Fractures of Spine in Children - Orthopaedic Trauma - Lecture Slides, Slides of Orthopedics

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Fractures of the Spine in Children

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

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 – C

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

Anatomy – C

• 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 – C

• 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-C instability

Anatomy – Lower Cervical Vertebrae C

• C
• 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 Docsity.com

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

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

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 Docsity.com

Keiper

Neuroradiology 1998

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