Vertebral Fractures in Children and Adolescents

Creating Vertebral Fractures in Children and Adolescents

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Top Contributors - Daisy Meffan, Alexia Derbyshire, Cindy John-Chu and Angeliki Chorti  

Epidemiology/Aetiology

Spinal fractures make up only 1-3% of all paediatric fractures (2). 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 (9). 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 (1). Spinal fractures in adolescents can have devastating consequences such as spinal deformity, scoliosis and Syringomyelia (1).​

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 (1). 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 (2).

The IV discs are strong and vertebral end plate hard meaning this child’s spine has a higher resistance against compression forces (1). In Japanese study (3) found the anterior compartment stress in these spines to be high 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 (8) where the vertebrae 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).​

Skeletal muscle strength can be increased by resistance training under safe circumstances which are appropriate to the child’s level of maturity impacts, resistance training increases muscle strength which increases bone mineral density (Behringer et al., 2010). 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). Because women have a higher risk of osteoporosis the review was limited by nearly all bar 3 observational studies being levels of girl gymnasts which may lead to osteoporosis being neglected in males (Tan et al., 2014).

Mechanism of Injury

Neck fractures are common in children due to their disproportionately large head in comparison to weak neck muscles, the upper cervical facet joints being 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). ​

• Motor Vehicle accidents – both passengers and pedestrians (Most Common) (Leonard et al,. 2007)(Saul and Dresing, 2018)​

• Cycling ​

• Falls from a height (also common)(Leonard et al,. 2007, Saul and Dresing, 2018)​

• Sporting Injuries (Saul and Dresing, 2018)(Leonard et al,. 2007)​

• Assault​

Fractures Types

Contiguous compression fractures are common in paediatrics - due to paediatrics having increased C- spine mobility, and commonly linked to flexion movements, however does mean there is reduced neurological compromise (Leonard et al,. 2007)​

Burst fractures – makes up 10% of all thoracolumbar injuries in paediatrics due to the increase in spinal flexibility in paediatric spines meaning the pressure isn't concentrated in one area (Leonard et al,. 2007)​

Chance fracture – common in children when wearing lap belts in motor traffic accidents as the 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)

Characteristics/ Clinical Presentation

Signs and Symptoms​

• Commonly seen with associated severe and frequently fatal injuries (Leonard et al,. 2007)​

In a report of a 10 year period at a childrens university hospital, symptoms were found as (Leonard et al,. 2007)​

C-spine Fracture (most commonly injured)​

• neck pain​

• neurological deficit​

• fixed abnormal head positions​

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

T-spine Fracture​

• 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/viceral injuries including splenic haematoma

L-spine Fracture (thoracolumbar most common presentation (Saul and Dresing, 2018)))​

• Back pain​

• ecchymoses​

• localised tenderness​

• abdominal pain​

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

Make sure to look for fractures at a different levels (Saul and Dresing, 2018)​

Prevalence

In children below 5 the most common area to injure was T8 followed by lumbar (Saul and Dresing, 2018)​

In paediatrics between 5-10 the most common area was thoracolumbar (Saul and Dresing, 2018)​

In teenagers the most common area begins to shift to lumbar (Saul and Dresing, 2018)​

From 15 years and older the lumbar area is most affected (Saul and Dresing, 2018)

Diagnostic Procedures

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