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

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

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

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

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)

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

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

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

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

Os Odontoideum

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

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

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

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

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

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

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

ED C Spine Evaluation

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

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

O – C1 Spinal Cord Injury

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

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

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

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

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

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

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

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

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

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

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

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)

Multiple Compression Fractures in 4 year old Leukemia Patient

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

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

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

4 yo Lap Belt Restrained Passenger Intraabdominal Injuries, Paraplegic

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

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

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

Rumball and Jarvis JBJS 74B Seatbelt Injury Classification

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

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

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

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 If you would like to volunteer as an author for the Resident Slide Project or recommend updates to any of the following slides, please send an e-mail to ota@aaos.org E-mail OTA about Questions/Comments Return to Pediatrics Index