Fractures of the Fractures of the Spine in ChildrenSpine in Children

Vahid Farsio Vahid Farsio , , MDMD

SINA SINA HOSPITALHOSPITAL

Important Pediatric Important Pediatric DifferencesDifferences

Anatomical differencesAnatomical differences Radiologic differencesRadiologic differences Increased elasticityIncreased elasticity

Anatomy – C1Anatomy – C1

3 ossification 3 ossification centers at birth – centers at birth – body and 2 body and 2 neurocentral neurocentral archesarches

Neurocentral Neurocentral synchondroses synchondroses (F) fuse (F) fuse at about at about 7 years 7 years of ageof age

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

Anatomy – C2Anatomy – C2

4 ossification centers at 4 ossification centers at birth – body, 2 neural birth – body, 2 neural arches, densarches, dens

Neurocentral Neurocentral synchondroses (F) fuse synchondroses (F) fuse at age 3-6 yearsat age 3-6 years

Synchondrosis between Synchondrosis between body and dens (L) fuses body and dens (L) fuses age 3 – 6 yearsage 3 – 6 years

Thus no physis / Thus no physis / synchondrosis should synchondrosis should be visible on open be visible on open mouth odontoid view in mouth odontoid view in child older than 6 years child older than 6 years

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

Anatomy – Lower Cervical Anatomy – Lower Cervical Vertebrae C3 – C7Vertebrae C3 – C7

Neurocentral Neurocentral synchondroses synchondroses (F) fuse at age 3-(F) fuse at age 3-6 years6 years

Ossified vertebral Ossified vertebral bodiebodies wedge s wedge shaped shaped until until square at about square at about age 7age 7

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

Epidemiology of Spinal Trauma in Epidemiology of Spinal Trauma in ChildrenChildren

Spinal injury is rare in childrenSpinal injury is rare in children

Pediatric vertebral injuries occur Pediatric vertebral injuries occur 60-80%60-80% of the time in the of the time in the cervical region cervical region (30-40% of all vertebral injuries in adults)(30-40% of all vertebral injuries in adults)

Overall incidence Overall incidence of spinal injury of spinal injury in children is 1-2%in children is 1-2%

Motor Vehicle Accidents Motor Vehicle Accidents are the leading cause of pediatric are the leading cause of pediatric SCI (SCI (60% of 60% of cases)…with cases)…with falls and sports falls and sports injuries (football injuries (football and diving) thereafterand diving) thereafter

M:F ratio of 2:1M:F ratio of 2:1

Pediatric vs. Adult Spine Pediatric vs. Adult Spine AnatomyAnatomy

……..……..Not just little adults!Not just little adults! Children younger than 8yrs are more susceptible to C-spine Children younger than 8yrs are more susceptible to C-spine

injuries because;injuries because; Larger head to body proportionLarger head to body proportion Higher fulcrum……. “Higher fulcrum……. “point of maximal mobilitypoint of maximal mobility” (C2-3 at birth, C3-5 ” (C2-3 at birth, C3-5

at 8-12yrs old to C5-6 at 12yrs old and adults)at 8-12yrs old to C5-6 at 12yrs old and adults)

Weaker cervical musculatureWeaker cervical musculature

Increased Increased ligamentous laxity ligamentous laxity leading to greater mobility of the c-leading to greater mobility of the c-spinespine

Immature joints and Ossification centersImmature joints and Ossification centers

Horizontal facet joints that facilitate sliding of the upper C-spineHorizontal facet joints that facilitate sliding of the upper C-spine

Spinal columns Spinal columns are are more elastic more elastic than the than the spinal cord spinal cord (tolerating (tolerating more distraction before rupture……. Thus leading to more distraction before rupture……. Thus leading to SCIWORASCIWORA

Key History and PE Key History and PE ComponentsComponents

HistoryHistory Cause…Cause…. MVA, Sports (Football/Diving), Falls. MVA, Sports (Football/Diving), Falls MechanismMechanism….. Hyperflexion (Clay shoveler’s or Teardrop ….. Hyperflexion (Clay shoveler’s or Teardrop

Fx’s), hyperextension (Hangman’s Fx), Rotational (Jumped Fx’s), hyperextension (Hangman’s Fx), Rotational (Jumped Facets), Compression or axial loading (Jefferson/Burst Fx)Facets), Compression or axial loading (Jefferson/Burst Fx)

SymptomsSymptoms….. Numbness, tingling, or weakness during any ….. Numbness, tingling, or weakness during any time since accident even if resolvedtime since accident even if resolved

Predisposing conditionsPredisposing conditions….. 15% ….. 15% Down’s Syndrome Down’s Syndrome pts have pts have atlantoaxial instability, atlantoaxial instability, Achondroplasia Achondroplasia (Cervicomedullary (Cervicomedullary Junction stenosis) Junction stenosis)

Physical ExamPhysical Exam Testing for motor or sensory deficits and levels if presentTesting for motor or sensory deficits and levels if present DTR’s and rectal toneDTR’s and rectal tone High index for High index for Multisystem trauma Multisystem trauma (40% of cases have (40% of cases have

associated intrabdominal injuries)associated intrabdominal injuries)

C Spine Immobilization C Spine Immobilization for Transport in Childrenfor Transport in Children

Large head will Large head will cause increased cause increased flexion of C spine on flexion of C spine on standard backboardstandard backboard

Bump beneath Bump beneath upper T spine or upper T spine or cutout in board for cutout in board for head to transport head to transport child with spine in child with spine in neutral alignmentneutral alignment

Imaging Evaluation of Spine Imaging Evaluation of Spine InjuriesInjuries

Are Xrays indicated?Are Xrays indicated? NEXUS Study Criteria NEXUS Study Criteria

Lateral, AP and Odontoid viewLateral, AP and Odontoid view

Flexion-Extension viewsFlexion-Extension views

CT C-spineCT C-spine

MRIMRI

anterior anterior wedging of wedging of vertebral vertebral bodiesbodies

horizontal horizontal alignment of alignment of facet jointsfacet joints

Children Children prone to prone to anterior anterior dislocationdislocationYoung ChildYoung Child MatureMature

Alignment - Alignment - PseudosubluxationPseudosubluxation

24% C2 on C324% C2 on C3 14% C3 on C414% C3 on C4

(Age <7 years)

Swischuk’s lineSwischuk’s line: : posterior arch posterior arch of C1 to C3 – of C1 to C3 – should come should come within 1 mm of within 1 mm of post arch of C2post arch of C2

C2-3 PseudosubluxationC2-3 Pseudosubluxation

Look for significant Look for significant prevertebral prevertebral soft soft tissuetissue

Shaw. Pseudosubluxation of C2 on C3 in Shaw. Pseudosubluxation of C2 on C3 in polytraumatized children: Prevalence and polytraumatized children: Prevalence and significance. Clin Radiol 1999;54: 377.significance. Clin Radiol 1999;54: 377.

DensDens Predental space Predental space – allow – allow

up to 5 mm in young up to 5 mm in young childrenchildren

Subdental synchondrosis Subdental synchondrosis - lucency at base of - lucency at base of densdens

Dens fuses with body Dens fuses with body of of C2 between C2 between ages 4 - 6 ages 4 - 6 yearsyears

A thin lucency may be A thin lucency may be appreciable on the lateral appreciable on the lateral view for many years (50% view for many years (50% up to age 11)up to age 11)

May have ossification May have ossification centre at centre at tip of dens os tip of dens os terminaleterminale

Prevertebral Soft TissuesPrevertebral Soft Tissues Allowable thickness Allowable thickness

changes with agechanges with age In general:In general:

Above glottis:Above glottis:

½ vertebral body½ vertebral body Below glottis:Below glottis:

1 vertebral body1 vertebral body Often falsely Often falsely

thickened 2° to neck thickened 2° to neck flexion (big occiput) flexion (big occiput) or expirationor expiration

Optimal if pt neck extended (and x ray taken at Optimal if pt neck extended (and x ray taken at END inspiration – less false +). END inspiration – less false +).

Cervical Spine Injuries from Cervical Spine Injuries from Birth TraumaBirth Trauma

Can occurCan occur

Upper cervical Upper cervical injuries may be a injuries may be a cause of perinatalcause of perinatal deathdeath

Newborn with C5/6 fracture Newborn with C5/6 fracture dislocationdislocation

Os OdontoideumOs Odontoideum

Usually Usually asymptomaticasymptomatic

Pain , mylopathyPain , mylopathy

instabilityinstability

Fielding. Os odontoideum. Fielding. Os odontoideum. J Bone Joint Surg Am 1980;62:376.J Bone Joint Surg Am 1980;62:376.

Atlanto-Occipital Atlanto-Occipital DislocationDislocation

2.5 x more common in 2.5 x more common in children than adultschildren than adults

Due to Due to small small occipital occipital condyles andcondyles and horizontal horizontal atlanto-atlanto-occipital jointsoccipital joints

Suspect if distance between occipital condyles and C1 is > 5mm at any point

Usually have Usually have ++ soft ++ soft tissue tissue swellingswelling

Dens FractureDens Fracture

Suspicious for Suspicious for dens fracture:dens fracture: widening of the widening of the

synchondrosissynchondrosis anterior tilting of anterior tilting of

the odontoidthe odontoid Believed to have Believed to have

high miss rate – can high miss rate – can lead to chronic lead to chronic problemsproblems

Hangman’s FractureHangman’s FractureThe hangman's The hangman's fracture ifracture i

Pseudosubluxation Pseudosubluxation !! !!

Spinal Cord Injury Without Radiographic Spinal Cord Injury Without Radiographic AbnormalityAbnormality

SCIWORASCIWORA

Defined as Defined as traumatic myelopathy traumatic myelopathy in the absence of findings in the absence of findings on plain radiographs, flexion-extension radiographs and on plain radiographs, flexion-extension radiographs and cervical CT scancervical CT scan

mechanism is mechanism is acceleration-decelerationacceleration-deceleration or or rotation rotation injury injury

30-50%30-50% delayed onset of neurologic deficits from delayed onset of neurologic deficits from 30mins-4 days30mins-4 days

MRIMRI should be done should be done

require immobilizationrequire immobilization

Mild Mild SCIWORA : SCIWORA : Cervical cord neurapraxiaCervical cord neurapraxia

Thoracic Spine FracturesThoracic Spine Fractures

Less common spinal fracture in Less common spinal fracture in children than in more mobile regionschildren than in more mobile regions

Child abuse Child abuse in very youngin very young

Slotkin. Thoracolumbar spinal trauma in children. Neurosurg. Clin. N. Am. 2007;18:621.Slotkin. Thoracolumbar spinal trauma in children. Neurosurg. Clin. N. Am. 2007;18:621.

Thoracolumbar Junction Thoracolumbar Junction InjuriesInjuriesT11-L2T11-L2

Classically lap-belt flexion-Classically lap-belt flexion-distraction injuriesdistraction injuries

Chance fractures and variantsChance fractures and variants High association with High association with

intraabdominal injury (50-90%)intraabdominal injury (50-90%) Neurologic injury infrequent but can Neurologic injury infrequent but can

occuroccur

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

Seatbelt Injury Seatbelt Injury ClassificationClassification

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

4 year Lap Belt 4 year Lap Belt Intraabdominal Injuries, Intraabdominal Injuries,

ParaplegicParaplegic

Lumbar Apophyseal InjuriesLumbar Apophyseal InjuriesSlipped ApophysisSlipped Apophysis

Compression-shear Compression-shear injuriesinjuries

Same age group as Same age group as SCFESCFE

Typically adolescent malesTypically adolescent males, , inferior inferior endplates endplates of of L4 or L5L4 or L5

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