Working Diagnosis:
Anterior compression fracture of T5.

Treatment:
Because his pain was mild, he did not demonstrate any neurological symptoms, and there was less than 50% loss of height and no middle or posterior vertebral column disruption, his fracture was classified as stable. He was held out of football for the rest of the season. Conservative therapy was implemented and he was placed on modified rest with no strenous activity for six weeks. He was also instructed on what to do if any neurological symptoms developed.

Outcome:
On follow up visit, he had no pain with back flexion and extension, no pain with palpation of the spinous processes and paraspinous muscles, clinically he was progressing well. Physical therapy was started to work on core strengthening. No contact sports for another 6-8 weeks. The patient did well with physical therapy and gradually increased his activity to the point were he was cleared to participate in spring football.

Author's Comments:
A thoracic vertebral fracture is a very uncommon spinal injury in sports. Most vertebral fractures occur in the cervical and lumbar spine. The thoracic spine has limited mobility and added support by the surrounding ribs. However, if there was any posterior vertebral body disruption which is a part of the posterior column or increased interspinous distance in the middle column, there would be more of a concern for instability and an unstable fracture in the thoracic spine. As for the mechanism of injury for this case, from the patient's history and picture he provided, it appears to have occurred while his neck was in extension. This is unusual because anterior wedge fractures normally occur after an axial load in flexion. Some possible theories for how the hit could have caused the anterior wedge fracture include; axial load with his neck in extension, but protected externally by his helmet and pads, which then transmitted the force to the apex of his kyphotic curve in his thoracic vertebrae, or after the hit he could have had a rebound hyperflexion of his neck and back or trauma to the ground in flexion.

Editor's Comments:
As stated by the author, traumatic isolated thoracic spine compression fractures are uncommon. They are often seen with concomitant cervical and lumbar spine injuries and rib fractures. MVA's are the most common cause of spinal fractures, along with falls, sports, and acts of violence.
Evaluation of the patient should focus on determining whether there is any neurologic compromise. The imaging modality of choice for most spinal injuries is a CT scan.
The key factor in determining whether surgical treatment is necessary is assessing stability of the fracture. This is based on the 3-column system developed by Denis (2). It divides the spine into anterior, middle, and posterior columns, with a fracture being considered unstable if 2 or more columns are disrupted.
Injury mechanisms include axial compression, which can result in a burst fracture, flexion (+/- rotation or distraction), extension, lateral compression, and shearing injuries. As stated by the author, most anterior column/ compression injuries result from axial load or hyperflexion. Hyperextension most often results in a posterior column injury, as we see in patients with spondylolysis.
If stable, compression fractures can be treated with a brace to limit flexion for a short period of time and then physical therapy. Two-column injuries will require more rigid immobilization or surgical treatment.

References:
1. Geffen S, et al. Thoracic Spinal Fracture in a Rugby League Footballer. Clin J Sports Med. 1997 Apr; 7(2): 144-46.
2. Denis F. The Three Column Spine and its Significance in the Classification of Acute Thoracolumbar Spinal Injuries. Spine. 1983; 8(8): 817-31.
3. Elatthrache N, et al. Thoracic Spine Fracture in a Football Player. AM J Sports Med. 1993 Jan-Feb; 21(1): 157-60.
4. Silver JR, Stuart D. The Prevention of Spinal Injuries in Rugby Football. Paraplegia. 1994 Jul; 32(7): 442-53.

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