VOL. 91-B, No. 1, JANUARY 2009 91

Fractures of the upper transthoracic cage

J.-L. Labbe, O. Peres, O. Leclair, R. Goulon, P. Scemama, F. Jourdel

From the Centre Hospitalier Régionale, Nouméa, New Caledonia, Melanesia

J.-L. Labbe, MD, Orthopaedic Surgeon

O. Peres, MD, Orthopaedic Surgeon

O. Leclair, MD, Orthopaedic Surgeon

R. Goulon, MD, Orthopaedic Surgeon

P. Scemama, MD, Orthopaedic Surgeon

F. Jourdel, MD, Orthopaedic SurgeonService de Chirurgie Orthopédique CHT, Nouméa BP J5, New Caledonia, Melanesia.

Correspondence should be sent to Dr J.-L. Labbe; e-mail: jl.labbe@cht.nc

©2009 British Editorial Society of Bone and Joint Surgerydoi:10.1302/0301-620X.91B1. 20769 $2.00

J Bone Joint Surg [Br] 2009;91-B:91-6.Received 17 January 2008; Accepted after revision 2 September 2008

We have reviewed our experience in managing 11 patients who sustained an indirect sternal fracture in combination with an upper thoracic spinal injury between 2003 and 2006. These fractures have previously been described as ‘associated’ fractures, but since the upper thorax is an anatomical entity composed of the upper thoracic spine, ribs and sternum joined together, we feel that the term ‘fractures of the upper transthoracic cage’ is a better description. These injuries are a challenge because they are unusual and easily overlooked. They require a systematic clinical and radiological examination to identify both lesions. This high-energy trauma gives severe devastating concomitant injuries and CT with contrast and reconstruction is essential after resuscitation to confirm the presence of all the lesions. The injury level occurs principally at T4-T5 and at the manubriosternal joint. These unstable fractures need early posterior stabilisation and fusion or, if treated conservatively, a very close follow-up.

When indirect fractures of the sternum are com-bined with an injury to the upper thoracic spinethey are usually described as an ‘associated’fracture.1-4 However, the upper thoracic cage isan anatomical entity including the thoracicspinal levels T1-T7, the ribs and the sternumsince they are directly joined together.5 For thisreason, these injuries should be described asfractures of the upper transthoracic cage.

We have reviewed a series of patients withthis uncommon injury and have analysed thelevel of injury, associated fractures, otherconcomitant injuries and treatment.

Patients and MethodsBetween August 2003 and December 2006,11 patients were admitted to our unit with frac-tures of the upper transthoracic cage (Fig. 1).There were six women and five men with amean age of 38.6 years (22 to 56; Table I).Eight were injured in car accidents; seven werewearing a seat belt. One was involved in amotor cycle accident, one fell from a ladderdirectly on to the apex of the skull and theremaining patient was knocked over by a wavecausing his head to strike the beach. Four of thepatients who had been wearing a seat-belt in acar accident had a complete neurological deficit(Frankel grade A6), and seven remained neuro-logically intact. After resuscitation all patientsunderwent CT with contrast and three-dimensional reconstruction. The CT scan

included the entire spine and thoracic regionfor all patients, with inclusion of the head andabdomen when an injury to these areas wassuspected. Nine patients had a fracture at eitherT4 or T5, and five at T3, one with a double-level fracture at T3 and T8 associated with adouble-level fracture of the sternum (Fig. 2). Insix patients A27 compression or A3 burst frac-tures were found involving one or two verte-brae (seven A.2.3, one A.3.2, one unknownoverlooked) with a mean kyphotic deformity of23° (14° to 30°) in the vertebral body and of38° (32° to 50°) in the thoracic spine. One A1-wedge compression at T3 and T5 produced akyphosis of the vertebral body of 10° represent-ing a kyphosis of the thoracic spine of 22°. Inall, four patients had fracture-dislocationsinvolving from one to four vertebrae with amean kyphosis of 36° (34° to 40°).

In nine patients sternal injuries were locatedat the manubriosternal joint of which fivewere fracture-dislocations, three a fracture-subluxation and one a subluxation. Only threefractures of the sternal body with minimal dis-placement were found. One patient had adouble fracture located at the manubriosternaljoint and the sternal body. In all cases of dislo-cation the proximal manubrial fragmenttended to displace posteriorly (Fig. 3). In thesternal fractures, which were difficult to clas-sify, CT reformatting with coronal and sagittalimages was used to confirm the diagnosis.

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All patients sustained concomitant fractures, six hadhyperextension injuries of the cervical spine below C5,involving laminae and spinous processes of two or morevertebrae. Three patients had clavicular fractures.

Severe associated injuries were sustained in nine patients.All of those with bilateral pulmonary contusions (nine),multiple rib fractures (nine) and bilateral haemothorax(five) or haemopneumothorax (four) required intubationand resuscitation. Head injuries resulting in a loss ofconsciousness or coma occurred in eight patients, and fivehad lacerations of the scalp. Widening of the mediastinumwas observed on a CT scan in three patients without anysigns of aortic injury on aortography. The motorcyclist hada tracheolaryngeal perforation with neck swelling, surgicalemphysema and dyspnoea, without an injury to the cervicalspine. One young woman presented with traumaticamputation of an arm.

In nine patients operative treatment to stabilise the thoracicspine was undertaken through a posterior approach. Thepatients were positioned prone in the reverse Trendelenburgposition with the anterior sternal pad placed on the epigastricarea on the prominences of the lower ribs to avoid any com-pression on the sternal fracture and to leave its proximal partfree from constraint for reduction. The head was placed in aMayfield headrest (Maquet, Rastatt, Germany), without trac-tion to protect the cervical spine. Posterior spinal stabilisationwas secured proximally by pediculotransverse claws and bypedicular hooks in the T1, T2 and T3 areas when the pedicleswere too narrow to accommodate pedicular screws. At leastone double-level polyaxial pedicular screw was placed below

the lesion. The Passmed (Medicrea, La Rochelle, France)pediculotransverse polyaxial claws comprise a main pediclehook and an opposing transverse counterhook which areconnected by a threaded rod and locked by a nut. They con-stitute a self-stabilising polyaxial anchor (Medicrea), which isas stable as a pedicle screw (Fig. 4). In all cases, passive reduc-tion of the sternal fracture was noted once thoracic spinal fix-ation had been achieved (Fig. 2). In one patient with severeoverlapping displacement with transection of the spinal cord,a posterior total vertebrectomy was performed to obtain thereduction without exerting traction on the fractures of thecervical spine and on the fragile pedicles of the first thoracicvertebra. The space created around the vertebral body by theanterior traumatic dissection allowed an approach to bemade in order to carry out its extraction as an en bloc resec-tion, following which an easy reduction of both spinal com-ponents was performed (Fig. 3). Of the two patients nottreated surgically, the first sustained a T3-T5 wedge-compression injury and was treated with an orthosis and fol-lowed for three months until the fractures had healed. Thesecond was not treated surgically since both burst fractureswere at T3 and T4 and the fracture-dislocation of the manu-briosternal joint had been undetected during initial admissionto the intensive-care unit for a pneumohaemothorax.

ResultsThe nine patients who underwent internal fixation allobtained fusion without late kyphotic deformity. The frac-tures healed with a mean kyphotic angulation of the thoracicspine of 23° (14° to 42°); the mean correction achieved was

Fig. 1b

CT scan and sagittal reconstruction showing a) a fracture-subluxation of the manubriosternal joint and fractures of T3 and T4 (A2:3) with no neuro-logical impairment and b) a fracture-dislocation of the manubriosternal joint and a fracture of T4 and T5 with paraplegia from the T4 level.

Fig. 1a

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14° (37° to 23°). Compression and burst fractures healedwith a mean of 9° (5° to 16°) kyphotic angulation of the ver-tebral body with a mean correction of 14° (23° to 9°; Figs 2and 4). The conservatively-treated A1-wedge-compressionfracture lost 2° after healing at three months. We had nocomplications such as displacement, failures of instrumenta-tion or screw and rod breakages. Sternal fractures consis-tently showed spontaneous anatomical reduction andhealing after spinal fixation. All the patients who suffered acervical hyperextension fracture were supported in a cervicalcollar for three months and recovered without complication.The patient treated conservatively by an orthosis recoveredafter three months and returned to normal activities. How-ever, the patient whose fractures were missed, when reviewedfor the first time three years after injury, had a kyphosis of90° with marked back pain. She has refused any surgicaltreatment. All patients treated without a neurological deficithad a total recovery and returned to normal activity (exceptfor one whose fractures were missed). None of the fourpatients with complete neurological lesions recovered.

DiscussionFractures of the upper transthoracic cage remain a chal-lenge because they are unusual and are easily missed inpatients with multiple trauma.3,8 They may have devastat-ing consequences because of the high levels of neuro-logical compromise and severe concomitant injuries.Many patients die before reaching hospital or duringattempts at resuscitation.2,3,8-10 These fractures are alsoextremely unstable.1,2,4 Failure to recognise them mayresult in a major kyphotic deformity, as occurred in one ofour patients. The rate of spinal fractures involving theupper thoracic region is estimated at 16%,11 but the inci-dence of indirect sternal fractures with upper thoracic spi-nal injury is uncertain and is most likely to beunderestimated because of failure to identify them.1,2,8

This injury is unusual and reports in the literature are lim-ited.1-3 In 1957, Fowler12 added five cases to the 16 previ-ously reported from a review of the literature over 50years. However, it is now accepted that sternal fracturesare not only associated with upper thoracic spinal

Table I. Details of the 11 patients

CaseAge (yrs) Gender Cause* Sternal injury Spinal injury Neurology Associated fracture Other injuries

1 41 M MCA MS† joint subluxation Fracture-dislocation at T3, T4, T5 and T6

Normal Ribs Tracheolaryngeal perforation and bilateral haemothorax

2 28 M RTA MS joint fracture-subluxation

Compression fracture A2.3 of T3 and burst fractureA.3.2 of T4

Normal Maxillofacial and skull

Bilateral fracture of the ribs, intracranial haemorrhage and facial nerve palsy

3 22 F RTA with SBF Buckling of body ofthe sternum

Fracture-dislocation of T4

Completeparaplegia T4

Lamina and spinous processes C5 and C7. Scapula clavicle, acetabulum and ilium

Bilateral haemo-pneumothorax and severe head injury with coma

4 56 F RTA with SBF Fracture of body of sternum

A1 wedge-compression fracture of T3 and T5

Normal Ribs None

5 49 M Fall MS joint fracture-subluxation

Compression fracture of A2.3 of T4 and T5

Normal Laminae and spinous processes C5 and C6

Scalp laceration and bilateral haemothorax, skull, clavicle, radius

6 27 F RTA with SBF MS joint fracture-dislocation andfracture of the body of the sternum

Compression fracture A2.3 of T3 and fracture-dislocation of T8

Complete paraplegia T7

Laminae and spinous processes C5 to C7

Scalp laceration, severe head injury with coma and bilateralhaemo-pneumothorax, traumatic amputation of right arm

7 26 M RTA with SBF MS joint fracture-dislocation

Fracture-dislocation of T4 and T5

Completeparaplegia T4

Laminae and spinous processes C5 to T1 and ribs

Severe head injury and bilateral haemothorax

8 40 F RTA with SBF MS joint fracture-dislocation

Fracture-dislocation of T4 and T5

Completeparaplegia T4

Laminae spinous processes C5 to C7, clavicle andbilateral ribs

Scalp laceration andbilateral haemothorax

9 50 F RTA with SBF MS joint fracture Burst fracture of T3 and T4

Normal Ribs Haemo-pneumothorax

10 56 M Fall in the sea MS joint fracture-dislocation

Compression fracture A2.3 of T3 and T4

Normal None Head injury and bilateral haemothorax

11 30 F RTA with SBF MS joint fracture-subluxation

Compression fracture A2.3 of T4

Normal Laminae and spinous processes C6 to T4 and bilateral rib fractures

Scalp laceration and haemo-pneumothorax

* MCA, motor-cycle accident; RTA, road-traffic accident involving collisions in cars; ; SBF, seat-belt fastened† MS, manubriosternal joint

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fractures, but also with lower thoracic, upper lumbar andcervical injuries. Gopalakrishnan and El Masri2 describedfour patients from a series of 12, with spinal fractures out-side the upper thoracic region, as was the case with four ofeight patients reported by Jones et al1 and four of tenpatients by Vioreanu et al.3 Our findings suggest thatthese spinal fractures outside the upper thoracic regionand associated with indirect sternal fracture are lesssevere, because of the low levels of neurological compro-mise and concomitant injuries. They do not appear to

result from the same mechanism of injury as those of theupper transthoracic cage.4

Proper diagnosis is hampered by the fact that the upperthoracic region is difficult to examine on standard chestand spinal radiographs and many fractures aremissed.8,10,13 CT with contrast and reconstruction is veryeffective in identifying these lesions and should be per-formed as soon as the injury is suspected and the generalcondition of the patient allows. The CT scan should detailboth sternal and vertebral fractures on the same sagittal

Fig. 2b

Pre-operative a) and post-operative b) CT with sagittal reconstruction of a double-level fracture of the uppertransthoracic cage located at T3 and T8, with a fracture-dislocation of the manubriosternal joint and a fractureof body of the sternum. There was paraplegia from the T7 level. Thoracic spinal fixation gave spontaneousreduction of the sternal fracture.

Fig. 2a

Fig. 3b

a) CT scan and sagittal reconstruction of a fracture of the upper transthoracic cage with fracture-dislocations of T4-T5 and ofthe manubriosternal joint. b) – Post-operative anteroposterior radiograph and follow-up sagittal CT reconstruction at twoyears showing good fusion and no loss of correction after compression osteosynthesis at T3-T5.

Fig. 3a

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reconstruction since it is often focused on the spinal injuryonly, and must include the entire spine to prevent otherfractures being overlooked particularly at the lowercervical spine (60% in our series) and at the lumbar level.

In our series, as described also by Gopalakrishnan andEl Masri,2 it appeared that a severe injury with paraplegiawas mainly associated with a fracture-dislocation of themanubriosternal joint and a burst or fracture-dislocation atT4. When this combination of injuries occurs with wideningof the mediastinum, a CT aortogram may be necessary toinvestigate whether there is an associated traumatic disrup-tion of the aorta.9 In patients without injury to the spinalcord our findings, like others,2,3 confirmed that there is wid-ening of the mediastinal shadow with a fracture of the upperthoracic spine and this may be considered to be due to a par-avertebral haematoma. In the same manner, a possible tra-cheo-oseophageal perforation may occur in association withhyperextension of the neck and shear-distraction injuries14,15

as we found in the motorcyclist with a fracture-dislocation atT3-T6. Other causes of perforation may result from a pene-trating injury, deceleration injury16 and anteroposterior com-pression of the thoracic cavity.17 When a tracheo-oesophageal perforation is suspected oesophagography andbronchoscopy are mandatory to confirm the diagnosis.18

The upper thoracic cage includes the upper thoracicspine, ribs and sternum which are joined together by costalcartilages and vertebrocostal articulations.8,19 The sternumin conjunction with the rib cage restricts movement andadds rigidity and stability to the spine to represent a realfourth column as an essential mechanical support for thethoracic spine.4 This fourth column supplements the three-

column model of spinal stability described by Denis.20 Theliterature contains references to spontaneous sternal fatiguefractures in patients with osteoporosis and severe thoracickyphosis1,21,22 confirming that the sternum has a role in tho-racic spinal stability. In the three-column spinal conceptinstability occurs when two or more columns are injured,20

but at the upper extent of the thoracic spine injury to onecolumn may cause instability if there is a fracture of the ster-num. Minimal fracture-like wedge compressions of the ver-tebral bodies can result in considerable instability, and iftreated conservatively, require close supervision untilhealed. Burst fractures or fracture-dislocations are bydefinition unstable and require immediate surgery for poste-rior stabilisation and fusion. Anterior interbody fusionneeds a thoracotomy and incurs too much risk in respect ofthe high incidence of severe associated intrathoracic injuries.In high overlap displacement cases with transection of thespinal cord, total vertebrectomy by the posterior approachmay be the best compromise. It has been found that openreduction of the sternum and fixation by wires or pins is notnecessary when posterior spinal reduction and stabilisationare undertaken since the fracture of the sternum reducesspontaneously.12,23 This was also our experience.

The upper thoracic cage functions as an anatomicalentity, and includes the upper thoracic spine from T1-T7,the ribs and the sternum since they are directly joinedtogether. Accordingly, fractures of the upper transthoraciccage should be considered as a separate entity and shouldno longer be referred to as associated fractures when anindirect fracture of the sternum is combined with an injuryto the upper thoracic spine.

Fig. 4b

a) Pre-operative CT scan and sagittal reconstruction showing A.2.3 compression fractures located at T3 and T4 with separation at the manubriosternaljoint and avulsion of a small articular fragment of sternum. b) Post-operative sagittal CT reconstruction and anteroposterior radiograph showing pos-terior reduction and fixation. Pediculotransverse claws were placed at T2, pedicular hooks at T3, and polyaxial pedicle screws at T6-T7.

Fig. 4a

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No benefits in any form have been received or will be received from a commer-cial party related directly or indirectly to the subject of this article.

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