The Effect of Trauma Mechanism on the Frequency of Accompanying Vertebral Fracture in Cases with Thoracic Trauma

Objective: Thoracic traumas are the third most common trauma among all trauma cases after head-neck and extremity traumas. The most common causes are motor vehicle accidents, falls from height, gunshot wounds, and stab wounds. In our study, it was aimed to investigate the mechanism of trauma and its effect on the frequency of accompanying vertebral fracture in patients who applied to the emergency department of a university hospital due to thoracic trauma. Material Method: Our study was planned retrospectively. The information of the patients who applied to the emergency department of our hospital between 01.01.2017 and 01.01.2021 due to thoracic trauma was examined. Demographic characteristics of the patients, mechanism of trauma, trauma-related thoracic injuries and accompanying vertebral fractures were evaluated. Results: The data of 515 patients exposed to thoracic trauma were analyzed. The median age of the patients included in the study was 52 and 72.4% (n: 373) were male. 96.3% (n: 496) of the patients presented because of blunt trauma. The most common trauma mechanisms were in-vehicle traffic accident (46.6% n:240) and falling from height (30.9% n:159). Pneumothorax was found in 34.7% (n: 179) of the patients, hemothorax in 40.2% (n: 207), and costal fracture in 81.9% (n: 422). The frequency of concomitant vertebral fracture was 33.98% (n: 175). Vertebral fractures were most commonly detected in the lumbar region (53.1%) and were most common in patients admitted after a non-vehicle traffic accident. A significant difference was found between the mechanism of trauma and accompanying vertebral fracture; vertebral fracture was seen in 53.8% (n:28) of the patients who applied after a non-vehicle traffic accident. (p=0.004


INTRODUCTION
Trauma is the third leading cause of death in all ages, after cancer and cardiovascular diseases, and ranks first in the young population (1,2).Thoracic traumas are the third most common trauma among all trauma cases after head-neck and extremity traumas (1,3).The most common causes of thoracic trauma in emergency departments are motor vehicle accidents, falls from height, gunshot wounds, and stab wounds.Thoracic traumas are divided into two groups as blunt (70%) and penetrating (30%) traumas (3).Extrathoracic organ injuries accompany high-energy traumas, which increases mortality and morbidity and leads to prolonged hospital stay (4).In the literature, there are studies similar to ours in which vertebral fractures accompanying thoracic traumas are examined (5,6).However, there are not enough studies examining the relationship between the trauma mechanism and vertebral fracture in thoracic traumas.In this study, we aimed to investigate the effect of trauma mechanism on the frequency of accompanying vertebral fracture in thoracic traumas and to contribute to the literature.

MATERIAL AND METHOD
Our study started with the approval of local Ethics Committee.The data of 515 patients who applied to the emergency department due to thoracic trauma between 01.01.2017 and 01.01.2021 were reviewed retrospectively.Patients were evaluated based on age, gender, trauma mechanism, trauma-related thoracic pathologies, vertebral fractures, and presence of extrathoracic pathologies based on computed tomography (CT) findings.Pneumothorax, hemothorax, parenchymal contusion and costal fractures were evaluated in the patients.According to thorax CT findings, it was classified as no pneumothorax:0, 20% ↓: 1, 20-40:2, 40% ↑:3.Hemothorax was classified as no:0, minimal:1, moderate:2, massive:3.No contusion was classified as 0 segmentary:1, lumbar:2, diffuse:3.The presence of costal fracture was recorded.Concomitant vertebral fractures were recorded according to CT findings.Vertebral fractures were classified according to their localization as cervical, thoracic and lumbar.Vertebral fractures detected in the patients were categorized according to the trauma mechanism.

Statistical Analyses
The data of the two groups were compared with the Mann-Whitney U test.The relationship between two categorical variables was examined with Pearson's Chi-square test or Fisher's Exact test.Continuous data were summarized as median (25th-75th percentile) and categorical data as frequency and percentage.Statistical software SPSS version 23 (SPSS Inc. , Armonk , NY) was used for all analyses .Significance level was determined as p < 0.05.RESULTS 72.4% (n: 373) of the patients included in the study were male and 27.5% (n:142) were female.The median age was calculated as 52 (37-65).96.3% (n: 496) of the applications made to the emergency department were due to thoracic trauma caused by blunt trauma.Considering the distribution of trauma mechanisms, it was seen that the most common reasons for admission were in-vehicle traffic accidents (IVTA) (46.6%, n:240) and falls from a height (30.9%, n: 159) (Table 1).The most common lung pathology developing due to thoracic trauma in patients was costal fracture (81.9%, n: 422) and the least common was pneumothorax (34.8%, n: 179).It was observed that pneumothorax was below 20% in 132 (25.6%) patients, between 20-40% in 38 (7.4%) patients, and over 40 % in 9 (1.7%) patients.Lung contusion was present in 55.1% (n: 284) of the patients, segmental contusion in 195 (37.9% ) patients, lumbar contusion in 83 (16.1%) patients, and diffuse contusion in 6 (1.2%) patients.Hemothorax was seen in 40.2% (n: 207) of the patients, minimal in 171 (33.2%) patients, moderate in 35 (6.8%) patients, and massive in 1 (0.2%) patient (Table 2  ).There was no statistically significant difference between gender and vertebral fracture.All of the patients with vertebral fracture were admitted after blunt trauma.A significant difference was found between the mechanism of trauma and accompanying vertebral fracture; simultaneous vertebral fracture was found in 53.8% (n: 28) of the patients who applied after a nonvehicle traffic accident and in 44.4% (n: 8) of the patients who applied due to a motorcycle accident (Table 5).Vertebral fractures were seen with a frequency of 47.4% (n: 83) in the lumbar region, 36.5% (n: 64) in the thoracic region, and 16.0% (n: 28) in the cervical region.

DISCUSSION
In our study, we aimed to examine the effects of trauma mechanism on the incidence of vertebral fracture in patients evaluated for thoracic trauma in the emergency department.In general, the incidence of vertebral fracture in patients admitted to the emergency department due to blunt trauma is around 7% (7).Although the incidence of vertebral fracture is low in blunt traumas, vertebral fracture is more common in patients with thoracic pathology as a result of trauma.In our study, we found vertebral fracture in 33.9% (n:175) of patients with thoracic trauma.When we classified these patients according to the trauma mechanisms, we determined that the frequency of accompanying vertebral fracture was statistically significant in patients admitted due to non-vehicle traffic accident.We think that this epidemiological information is important in the approach of patients admitted to the emergency department due to high-energy trauma.
Studies have shown that the transition region from the thoracic vertebrae to the lumbar vertebrae is the region most prone to fracture development in patients exposed to blunt trauma.The kyphotic structure in the thoracic region returns to lordosis in the lumbar region, and the risk of injury in the angulation region increases with exposure to trauma.In addition, the support of the ribs to the vertebrae in the thoracic region reduces the rate of thoracic vertebral fractures (8,9).Lumbar vertebral fractures were seen more frequently in our study, and our results are consistent with the literature.However, in the study of Wang et al., thoracic vertebral fractures were observed more frequently in patients with thoracic trauma with first rib fracture (10).
In blunt traumas, the rate of fracture development increases with age due to degenerative changes.Osteopenia, degenerative diseases of bone and soft tissue in the elderly population can be shown as causes that increase the rate of injury (11)  showing that the presence of aortic calcification in patients may be associated with vertebral and other bone fractures (12).In the light of this information, we think that a more detailed examination should be done in terms of vertebral fracture in elderly patients with osteopenia, degenerative bone pathology or aortic calcification who applied to the emergency department with blunt trauma.Diagnosis of thoracolumbar vertebral fracture is made by physical examination together with computerized tomography in emergency conditions.Although plain radiography gives findings related to fracture, the diagnostic accuracy is superior in CT (13).In cases where the diagnosis of vertebral fracture is delayed or undiagnosed, complications such as radiculopathy or spinal cord injury may develop in 19-50% (13).Therefore, we think that an earlier CT decision should be made in elderly patients presenting due to trauma.Vertebral traumatic injuries often occur after motor vehicle accidents, falls from height, recreational injuries and work accidents (14).Motor vehicle accidents are the most common mechanism in adults with 36.70%, followed by falls from a height with 31.70% (7).In our study, 33.9% (n: 175) of the patients with thoracic trauma were accompanied by vertebral fracture.All of the patients with vertebral fracture had applied after blunt trauma.We detected vertebral fracture in 53.8% (n: 28) of the patients who applied after NVTA, 44.4% (n: 8) of the patients applied due to motorcycle accident, 38.3% (n: 61) of the patients who applied due to falling from a height, and 30.4% (n: 73) of the patients who applied after IVTA.The most common pathology in patients evaluated for thoracic trauma is rib fracture, and it should be considered as a sign of a serious injury and accompanying other organ injuries should be kept in mind (15).

CONCLUSION
The incidence of vertebral fracture increases significantly in thoracic injuries, which are frequently seen as a result of blunt trauma.The frequency of accompanying vertebral fracture should be considered in patients with thoracic trauma who apply to the emergency department due to motor vehicle accidents and falls from a height.We believe that the evaluation of patients with thoracic trauma by the emergency department physicians by keeping this information in mind will guide to early diagnosis and prevent serious complications such as spinal cord injury.

March 2023, Volume 5 No 1 44Table 3 :
Thorax Treatment . While the age range where fractures are most common in the literature is 70-79, in our study, the median age was calculated as 56 in patients with accompanying Phnx Med J.

Table 5 :
Vertebral Fracture.We believe that this age group is exposed to trauma more frequently due to being more active in business and social life, and for this reason, our study is not compatible with the literature.In the study of Wang et al., similar to our study, the majority of patients with accompanying vertebral fractures were patients under 60 years of age (2).In addition, studies have been conducted