Spinal Fractures

Cervical spine Fractures

 

Incidence

 

Rare

- < 1% children's fractures

 

< 7

- upper cervical

- craniocervical junction

 

> 7

- lower C spine predominate

 

Immobilisation

 

Very big heads

- will flex neck on spinal board

- need bump under T spine or

- cut out for head

 

Clinical

 

Beware distracting injuries

- cannot clear C spine clinically

 

Clearance

- normal mental state

- no distracting injuries

- not intoxicated

- able to adequately communicate

- no neck pain or tenderness

- Full ROM

 

X-rays

 

Issues

 

Soft tissue swelling

- unreliable in crying child

 

Paeds C spine

- not well cleared by X ray

- much of cervical spine cartilaginous

- CT invaluable

 

Normal findings

 

C2/3 pseudosubluxation

- up to 4 mm

- common / seen in 40% < 8 years old

- reduced in extension

- Swischuk's line:  posterior arch C1 - C3, C2 shoulde be within 1.5 mm

 

ADI > 3 mm in 20% children

 

Vertebral bodies classically wedged

 

CT

 

Fast

- may not need sedation

 

Essential for C0-2 if intubated

- include in any child having CT head

 

Will pick up vast majority of unstable fractures

 

MRI

 

Show disruption of endplate / disc junction

Ligamentous injuries

SCIWORA

 

SCIWORA

 

Spinal cord injury without radiographic abnormality

- C spine very flexible

- traction injury with normal X-ray

- usually upper C spine < 8

 

Immature C spine can stretch 5 cm without fracture

- spinal cord ruptures with 5 mm traction

- it is less elastic and tethered

 

Must be aware of possibility especially with GCS <3

 

Management of obtunded patient

- unable to clear C spine

- Aspen collar will cause pressure areas / increase ICP

- MRI within 12 hours

 

Upper C spine Fractures

 

Aetiology

 

< 8

- mobile neck

- ligamentous laxity

- shallow facets

- big head

 

Usually falls and MVA

 

Ossification

 

Axis

- 3 primary

- body and two arches

- fuse age 7

 

Atlas

- 4 primary

- body, 2 arches, dens

- dens fuses age 6

- summit ossification appears 3-6, fuses 12

 

Problems

 

1.  Os ondontoid

 

Thought to be related to previous trauma

- can give C1 / 2 instability

 

2.  C0/1 dislocation

 

Terrible injury

- quadriplegia

- can be fatal

 

C0-C1

- Basion axial / Basion Dens interval

- each less than 12 mm

 

Powers ratio

- tip of basion to posterior arch (BP)

- tip of opisthon to anterior arch (AO)

- BP / AO

- > 1 anterior dislocation

- < 1 posterior dislocation

 

3.  Ondontoid Fractures

 

Pathology

- occurs at the synchondrosis

- intact anterior periosteal sleeve

 

Mechanism

- MVA deceleration injury

 

Clinical

- neurological defects rare

 

Xray

- anterior displacement

 

Management

- reduce with extension and application HTB

- 50% apposition required

- non union rare

 

Lower C spine

 

Anatomy

 

Neurocentral synchondroses fuse 3-6

Bodies wedge shaped until become square at 7

Superior / inferior cartilage end plates attached to disc

 

Pathology

 

Fractures occur between cartilaginous end plate and vertebral body

- between hypertrophic and calcified zones

 

Thoracic spine fracture

 

Uncommon

- protected by rib cage

 

Cause

- MVA, falls

- osteopenia ( OI, chemo, leukaemia)

 

Fracture / dislocations / Chance fractures

 

High energy

- usually TL junction

- lap belt injuries

- high association with intra-abdominal injuries

 

Apophyseal ring injuries