1. Pediatric Trauma C-Spine X-Ray Ashlea Wilmott PGY-1 Emergency Medicine

2. Objectives Approach to the c-spine film with notable pediatric variations Ossification centre VS fracture Cases covering common pediatric injury patterns

3. We will not cover Non-traumatic findings (ie: epiglottitis, foreign body) Management of fractures Literature review of C-spine rules in children

4. Peds C-Spine Primers 2/3rds of pediatric spinal injuries occur in the C-Spine Many have associated neurologic deficit Pediatric patients injure their c-spine higher than adults

5. Anatomical Differences that Influence C-Spine Injury Big Heads Weak Muscles and Ligamentous Laxity Growth plates and inherently immature bones

6. Pediatric C-Spine < 8-10 yrs

7. Your typical approach… Loss of Lordosis Oval Contour Pseudosubluxation Ossification Centres Pre-dental Space Pseudospread C1 Soft tissue measurements With some pediatric variations…

8. dequacy

9. lignment A- Anterior vertebral line B- Posterior vertebral line C- Spinolaminar line D- Spinous processes

10. Loss of Lordosis Pseudosubluxation

11. Loss of Lordosis Distance between spines not > 1.5X adjacent C1-2 normal up to 10-12mm

12. Pseudosubluxation and Swischuk’s line

13. 2mm

14. Child on a Spine board = flexion

15. Alignment - Odontoid Normal up to 7mm of lateral displacement

16. Rotation = False displacement

17. one Oval contour and anterior wedging Ossification centres

18. Contour and Wedging 3mm

19. Ossification Centres C1 3 77

20. Ossification Centres C2 3 6 6

21. Odontoid age 4Odontoid age 8

22. Ossification Centres C3-C7 3 6 6

23. So many ossification centres…so little memory… The spinous process should be fused by 2-3 years This “wishbone” should fuse with the body by age 6 – can be later in C1 Extra caution with C2’s late fusing centres: – Base of the dens – Top of the dens

24. Growth PlateFracture Smooth, regular boarders Irregular boarders Predictable locationUn predictable location ScleroticNon-sclerotic

25. artilage

26. ensens 5 mm

27. oft Tissue

28. Summary Loss of lordosis, Pseudosubuxation, C1 spread Oval contour, Ant. Wedging, ossification centres As in adults Pre-dental space, Tilt Changes with age

29. Cases to highlight a few points…

30. Case 1 Something just doesn’t look right here…

31. Powers Ratio A-B/C-D < 1 A B D C

32. Case Two

33. A normal Swischuk’s line does not equal pseudosubluxation!

34. Case Three

35. A lucency at the physis is not always just the physis Beware the odontoid and all it’s ossification centres

36. Case Four The absence of a visible neural arch fracture does NOT rule out hangman’s fracture

37. Summary Loss of lordosis, Pseudosubuxation, C1 spread Oval contour, Ant. Wedging, ossification centres As in adults Pre-dental space, Tilt Changes with age