summary Chance Fractures are traumatic fractures of the thoracic and lumbar spine that occur by a flexion-distraction injury mechanism and are associated with high rates of mechanical instability and gastrointestinal injuries. Diagnosis of bony Chance fractures is made with radiographs or a CT scan. An MRI may be required to identify a ligamentous Chance injury with disruption of the PLC. Treatment can be nonoperative or surgical spinal stabilization depending on the presence of mechanical instability and/or neurological deficits. Etiology Mechanism a flexion-distraction injury (seatbelt injury) may be a bony injury may be ligamentous injury (flexion-distraction injury) more difficult to heal middle and posterior columns fail under tension anterior column fails under compression Associated injuries high rate of gastrointestinal injuries (50%) Imaging Radiographs obtain AP and lateral flexion-extension radiographs MRI important to evaluate for injury to the posterior elements CT important to evaluate degree of bone injury and retropulsion of posterior wall into canal Treatment Nonoperative immobilization in cast or TLSO indications neurologically intact patients with stable injury patterns with intact posterior elements bony Chance fracture technique may cast or brace (TLSO) in extension must be followed for non-union and kyphotic deformity Operative surgical decompression and stabilization indications patients with neurologic deficits unstable spine with injury to the posterior ligaments (soft-tissue Chance fx) techniques anterior decompression and stabilization usually with vertebrectomy and strut grafting followed by instrumentation posterior indirect decompression and stabilization and compression fusion construct historically three levels above and two levels below modern pedicle screws have changed this to one level above and one level below distraction construct in burst fractures compression construct in Chance fractures Complications Pain most common Deformity scoliosis progressive kyphosis common with unrecognized injury to PLL flat back leads to pain, a forward flexed posture, and easy fatigue post-traumatic syringomyelia Nonunion