a car sustained anopen fracture dislocation of the thoracic spine, an eventnot reported previously. Definitive management at the timeof presentation with thorough irrigation and debridementfollowed by primary posterior stabilization resulted in asuccessful outcome without complication. This approachis supported by similar reports in the lumbosacral spine.

However, the success of this case reflects the importanceof early and complete wound management. In light of theinitial degree of contamination, after the irrigation and de-bridement, it was elected to proceed with an instrumentedfusion using a synthetic bone graft substitute. Had the ini-tial wound been prohibitive or if the debridement was lessthan complete, staged management would have been neces-sary. With this in mind, the rarely seen open fracture dis-locations of the thoracic and lumbosacral spine can besuccessfully treated with appropriate wound managementat the time of presentation followed by posterior stab-ilization and fusion.

References

[1] Griffen JB, Sutherland GH. Traumatic posterior fracture-dislocation of

the lumbosacral joint. J Trauma 1980;20:426–8.

[2] Cohn SL, Keppler L, Akbarnia BA. Traumatic retrolisthesis of the

lumbosacral junction. Spine 1989;14:132–4.

[3] Finkelstein JA. Open posterior dislocation of the lumbosacral junction:

a case report. Spine 1996;21:378–80.

[4] Carlson JR. Traumatic open anterior lumbosacral fracture dislocation:

a report of two cases. Spine 1999;24:184–8.