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