---
title: "Fourth-column thoracic vertebral fractures: concomitant thoracic cage injuries and in-hospital mor"
id: "pubmed-42667345"
canonical_url: "https://medichelpline.com/clinical-feed/pubmed-42667345"
content_type: "clinical_feed_article"
specialty: "Critical Care"
source_name: "PubMed / NCBI"
source_url: "https://pubmed.ncbi.nlm.nih.gov/42667345/"
doi: "10.1007/s00586-026-10327-2"
published_at: "2026-08-29T00:00:00.000Z"
evidence_level: "Journal Article"
license: "CC-BY-NC-4.0 / Informational Use"
---
# Fourth-column thoracic vertebral fractures: concomitant thoracic cage injuries and in-hospital mor
## Provenance & Clinical Metadata
- **Canonical URL:** https://medichelpline.com/clinical-feed/pubmed-42667345
- **Specialty:** [Critical Care](https://medichelpline.com/clinical-feed/critical-care.md)
- **Primary Source:** PubMed / NCBI
- **Source URL:** [Original Journal Publication](https://pubmed.ncbi.nlm.nih.gov/42667345/)
- **DOI:** [10.1007/s00586-026-10327-2](https://doi.org/10.1007%2Fs00586-026-10327-2)
- **Published At:** 2026-08-29T00:00:00.000Z
- **Evidence Rating:** Journal Article
## Executive GIST (TL;DR)
- This nationwide cross-sectional analysis used the 2024 German DRG inpatient dataset to describe epidemiology and outcomes for adult **thoracic vertebral fractures** (ICD-10-GM S22.0x/S22.1), including a subgroup with concomitant sternal fracture defined as **fourth column fractures**. - The cohort comprised 27,814 cases; 63.0% were female and 58.5% were aged ≥75 years, indicating a large geriatric burden. - A defined **fourth column group** with sternal fracture accounted for 499 cases (1.8%) and differed from the broader thoracic spine group by male predominance (57.7%), younger age distribution (only 30.3% ≥75 years vs 59.0% in overall group), longer hospital stay (14.7 vs 10.1 days) and higher comorbidity burden (PCCL ≥3: 59.3% vs 11.7%). - Overall **in-hospital mortality** in the thoracic spine group was 2.00%; mortality rose to 2.89% in patients aged ≥75 years, who represented 86.1% of all deaths. - In the geriatric subgroup, deaths were mainly associated with acute organ failure diagnoses, with the strongest associations reported for cardiac arrest, sepsis, and respiratory insufficiency (odds ratios reported in the source abstract). - Concomitant thoracic cage injuries in the thoracic spine cohort were linked to higher mortality: specifically, haemothorax (OR = 5.73) and serial rib fractures (≥4 ribs, OR = 3.31) increased risk. - The authors conclude that **fourth column fractures** represent a mechanistically distinct, high-energy injury pattern, while mortality in geriatric thoracic spine fracture patients is driven more by patient vulnerability and frailty than by fracture severity alone, suggesting value in frailty assessment and risk-stratified pathways. - Data were provided by the German Institute for the Hospital Remuneration System. Detailed methods, statistical adjustment variables, and granular clinical management data were not reported in the abstract.
## Clinical Analysis & Structured Key Points
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Online ahead of print. # The fourth column in thoracic vertebral fractures: concomitant thoracic cage injuries and mortality in 27,814 inpatient cases from the german national DRG database [Josina Straub](https://pubmed.ncbi.nlm.nih.gov/?term=Straub+J&cauthor_id=42667345)[ 1 ](https://pubmed.ncbi.nlm.nih.gov/42667345/#full-view-affiliation-1 "Department for Trauma Surgery, University Hospital Regensburg, Regensburg, Germany. josina.straub@klinik.uni-regensburg.de."), [Melanie Ardelt](https://pubmed.ncbi.nlm.nih.gov/?term=Ardelt+M&cauthor_id=42667345)[ 2 ](https://pubmed.ncbi.nlm.nih.gov/42667345/#full-view-affiliation-2 "Division of Orthopeadics and Traumatology, Universitätsklinikum Krems, Krems, Austria."), [Jan Reinhard](https://pubmed.ncbi.nlm.nih.gov/?term=Reinhard+J&cauthor_id=42667345)[ 3 ](https://pubmed.ncbi.nlm.nih.gov/42667345/#full-view-affiliation-3 "Department of Orthopaedics, University of Regensburg, Regensburg, Germany."), [Addisu Mesfin](https://pubmed.ncbi.nlm.nih.gov/?term=Mesfin+A&cauthor_id=42667345)[ 4 ](https://pubmed.ncbi.nlm.nih.gov/42667345/#full-view-affiliation-4 "Department of Orthopedic Surgery, MedStar Washington Hospital Center, Washington, USA."), [Helena Arias](https://pubmed.ncbi.nlm.nih.gov/?term=Arias+H&cauthor_id=42667345)[ 5 ](https://pubmed.ncbi.nlm.nih.gov/42667345/#full-view-affiliation-5 "Department for Trauma Surgery, University Hospital Regensburg, Regensburg, Germany."), [Nike Walter](https://pubmed.ncbi.nlm.nih.gov/?term=Walter+N&cauthor_id=42667345)[ 6 ](https://pubmed.ncbi.nlm.nih.gov/42667345/#full-view-affiliation-6 "Department oof Psychosomatic Medicine, University Hospital Regensburg, Regensburg, Germany."), [Volker Alt](https://pubmed.ncbi.nlm.nih.gov/?term=Alt+V&cauthor_id=42667345)[ 5 ](https://pubmed.ncbi.nlm.nih.gov/42667345/#full-view-affiliation-5 "Department for Trauma Surgery, University Hospital Regensburg, Regensburg, Germany."), [Daniel Popp](https://pubmed.ncbi.nlm.nih.gov/?term=Popp+D&cauthor_id=42667345)[ 5 ](https://pubmed.ncbi.nlm.nih.gov/42667345/#full-view-affiliation-5 "Department for Trauma Surgery, University Hospital Regensburg, Regensburg, Germany."), [Siegmund Lang](https://pubmed.ncbi.nlm.nih.gov/?term=Lang+S&cauthor_id=42667345)[ 5 ](https://pubmed.ncbi.nlm.nih.gov/42667345/#full-view-affiliation-5 "Department for Trauma Surgery, University Hospital Regensburg, Regensburg, Germany.") Affiliations Expand ### Affiliations * 1 Department for Trauma Surgery, University Hospital Regensburg, Regensburg, Germany. josina.straub@klinik.uni-regensburg.de. * 2 Division of Orthopeadics and Traumatology, Universitätsklinikum Krems, Krems, Austria. * 3 Department of Orthopaedics, University of Regensburg, Regensburg, Germany. * 4 Department of Orthopedic Surgery, MedStar Washington Hospital Center, Washington, USA. * 5 Department for Trauma Surgery, University Hospital Regensburg, Regensburg, Germany. * 6 Department oof Psychosomatic Medicine, University Hospital Regensburg, Regensburg, Germany. * PMID: **42667345** * DOI: [ 10.1007/s00586-026-10327-2 ](https://doi.org/10.1007/s00586-026-10327-2) Item in Clipboard # The fourth column in thoracic vertebral fractures: concomitant thoracic cage injuries and mortality in 27,814 inpatient cases from the german national DRG database Josina Straub et al. Eur Spine J. 2026. Show details Display options Display options Format Abstract PubMed PMID Eur Spine J Actions * [ Search in PubMed ](https://pubmed.ncbi.nlm.nih.gov/?term=%22Eur+Spine+J%22%5Bjour%5D&sort=date&sort_order=desc) * [ Search in NLM Catalog ](https://www.ncbi.nlm.nih.gov/nlmcatalog?term=%22Eur+Spine+J%22%5BTitle+Abbreviation%5D) * [ Add to Search ](https://pubmed.ncbi.nlm.nih.gov/42667345/) . 2026 Aug 29. doi: 10.1007/s00586-026-10327-2. Online ahead of print. ### Authors [Josina Straub](https://pubmed.ncbi.nlm.nih.gov/?term=Straub+J&cauthor_id=42667345)[ 1 ](https://pubmed.ncbi.nlm.nih.gov/42667345/#short-view-affiliation-1 "Department for Trauma Surgery, University Hospital Regensburg, Regensburg, Germany. josina.straub@klinik.uni-regensburg.de."), [Melanie Ardelt](https://pubmed.ncbi.nlm.nih.gov/?term=Ardelt+M&cauthor_id=42667345)[ 2 ](https://pubmed.ncbi.nlm.nih.gov/42667345/#short-view-affiliation-2 "Division of Orthopeadics and Traumatology, Universitätsklinikum Krems, Krems, Austria."), [Jan Reinhard](https://pubmed.ncbi.nlm.nih.gov/?term=Reinhard+J&cauthor_id=42667345)[ 3 ](https://pubmed.ncbi.nlm.nih.gov/42667345/#short-view-affiliation-3 "Department of Orthopaedics, University of Regensburg, Regensburg, Germany."), [Addisu Mesfin](https://pubmed.ncbi.nlm.nih.gov/?term=Mesfin+A&cauthor_id=42667345)[ 4 ](https://pubmed.ncbi.nlm.nih.gov/42667345/#short-view-affiliation-4 "Department of Orthopedic Surgery, MedStar Washington Hospital Center, Washington, USA."), [Helena Arias](https://pubmed.ncbi.nlm.nih.gov/?term=Arias+H&cauthor_id=42667345)[ 5 ](https://pubmed.ncbi.nlm.nih.gov/42667345/#short-view-affiliation-5 "Department for Trauma Surgery, University Hospital Regensburg, Regensburg, Germany."), [Nike Walter](https://pubmed.ncbi.nlm.nih.gov/?term=Walter+N&cauthor_id=42667345)[ 6 ](https://pubmed.ncbi.nlm.nih.gov/42667345/#short-view-affiliation-6 "Department oof Psychosomatic Medicine, University Hospital Regensburg, Regensburg, Germany."), [Volker Alt](https://pubmed.ncbi.nlm.nih.gov/?term=Alt+V&cauthor_id=42667345)[ 5 ](https://pubmed.ncbi.nlm.nih.gov/42667345/#short-view-affiliation-5 "Department for Trauma Surgery, University Hospital Regensburg, Regensburg, Germany."), [Daniel Popp](https://pubmed.ncbi.nlm.nih.gov/?term=Popp+D&cauthor_id=42667345)[ 5 ](https://pubmed.ncbi.nlm.nih.gov/42667345/#short-view-affiliation-5 "Department for Trauma Surgery, University Hospital Regensburg, Regensburg, Germany."), [Siegmund Lang](https://pubmed.ncbi.nlm.nih.gov/?term=Lang+S&cauthor_id=42667345)[ 5 ](https://pubmed.ncbi.nlm.nih.gov/42667345/#short-view-affiliation-5 "Department for Trauma Surgery, University Hospital Regensburg, Regensburg, Germany.") ### Affiliations * 1 Department for Trauma Surgery, University Hospital Regensburg, Regensburg, Germany. josina.straub@klinik.uni-regensburg.de. * 2 Division of Orthopeadics and Traumatology, Universitätsklinikum Krems, Krems, Austria. * 3 Department of Orthopaedics, University of Regensburg, Regensburg, Germany. * 4 Department of Orthopedic Surgery, MedStar Washington Hospital Center, Washington, USA. * 5 Department for Trauma Surgery, University Hospital Regensburg, Regensburg, Germany. * 6 Department oof Psychosomatic Medicine, University Hospital Regensburg, Regensburg, Germany. * PMID: **42667345** * DOI: [ 10.1007/s00586-026-10327-2 ](https://doi.org/10.1007/s00586-026-10327-2) Item in Clipboard Cite Display options Display options Format Abstract PubMed PMID ## Abstract **Purpose:** Population-level data on fourth column fractures and prognostic implications remain lacking. This study aimed to characterise the epidemiology of thoracic vertebral fractures in Germany, including the prevalence of fourth column injuries and geriatric patients, comorbidity burden and the in-hospital mortality across distinct fracture populations. **Methods:** A Nationwide cross-sectional administrative inpatient data analysis of all adult thoracic vertebral fracture cases (ICD-10-GM S22.0x/S22.1) from the 2024 German Diagnosis Related Groups database was conducted across three groups: thoracic spine group (n = 27,315), geriatric subgroup (≥ 75 years; n = 16,276), and fourth column group with concomitant sternal fracture (n = 499). Data were provided by the German Institute for the Hospital Remuneration System. **Results:** Among 27,814 cases 63.0% were female and 58.5% aged ≥ 75 years. Fourth column fractures (1.8%) defined a mechanistically distinct entity: male predominance (57.7%), younger age distribution (≥ 75 years: 30.3% vs. 59.0%), prolonged hospitalisation (14.7 vs. 10.1 days) and comorbidity burden (PCCL ≥ 3: 59.3% vs. 11.7%). Mortality in the thoracic spine group was 2.00%, rising to 2.89% in patients aged ≥ 75 years, accounting for 86.1% of all deaths. In geriatric subgroup, mortality was dominated by acute organ-failure: cardiac arrest (OR = 51.74), sepsis (OR = 42.96) and respiratory insufficiency (OR = 14.67). In thoracic spine group, concomitant thoracic cage injuries were associated with elevated mortality: haemothorax (OR = 5.73) and serial rib fractures (≥ 4 ribs, OR = 3.31). **Conclusions:** Fourth column fractures constitute a mechanistically distinct high-energy injury entity, while in the geriatric thoracic spine fracture population, mortality is governed by vulnerability rather than fracture severity, suggesting that frailty assessment may be of value and risk-stratified clinical pathways. **Keywords:** Concomitant injury; DRG; Fourth column fracture; In-hospital mortality; Sternum fracture; Thoracic vertebral fracture. © 2026. The Author(s). [PubMed Disclaimer](https://pubmed.ncbi.nlm.nih.gov/disclaimer/) ## Conflict of interest statement Declarations. Conflict of interest: The authors declare no competing interests. ## References 1. 1. Lang S, Walter N, Freigang V et al (2023) Increased incidence of vertebral fractures in German adults from 2009 to 2019 and the analysis of secondary diagnoses, treatment, costs, and in-hospital mortality. Sci Rep 13:6984. - [DOI](https://doi.org/10.1038/s41598-023-31654-0) - [PubMed](https://pubmed.ncbi.nlm.nih.gov/37117230/) - [PMC](https://pmc.ncbi.nlm.nih.gov/articles/10147602/) 2. 1. Watkins R, Watkins R, Williams L et al (2005) Stability provided by the sternum and rib cage in the thoracic spine. Spine 30:1283–1286. - [DOI](https://doi.org/10.1097/01.brs.0000164257.69354.bb) - [PubMed](https://pubmed.ncbi.nlm.nih.gov/15928553/) 3. 1. Oda I, Abumi K, Lü D et al (1996) Biomechanical role of the posterior elements, costovertebral joints, and rib cage in the stability of the thoracic spine. Spine 21:1423–1429. - [DOI](https://doi.org/10.1097/00007632-199606150-00005) - [PubMed](https://pubmed.ncbi.nlm.nih.gov/8792518/) 4. 1. Horton WC, Kraiwattanapong C, Akamaru T et al (2005) The role of the sternum, costosternal articulations, intervertebral disc, and facets in thoracic sagittal plane biomechanics: a comparison of three different sequences of surgical release. Spine 30:2014–2023. - [DOI](https://doi.org/10.1097/01.brs.0000180478.96494.88) - [PubMed](https://pubmed.ncbi.nlm.nih.gov/16166888/) 5. 1. Oyetunji TA, Jackson HT, Obirieze AC et al (2013) Associated injuries in traumatic sternal fractures: a review of the National Trauma Data Bank. Am Surg 79:702–705 - [DOI](https://doi.org/10.1177/000313481307900714) - [PubMed](https://pubmed.ncbi.nlm.nih.gov/23816003/) Show all 28 references [x] Cite Copy Download .nbib .nbib Format: AMA APA MLA NLM **Send To** * [Clipboard](https://pubmed.ncbi.nlm.nih.gov/42667345/) * [Email](https://account.ncbi.nlm.nih.gov/?back_url=https%3A%2F%2Fpubmed.ncbi.nlm.nih.gov%2F42667345%2F%23open-email-panel) * [Save](https://pubmed.ncbi.nlm.nih.gov/42667345/) * [My Bibliography](https://account.ncbi.nlm.nih.gov/?back_url=https%3A%2F%2Fpubmed.ncbi.nlm.nih.gov%2F42667345%2F%23open-bibliography-panel) * [Collections](https://account.ncbi.nlm.nih.gov/?back_url=https%3A%2F%2Fpubmed.ncbi.nlm.nih.gov%2F42667345%2F%23open-collections-panel) * [Citation Manager](https://pubmed.ncbi.nlm.nih.gov/42667345/) [x] NCBI Literature Resources [MeSH](https://www.ncbi.nlm.nih.gov/mesh/) [PMC](https://www.ncbi.nlm.nih.gov/pmc/) [Bookshelf](https://www.ncbi.nlm.nih.gov/books) [Disclaimer](https://pubmed.ncbi.nlm.nih.gov/disclaimer/) The PubMed wordmark and PubMed logo are registered trademarks of the U.S. Department of Health and Human Services (HHS). 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