Unique Mechanism of Chance Fracture in a Young Adult Male
We present a 21-year-old male with no significant past medical history who presented to the emergency department (ED) after a fall down approximately 10 stairs. The patient reported he was wearing a heavy mountaineering style backpack when he tripped, fell onto the side of his low back and then slid down the stairs. On initial presentation, he complained of severe pain to his low back. The patient was deemed reliable, without any propensity for dishonesty or malingering, and there was no identifiable recompense or profitable gain other than correcting his condition.\nPhysical exam showed normal vital signs and no external evidence of trauma with midline point tenderness from his mid-thoracic to lumbar spine without crepitus. A neurologic exam was normal to include full range of motion and sensation to both his lower extremities with normal rectal tone and no saddle anesthesia. Cervical, thoracic, and lumbar spine radiographs were obtained, which were significant for mild anterior wedging of the first lumbar (L1) vertebrae of uncertain chronicity. The patient’s pain was resolved after morphine 12mg IV and ketorolac 30 mg IV. After a period of observation, he was found to be ambulatory and was therefore discharged home with oxycodone/acetaminophen, 72-hour primary care follow-up, and strict return precautions.\nThe patient returned 30 hours after discharge with continued severe low-back pain that was unrelieved with the prior pain medications. His exam was unchanged from the prior ED visit with normal vital signs. During this visit a magnetic resonance image of the lumbar spine was obtained which revealed a Chance fracture involving the body of L1 extending into the pedicle with probable pars interarticularis involvement without cord compression (). Neurosurgery was consulted, and the patient was initially treated by conservative medical management with a thoracolumbar spinal orthosis, and later taken to the operating room for postero-lateral fusion of T12-L2. He was discharged after 7 days in good condition.