1. A Paediatric Spinal Injury
Andreas Crede
Emergency Medicine Registrar

2. 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

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

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

5. 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

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

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

10. Mechanism of Injury

11. 3 Column Model of Denis

12. 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

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

14. 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

15. 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).

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

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

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

19. 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

20. 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

21. 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

22. 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

23. 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

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

25. References www.radiologyassistant.nl www.imaging.consult.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:
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:
Groves CJ et al. Chance type flexion-extension injuries in the thoracolumbar spine: MR imaging characteristics. Radiology 2005; 236: 601-8

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