Vertebral Fractures in Children and Adolescents: Difference between revisions

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== Definition/Description ==
== Definition/Description ==
A spinal fracture happens when a vertebral body collapses and when this happens in the paediatric population the bones are still developing and therefore can have severe consequences. A vertebral fracture is less obvious compared to a long bone fracture and is often very painful (Todd and Di Marco., 2019).
A spinal fracture happens when a vertebral body collapses. When this occurs in the paediatric population and because the bones are still developing, this may have severe consequences. A vertebral fracture is less obvious compared to a long bone fracture but is often very painful. <ref>Todd S., Di Marco M. Vertebral Fractures in Children. NHS Greater Glasgow and Clyde. Available from:https://www.smn.scot.nhs.uk/wp-content/uploads/2019/01/Vertebral-fractures-in-children.pdf [Accessed 11/3/2023].  </ref>


==Clinically Relevant Anatomy  ==
==Clinically Relevant Anatomy  ==


C- spine:
=== Cervical spine ===
*Epiphyseal variants
*Epiphyseal variants
*Epiphyseal plates are smooth and regular and have sclerotic lines  
*Epiphyseal plates are smooth and regular and have sclerotic lines  
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*Hyper-mobility
*Hyper-mobility


[[File:Cpsine.png|thumb|Ossification centres of C1 with open synchondroses (arrows) <ref name=":0">Lustrin E., Karakas S., Ortiz A., Cinnamon J., Castillo M., Vaheesan K., Brown J., Diamond A., Black K., Singh S. [https://doi.org/10.1148/rg.233025121 Pediatric cervical spine: normal anatomy, variants, and trauma]. Radiographics. 2003 May;23(3):539-60.</ref> |alt=|200x200px]]


C1:
=== C1 ===
[[File:Cpsine.png|thumb|Ossification centres of C1 with open synchondroses (arrows).]]
*Anterior arch is ossified in only 20% of cases at birth
*Anterior arch is ossified in only 20% of cases at birth  
*Becomes visible as an ossification centre by 1 year of age
*Becomes visible as an ossification centre by 1 year of age  
*Neural arches appear in 7th foetal week
*Neural arches appear in 7th foetal week
*Anterior arch fuses with the neural arches by 7  
*Anterior arch fuses with the neural arches by 7
*Non-fusion before this can be mistaken for a fracture
*Non-fusion before this can be mistaken for a fracture
*The neural arches fuse posteriorly by 3 years of age.  
*The neural arches fuse posteriorly by 3 years of age.
*Occasionally, the anterior ossification centre of C1 does not develop and the neural arches attempt to fuse anteriorly- This fusion abnormality can be differentiated from a fracture in that it demonstrates sclerotic margins
*Occasionally, the anterior ossification centre of C1 does not develop and the neural arches attempt to fuse anteriorly- This fusion abnormality can be differentiated from a fracture in that it demonstrates sclerotic margins


 
=== C2 ===
C2 (the axis, has the most complex and unique development of all vertebrae):
[[File:C2 2.png|thumb|Ossification centres of C2 with open synchondroses (arrows) <ref name=":0" />]]
[[File:C2 2.png|thumb|Ossification centres of C2 with open synchondroses (arrows).]]
The axis, has the most complex and unique development of all vertebrae. There are four ossification centres at birth:  
There are four ossification centres at birth:  
*One for each neural arch
*One for each neural arch
*One for the body
*One for the body
*One for the odontoid process  
*One for the odontoid process  


The odontoid process forms in utero from two separate ossification centres that fuse in the midline by the 7th foetal month.  
The odontoid process forms in utero from two separate ossification centres that fuse in the midline by the 7th foetal month. A secondary ossification centre appears at the apex of the odontoid process (os terminale) between 3 and 6 years of age and fuses by age 12 years. The body of C2 fuses with the odontoid process by 3–6 years of age. This fusion line (subdental synchondrosis), or the remnant of the cartilaginous synchondrosis, can be seen until age 11 years and may be confused with a fracture. The neural arches fuse posteriorly by 2–3 years of age and with the body of the odontoid process between 3 and 6 years of age <ref name=":1">Gray H., Bannister L., Berry M., Williams P. Gray's anatomy. 37th ed. Philadelphia, Pa: Lea and Febiger; 1989.</ref> <ref name=":2">Harris J., Harris J., Mirvis S. The radiology of acute cervical spine trauma. Lippincott Williams & Wilkins; 1996.</ref> <ref name=":3">Herman M., Pizzutillo P. [https://doi.org/10.1016/S0030-5898(05)70098-5 Cervical spine disorders in children.] Orthop Clin North Am. 1999 Jul 1;30(3):457-66.</ref> <ref name=":4">Ogden J. [https://link.springer.com/article/10.1007/BF00361083 Radiology of postnatal skeletal development.] Skeletal Radiology. 1984 Sep;12(3):169-77.</ref> <ref name=":5">Swischuk L. [https://books.google.com.ng/books?hl=en&lr=&id=rkEZbnCVnBkC&oi=fnd&pg=PR11&dq=Swischuk+LE.+Emergency+imaging+of+the+acutely+ill+or+injured+child.+Lippincott+Williams+%26+Wilkins%3B+2000&ots=mT-0HgnTcj&sig=YxCAMAiCzv_EEx2yTmzvxwJt0Xk&redir_esc=y#v=onepage&q=Swischuk%20LE.%20Emergency%20imaging%20of%20the%20acutely%20ill%20or%20injured%20child.%20Lippincott%20Williams%20%26%20Wilkins%3B%202000&f=false Emergency imaging of the acutely ill or injured child]. Lippincott Williams & Wilkins; 2000.</ref>. C3 through C7 can be discussed as a unit because they exhibit the same developmental pattern.  
A secondary ossification centre appears at the apex of the odontoid process (os terminale) between 3 and 6 years of age and fuses by age 12 years.  
The body of C2 fuses with the odontoid process by 3–6 years of age.  
This fusion line (subdental synchondrosis), or the remnant of the cartilaginous synchondrosis, can be seen until age 11 years and may be confused with a fracture.  
The neural arches fuse posteriorly by 2–3 years of age and with the body of the odontoid process between 3 and 6 years of age (16,17,19,20,22).  
C3 through C7 can be discussed as a unit because they exhibit the same developmental pattern.  


Three ossification sites are present:  
Three ossification sites are present in:  
*The body - which arises from a single ossification site
*The body - which arises from a single ossification site
*The two neural arches  
*The two neural arches  


The neural arches fuse posteriorly by age 2–3 years, and the body fuses with the neural arches between 3 and 6 years of age. Additionally, secondary ossification centres may be seen at the tips of the transverse processes and spinous processes that may persist until early in the 3rd decade of life and simulate fractures. Secondary ossification centres can also appear at the superior and inferior aspects of the cervical vertebral bodies and remain unfused until early adulthood.  <ref name=":1" /> <ref name=":2" /> <ref name=":3" /><ref name=":4" /><ref>Bailey D. [https://doi.org/10.1148/59.5.712 The normal cervical spine in infants and children.] Radiology. 1952 Nov;59(5):712-9.</ref>


The neural arches fuse posteriorly by age 2–3 years, and the body fuses with the neural arches between 3 and 6 years of age. Additionally, secondary ossification centres may be seen at the tips of the transverse processes and spinous processes that may persist until early in the 3rd decade of life and simulate fractures.
=== Ligaments ===
Secondary ossification centres can also appear at the superior and inferior aspects of the cervical vertebral bodies and remain unfused until early adulthood (Fig 4) (1,16,17, 19,20)
 
Ligaments in the C-spine:
*The anterior and posterior atlanto-occipital membranes extend from the upper aspect of C1 to the anterior and posterior aspects of the foramen magnum.  
*The anterior and posterior atlanto-occipital membranes extend from the upper aspect of C1 to the anterior and posterior aspects of the foramen magnum.  
*The anterior atlantoaxial ligament extends from the anterior midportion of the dens to the inferior aspect of the anterior arch of C1.  
*The anterior atlantoaxial ligament extends from the anterior midportion of the dens to the inferior aspect of the anterior arch of C1.  
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*The transverse ligament extends from the tubercle on the inner aspect of one side of the atlas to the tubercle on the other side.  
*The transverse ligament extends from the tubercle on the inner aspect of one side of the atlas to the tubercle on the other side.  
*The apical ligament lies between the superior longitudinal fasciculus of the cruciform ligament and the anterior atlanto-occipital membrane.  
*The apical ligament lies between the superior longitudinal fasciculus of the cruciform ligament and the anterior atlanto-occipital membrane.  
*The alar ligaments connect the lateral aspect of the dens and the medial inferior aspect of the occipital condyles- the main function of the alar ligaments is to limit rotation to the contralateral side (16,19, 20,23).
*The alar ligaments connect the lateral aspect of the dens and the medial inferior aspect of the occipital condyles- the main function of the alar ligaments is to limit rotation to the contralateral side.                            <ref name=":1" /><ref name=":2" /><ref name=":5" /><ref>Cattell H., Filtzer D. [https://journals.lww.com/jbjsjournal/Abstract/1965/47070/Pseudosubluxation_and_Other_Normal_Variations_in.1.aspx Pseudosubluxation and other normal variations in the cervical spine in children: A study of one hundred and sixty children]. JBJS. 1965 Oct 1;47(7):1295-309.</ref>


==Paediatric Versus Adult Cervical Spine ==
==Paediatric Versus Adult Cervical Spine ==


Cervical spine injuries in children usually occur in the upper cervical spine from the occiput to C3.  
Cervical spine injuries in children usually occur in the upper [[Cervical Spine Case Studies|cervical spine]] from the occiput to C3. This fact may be explained by the unique biomechanics and anatomy of the paediatric cervical spine.  
This fact may be explained by the unique biomechanics and anatomy of the paediatric cervical spine.  
*The fulcrum of motion in the cervical spine in children is at the C2-C3 level; in the adult cervical spine, the fulcrum is at the C5-C6 level. <ref>Kokoska E., Keller M., Rallo M., Weber T.. [https://doi.org/10.1053/jpsu.2001.20022 Characteristics of pediatric cervical spine injuries.] J Ped Surg. 2001 Jan 1;36(1):100-5.</ref> <ref name=":6">Roche C., Carty H. [https://link.springer.com/article/10.1007/s002470100532 Spinal trauma in children.] Pediatric Radiology. 2001 Oct;31(10):677-700.</ref>
*The fulcrum of motion in the cervical spine in children is at the C2-C3 level; in the adult cervical spine, the fulcrum is at the C5-C6 level (11,13).
*The immature spine is hypermobile because of ligamentous laxity, shallow and angled facet joints, underdeveloped spinous processes, and physiologic anterior wedging of vertebral bodies, all of which contribute to high torque and shear forces acting on the C1-C2 region.  
*The immature spine is hypermobile because of ligamentous laxity, shallow and angled facet joints, underdeveloped spinous processes, and physiologic anterior wedging of vertebral bodies, all of which contribute to high torque and shear forces acting on the C1-C2 region.  
*Incomplete ossification of the odontoid process, a relatively large head, and weak neck muscles are other factors that predispose to instability of the paediatric cervical spine (6,13,17,19,20,24,25).
*Incomplete ossification of the odontoid process, a relatively large head, and weak neck muscles are other factors that predispose to instability of the paediatric cervical spine. <ref name=":2" /> <ref name=":3" /> <ref name=":5" /> <ref name=":6" /> <ref>McGrory B., Klassen R., Chao E., Staeheli J., Weaver A. [https://europepmc.org/article/med/8335674 Acute fractures and dislocations of the cervical spine in children and adolescents.] J Bone Joint Surg. American volume. 1993 Jul 1;75(7):988-95.</ref> <ref>Davis B. Media Reviews. [https://doi.org/10.1080/312703002831 Rosen's Emergency Medicine: Concepts and Clinical Practice]. Prehosp Emerg Care. 2004 Jan 1;8(3):334-5.</ref><ref>Bilston L., Brown J. [https://journals.lww.com/spinejournal/Abstract/2007/10010/Pediatric_Spinal_Injury_Type_and_Severity_Are_Age.11.aspx Pediatric spinal injury type and severity are age and mechanism dependent.] Spine. 2007 Oct 1;32(21):2339-47.</ref>


==Kyphosis and Lordosis==
==Kyphosis and Lordosis==


Kyphosis and lordosis are shown to increase at a linear rate from a child to adolescent age.  
[[Kyphosis]] and lordosis are shown to increase at a linear rate from a child to adolescent age.  
*Kyphotic curves increase  from 25° at 7 years of age to 38° at 19 years of age (kyphotic angle = 25° + 0.58 × age)
*Kyphotic curves increase  from 25° at 7 years of age to 38° at 19 years of age (kyphotic angle = 25° + 0.58 × age)
*Lordotic curves increase from 22° at 5 years of age to 32° at 20 years of age (lordotic angle = 24° + 0.51 × age).  
*Lordotic curves increase from 22° at 5 years of age to 32° at 20 years of age (lordotic angle = 24° + 0.51 × age).  
*There were no differences between males and females.  
*No differences were reported between males and females. <ref>Giglio C., Volpon J. [https://doi.org/10.1007/s11832-007-0033-5 Development and evaluation of thoracic kyphosis and lumbar lordosis during growth.] J Child Orthop. 2007 Sep 1;1(3):187-93.</ref>


Giglio CA, Volpon JB. Development and evaluation of thoracic kyphosis and lumbar lordosis during growth. Journal of children's orthopaedics. 2007 Sep 1;1(3):187.
[[File:Screenshot 2021-05-23 at 22.23.10.png|center|thumb|600x600px|Heights of thoracolumbar vertebra at birth, during childhood, pre-adolescence and adulthood. <ref>Dimeglio A., Canavese F. [https://link.springer.com/article/10.1007/s00586-011-1983-3 The growing spine: how spinal deformities influence normal spine and thoracic cage growth]. Eur Spine J. 2012 Jan;21(1):64-70.</ref>]]
[[File:Screenshot 2021-05-23 at 22.23.10.png|center|thumb|600x600px|Dimeglio A, Canavese F. The growing spine: how spinal deformities influence normal spine and thoracic cage growth. European Spine Journal. 2012 Jan;21(1):64-70.]]


== Epidemiology/Aetiology ==
== Epidemiology/Aetiology ==


Spinal fractures make up only 1-3% of all paediatric fractures (Bouyer et al., 2015). This is less incidence than in the adult population due to the child’s spine being more mobile and elastic and having a smaller mass compared to adults (Parsinni et al., 2002). Bone structure and strength are considered a vital predictors of fracture occurrence (Tan et al., 2014) in children a bone mass reduction of 6.4% doubles the risk of fracture (Colin et al., 2011). The incidence of these fractures are higher in children under the age of 5 and over the age of 10 years (Saul and Dresing, 2018). Spinal fractures in adolescents can have devastating consequences such as spinal deformity, scoliosis and Syringomyelia (Saul and Dresing, 2018).​
Spinal fractures make up only 1-3% of all paediatric fractures. <ref name=":7">Bouyer B., Vassal M., Zairi F., Dhenin A., Grelat M., Dubory A., Giorgi H., Walter A., Lonjon G., Dauzac C., Lonjon N. [https://doi.org/10.1016/j.otsr.2014.11.012 Surgery in vertebral fracture: epidemiology and functional and radiological results in a prospective series of 518 patients at 1 year's follow-up]. Orthop Traumatol Surg Res. 2015 Feb 1;101(1):11-5.</ref> This is less incidence than in the adult population due to the child’s spine being more mobile and elastic and having a smaller mass compared to adults. <ref name=":9">Parisini P., Di Silvestre M., Greggi T. [https://journals.lww.com/spinejournal/Abstract/2002/09150/Treatment_of_Spinal_Fractures_in_Children_and.6.aspx Treatment of spinal fractures in children and adolescents: long-term results in 44 patients]. Spine. 2002 Sep 15;27(18):1989-94.</ref> Bone structure and strength are considered vital predictors of fracture occurrence in children <ref name=":10">Tan V., Macdonald H., Kim S., Nettlefold L., Gabel L., Ashe M., McKay H. [https://doi.org/10.1002/jbmr.2254 Influence of physical activity on bone strength in children and adolescents: a systematic review and narrative synthesis]. J Bone Mineral Res. 2014 Oct;29(10):2161-81.</ref> and a bone mass reduction of 6.4% doubles the risk of fracture.<ref name=":11">Boreham C., McKay H. [http://dx.doi.org/10.1136/bjsports-2011-090188 Physical activity in childhood and bone health.] Br J Sports Med. 2011 Sep 1;45(11):877-9.</ref>  The incidence of these fractures is higher in children under the age of 5 and over the age of 10 years. <ref name=":8">Saul D., Dresing K. [https://doi.org/10.4081/pr.2018.7232 Epidemiology of vertebral fractures in pediatric and adolescent patients]. Pediatr Rep. 2018 Mar;10(1):17-23.</ref> Spinal fractures in adolescents can have devastating consequences such as spinal deformity, [[scoliosis]] and [[syringomyelia]]. <ref name=":8" />


The cervical spine is the most common location for factures in infants, because of the anatomy of the infant spine such as a heavy head and less muscular development of the neck which puts more strain on the spine (Saul and Dresing, 2018). As previously mentioned, the paediatric spinal anatomy is different to the adult which predisposes children to flexion and extension injuries. Some of these differences include the facet joints being orientated different meaning there is a greater mobility but worse stability in the spine (Bouyer et al., 2015).
The cervical spine is the most common location for factures in infants, because of the peculiarity of the anatomy of the infant spine such as having a heavy head and less muscular neck which puts more strain on the spine. <ref name=":8" /> As previously mentioned, the paediatric spinal anatomy is different from the adult's which predisposes children to flexion and extension injuries. Some of these differences include the facet joints being oriented differently leading to greater mobility but worse stability in the spine. <ref name=":7" />


The IV discs are strong and vertebral end plate hard meaning this child’s spine has a higher resistance against compression forces (Saul and Dresing, 2018).  A Japanese study found a high stress distribution in the anterior compartment in children's spines predisposing this area in particular to fractures. Paediatric spinal fractures are normally caused by high impact and speed injuries. These include predominantly falls, sporting impact injuries and road traffic accidents. These include predominantly falls, sporting impact injuries and road traffic accidents. The most common fractures are compression fractures (Falavigna et al., 2018) where the vertebrae bodies collapse.
In a child's spine, there is a high resistance against compression forces largely due to resilient intevertebral discs. <ref name=":8" /> A high stress distribution in the anterior compartment of children's spines predisposes this area in particular to fractures. <ref name=":8" /> Paediatric spinal fractures are usually caused by high impact and speed injuries. These predominantly include: falls, sporting impact injuries and road traffic accidents with the most common fractures being compression fractures where the vertebral bodies collapse.


In a review by Tan et al (2014) bone strength was the main outcome assessed which was defined as the ability to resist fractures including bones extrinsic properties of bone mineral mass and distribution of bone mass. Studies provide strong evidence of the relationship between physical activity on bone mass due to concentric and eccentric muscle contractions caused during physical activity which cause high loads being placed on the skeleton (Tan et al., 2014).​
In a review by Tan et al. <ref name=":10" /> bone strength was defined as the ability to resist fractures while taking into consideration extrinsic properties of bones such as mineral mass and distribution of bone mass. Studies provide strong evidence of the relationship between [[Physical Activity|physical activity]] and bone mass as concentric and eccentric muscle contractions elicited from physical activity place high loads on the skeleton. <ref name=":10" /> Also, fracture incidence was shown to be at its peak in early puberty at 10-12 years in girls and 13-15 years for boys. <ref name=":11" />​
 
In the review by Tan et al (2014) all physical activities and observational studies were included; it was found that bone apposition (diameter) was highly related to pubertal stage, fracture incidence peaks at early puberty, 10-12 year in girls and 13-15 years in boys (Colin et al., 2011). 


==Mechanism of Injury==
==Mechanism of Injury==


Neck fractures are common in children due to their disproportionately large head in comparison to weak neck muscles, which cause a bending movement on impact that is larger than the neck muscles can protect from. The upper cervical facet joints are also horizontally orientated and shallow with laxity in the ligaments (Leonard et al,. 2007). Usually ligament laxity prevents injury in other body parts by transferring energy however this property is not shared by the spinal cord (Leonard et al,. 2007). ​
Neck fractures are common in children due to their disproportionately large head in comparison to weak neck muscles, which cause a bending movement on impact that is larger than the neck muscles can protect from. The upper cervical facet joints are also horizontally orientated and shallow with laxity in the ligaments. <ref name=":12">Leonard M., Sproule J., Mc Cormack D. [https://doi.org/10.1016/j.injury.2006.09.019 Paediatric spinal trauma and associated injuries.] Injury. 2007 Feb 1;38(2):188-93.</ref> Usually ligament laxity prevents injury in other body parts by transferring energy however this property is not shared by the spinal cord. <ref name=":12" />


Due to the positioning of the paediatric spine and it's increased elasticity from the increased cartilage and intervertebral disc thickness, there has to be a considerable amount of force obtained to cause an unstable fracture (Parisini et al., 2002).
Due to the positioning of the paediatric spine and it's increased elasticity from the increased cartilage and intervertebral disc thickness, there has to be a considerable amount of force obtained to cause an unstable [[fracture]]. <ref name=":9" />


*Motor Vehicle accidents – both passengers and pedestrians (Most Common) (Leonard et al,. 2007)(Saul and Dresing, 2018)
*Motor Vehicle accidents – both passengers and pedestrians (Most Common) <ref name=":8" /><ref name=":12" />


*Cycling ​
*Cycling ​


*Falls from a height (also common)(Leonard et al,. 2007, Saul and Dresing, 2018)
*Falls from a height (also common) <ref name=":8" /><ref name=":12" />


*Sporting Injuries (Saul and Dresing, 2018)(Leonard et al,. 2007)
*Sporting Injuries <ref name=":8" /><ref name=":12" />


*Assault​
*Assault​


=== Fractures Types ===
'''Contiguous compression fractures''' - common in paediatric spinal injury  due to the increased C- spine mobility, commonly linked to flexion movements, however increased mobility does mean there is reduced neurological compromise. <ref name=":12" />​


'''Fractures Types'''  
'''Burst fractures''' – make up only 10% of all thoracolumbar injuries in paediatrics due to the increase in spinal flexibility, meaning the pressure is not concentrated in one area - the common cause of burst fractures. This also reduces neurological damage along the increased size of the paediatric spinal canal compared to the spinal cord and cauda equina. <ref name=":12" />
 
Contiguous compression fractures - common in paediatric spinal injury  due to the increased C- spine mobility, commonly linked to flexion movements, however increased mobility does mean there is reduced neurological compromise (Leonard et al,. 2007)​
 
Burst fractures – make up only 10% of all thoracolumbar injuries in paediatrics due to the increase in spinal flexibility meaning the pressure isn't concentrated in one area - the common cause of burst fractures. This also reduces neurological damage along the increased size of the paediatric spinal canal compared to the spinal cord and cauda equina (Leonard et al,. 2007)​
 
Chance fracture – common in children when wearing lap belts in motor traffic accidents. The seat belt acts as a fulcrum causing hyperflexion, commonly seen alongside intra-abdominal and head injuries (Leonard et al,. 2007). ​
 
Impression fractures (Saul and Dresing, 2018)
 
Apophyseal ring fractures - only found in the paediatric population. Normally seen in adolescents and occurs due to the ring apophysis and the vertebral body not fusing completely and may separate in the process (Gadi et al., 2015).
[[File:Picture to show compression fracture .png|thumb|Figure 1|alt=]]


'''Chance fracture''' – common in children when wearing lap belts in motor traffic accidents. The seat belt acts as a fulcrum causing hyperflexion, commonly seen alongside intra-abdominal and head injuries. <ref name=":12" /> ​


'''Apophyseal ring fractures''' - only found in the paediatric population. Normally seen in adolescents and occurs due to the ring apophysis and the vertebral body not fusing completely and may separate in the process. <ref>Ravi Kumar T., Rao R., Gadi D., Grover A. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4484115/ Lumbar apophyseal ring fracture-a case report.] JCDR. 2015 May;9(5):RD01.</ref>[[File:Picture to show compression fracture .png|thumb|Visualisation of vertebral compression fracture|alt=|center]]


==Characteristics/ Clinical Presentation==
==Characteristics/ Clinical Presentation==


'''Signs and Symptoms'''​
A 10 year report at a children's university hospital found symptoms were as follows:  <ref name=":8" /><ref name=":12" />
 
*Commonly seen with associated severe and frequently fatal injuries (Leonard et al,. 2007)​
 
 
'''A 10 year report at a children's university hospital, found symptoms were: ''' (Leonard et al,. 2007)and (Saul and Dresing, 2018)
 
'''C-spine Fracture'''


*neck pain​
=== '''C-spine Fracture''' ===
*[[Neck Pain: Clinical Practice Guidelines|neck pain]]​


*neurological deficit​
*neurological deficit​
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*Common Additional Injuries - facial/head injuries, skull and facial fractures, facial lacerations, intercranial injury​
*Common Additional Injuries - facial/head injuries, skull and facial fractures, facial lacerations, intercranial injury​


 
=== '''T-spine Fracture''' ===
'''T-spine Fracture'''
 
*back pain​
*back pain​


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'''L-spine Fracture'''
=== '''L-spine Fracture''' ===
 
*Back pain​
*Back pain​


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Due to children having a larger spinal canal than their spinal cord they can tolerate more compression than adults can before neural damage​
Due to children having a larger spinal canal than their spinal cord they can tolerate more compression than adults can before neural damage occurs​


Make sure to look for fractures at all levels of the spine (C-spine, T-spine and L-spine) when assessing for potential spinal fracture (Saul and Dresing, 2018)
'''N/B''': Ensure to look for fractures at all levels of the spine (C-spine, T-spine and L-spine) when assessing for potential spinal fracture in children. <ref name=":8" />


==Prevalence==
===Fracture trends===


In children below 5 the most common area to injure was T8 followed by lumbar  (Saul and Dresing, 2018)
* In children below 5 the most common area to injure was T8 followed by lumbar  ​
 
* Between the ages of 5-10 the most common fracture area was the thoracolumbar region ​
Between the ages of 5-10 the most common fracture area was the thoracolumbar region (Saul and Dresing, 2018)
* In teenagers the most common area begins to shift to the lumbar spine ​
 
* From 15 years and older the lumbar area is most affected   
In teenagers the most common area begins to shift to the lumbar spine (Saul and Dresing, 2018)
<ref name=":8" />
 
From 15 years and older the lumbar area is most affected  (Saul and Dresing, 2018)


==Differential Diagnosis==
==Differential Diagnosis==
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* [[Ankylosing Spondylitis (Axial Spondyloarthritis)|Juvenile Ankylosing Spondylitis]]  
* [[Ankylosing Spondylitis (Axial Spondyloarthritis)|Juvenile Ankylosing Spondylitis]]  
* [[Disc Herniation]]
* [[Disc Herniation]]
* Spinal cord injury without radiographic abnormality  
* [[Spinal Cord Injury|Spinal cord injury]] without radiographic abnormality


==Diagnostic Procedures==
==Diagnostic Procedures==


* Sensation of ‘breath arrest’ - immediately after the trauma the children would feel extremely short of breath, this is a predictive factor for vertebral fracture, particularly thoracolumbar fractures. ​
* '''Sensation of ‘breath arrest’''' - immediately after the trauma the children would feel extremely short of breath, this is a predictive factor for vertebral fracture, particularly thoracolumbar fractures. ​


* X-ray – due to cartilaginous nature of the vertebra, fractures were not always clear from routine x-rays and children can go undiagnosed. ​
* '''X-ray''' – due to the cartilaginous nature of the vertebra, fractures are not always clear from routine x-rays and children can go undiagnosed. ​


* MRI – used to determine diagnosis of potential fractures shown on x-ray, they give clear images of the vertebra allowing for more accurate diagnosis. This allows for direct visualisation and confirmation of the fracture, where it is in the spine and what type of fracture has occurred. ​
* '''MRI''' – used to determine diagnosis of potential fractures shown on x-ray. They give clear images of the vertebra allowing for more accurate diagnosis. This allows for direct visualisation and confirmation of the fracture, where it is in the spine and what type of fracture has occurred. ​


* CT scan – CT scans have better prognostic ability than x-ray as they show bony details in higher definition than an x-ray, its therefore more likely to get a clearly diagnosis from a CT scan than x-ray. However, like with x-rays fractures can go unnoticed on CT scans, therefore if there is any doubt about the potential of a fracture it will be followed up with an MRI scan to clarify a potential diagnosis. ​
* '''CT scan''' these have better prognostic ability than x-ray as they show bony details in higher definition than an x-ray. It is therefore more likely to get a clear diagnosis from a CT scan than an x-ray. However, like with x-rays fractures can go unnoticed on CT scans, therefore if there is any doubt about the potential of a fracture it should be followed up with an MRI scan to clarify a potential diagnosis. ​


* Flexion/Extension C-spine x-rays – often used after CT scans if no findings are present to determine if there is any undiagnosed cervical instability ​
* '''Flexion/Extension C-spine x-rays –''' often used after CT scans if no findings are present to determine if there is any undiagnosed cervical instability <ref>Leroux J., Vivier P., Slimane M., Foulongne E., Abu-Amara S., Lechevallier J., Griffet J. [https://doi.org/10.1016/j.otsr.2012.10.009 Early diagnosis of thoracolumbar spine fractures in children. A prospective study]. Orthopaedics & Traumatology: Surgery & Research. 2013 Feb 1;99(1):60-5.</ref><ref>Cui S., France J. Fractures of the Spine in Children. Available from: https://ota.org/sites/files/2018-06/P13-Fractures%20of%20the%20Spine%20in%20Children.pdf [Accessed 18//05/2021]</ref><ref>Murphy A. Cervical spine (flexion and extension views). Radiopaedia. Available from: https://radiopaedia.org/articles/58732 [Accessed 18/05/2021]</ref>


(Leroux J 2013), (Cui S 2016), (Murphy 2015)
=== Other Diagnostic Tools ===


Other Diagnostic Tools:
==== '''Nexus criteria''' ====
National Emergency R-ray Utilisation Group criteria assesses low-risk patients for cervical spine injury. It is primarily used to determine if an x-ray is required or if further imaging is needed after an x-ray to determine possible diagnosis.


Nexus criteria – National Emergency R-ray Utilisation Group criteria assess low-risk patients for cervical spine injury, it is primarily used to determine if an x-ray is required or if further imaging is needed after an x-ray to determine possible diagnosis.
Nexus criteria: <ref>Stiell I., Clement C., Wells G., Morrison L. [https://www.proquest.com/openview/29d86e493a0dfb6541fd112b5e0cf370/1?pq-origsite=gscholar&cbl=45787 Prospective validation of the NEXUS low-risk criteria for cervical spine radiography.] CJEM 2002 Mar 1;4(2):129.</ref>
 
Nexus criteria: ​


*Absence of midline cervical tenderness​
*Absence of midline cervical tenderness​
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*Absence of a painful, distracting injury​
*Absence of a painful, distracting injury​
(Stiell 2002)


Canadian C-spine Rule – these are a set of guidelines to help a clinician decide if cervical imaging (i.e. x-ray, CT or MRI scan) are appropriate for trauma patients. However, for children consideration needs to be taken around developmental stage, so applying these rules can be difficult.
==== '''Canadian C-spine Rule''' ====
These are a set of guidelines to help a clinician decide if cervical imaging (i.e. x-ray, CT or MRI) are appropriate for trauma patients. For children however, consideration needs to be taken around developmental stage, so applying these rules can be difficult.


C-spine rules: ​
C-spine rules: <ref>Fox S.. Paediatric Cervical Spine Injury. Paediatric EM Morsels: Paediatric Emergency Medicine Education. Available from: https://pedemmorsels.com/pediatric-cervical-spine-injury/ [Accessed 18/05/2021]</ref>


# Any high-risk factors which mandate radiography ​
# Any high-risk factors which mandate radiography ​
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# Able to actively rotate neck ​
# Able to actively rotate neck ​
#* 45 degrees left and right ​
#* 45 degrees left and right ​
(Fox 2019)


== Management ==
== Management ==


'''Conservative Management'''
=== '''Conservative Management''' ===
 
*Casting - There are two types, Minerva and Plaster and usually stay on for period of around 2 months (Parisini et al., 2002)
 
* Halo Vests - to be worn for an average of 8 weeks (Parisini et al., 2002)
 
* Bed Rest - until acute symptoms subside, followed by a moulded body cast (Parisini et al., 2002)


==== Casting ====
There are two types: Minerva and Plaster and they usually stay on for a period of around 2 months.


In a case series of adolescents below the age of 16 with traumatic spine injury, in the 44 patients, 20 had stable injuries and were managed conservatively with the above methods. It was identified that the three cervical fractures, and nine wedge-shaped compression fractures, healed without significant deformity (Parisini et al., 2002).
==== Halo Vests ====
The eight stable burst fractures managed with conservative management showed the vertebral body had non-perfect reconstruction, however at follow up the maximum deformity was maximum 10 degrees involving one vertebrae above and below (Parisini et al., 2002).
To be worn for an average of 8 weeks.
The remaining six fractures that were conservatively managed, all had significant angular deformities (Parisini et al., 2002).


Conservative management, particularly of wedge fractures without neurological lesions can be successful, leaving only moderate residual deformities, however it is important there is an accurate diagnosis to confirm the stability of the fracture to ensure accurate and correct treatment is provided (Parisini et al., 2002).Whilst nonoperative treatment is viable for burst fractures in children with no neurological deficits and minimal initial kyphosis, operative treatments are recommended for unstable  burst fractures to correct the deformity (Parisini et al., 2002).
==== Bed Rest ====
Until acute symptoms subside, followed by a moulded body cast.


'''Angelliaume et al, 2017:'''
Conservative management, particularly of wedge fractures without neurological lesions can be successful, leaving only moderate residual deformities. However, it is important there is an accurate diagnosis to confirm the stability of the fracture to ensure accurate treatment is provided.Whilst nonoperative treatment is viable for burst fractures in children with no neurological deficits and minimal initial kyphosis, operative treatments are recommended for unstable  burst fractures to correct the deformity. <ref name=":9" />
* In a case of a stable spinal fracture without neurological deficiency, conservative treatment must be the first treatment of choice in children
*The significant difference between the initial and the final local kyphosis at the thoracic level was not found for the lumbar level.  
*It is hypothesized that the brace is more efficient at the thoracic level than at the lumbar level and enables more remodelling, decreasing compressive forces by an antikyphotic effect- furthermore, it is easier to correct a thoracic kyphosis than a lumbar one using an antikyphotic brace


'''Angelliaume et al, 2017:''' <ref>Angelliaume A., Simon A., Boissière L., Bouty A., Sales de Gauzy J., Vital J., Gille O., Tournier C., Aunoble S., Pontailler J., Lefèvre Y. [https://doi.org/10.1097/BPB.0000000000000329 Conservative treatment of pediatric thoracic and lumbar spinal fractures: outcomes in the sagittal plane.] J Pediatr Orthop B. 2016 Jan 1;26(1):73-9.</ref>
* In a case of a stable spinal fracture without [[Neurological Disorders|neurological]] deficiency, conservative treatment must be the first treatment of choice in children
*The significant difference between the initial and the final local kyphosis at the thoracic level was not found for the lumbar level.
*It is hypothesised that the brace is more efficient at the thoracic level than at the lumbar level and enables more remodelling, decreasing compressive forces by an antikyphotic effect- furthermore, it is easier to correct a thoracic kyphosis than a lumbar one using an antikyphotic brace


Functional outcomes:
==== Functional outcomes ====
*Functional results indicated a high rate of back pain.
*Functional results indicated a high rate of back pain.
*However, patients’ functional results were satisfactory because they reported no limitations in their daily life activities and did not use painkillers.
*However, patients’ functional results were satisfactory because they reported no limitations in their daily life activities and did not use painkillers.
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*However, rates of back pain in adolescents without back injury are also high, with a prevalence of 7–70% .
*However, rates of back pain in adolescents without back injury are also high, with a prevalence of 7–70% .


=== Surgical Management ===
[[File:Post-operative radiographs after short instrumentation and anterior grafting to treat a burst fracture of T12..png|thumb|Spinal internal fixation <ref name=":13" /> ]]Overall surgical interventions depend on the type and severity of the fracture. The Denis classification can be used to differentiate between a stable and a unstable vertebral fracture which can help decide on management options. Generally according to the evidence, lots of stable fractures can be treated conservatively however unstable fractures will require surgical management. <ref name=":9" />  <ref name=":13">Sayama C., Chen T., Trost G., Jea A. [https://doi.org/10.3171/2014.5.FOCUS1490 A review of pediatric lumbar spine trauma.] Neurosurgical Focus. 2014 Jul 1;37(1):E6.</ref> Furthermore, if the patient has a neurological deficit or a spinal cord injury, surgery is necessary to stabilise the fracture and gain neurological function. <ref>Ferrero E., Compagnon R., Pesenti S., Lefèvre Y., Polirsztok E., Ilharreborde B., de Gauzy J. [https://doi.org/10.1016/j.otsr.2019.08.021 Surgical management of burst fractures in children and adolescents: A Multicentre Retrospective Study.] Orthopaedics & Traumatology: Surgery & Research. 2020 Feb 1;106(1):173-8.</ref> Surgical outcomes within the population have been positive. Vander Have et al. <ref>Vander Have K., Caird M., Gross S., Farley F., Graziano G., Stauff M., Segal L. [https://journals.lww.com/pedorthopaedics/Abstract/2009/10000/Burst_Fractures_of_the_Thoracic_and_Lumbar_Spine.11.aspx Burst fractures of the thoracic and lumbar spine in children and adolescents.] J Pediatr Orthop. 2009 Oct 1;29(7):713-9.</ref> found that surgical intervention was positive in ensuring the correction of the kyphosis of the spine compared to conservative management that which led to worsening of kyphosis.


'''Surgical Management'''[[File:Post-operative radiographs after short instrumentation and anterior grafting to treat a burst fracture of T12..png|thumb|Figure 2 ]]Overall surgical interventions depends on the type and severity of the fracture. The Denis classification can be used to differentiate between a stable and a unstable vertebral fracture which can help decide on management options. Generally according to the evidence lots of stable fractures can be treated conservatively however unstable fractures will require surgical management (Sayama., 2014)(Parsisni et al., 2002) Furthermore if the patient has a neurological deficit or a spinal cord injury, surgery is necessary to stabilise the fracture and gain neurological function (Ferrero et al, 2020). Surgical outcomes within the population have been positive, Vander et al (2009) found surgical intervention was positive in ensuring the correction of the kyphosis of the spine compared to conservative management that which led to worsening of kyphosis.
Types of surgery can vary depending on the type of fracture and the age. Adolescents can be treated using adult type instrumentation due to a more developed spine <ref name=":13" /> whereas, younger children have smaller pedicles so a normal screw placement in this area can be challenging. <ref name=":13" /> Evidence suggests a shorted fusion is the prefered approach in peadiactric fractures in order to preserve growth and mobility. <ref>Lalonde F., Letts M., Yang J., Thomas K. [https://europepmc.org/article/med/11234937 An analysis of burst fractures of the spine in adolescents.] Am J Orthop. 2001 Feb 1;30(2):115-20.</ref> In the lumbar spine, lumbar fusion can be used which involves fusing the vertebral bodies together so no movement can occur between them enabling the fracture to be repaired, this can be managed via a posterior approach. <ref name=":14">Boddu S. Spinal Compression Fractures. Weill Cornell Brain and Spine Centre. Available from: https://weillcornellbrainandspine.org/condition/spinal-compression-fractures/surgery-spinal-compression-fractures [Accessed 12/03/2023]</ref> If the fracture is more severe, reconstruction surgery such as vertebroplasty or kyphoplasty can take place. <ref name=":14" /> Although conservative management has been proven to correct initial conditions and deformities, these deformities can return overtime leading to a short term fix as opposed to a long term fix.
 
Types of surgery can vary depending on the type of fracture and the age. Adolescent’s can be treated using adult type instrumentation due to a more developed spine (Sayama), where as younger children have smaller pedicles so a normal screw placement in this area can be challenging (Sayama). Evidence suggest a shorted fusion is the prefered approach in peadiactric fractures in order to preserve growth and mobility (Lalonde et al, 2001). In the lumbar spine, lumbar fusion can be used which involves fusing the vertebral bodies together so no movement can occur between them enabling the fracture to be repaired, this can be managed via a posterior approach (Boddu, 2020). If the fracture is more severe reconstruction surgery such as vertebroplasty or kyphoplasty can take place (Boddu, 2020). Although conservative management has been proven to correct initial conditions and deformity’s these deformities can return overtime leading to a short term fix as opposed to a long term fix.
== Prevention ==
== Prevention ==


Over recent years there has been an increased recognition of the need to identify children with bone fragility (Ward et al., 2020), this is due to osteoporosis being thought to root from childhood therefore preventative efforts should be initiated in early life to ensure life-long bone health (Golden et al., 2014).
Over recent years, there has been an increased recognition of the need to identify children with bone fragility, <ref name=":15">Ward L., Weber D., Munns C., Högler W., Zemel B. [https://doi.org/10.1210/clinem/dgz294 A contemporary view of the definition and diagnosis of osteoporosis in children and adolescents.] J Clin Endocrinol Metab. 2020 May;105(5):e2088-97.</ref> this is due to [[osteoporosis]] being thought to root from childhood therefore preventative efforts should be initiated in early life to ensure life-long bone health. <ref name=":16">Golden N., Abrams S. [https://pediatrics.aappublications.org/content/134/4/e1229.short Optimizing bone health in children and adolescents.] Pediatrics. 2014 Oct 1;134(4):e1229-43.</ref>


*calcium: intake during infancy, childhood and adolescents contribute to bone mass gain. Dietary supplementations may be offered to those who cannot intake enough calcium. (Golden et al., 2014).
*'''Calcium''': intake during infancy, childhood and adolescence contribute to bone mass gain. Dietary supplementations may be offered to those who cannot take in enough calcium. <ref name=":16" />


*vitamin D: testing for vitamin D deficiency is recommended for those who have recurrent traumatic fractures even on low-impact. (Golden et al., 2014).
*'''Vitamin D:''' testing for vitamin D deficiency is recommended for those who have recurrent traumatic fractures even on low-impact. <ref name=":16" />
 


*mechanical loading and weight bearing exercise: puts force on the skeleton that increases bone formation (Golden et al., 2014). In a review by Tan et al (2014) bone strength was the main outcome assessed which was defined as the ability to resist fractures including bones extrinsic properties of bone mineral mass and distribution of bone mass. Studies included in the review provided strong evidence of the relationship between physical activity on bone mass due to concentric and eccentric muscle contractions caused during physical activity which cause high loads being placed on the skeleton (Tan et al., 2014).
*'''Mechanical loading and weight bearing exercise''': puts force on the skeleton that increases bone formation. <ref name=":16" />




Dual Energy X-ray absorptiometry (DXA) is the most used method of assessment for bone mass, its preferred due to low radiation and is  used commonly used for the lumbar  (Golden et al., 2014). Fracture risk not only depends on the factors above but also history of fractures, there is growing literature showing an association between low bone mass measured using DXA and increased fracture risk in children. (Golden et al., 2014).In adolescent females if mensuration has not occurred for more than 6 months then a DXA should be considered and clinicians, athletes and parents should be educated on female the athlete triad (Golden et al., 2014).


There is a need to evaluate each child on an individual basis to identify if they need a bone health evaluation, in the figure (  ) it can be seen that health factors  should be considered in the decision of whether to conduct a bone health evaluation, for example joint hypermobility or family history of osteoporosis (Ward et al., 2020)


An additional consideration is road traffic safety, Leonard et al (2007) investigated paediatric spinal trauma and associated injuries found that those who were restrained by a lap belt in rear of a vehicle whereby head on collision occurred leads to smaller children particular to ‘submarine’ beneath the belt causing hyperflexion of the spine to take-place. Associated injuries from this causes included both intra-abdominal and head injuries (Leonard et al., 2007). To prevent these injuries cross-body seat belts and booster seats where needed should be used.  
Dual Energy X-ray absorptiometry (DXA) is considered the gold standard for the assessment for bone mass as it is preferred due to low radiation. <ref name=":16" />  It is reported that an association occurs between low bone mass measured using DXA and increased fracture risk in children.<ref name=":16" />


[[File:Example of supporting evidence needed to trigger a bone health evaluation.png|thumb|Figure 3]]
There is a need to assess each child on an individual basis to identify if they need a bone health evaluation. In the diagram below,<ref name=":16" /> it can be seen what health factors should be considered in the decision of whether to conduct a bone health evaluation. <ref name=":15" />


An additional consideration is road traffic safety. Leonard et al. <ref name=":12" /> found in their study of paediatric spinal trauma that children who were restrained by a lap belt in the rear of a vehicle whereby a head on collision occurred led to hyperflexion of their spine and resulting in intra-abdominal and head injuries. <ref name=":12" /> To prevent these injuries from occuring, it is recommended that cross-body seat belts and booster seats be used to strap chiodren in vehicles.  


[[File:Example of supporting evidence needed to trigger a bone health evaluation.png|thumb|The extent of supporting evidence needed to trigger a bone health evaluation in relation to fracture characteristics <ref name=":15" />|alt=|center|600x600px]]


== References  ==
== References  ==
<references />
<references />
[[Category:Nottingham University Spinal Rehabilitation Project]]
[[Category:Paediatrics]]
[[Category:Paediatrics - Conditions]]
[[Category:Paediatrics - Assessment and Examination]]
[[Category:Paediatrics - Interventions]]

Latest revision as of 11:30, 12 March 2023


Definition/Description[edit | edit source]

A spinal fracture happens when a vertebral body collapses. When this occurs in the paediatric population and because the bones are still developing, this may have severe consequences. A vertebral fracture is less obvious compared to a long bone fracture but is often very painful. [1]

Clinically Relevant Anatomy[edit | edit source]

Cervical spine[edit | edit source]

  • Epiphyseal variants
  • Epiphyseal plates are smooth and regular and have sclerotic lines
  • Unique vertebral architecture
  • Incomplete ossification of synchondroses and apophyses
  • Hyper-mobility
Ossification centres of C1 with open synchondroses (arrows) [2]

C1[edit | edit source]

  • Anterior arch is ossified in only 20% of cases at birth
  • Becomes visible as an ossification centre by 1 year of age
  • Neural arches appear in 7th foetal week
  • Anterior arch fuses with the neural arches by 7
  • Non-fusion before this can be mistaken for a fracture
  • The neural arches fuse posteriorly by 3 years of age.
  • Occasionally, the anterior ossification centre of C1 does not develop and the neural arches attempt to fuse anteriorly- This fusion abnormality can be differentiated from a fracture in that it demonstrates sclerotic margins

C2[edit | edit source]

Ossification centres of C2 with open synchondroses (arrows) [2]

The axis, has the most complex and unique development of all vertebrae. There are four ossification centres at birth:

  • One for each neural arch
  • One for the body
  • One for the odontoid process

The odontoid process forms in utero from two separate ossification centres that fuse in the midline by the 7th foetal month. A secondary ossification centre appears at the apex of the odontoid process (os terminale) between 3 and 6 years of age and fuses by age 12 years. The body of C2 fuses with the odontoid process by 3–6 years of age. This fusion line (subdental synchondrosis), or the remnant of the cartilaginous synchondrosis, can be seen until age 11 years and may be confused with a fracture. The neural arches fuse posteriorly by 2–3 years of age and with the body of the odontoid process between 3 and 6 years of age [3] [4] [5] [6] [7]. C3 through C7 can be discussed as a unit because they exhibit the same developmental pattern.

Three ossification sites are present in:

  • The body - which arises from a single ossification site
  • The two neural arches

The neural arches fuse posteriorly by age 2–3 years, and the body fuses with the neural arches between 3 and 6 years of age. Additionally, secondary ossification centres may be seen at the tips of the transverse processes and spinous processes that may persist until early in the 3rd decade of life and simulate fractures. Secondary ossification centres can also appear at the superior and inferior aspects of the cervical vertebral bodies and remain unfused until early adulthood. [3] [4] [5][6][8]

Ligaments[edit | edit source]

  • The anterior and posterior atlanto-occipital membranes extend from the upper aspect of C1 to the anterior and posterior aspects of the foramen magnum.
  • The anterior atlantoaxial ligament extends from the anterior midportion of the dens to the inferior aspect of the anterior arch of C1.
  • The tectorial membrane is the superior extension of the posterior longitudinal ligament and attaches to the anterolateral aspect of the foramen magnum.
  • The transverse ligament extends from the tubercle on the inner aspect of one side of the atlas to the tubercle on the other side.
  • The apical ligament lies between the superior longitudinal fasciculus of the cruciform ligament and the anterior atlanto-occipital membrane.
  • The alar ligaments connect the lateral aspect of the dens and the medial inferior aspect of the occipital condyles- the main function of the alar ligaments is to limit rotation to the contralateral side. [3][4][7][9]

Paediatric Versus Adult Cervical Spine[edit | edit source]

Cervical spine injuries in children usually occur in the upper cervical spine from the occiput to C3. This fact may be explained by the unique biomechanics and anatomy of the paediatric cervical spine.

  • The fulcrum of motion in the cervical spine in children is at the C2-C3 level; in the adult cervical spine, the fulcrum is at the C5-C6 level. [10] [11]
  • The immature spine is hypermobile because of ligamentous laxity, shallow and angled facet joints, underdeveloped spinous processes, and physiologic anterior wedging of vertebral bodies, all of which contribute to high torque and shear forces acting on the C1-C2 region.
  • Incomplete ossification of the odontoid process, a relatively large head, and weak neck muscles are other factors that predispose to instability of the paediatric cervical spine. [4] [5] [7] [11] [12] [13][14]

Kyphosis and Lordosis[edit | edit source]

Kyphosis and lordosis are shown to increase at a linear rate from a child to adolescent age.

  • Kyphotic curves increase from 25° at 7 years of age to 38° at 19 years of age (kyphotic angle = 25° + 0.58 × age)
  • Lordotic curves increase from 22° at 5 years of age to 32° at 20 years of age (lordotic angle = 24° + 0.51 × age).
  • No differences were reported between males and females. [15]
Heights of thoracolumbar vertebra at birth, during childhood, pre-adolescence and adulthood. [16]

Epidemiology/Aetiology[edit | edit source]

Spinal fractures make up only 1-3% of all paediatric fractures. [17] This is less incidence than in the adult population due to the child’s spine being more mobile and elastic and having a smaller mass compared to adults. [18] Bone structure and strength are considered vital predictors of fracture occurrence in children [19] and a bone mass reduction of 6.4% doubles the risk of fracture.[20] The incidence of these fractures is higher in children under the age of 5 and over the age of 10 years. [21] Spinal fractures in adolescents can have devastating consequences such as spinal deformity, scoliosis and syringomyelia. [21]

The cervical spine is the most common location for factures in infants, because of the peculiarity of the anatomy of the infant spine such as having a heavy head and less muscular neck which puts more strain on the spine. [21] As previously mentioned, the paediatric spinal anatomy is different from the adult's which predisposes children to flexion and extension injuries. Some of these differences include the facet joints being oriented differently leading to greater mobility but worse stability in the spine. [17]

In a child's spine, there is a high resistance against compression forces largely due to resilient intevertebral discs. [21] A high stress distribution in the anterior compartment of children's spines predisposes this area in particular to fractures. [21] Paediatric spinal fractures are usually caused by high impact and speed injuries. These predominantly include: falls, sporting impact injuries and road traffic accidents with the most common fractures being compression fractures where the vertebral bodies collapse.

In a review by Tan et al. [19] bone strength was defined as the ability to resist fractures while taking into consideration extrinsic properties of bones such as mineral mass and distribution of bone mass. Studies provide strong evidence of the relationship between physical activity and bone mass as concentric and eccentric muscle contractions elicited from physical activity place high loads on the skeleton. [19] Also, fracture incidence was shown to be at its peak in early puberty at 10-12 years in girls and 13-15 years for boys. [20]

Mechanism of Injury[edit | edit source]

Neck fractures are common in children due to their disproportionately large head in comparison to weak neck muscles, which cause a bending movement on impact that is larger than the neck muscles can protect from. The upper cervical facet joints are also horizontally orientated and shallow with laxity in the ligaments. [22] Usually ligament laxity prevents injury in other body parts by transferring energy however this property is not shared by the spinal cord. [22]

Due to the positioning of the paediatric spine and it's increased elasticity from the increased cartilage and intervertebral disc thickness, there has to be a considerable amount of force obtained to cause an unstable fracture. [18]

  • Motor Vehicle accidents – both passengers and pedestrians (Most Common) [21][22]
  • Cycling ​
  • Falls from a height (also common) [21][22]
  • Assault​

Fractures Types[edit | edit source]

Contiguous compression fractures - common in paediatric spinal injury due to the increased C- spine mobility, commonly linked to flexion movements, however increased mobility does mean there is reduced neurological compromise. [22]

Burst fractures – make up only 10% of all thoracolumbar injuries in paediatrics due to the increase in spinal flexibility, meaning the pressure is not concentrated in one area - the common cause of burst fractures. This also reduces neurological damage along the increased size of the paediatric spinal canal compared to the spinal cord and cauda equina. [22]

Chance fracture – common in children when wearing lap belts in motor traffic accidents. The seat belt acts as a fulcrum causing hyperflexion, commonly seen alongside intra-abdominal and head injuries. [22]

Apophyseal ring fractures - only found in the paediatric population. Normally seen in adolescents and occurs due to the ring apophysis and the vertebral body not fusing completely and may separate in the process. [23]

Visualisation of vertebral compression fracture

Characteristics/ Clinical Presentation[edit | edit source]

A 10 year report at a children's university hospital found symptoms were as follows: [21][22]

C-spine Fracture[edit | edit source]

  • neurological deficit​
  • fixed abnormal head positions​
  • Common Additional Injuries - facial/head injuries, skull and facial fractures, facial lacerations, intercranial injury​

T-spine Fracture[edit | edit source]

  • back pain​
  • ecchymoses (skin discolouration due to bleeding below skin)​
  • localised tenderness ​
  • neurological deficit​
  • Common Additional injuries - simple or multiple rib fractures, fractured sternum, pulmonary contusion, abdominal/visceral injuries including splenic haematoma

L-spine Fracture[edit | edit source]

  • Back pain​
  • ecchymoses​ (skin discolouration due to bleeding below skin)
  • localised tenderness​
  • abdominal pain​

​ Due to children having a larger spinal canal than their spinal cord they can tolerate more compression than adults can before neural damage occurs​

N/B: Ensure to look for fractures at all levels of the spine (C-spine, T-spine and L-spine) when assessing for potential spinal fracture in children. [21]

Fracture trends[edit | edit source]

  • In children below 5 the most common area to injure was T8 followed by lumbar ​
  • Between the ages of 5-10 the most common fracture area was the thoracolumbar region ​
  • In teenagers the most common area begins to shift to the lumbar spine ​
  • From 15 years and older the lumbar area is most affected

[21]

Differential Diagnosis[edit | edit source]

Diagnostic Procedures[edit | edit source]

  • Sensation of ‘breath arrest’ - immediately after the trauma the children would feel extremely short of breath, this is a predictive factor for vertebral fracture, particularly thoracolumbar fractures. ​
  • X-ray – due to the cartilaginous nature of the vertebra, fractures are not always clear from routine x-rays and children can go undiagnosed. ​
  • MRI – used to determine diagnosis of potential fractures shown on x-ray. They give clear images of the vertebra allowing for more accurate diagnosis. This allows for direct visualisation and confirmation of the fracture, where it is in the spine and what type of fracture has occurred. ​
  • CT scan – these have better prognostic ability than x-ray as they show bony details in higher definition than an x-ray. It is therefore more likely to get a clear diagnosis from a CT scan than an x-ray. However, like with x-rays fractures can go unnoticed on CT scans, therefore if there is any doubt about the potential of a fracture it should be followed up with an MRI scan to clarify a potential diagnosis. ​
  • Flexion/Extension C-spine x-rays – often used after CT scans if no findings are present to determine if there is any undiagnosed cervical instability [24][25][26]

Other Diagnostic Tools[edit | edit source]

Nexus criteria[edit | edit source]

National Emergency R-ray Utilisation Group criteria assesses low-risk patients for cervical spine injury. It is primarily used to determine if an x-ray is required or if further imaging is needed after an x-ray to determine possible diagnosis.

Nexus criteria: [27]

  • Absence of midline cervical tenderness​
  • No evidence of intoxication​
  • Normal level of alertness​
  • Normal neurological exam​
  • Absence of a painful, distracting injury​

Canadian C-spine Rule[edit | edit source]

These are a set of guidelines to help a clinician decide if cervical imaging (i.e. x-ray, CT or MRI) are appropriate for trauma patients. For children however, consideration needs to be taken around developmental stage, so applying these rules can be difficult.

C-spine rules: [28]

  1. Any high-risk factors which mandate radiography ​
    • Dangerous mechanism of injury ​
    • Age > 65 ​
    • Paraesthesia in extremities ​
  2. Any low-risk factor which allows safe assessment of range of motion ​
    • Simple rear-end motor vehicle collision​ ​
    • Sitting position in ED​
    • Ambulatory at any time​
    • Delayed onset of neck pain​
    • Absence of midline spine tenderness
  3. Able to actively rotate neck ​
    • 45 degrees left and right ​

Management[edit | edit source]

Conservative Management[edit | edit source]

Casting[edit | edit source]

There are two types: Minerva and Plaster and they usually stay on for a period of around 2 months.

Halo Vests[edit | edit source]

To be worn for an average of 8 weeks.

Bed Rest[edit | edit source]

Until acute symptoms subside, followed by a moulded body cast.

Conservative management, particularly of wedge fractures without neurological lesions can be successful, leaving only moderate residual deformities. However, it is important there is an accurate diagnosis to confirm the stability of the fracture to ensure accurate treatment is provided.Whilst nonoperative treatment is viable for burst fractures in children with no neurological deficits and minimal initial kyphosis, operative treatments are recommended for unstable burst fractures to correct the deformity. [18]

Angelliaume et al, 2017: [29]
  • In a case of a stable spinal fracture without neurological deficiency, conservative treatment must be the first treatment of choice in children
  • The significant difference between the initial and the final local kyphosis at the thoracic level was not found for the lumbar level.
  • It is hypothesised that the brace is more efficient at the thoracic level than at the lumbar level and enables more remodelling, decreasing compressive forces by an antikyphotic effect- furthermore, it is easier to correct a thoracic kyphosis than a lumbar one using an antikyphotic brace

Functional outcomes[edit | edit source]

  • Functional results indicated a high rate of back pain.
  • However, patients’ functional results were satisfactory because they reported no limitations in their daily life activities and did not use painkillers.
  • Variable rates of functional outcomes have been reported, with 12–57% incidences of back pain after a conservative treatment
  • However, rates of back pain in adolescents without back injury are also high, with a prevalence of 7–70% .

Surgical Management[edit | edit source]

Spinal internal fixation [30]

Overall surgical interventions depend on the type and severity of the fracture. The Denis classification can be used to differentiate between a stable and a unstable vertebral fracture which can help decide on management options. Generally according to the evidence, lots of stable fractures can be treated conservatively however unstable fractures will require surgical management. [18] [30] Furthermore, if the patient has a neurological deficit or a spinal cord injury, surgery is necessary to stabilise the fracture and gain neurological function. [31] Surgical outcomes within the population have been positive. Vander Have et al. [32] found that surgical intervention was positive in ensuring the correction of the kyphosis of the spine compared to conservative management that which led to worsening of kyphosis.

Types of surgery can vary depending on the type of fracture and the age. Adolescents can be treated using adult type instrumentation due to a more developed spine [30] whereas, younger children have smaller pedicles so a normal screw placement in this area can be challenging. [30] Evidence suggests a shorted fusion is the prefered approach in peadiactric fractures in order to preserve growth and mobility. [33] In the lumbar spine, lumbar fusion can be used which involves fusing the vertebral bodies together so no movement can occur between them enabling the fracture to be repaired, this can be managed via a posterior approach. [34] If the fracture is more severe, reconstruction surgery such as vertebroplasty or kyphoplasty can take place. [34] Although conservative management has been proven to correct initial conditions and deformities, these deformities can return overtime leading to a short term fix as opposed to a long term fix.

Prevention[edit | edit source]

Over recent years, there has been an increased recognition of the need to identify children with bone fragility, [35] this is due to osteoporosis being thought to root from childhood therefore preventative efforts should be initiated in early life to ensure life-long bone health. [36]

  • Calcium: intake during infancy, childhood and adolescence contribute to bone mass gain. Dietary supplementations may be offered to those who cannot take in enough calcium. [36]
  • Vitamin D: testing for vitamin D deficiency is recommended for those who have recurrent traumatic fractures even on low-impact. [36]
  • Mechanical loading and weight bearing exercise: puts force on the skeleton that increases bone formation. [36]



Dual Energy X-ray absorptiometry (DXA) is considered the gold standard for the assessment for bone mass as it is preferred due to low radiation. [36] It is reported that an association occurs between low bone mass measured using DXA and increased fracture risk in children.[36]

There is a need to assess each child on an individual basis to identify if they need a bone health evaluation. In the diagram below,[36] it can be seen what health factors should be considered in the decision of whether to conduct a bone health evaluation. [35]

An additional consideration is road traffic safety. Leonard et al. [22] found in their study of paediatric spinal trauma that children who were restrained by a lap belt in the rear of a vehicle whereby a head on collision occurred led to hyperflexion of their spine and resulting in intra-abdominal and head injuries. [22] To prevent these injuries from occuring, it is recommended that cross-body seat belts and booster seats be used to strap chiodren in vehicles.  

The extent of supporting evidence needed to trigger a bone health evaluation in relation to fracture characteristics [35]

References[edit | edit source]

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