1. Fractures of the Spine in Children
Steven Frick, MD
Created March 2004; Revised August 2006

2. Important Pediatric Differences
Anatomical differences
Radiologic differences
Increased elasticity
Periosteal tube fractures – apparent dislocations
Immobilization well tolerated

3. Cervical Spine Injuries
Rare in children - < 1% of children’s fractures
Quoted rates of neurologic injury in children’s C spine injuries vary from “rare” to 44% in large series
< age 7 – majority of C spine injuries are upper cervical, esp. craniocervical junction
> age 7 – lower C spine injuries predominate

4. Multiple Small Diameter Pin Child’s Halo for Displaced C2 Fracture
Note bolster behind neck to maintain lordosis and reduce angulation

5. Traumatic Spinal Cord Injury
Rare in children
Better prognosis for recovery than adults
Late sequelae = paralytic scoliosis (almost all quadriplegic children if injured at less than 10 years of age)

6. Anatomy – C1
3 ossification centers at birth – body and 2 neurocentral arches
Neurocentral synchondroses (F) fuse at about 7 years of age

7. Anatomy – C2
4 ossification centers at birth – body, 2 neural arches, dens
Neurocentral synchondroses (F) fuse at age 3-6 years
Synchondrosis between body and dens (L) fuses age 3 – 6 years
Thus no physis / synchondrosis should be visible on open mouth odontoid view in child older than 6 years

8. Anatomy – C2
Summit ossification center (H) appears at age 3 – 6 and fuses around age 12
Do not confuse with os odontoideum

9. Os Odontoideum Thought to be sequelae of prior trauma
May result in C1-C2 instability

10. Os Odontoideum

11. Anatomy – Lower Cervical Vertebrae C3 – C7
Neurocentral synchondroses (F) fuse at age 3-6 years
Ossified vertebral bodies wedge shaped until square at about age 7
Superior and inferior cartilage endplates firmly attached to disc

12. Mechanism of Injury
Child’s neck very mobile – ligamentous laxity and shallow angle of facet joints
Relatively larger head
In younger patients this combination leads to upper cervical injuries
Falls and motor vehicle accidents most common cause in younger children

13. Cervical Spine Injuries from Birth Trauma
Can occur
May have associated spinal cord or brachial plexus injury
Upper cervical injuries may be a cause of perinatal death
Newborn with C5/6 fracture dislocation

14. Typical Fracture Pattern
Fractures tend to occur within the endplate between the cartilaginous endplate and the vertebral body
Clinically and experimentally fractures occur by splitting the endplate between the columnar growth cartilage and the calcified cartilage
Does not typically occur by fracture through the endplate – disc junction

15. C Spine Immobilization for Transport in Children
Large head will cause increased flexion of C spine on standard backboard
Bump beneath upper T spine or cutout in board for head to transport child with spine in neutral alignment

16. C Spine Radiographic Evaluation in Children
Be aware of normal ossification centers and physes
C2/3 pseudosubluxation common in children younger than 8, check spinolaminar line of Swischuk
Evaluation of soft tissues anterior to spine may be unreliable in the crying child

17. C Spine Evaluation in Children
Similar protocol as adults
Consider mechanism of injury
Physical exam – tenderness (age, distracting injuries), neurological exam
C Spine series

18. ED C Spine Evaluation

19. Spinal Cord Injury without Radiographic Abnormality (SCIWORA)
Cervical spine is more flexible than the spinal cord in children
Can have traction injury to spinal cord in a child with normal radiographs
Usually occurs in upper C spine, in children younger than 8
MRI can diagnose injury to spinal cord and typically posterior soft tissues
Occiput –C1 SCIWORA

20. SCIWORA
Spinal cord injury without radiographic abnormality (plain x-rays, not MRI)
distraction mechanism of injury
spinal cord least elastic structure
young children <8 yo
be aware GCS 3 and normal CT head may be upper cervical spinal cord injury

21. O – C1 Spinal Cord Injury

22. Not “Cleared” by Plain Films
CT scan – much of peds c-spine cartilaginous
Advantage – fast (no sedation -anesthesia)
Assess alignment

23. Not “Cleared” MRI scan – currently favored
Rapid sequence/image acquisition algorithms – gradient echo
Evaluate non osseous tissues and spinal cord
MRI scan should be considered in critically injured child for whom adequate plain films cannot be obtained to rule out spinal injury

24. Imaging 3 view plain film series Obliques if requested by radiologist
CT scan upper C-spine (O-C2) if intubated, or consider MRI

25. If not “Cleared” within 12 Hours
Switch to pediatric Aspen or Miami J collar
Consider CT or MRI

26. Baker et al AJEM 1999 5 year review peds CSI 40/72 evident on plain XR
32 SCIWORA
80% abnormal PE
16% neuro abnormal
3 view XR 94% sensitive

27. Finch and Barnes JPO 1998 CSI
<10 years old- MVC, upper C-spine
>10 years old- recreational sports, lower C-spine.

28. Givens et. al J Trauma 1991 3 year review, 34 children CSI
53% also TBI
41% mortality
50% of pts <8 injury below C4
Fatal O-C1 dislocation

29. Keiper Neuroradiology 1998
31 % of peds trauma patients (+) MRI C-spine
Persistent neck symptoms or radiographs inconclusive- check MRI

30. Scarrow et al Peds Neurosurgery 1999
3 view XR, CT (-)
Persistent altered mental status
Flex/ext with SSEP monitoring
If (+) --- MRI
Risks--- just do MRI

31. Flynn, Dormans et al. CHOP Protocol
Obtunded patient
Unable to clear within 36 hrs
MRI C spine
If normal discontinue C collar
No significant missed injuries
Continue C collar if posterior soft tissues appear injured on MRI, obtain later dynamic studies

32. If You See a Spine Fracture in a Child
Look hard for another one
“The most commonly missed spinal fracture is the second one”. -J. Dormans
High incidence of noncontiguous spine fractures in children

33. Thoracic Spine Fractures
Less common spinal fracture in children than in more mobile regions
Rib cage offers some support / protection
Motor vehicle crashes, falls from heights
Child abuse in very young
Compression fractures in severely osteopenic conditions (OI, chemotherapy)

34. Multiple Compression Fractures in 4 year old Leukemia Patient

35. Thoracic Spine Fracture Dislocations
High energy mechanisms
Often spinal cord injury, can be transected
Prognosis for recovery most dependent on initial exam – complete deficits unlikely to have recovery
Infarction of cord (artery of Adamkiewicz) may play some role –especially in delayed paraplegia

36. Thoracolumbar Junction Injuries T11-L2
Classically lap-belt flexion-distraction injuries
Chance fractures and variants
High association with intraabdominal injury (50-90%)
Neurologic injury infrequent but can occur

37. Lap Belt Sign
High association with intraabdominal injury and lumbar spine fracture
Lumbar spine films mandatory

38. 4 yo Lap Belt Restrained Passenger Intraabdominal Injuries, Paraplegic

39. 2 Year Old with Old L2-3 Fracture Dislocation from NAT

40. Lumbar Spine Fractures L3-L5
Infrequent until late adolescence
Usually compression fractures that are stable injuries
Can be associated with lap belt injuries
Burst fractures – may progress to kyphosis
Lumbar apophyseal injuries – posterior displacement can cause stenosis, may need surgical excision

41. Chance Fractures and Variants
Flexion over fulcrum
Posterior elements fail in tension, anterior elements in compression
Can occur through bone, soft tissue or combination
Pure bony injuries can be treated with immobilization in extension
Injuries with posterior ligamentous component may be best treated with surgical stabilization

42. Rumball and Jarvis JBJS 74B Seatbelt Injury Classification

43. Flexion-Distraction Injury L2-L3 6 Months after Compression Fixation, Posterolateral Fusion

44. Lumbar Apophyseal Injuries Slipped Apophysis
Compression-shear injuries
Same age group as SCFE
Typically adolescent males, inferior endplates of L4 or L5
Traumatic displacement of vert. ring apophysis and disc into spinal canal
If causes significant compression of cauda equina, treatment is surgical excision

45. 3 Types of Slipping of Vertebral Apophysis Tarr et al
3 Types of Slipping of Vertebral Apophysis Tarr et al. J Comput Assist Tomogr

46. Burst Fractures Usually in older adolescents
Treatment similar to adults
May not need surgery in neurologically intact patient
Injuries at thoracolumbar junction higher risk for progressive kyphosis
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