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Important Pediatric Differences. Anatomical differencesRadiologic differencesIncreased elasticityPeriosteal tube fractures
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1. Fractures of the Spine in Children Steven Frick, MD
Created March 2004; Revised August 2006
2. Important Pediatric Differences Anatomical differences
Radiologic differences
Increased elasticity
Periosteal tube fractures – apparent dislocations
Immobilization well tolerated
3. 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
4. Multiple Small Diameter Pin Child’s Halo for Displaced C2 Fracture
5. 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)
6. Anatomy – C1 3 ossification centers at birth – body and 2 neurocentral arches
Neurocentral synchondroses (F) fuse at about 7 years of age
7. 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
8. Anatomy – C2 Summit ossification center (H) appears at age 3 – 6 and fuses around age 12
Do not confuse with os odontoideum
9. Os Odontoideum Thought to be sequelae of prior trauma
May result in C1-C2 instability
10. Os Odontoideum
11. 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
12. 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
13. 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
14. 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
15. 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
16. 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
17. C Spine Evaluation in Children Similar protocol as adults
Consider mechanism of injury
Physical exam – tenderness (age, distracting injuries), neurological exam
C Spine series
18. ED C Spine Evaluation
19. 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
20. 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
21. O – C1 Spinal Cord Injury
22. Not “Cleared” by Plain Films CT scan – much of peds c-spine cartilaginous
Advantage – fast (no sedation -anesthesia)
Assess alignment
23. 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
24. Imaging 3 view plain film series
Obliques if requested by radiologist
CT scan upper C-spine (O-C2) if intubated, or consider MRI
25. If not “Cleared” within 12 Hours Switch to pediatric Aspen or Miami J collar
Consider CT or MRI
26. 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
27. Finch and Barnes JPO 1998 CSI <10 years old- MVC, upper C-spine
>10 years old- recreational sports, lower C-spine.
28. Givens et. al J Trauma 1991 3 year review, 34 children CSI
53% also TBI
41% mortality
50% of pts <8 injury below C4
29. Keiper Neuroradiology 1998 31 % of peds trauma patients (+) MRI C-spine
Persistent neck symptoms or radiographs inconclusive- check MRI
30. 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
31. 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
32. If You See a Spine Fracturein 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
33. 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)
34. Multiple Compression Fractures in 4 year old Leukemia Patient
35. 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
36. Thoracolumbar Junction InjuriesT11-L2 Classically lap-belt flexion-distraction injuries
Chance fractures and variants
High association with intraabdominal injury (50-90%)
Neurologic injury infrequent but can occur
37. Lap Belt Sign High association with intraabdominal injury and lumbar spine fracture
Lumbar spine films mandatory
38. 4 yo Lap Belt Restrained PassengerIntraabdominal Injuries, Paraplegic
39. 2 Year Old with Old L2-3 Fracture Dislocation from NAT
40. 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
41. 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
42. Rumball and Jarvis JBJS 74BSeatbelt Injury Classification
43. Flexion-Distraction Injury L2-L3 6 Months after Compression Fixation, Posterolateral Fusion
44. Lumbar Apophyseal InjuriesSlipped 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
45. 3 Types of Slipping of Vertebral Apophysis Tarr et al. J Comput Assist Tomogr
46. 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