Vertebral Fractures in Children and Adolescents

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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 all levels of the spine (C-spine, T-spine and L-spine) when assessing for potential spinal fracture (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

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. ​

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. ​

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: ​

• 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 – 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. ​

C-spine rules: ​

Any high-risk factors which mandate radiography​

• Age >65​

• Dangerous mechanism of injury​

• Paraesthesia in extremities ​

• 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​

• Able to actively rotate neck​

• 45 degrees left and right​

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 ​

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