Thoracic Spine Fracture


Most thoracic spine fractures occur in the lower thoracic spine, with 60% to 70% of thoracolumbar fractures occurring in the T11 to L2 region, which is the biomechanically weak for stress. The majority of these fractures occur without spinal cord injury. Twenty to forty percent of the fractures are associated with neurologic injuries. Major (high-energy) trauma, is the most common cause of thoracic fractures. Minor trauma can also cause a thoracic spine fracture in individuals who have a condition associated with loss of bone mass.

There are four major types (based on the mechanism of injury):

- Compression (wedge fractures):caused by axial compression alone or flexion forces, when the spine is bent forward or sideways at the moment of trauma. It is a stable fracture and patients rarely show neurologic deficits.

- Burst: Similar to compression, except that the entire vertebra is evenly crushed. It is a very severe fracture, accompanied with retropulsed bone fragments into spinal canal. Neurologic injury and posterior column injury can occur more frequently.

- Flexion-distraction (seatbelt injury/ Chance fracture): Involves the separation (distraction) of the fractured vertebra. It occurs by primary distractive forces on the spine. The axis of rotation is located within or in front of anterior vertebral body.

- Fracture-dislocation: Are found in combination with displacement of adjacent vertebrae. It is caused by various combinations of forces. It is very unstable and can cause complete neurologic deficit.

FIG. 1: Denis F. The three-column spine and its significance in the classification of acute thoracolumbar spinal injuries. Spine. 1983;8:817-831

There are several classification systems. The most frequently used is the Denis classification, but this is based on the so-called middle column, which is anatomically unidentifiable.For this reason, the AO Group has developed a new classification system, which is based on the severity of the injury. The severity is defined by the pathomorphological findings, the prognosis in terms of healing and potential of neurological damage.


Vaccaro et al. proposed the thoracolumbar injury classification and severity score (TLICSS). This new classification is based on the integrity of the posterior ligament complex (PLC), the patient's neurologic status and the fracture morphology, instead of the mechanism of injury. This TLCIS is the most effective classification system for the treatment of thoracolumbar fractures and it has a good reliability.

Normal Thoracic Spine MRI


Permission granted on 29 Apr 2011.

CT scan of a Compression fracture of the Thoracic Spine

Epidemiology /Etiology


Failure of the anterior column of the spine due to compression forces, mainly into flexion. The most common causes in younger patients are falls and motor vehicle accidents. The most common causes in older patients are minor incidents during normal activities of daily living secondary to osteoporosis or metabolic bone diseases.[2] Associated neurological complications are rare[3].


Fracture of the anterior and middle columns of the spine due to axial loading[4] such as from a fall landing on  the buttocks or lower extremities. The concentration of axial forces is to the thoracolumbar junction. [5][3]


(seat belt injury)

Failures of the posterior and middle columns of the spine under tension usually from a trauma involving sudden upper body forward flexion while the lower body remains stationary. Often associated with abdominal trauma due to compression of abdominal cavity during injury. The anterior column may be mildly affected, but the annulus fibrosis and anterior longitudinal ligament are intact, preventing dislocation or subluxation. A gap between the spinous processes is often present upon palpation.[3]


Failure of all three spinal columns under compression, flexion, rotation, or shear forces. The most unstable of all thoracolumbar spine injuries, they are highly associated with neurological deficits. They can be caused by a severe flexion force similar to that of a seat belt injury, or an object falling across the back.[3]

Clay-Shoveler's Fracture

Rare, fatigue fracture of the upper thoracic spinous process. Seen in powerlifters or in patients that are involved in hard labour causing shear forces on the vertebra, hyperflexed spine, or direct trauma.[6]

Characteristics/Clinical Presentation

Over 65% of vertebral fractures are asymptomatic [7]. They are sometimes detected via radiograph when a patient is being screened for another injury.

Presentation of symptomatic fractures includes: [7][2][8][9][10][11]

  • Chronic back pain in thoracic and/or lumbar region
  • Slower gait
  • Decreased range of motion
  • Impaired pulmonary function
  • Increased kyphosis especially in osteoporotic patients with compression fractures
  • Neurological deficits due to narrowing of spinal canal - can present as long as 1.5 years post injury

Prolonging of these symptoms leads to decreased physical function and performance of activities of daily living, and increased risk of disability. Vertebral deformities are also associated with significantly increased risk of future fractures, including hip fractures[7].

Patients with non-compression fractures are usually involved in a multi-trauma, and will have various injuries and sources of pain. Clinicians must use their best judgment and employ clinical screening criteria to determine if the thoracic spine is involved.[2]

Differential Diagnosis

Plain radiographs are historically the "gold standard" for detecting thoracolumbar fractures, although due to the organs and soft tissue in the thoracic region, fractures can be missed on radiographs. A CT scan is recommended to visualize thoracic fractures and an MRI to assess soft tissue damage. [12][8][9]

Multiple Myeloma and other cancers can present as thoracic pain, but will have additional signs such as unexplained weight loss and fever.[13]

Scheuermann Disease presents as exaggerated kyphosis, anterior body extension and schmorl’s nodes; can be distinguished by vetebral body height parameters on radiograph. [14]


Screening for Fracture

Algorithms for screening patients for thoracic fractures and the need for imaging have been developed but not fully validated.

O'Connor and Walsham (2009) [2]

Presence of one or more of the following criteria in a patient with blunt multi-trauma is an indication for thoracolumbar imaging (Sn=0.99):

High-Risk Mechanism of Injury (MOI) Motor vehicle accident at speed >70 kph, fall from height >3 m, ejection from motor vehicle or motorcycle, plus any injury outside of these criteria that could cause a thoracolumbar fracture
Painful Distracting Injury Painful torso or long-bone injury sufficient to distract the patient from noticing the pain of the thoracolumbar injury
New Neurological Signs or Back Pain/Tenderness Clinical findings suspicious of new vertebral fracture, including back pain, back tenderness, a palpable step in vertebral palpation, midline bruising, neurological signs consistent with spinal cord injury
Cognitive Impairment Glasgow Coma Score (GCS) < 15, abnormal mentation, clinical intoxication
Known Cervical Spine Fracture Evidence of a new traumatic cervical spine fracture

These results were derived from low-level evidence. The authors recommend future controlled trials to standardize these definitions and validate the algorithm.[2]

Holmes et al. (2003)[10]

Screening criteria for radiograph of blunt trauma patients with thoracolumbar injuries (Sn=1.00, Sp=0.039)

  • Complaints of thoracolumbar spine pain
  • Thoracolumbar spine tenderness
  • Decreased level of consciousness
  • Intoxication with alcohol or drugs
  • Neurologic deficit
  • Painful distracting injury
Singh et al. (2011)[9]

Three predictive variables for thoracic spine fracture based on a case control study (Sp=0.93):

  • Fall > 2m
  • Thoracic pain
  • Intoxication

Physical Therapy Exam

  • Thorough history including MOI and previous spine fractures
  • Neurological screen
  • Assessment of patient's pain level and location
  • Palpation of the thoracic spine
  • Screen for thoracic fracture
  • Identification of impairments in ROM, strength, flexibility

Medical Management


The benefits of a surgical treatment of thoracolumbar fractures compared to a non-operative approach include avoiding an orthosis in the presence of multiple injuries, skin injuries, and obesity, immediate mobilization and earlier rehabilitation and better restoration of sagittal alignment. On the other hand, these benefits should be weighed against the possible surgical morbidity. Conventional open surgical techniques may be accompanied by approach-related muscle injury, increased infection rates and higher blood loss. There is no difference between operative and non-operative treatment regarding neurological recovery and long-term functional outcomes. (Level of evidence 3A)

Indications for surgery include neurological involvement and/or progressive neurological deterioration, >50% spinal canal compromise, >50% anterior vertebral body height loss, >25° to 35° angle of kyphotic deformity, and posterior ligament complex (PLC) compromise. Surgical approaches can be anterior, posterior or a combination.[5] (Level of evidence 3A) Recently, minimally invasive techniques have been described in thoracolumbar fractures. (Level of evidence 3A)

For more information on spinal surgery refer to:


Compression fractures, stable burst fractures and neurologically intact patients can typically be treated non-operatively:[5][16][17][18][19] (Level of evidence 1B; 3A; 4)

  • Bed rest/activity limitation ranging from days to weeks
  • Bracing: 8 to 12 weeks in Jewett or Cruciform Anterior Spinal Hyperextension (CASH) 
    Jewett (left) & CASH (right) Braces - courtesy of Orthotic & Prosthetic Technologies, Inc., San Marcos, TX
  • Casting: 8 to 12 weeks
    CASH (left) & Jewett (right) Braces - courtesy of Orthotic & Prosthetic Technologies, Inc., San Marcos, TX
  • Closed reduction
  • Pain medication
  • Physical therapy

There is no consensus on the exact duration of treatment. (Level of evidence 3A)

Preventative treatment for fractures related to osteoporosis include bisophosphonates, calcium, vitamin D and exercise.[6]
(Level of evidence 3B)

Wood et al. found no significant long-term difference in pain, disability and return to work for non-neurologically involved patients who received surgery compared to those who received bracing or casting.[17]  (Level of evidence 1B) This indicates that the higher risk and cost of surgery may not be justified and that bracing/casting would be the preferred treatment in this patient population. Braces are a common component of both post-operative and non-operative thoracic fracture treatment protocols.[19] (Level of evidence 1B)

Physical Therapy Management (current best evidence)

Management of vertebral fractures remains controversial [5] ,[20],[21](level of evidence:3A,2A,2B) and research is limited on identifying physical therapy intervention. Until recently, conservative management of fractures consisted of pain medications, rest and bracing to reduce spinal movements [22],[20],[23],[17].(level of evidence: 1B,2A,3A,1B)
Rehabilitation programs must be designed specifically for the individual based on their physical abilities and impairments.

With conservative treatment, the majority of fractures heal with a significant decrease in pain in 8-12 weeks. Significant declines in pain (5.9cm on VAS) are experienced 12-24 hours post-surgery [22](LoE:1B).  Therefore, interventions depend largely on whether the patient chose surgery or conservative treatment. Interventions should always be prescribed and progressed based on patient tolerance.

Physical Therapy Goals

  • Reduce pain
  • Improve posture
  • Improve thoracic mobility
  • Strengthen trunk extensors
  • Improve trunk control
  • Provide education
  • Lower extremity strengthening

Bennell et al. found that a multimodal treatment approach over a 10-week period was successful in reducing pain and improving function in patients who suffered from osteoporotic vertebral fractures [24](LoE:2B).  However, because it was a multimodal approach the effectiveness of each treatment is unclear.

APTA Preferred Practice Patterns[25](LoE:5)

4B: Impaired Posture

4G: Impaired Joint Mobility, Muscle Performance, and Range of Motion Associated with Fracture 

4I: Impaired Joint Mobility, Muscle Performance, and Range of Motion Associated with Bony or Soft Tissue Surgery

General Exercise Recommendations [24],[25] (level of evidence: 2B,5)

A major concern is refracture within a year of the initial injury. Researchers agree that strengthening back-extensor muscles can help decrease the rate of refracture or prolong occurance of refracture [23](LoE:3A),[24](LoE:2B) Studies show significant improvement in reported pain levels and increased function in patients with back-extensor exercises as part of their exercise regimen [23],[26],[27],[24]. (level of evidence: 3A,1B,2B,2B)Therefore, patient should begin strengthening back-extensor muscles as soon as they are physically able.

When developing a plan of care, the therapist should consider the individual characteristics of a vertebral fracture and possible secondary limitations.

Physiotherapy and Home Exercise Program

Adapted from: Bennell et al (2010). [24](LoE:2B)

Within a pain-free range, progressed as tolerated:

Technique/Exercise Dosage Weeks

Postural taping*

 - From anterior aspect of each shoulder, posteriorly and obliquely to opposite rib cage

Worn full time 1

Soft tissue massage*

 - In prone, to erector spinae, rhomboids, upper traps - stroking, circular frictions, petrissage

5 mins 1-10

Passive accessory postero-anterior vertebral moblisation*

 - In prone from T1 down to 2 levels below most painful vertebral region (Grd 2-3)

5 mobilising movements
at each
central level
x2 reps

Supine lying over rolled up towel

 - Towel placed lengthways along the back to facilitate thoracic extension

5-10 mins 1 daily

Erect sitting with transversus abdominus stabilising

 - Sit forward on chair (no back rest), chin retraction, scapular retraction and TA contraction

10 sec hold
x 5 reps
1-10 daily

Elbows back in sitting

 - Hands befind head, elbows pointing out to side. Press elbows back by scapular retraction

Trunk mobility in sitting - extension
5 sec hold
x5 reps
1-10 daily

Trunk mobility in sitting

 - Hands on shoulders, gentle rotation in both directions and lateral flexion to each side

5 reps in
each direction
1-10 daily

Head to wall in standing

 - Back and heels agaist wall with rolled up towel behind head. Chin retraction

10 sec hold
x 5 reps
1-10 daily

Standing corner stretch

 - Face corner, both hands chest height on wall and moving in closer to stretch anterior chest

10-30 sec hold
x 3 reps
2-10 daily

Walking hands up wall in standing

 - Facing wall, walking hands up wall until arms upstretched then holding hands off wall

5 sec hold
x5 reps
3-10 daily

Shoulder flexion in supine

 - Arms outstretched holding onto cane/towel and taking arms over head to hold at end of range

10- sec hold
x5 reps
3-10 daily

Standing wall push ups

 - Face wall, arms in front, shoulder height. Keep body straight, bend and straighten elbows

Standing wall pushups
8-10 reps
1-10 3x/week

Seated row with dumbbells

 - Upright sitting and pull hands up towards chest by bending elbows and then lowering

8-10 reps
1-10 3x/week

Seated overhead dumbbell press

 - With elbows bent and out to side, press dumbbells straight up until arms extended overhead

8-10 reps
3-10 3x/week

Bridging in supine

 - Knee bent and feet flat on ground. Pushing through feet to lift back and pelvis off ground

Bridging in supine
5-10 sec hold
1-2 3x/week

Hip extension in prone

 - Raising one leg off the ground and then the other

Hip extension in prone
8-10 reps
3-10 3x/week

Half squats - progress to holding dumbbells

 - Standing in front of chair and squatting down to touch chair with buttocks then standing up

8-10 reps
1-2 3x/week

Step ups - progress to holding dumbells

 - Stepping up and down a 10 cm step. Alternate legs

8-10 reps



Scapular retraction with theraband in sitting

 - Holding theraband in both hands with elbows tucked into sides and performing wrist extension, supination and shoulder external rotation then scapular retraction

Scapular retraction with theraband in sitting + Chin tuck + TA
8-10 reps
1-10 3x/week

Four-point kneeling with transversus abdominus

 - Push into floor with hands, knees and feet then draw navel up and in, hold 5 secs

8-10 reps



Four point kneeling with one arm and leg lift

 - As above; lift one arm off ground. Progress to also lifting extended leg off ground at same time

Four-Point Kneeling + TA
8-10 reps
3-10 3x/week

Prone lying with arm elevation

 - Arms at shoulder height and bent at elbows. Scapular retraction then lift arms off floor

5-10 sec hold
2-3 3x/week

Prone trunk extension

 - Lift head and shoulders off floor while maintaining chin retraction

5-10 sec hold
4-10 3x/week
*performed by the therapist

Complications to Consider [5],[21],[23] (level of evidence:3A,2B,3A)

  • Cardiorespiratory compromise
  • Additional Fractures
  • Refractures
  • Osteoporosis
  • Prolonged Pain
  • Limited Range of Motion
  • Limited Strength
  • Neurological Compromise
  • Postural Dysfunction
  • General Deconditioning
  • Gait/Ambulation Abnormalities
  • Loss of Balance


  1. Corenman DS. Thoraco-lumbar spine fractures. Available from: (accessed 20 Sep 2011).
  2. MD Guidelines. Fracture, thoracic spine (without spinal cord injury). Available from: (accessed 20 Sep 2011).
  3. AO Foundation, Available from: (accessed 20 Sep 2011).
  4. Leahy M and Gellman H. Thoracic spine fractures and dislocation. Medscape Reference. Available from: (accessed 20 Sep 2011).

Clinical Bottom Line

There is a lack of high-quality evidence for the management of thoracic spine fractures. Physical therapists should be familiar with screening for thoracic fractures and take an impairment-based approach when treating post-operative or non-operative patients.


https:// fracture ppt.PNG
Diagnosis and Management of Thoracic Spine Fractures

This presentation, created by Caughey Richardson, Jacquelyne Rodriguez, James Rodriguez, and JohnPaul Rodriguez; Texas State DPT Class.

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https:// fracture2 ppt.PNG
Diagnosis and Management of Thoracic Spine Fractures

This presentation, created by Jason Moreno, Elaine Tsay, Chris Webb; Texas State Class of 2014, Evidence-based Practice projects for PT7539 Ortho Spine course.

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