Burst fractures are usually caused by an axial load and involve failure of the anterior and middle columns. Retropulsion of bone into the canal may compress the cord, particularly in the narrower canal of the thoracic spine. Generally, burst fractures may be treated nonoperatively with or without a brace if the posterior ligamentous complex is preserved, but they require fusion if the complex is disrupted. Surgical decompression is generally required regardless of stability if there is neurologic compromise.

Flexion-distraction injuries (see Fig. 27.2), also called “Chance” injuries, are associated with lap belts and abdominal trauma and may be bony or purely ligamentous. They result from failure of the anterior and middle columns in compression with concomitant failure of the posterior column in tension. Purely ligamentous injuries may be easy to miss; high suspicion necessitates MRI. Bony injuries may be treated nonoperatively if the pattern is stable; for all other patterns, decompression and fusion are required.