1. Fractures of the Spine in Children
Vahid Farsio , MD
SINA HOSPITAL

2. Important Pediatric Differences
Anatomical differences
Radiologic differences
Increased elasticity

3. Anatomy – C1
3 ossification centers at birth – body and 2 neurocentral arches
Neurocentral synchondroses (F) fuse at about 7 years of age
Copley. Cervical spine disorders in infants and children. J Am Acad Orthop Surg. 1998;6:204.

4. 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
Copley. Cervical spine disorders in infants and children. J Am Acad Orthop Surg. 1998;6:204.

5. 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
Copley. Cervical spine disorders in infants and children. J Am Acad Orthop Surg. 1998;6:204.

6. Epidemiology of Spinal Trauma in Children
Spinal injury is rare in children
Pediatric vertebral injuries occur 60-80% of the time in the cervical region (30-40% of all vertebral injuries in adults)
Overall incidence of spinal injury in children is 1-2%
Motor Vehicle Accidents are the leading cause of pediatric SCI (60% of cases)…with falls and sports injuries (football and diving) thereafter
M:F ratio of 2:1

7. Pediatric vs. Adult Spine Anatomy ……..Not just little adults!
Children younger than 8yrs are more susceptible to C-spine injuries because;
Larger head to body proportion
Higher fulcrum……. “point of maximal mobility” (C2-3 at birth, C3-5 at 8-12yrs old to C5-6 at 12yrs old and adults)
Weaker cervical musculature
Increased ligamentous laxity leading to greater mobility of the c-spine
Immature joints and Ossification centers
Horizontal facet joints that facilitate sliding of the upper C-spine
Spinal columns are more elastic than the spinal cord (tolerating more distraction before rupture……. Thus leading to SCIWORA

8. Key History and PE Components
Cause…. MVA, Sports (Football/Diving), Falls
Mechanism….. Hyperflexion (Clay shoveler’s or Teardrop Fx’s), hyperextension (Hangman’s Fx), Rotational (Jumped Facets), Compression or axial loading (Jefferson/Burst Fx)
Symptoms….. Numbness, tingling, or weakness during any time since accident even if resolved
Predisposing conditions….. 15% Down’s Syndrome pts have atlantoaxial instability, Achondroplasia (Cervicomedullary Junction stenosis)
Physical Exam
Testing for motor or sensory deficits and levels if present
DTR’s and rectal tone
High index for Multisystem trauma (40% of cases have associated intrabdominal injuries)

9. 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

10. Imaging Evaluation of Spine Injuries
Are Xrays indicated?
NEXUS Study Criteria
Lateral, AP and Odontoid view
Flexion-Extension views
CT C-spine
MRI

11. anterior wedging of vertebral bodies
horizontal alignment of facet joints
Children prone to anterior dislocation
Young Child
Mature

12. Alignment - Pseudosubluxation
24% C2 on C3
14% C3 on C4
(Age <7 years)
Swischuk’s line: posterior arch of C1 to C3 – should come within 1 mm of post arch of C2

13. C2-3 Pseudosubluxation Look for significant prevertebral soft tissue
Shaw. Pseudosubluxation of C2 on C3 in polytraumatized children: Prevalence and significance. Clin Radiol 1999;54: 377.

14. Dens Predental space – allow up to 5 mm in young children
Subdental synchondrosis - lucency at base of dens
Dens fuses with body of C2 between ages years
A thin lucency may be appreciable on the lateral view for many years (50% up to age 11)
May have ossification centre at tip of dens os terminale

15. Prevertebral Soft Tissues
Allowable thickness changes with age
In general:
Above glottis:
½ vertebral body
Below glottis:
1 vertebral body
Often falsely thickened 2° to neck flexion (big occiput) or expiration

16. L abnormal, R normalized with repositioning.
Optimal if pt neck extended (and x ray taken at END inspiration – less false +).

17. Cervical Spine Injuries from Birth Trauma
Can occur
Upper cervical injuries may be a cause of perinatal death
Newborn with C5/6 fracture dislocation

18. Os Odontoideum Usually asymptomatic Pain , mylopathy instability
Fielding. Os odontoideum. J Bone Joint Surg Am 1980;62:376.

19. Atlanto-Occipital Dislocation
2.5 x more common in children than adults
Due to small occipital condyles and horizontal atlanto-occipital joints
Suspect if distance between occipital condyles and C1 is > 5mm at any point
Usually have ++ soft tissue swelling

21. Dens Fracture Suspicious for dens fracture:
widening of the synchondrosis
anterior tilting of the odontoid
Believed to have high miss rate – can lead to chronic problems

22. Hangman’s Fracture
The hangman's fracture i
Pseudosubluxation !!

23. Spinal Cord Injury Without Radiographic Abnormality SCIWORA
Defined as traumatic myelopathy in the absence of findings on plain radiographs, flexion-extension radiographs and cervical CT scan
mechanism is acceleration-deceleration or rotation injury
30-50% delayed onset of neurologic deficits from 30mins-4 days
MRI should be done
require immobilization
Mild SCIWORA : Cervical cord neurapraxia

24. Thoracic Spine Fractures
Less common spinal fracture in children than in more mobile regions
Child abuse in very young
Slotkin. Thoracolumbar spinal trauma in children. Neurosurg. Clin. N. Am. 2007;18:621.

25. 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
Arkader. Pediatric chance fractures: a multicenter perspective. J Pediatr Orthop. 2011;31:741.

26. Seatbelt Injury Classification
Rumball. Seat-belt injuries of the spine in young children. J Bone Joint Surg Br. 1992;74:571.

27. 4 year Lap Belt Intraabdominal Injuries, Paraplegic

28. Lumbar Apophyseal Injuries Slipped Apophysis
Compression-shear injuries
Same age group as SCFE
Typically adolescent males, inferior endplates of L4 or L5

29. Thank You