A Paediatric Spinal Injury Andreas Crede Emergency Medicine Registrar

Introduction 5 Year old male Involved in MVA as restrained passenger near Beaufort West Head on collision, no history about other passengers Referred because of abdominal pain and distension - ?blunt abdominal organ injury

Introduction Arrived via AMS Immobilised on spine board No significant past medical history

Introduction Clinical examination: ABC’s stable Chest, CVS: NAD Abdo: soft, suprapubic distension and discomfort. Urinary catheter drained 900ml clear urine

Introduction CNS: GCS 15/15. No signs of head injury T12 Sensory level on right L1 Sensory level on left Lower limbs: complete motor deficit, bilateral unresponsive plantar reflexes Absent anal tone Right upper limb: C4-T2 sensory deficit, no motor deficit

Investigations Bloods normal Lodox normal, incl c-spine views Thoraco lumbar spine x-rays:

MRI findings Extensive haematoma T11 – L2 Multiple ligament tears, mainly posterior complex L2 vertebral body fracture Additional haematoma C7 with extensive cervical spine oedema

Mechanism of Injury

3 Column Model of Denis

Column Model 3 columns required to maintain spinal stability Wedge fracture = stable Wedge fracture with ligamentous rupture = unstable Predictors of soft tissue injury: Angulation >20° or translation >3,5mm

Adult Classification A: Classic Chance Fracture B: Fulcrum Fracture C: Soft tissue flexion-distraction injury

Paediatric Classification Different to adults Presence of growth plate Different characteristics of intervertebral disc allowing greater deformity: more water content of nucleus pulposus more elastic content

Paediatric Classification Type I: physeal injury of the superior growth plate associated with posterior lesion above the pedicle (soft tissue injury or superior facet fracture). Type II: osseous type. Fracture through the vertebral body, pedicle, lamina and spinous process. Type III: physeal injury of the inferior growth plate associated with posterior lesion below the pedicle (soft tissue injury or inferior facet fracture).

Type I Physeal injury of the superior growth plate associated with posterior lesion above the pedicle (soft tissue injury or superior facet fracture).

Type II Osseous type. Fracture through the vertebral body, pedicle, lamina and spinous process.

Type III Physeal injury of the inferior growth plate associated with posterior lesion below the pedicle (soft tissue injury or inferior facet fracture).

Alternate Classification Rumball and Jarvis A-D (X-ray classification) A: Disruption of Posterior Column extending into middle column B: Avulsion of Posterior elements with facet joint disruption C: Posterior ligament disruption with fracture line extending into vertebra D: Posterior ligament rupture with fracture line through lamina extending into physis of adjacent vertebral body

Imaging Standard X-rays view boney components/ alignment X-rays cannot view soft tissues MRI can identify ligamentous/ soft tissue and growth plate injuries Absent epiphysis in human spines CT scan not indicated unless MRI not available or intra-abdominal injury suspected

Chance Fractures Unique to thoracolumbar spine (T10 – L2) Variant of flexion-distraction injury Due to lap belt injury without shoulder belt restraint Fulcrum of flexion lies anterior to vertebral column allowing no compression of vertebral body Flexion results in either ligamentous tear or combination of ligament, bone and disc injuries

Chance Fractures 15-42% chance intra-abdominal organ injury: pancreas, duodenum and prox small bowel 79% hollow viscus injury in New Zealand case series 25-83% neurologic deficit/vertebral injury 1/3 patients have Type II fracture 2/3 Type I or III fracture 96% patients bone and soft tissue injury, 4% soft tissue injury alone Almost all patients have extensive soft tissue oedema and posterior osteo-ligamentous complex disruption

Management ABC’s Prevent secondary injury High index of suspicion in patients restrained by lap seat belts Regular reassessment for abdo injuries Unstable fracture: requires immobilisation/ stabilisation

Management Conservative: reduction of dislocation + application of TLSO 2-3 months Surgical: large body habitus, polytrauma, failure to stabilise conservatively.

References www.radiologyassistant.nl www.imaging.consult.com www.emedicine.medscape.com Ceroni, Mousny, Lironi, Kaelin. Paediatric seat belt injuries: Unusual Chance’s fracture associated with intra-abdominal lesions in a child. Eur Spine J 2004; 13:167-171 De Gauzy et al. Classification of Chance Fracture in Children Using Magnetic Resonance Imaging. Spine 2007; 32: E89-E92 Sheperd, Hamill, Segedin. Paediatric lap-belt injury: A 7 year experience. Emergency Medicine Australasia 2006; 18: 57-63 Leonard M, Sproule J, McCormack D. Paediatric Spinal Trauma and Associated Injuries. Injury 2007; 38: 188-193 Groves CJ et al. Chance type flexion-extension injuries in the thoracolumbar spine: MR imaging characteristics. Radiology 2005; 236: 601-8

Also Check… ‘Seatbelt syndromes’ Google/pubmed etc it Soft tissue injuries associated with ‘seat belt sign’