Chapter 65
Pediatric Spine Trauma
William C. Warner, Jr, MD
Gregory A. Mencio, MD
Introduction
Cervical spine injuries are uncommon in children and
usually are associated with motor vehicle crashes,
pedestrian-vehicle accidents, or falls in young children.
In older children, sports injuries, diving accidents, and
gunshot injuries are the most common causes. An
awareness of the unique aspects of the pediatric cervical
spine and an understanding of its growth and develop-
ment are necessary for correct diagnosis and proper
treatment. Normal physes may be mistaken for frac-
tures, resulting in overtreatment, and certain fractures
that occur through open physes may be undertreated.
The atlas develops from three ossification centers
(Figure 1). The posterior arches fuse by 3 to 4 years of
age, and the neurocentral synchondrosis between the lat-
eral masses and the body fuse at approximately 7 years
of age. The odontoid process is separated from the body
of the axis by a synchondrosis, which usually is fused by
6 to 7 years of age. This synchondrosis appears as a cork
in a bottle on an open mouth odontoid radiograph. The
lower cervical vertebrae also are composed of three pri-
mary ossification centers, one for the body and two for
the neural arches. The neural arches fuse posteriorly by
3 years of age, and the neurocentral synchondrosis fuses
with the body between 3 and 6 years of age. The verte-
bral bodies are wedge-shaped until 7 years of age, and
then gradually become rectangular.
Upper cervical spine injuries are more common in
children between birth and 8 years of age. After 8 years
of age, the injury patterns become more like those in
adults, with the lower cervical spine more frequently in-
volved. Factors contributing to the increased frequency
of upper cervical spine injuries in the young child in-
clude the relatively horizontal facets, the large head size
relative to trunk size, muscle weakness, and the in-
creased physiologic motion of the neck in children.
In young children, diagnosis of a cervical spine in-
jury may be difficult; repeated examinations and a high
index of suspicion often are needed. Upper cervical
spine injuries are frequent in young children with facial
trauma (fractures) and head trauma. Any pain or persis-
American Academy of Orthopaedic Surgeons
tent tenderness, paraspinal muscle spasms, limitation of
motion, or persistent torticollis should alert the exam-
iner to a possible cervical spine injury. An adequate
neurologic examination is difficult in a frightened child,
and frequent examinations may be required to reliably
determine neurologic status.
Initial radiographs should include cross-table lateral,
AP, and odontoid open-mouth views. It is mandatory that
the cervicothoracic junction be visible on the plain radio-
graphs. On the lateral radiographs, four lines should be
drawn corresponding to the anterior vertebral bodies, the
posterior vertebral bodies, the inside of the lamina (spino-
laminar line), and the tips of the spinous processes (Fig-
ure 2). All four of these lines should follow a smooth, even
contour.The articular facets should be parallel and the in-
terspinous ligaments balanced.The retropharyngeal space
should be less than 7 mm, and the retrotracheal space
should be less than 14 mm in children.An atlanto-dens in-
terval of 4 to 5 mm is normal in young children; in adults
and adolescents, this interval should be 3 mm.The atlanto-
dens interval is increased in young children because a sig-
nificant portion of the dens is cartilaginous and not visi-
ble on plain radiographs. This situation also gives the
appearance of overriding of the atlas on the unossified od-
ontoid on extension lateral radiographic views. Oblique
radiographs show details of the facet joints and pedicles
and are useful for determining if a fracture or fracture-
dislocation is present. Flexion and extension radiographs
should be obtained only in an awake and cooperative
child under the supervision of a physician; these radio-
graphs may be inappropriate in a very young child or an
obtunded patient. Because of the increased physiologic
motion in young children, pseudosubluxation of the sec-
ond cervical vertebra on the third or the third cervical ver-
tebra on the fourth may be present, most commonly in
children 1 to 7 years of age. Swischuks line is helpful in
differentiating this phenomenon from true injury.This line
is drawn along the posterior arch (spinolaminar line) of
C1 to C3 and should pass within 1.5 mm of the posterior
arch of C2 (Figure 3).
CT scans with three-dimensional reconstruction views
may be helpful in identifying fractures of the upper cer-
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Pediatric Spine Trauma
Figure 1 A, Ossification centers of the atlas. B, Ossification centers for the axis.
(Reproduced from Copley LA, Dormans JP: Cervical spine disorders in infants and
children. J Am Acad Orthop Surg 1998;6:205.)
vical spine (base of the skull, C1 or C2 vertebra) and in
evaluating atlantoaxial rotatory subluxation. MRI is espe-
cially useful for ruling out cervical spine injuries in pa-
tients who are obtunded or have a closed head injury and
may be difficult to evaluate because of their associated in-
juries. In a recent study, MRI was able to clear the cer-
vical spine in intubated, obtunded, and uncooperative
children with suspected cervical spine injuries. MRI also
was useful in documenting or ruling out injuries suggested
by plain radiographs and CT scans. MRI confirmed the
plain radiography diagnosis in 66% of patients and altered
the diagnosis in 34%.
Adequate immobilization of the cervical spine is dif-
ficult in children. Because commercial cervical collars of-
ten do not fit properly, they do not provide adequate im-
mobilization. Sandbags can be placed on each side of the
head to prevent motion. Spine boards used for children
should be modified to accommodate the large size of the
head in relationship to the trunk. An occipital recess or a
split mattress technique should be used to prevent un-
wanted flexion of the cervical spine (Figure 4). A halo ring
and vest can be used for immobilization of the cervical
spine in children, but an increased complication rate has
been reported in children compared with adults. CT scan-
ning can help in pin placement to avoid cranial sutures
and thin areas of the skull. Eight to 12 pins with low in-
sertional torques of 1 to 5 inch-lb are used in children.The
vest often must be custom fitted to avoid motion in the
vest portion while the head is fixed in the halo portion of
the orthosis.
Specific Cervical Spine Injuries
Atlanto-Occipital Dislocation
In the past, atlanto-occipital dislocation usually was a
fatal injury, but with current emergency medical care
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Orthopaedic Knowledge Update 8
Figure 2 Normal relationships in the lateral aspect of the cervical spine. 1 = spinous
processes, 2 = spinolaminar line, 3 = posterior vertebral body line, and 4 = anterior
vertebral body line. (Reproduced from Copley LA, Dormans JP: Cervical spine disor-
ders in infants and children. J Am Acad Orthop Surg 1998; 6:205.)
and increased awareness of this injury, more children
are surviving atlanto-occipital dislocations. Dislocation
of the atlanto-occipital joint is caused by a sudden de-
celeration injury, such as a motor vehicle or pedestrian-
vehicle accident. The childs head is thrown forward on
the relatively fixed trunk, causing sudden cranioverte-
bral separation. Because the atlanto-occipital joint has
little inherent bony stability and most of its stability is
provided by its ligamentous attachments, most atlanto-
occipital dislocations are unstable and require surgical
stabilization. The diagnosis of this condition may be dif-
ficult but is suggested by the mechanism of injury and
the significant amount of anterior soft-tissue swelling
visible on lateral radiographs.
The three most reliable radiographic findings to as-
sist in the diagnosis of atlanto-occipital dislocation are
(1) the Wackenheim line, (2) the Powers ratio, and (3)
the occipital condylar distance. The Wackenheim line is
drawn along the clivus and should intersect tangentially
the tip of the odontoid (Figure 5). An anterior or poste-
rior shift of this line indicates an anterior or posterior
displacement of the occiput on the atlas. The Powers ra-
tio is determined by drawing a line from the basion to
the posterior arch of the atlas and a second line from
the opisthion to the anterior arch of the atlas (Figure 6).
A ratio of more than 1.0 or less than 0.55 represents a
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 Orthopaedic Knowledge Update 8 Chapter 65 Pediatric Spine Trauma

Figure 4 Spine boards used for transportation of young children should be modified
to include either an occipital recess (top figure) or a mattress pad (bottom figure) to
accommodate the relatively large head. (Reproduced from Dormans JP: Evaluation of
children with suspected cervical spine injury. Instr Course Lect 2002;51:403.)
Figure 3 The spinolaminar (Swischuks) line is used to differentiate pseudosublux-
ation from true injury. (Reproduced from Copley LA, Dormans JP: Cervical spine disor-
ders in infants and children. J Am Acad Orthop Surg 1998;6:205.)

disruption of the atlanto-occipital joint. An occipital

condyle facet distance of more than 5 mm from the oc-
cipital condyle to the C1 facet also represents a disrup-
tion of the atlanto-occipital joint. MRI also is useful for
documenting soft-tissue injury associated with atlanto-
occipital dislocation.
Atlanto-occipital dislocation should be stabilized
surgically with a posterior occiput to C1 or C2 fusion.
Because of the instability of this injury, the preoperative
use of a halo or traction may be contraindicated.

Fractures of the Ring of C1

Fractures of the ring of C1 are uncommon injuries in
both children and adults. The mechanism of injury is an
axial load to the head; the force is transmitted through
the occipital condyles to the lateral masses of C1. In
adults, the ring usually breaks in two places, but in chil-
dren the open synchondrosis of C1 allows a single frac-
ture of the ring and a greenstick fracture through the
synchondrosis. Widening of the lateral masses of more
than 7 mm beyond the borders of the axis on an AP ra-
diograph indicates an injury to the transverse ligament.
In children, avulsion of the ligament from its attach-
ments is more likely than a true rupture of the trans-
verse ligament. Nonsurgical treatment is recommended
for most patients with this injury.
Odontoid Fractures
Odontoid fractures are one of the most common cervi-
cal spine fractures in children. Most are associated with
head trauma from a motor vehicle crash or a fall from a
height, although odontoid fracture can occur with trivial
head trauma. In children, this fracture most often occurs
Figure 5 Wackenheim clivus-canal line is drawn along the clivus into the cervical
spinal canal and should pass just posterior to the tip of the odontoid. (Reproduced
with permission from Menezes AH, Ryken TC: Craniovertebral junction abnormalities, in
Weinstein SL (ed): The Pediatric Spine: Principles and Practice. New York, NY, Raven,
1994.)
through the synchondrosis of C2 distally at the base of
the odontoid and appears on radiographs as a physeal
(Salter-Harris type I) injury. The fracture usually is ap-
parent on plain lateral radiographs, which show the an-
terior displacement of the odontoid. If the fracture
through the synchondrosis has spontaneously reduced, it
appears as a nondisplaced Salter-Harris type I fracture.
CT and MRI may be necessary to fully delineate the in-
jury. Most odontoid fractures in children heal unevent-
fully and complications are rare. Closed reduction is ob-
tained by extension or slight hyperextension of the
neck. At least 50% apposition should be obtained (com-

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Pediatric Spine Trauma
Figure 6 The Powers ratio is determined by drawing a line from the basion (B) to the
posterior arch of the atlas (C) and a second line from the opisthion (O) to the anterior
arch of the atlas (A). The length of line BC is divided by the length of the line OA. A ratio
of more than 1 is diagnostic of anterior atlanto-occipital translation and a ratio of less
than 0.55 indicates posterior translation. (Reproduced with permission from Parfen-
chuck TA, Bertrand SL, Powers MJ, et al: Posterior occipitoatlantal hypermobiliy in
Down syndrome: An analysis of 199 patients. J Pediatr Orthop 1994; 304.)
plete reduction of the translation is not necessary) be-
fore immobilization in a Minerva or halo cast or custom
orthosis for 6 to 8 weeks. Manipulation under anesthesia
or open reduction and internal fixation rarely are re-
quired.
Traumatic Ligamentous Dislocation
Acute rupture of the tranverse ligament is rare, re-
ported to occur in less than 10% of pediatric cervical
spine injuries; avulsion of the attachment of the trans-
verse ligament to C1 is more common. The transverse
ligament is the primary stabilizer of an intact odontoid
against forward displacement. The normal distance from
the anterior cortex of the dens to the posterior cortex of
the anterior ring of C1 is 4.5 mm in children and a dis-
tance of more than this, measured on a lateral radio-
graph, suggests disruption of the transverse ligament.
CT is useful to show avulsion of the transverse ligament
from the ring of C1. For acute injuries, reduction in ex-
tension is recommended, followed by surgical stabiliza-
tion of C1 and C2 and immobilization for 8 to 12 weeks
in a Minerva cast, halo brace, or cervical orthosis.
Atlantoaxial Rotatory Subluxation
Atlantoaxial rotatory subluxation is a common cause of
childhood torticollis and is most often caused by trauma
or infection. The most common cause is an upper respi-
ratory infection (Grisels syndrome), but subluxation
can occur after a retropharyngeal abscess, tonsillectomy,
pharyngoplasty, or trivial trauma. Atlantoaxial rotatory
subluxation is classified into four types: type I, unilateral
facet subluxation with an intact transverse ligament
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Orthopaedic Knowledge Update 8
(most common and benign); type II, unilateral facet sub-
luxation with 3 to 5 mm of anterior displacement; type
III, bilateral anterior facet displacement of more than 5
mm; type IV, posterior displacement of the atlas (Figure
7). Types III and IV are rare, but neurologic involve-
ment may be present or instantaneous death can occur;
these types must be treated with great care.
Children with acute atlantoaxial rotatory sublux-
ation usually report neck pain and headaches and hold
the head tilted and rotated to one side, resisting any ef-
forts to move the head. If the deformity becomes fixed,
the pain subsides but the torticollis and decreased range
of motion persist.
Radiographic evaluation may be difficult because of
the position of the head. AP and open-mouth odontoid
views should be taken with the shoulders flat and the
head in as neutral position as possible. Lateral masses
that have rotated forward appear wider and closer to
the midline, whereas the opposite lateral mass appears
narrower and farther away from the midline. On the lat-
eral view, the lateral facet appears anterior and usually
wedge-shaped rather than the normal oval shape. Flex-
ion and extension views can be used to exclude instabil-
ity. CT scanning is useful to show superimposition of C1
on C2 in a rotated position and to determine the degree
and amount of malrotation. Three-dimensional CT scans
are helpful to identify rotatory subluxation. MRI is of
little value unless neurologic findings are present.
Treatment depends on the duration of symptoms.
Many patients probably never receive medical treat-
ment because symptoms are mild and the subluxation
reduces spontaneously over a few days. If rotatory sub-
luxation has been present for a week or less, a soft col-
lar, anti-inflammatory drugs, and an exercise program
are sufficient. If symptoms persist after a week of this
treatment, head halter traction should be initiated, ei-
ther in the hospital or at home; muscle relaxants and an-
algesics may be needed. If the subluxation is present for
longer than a month, halo traction can be used. If reduc-
tion cannot be obtained or maintained, if signs of insta-
bility or neurologic deficits are present, or if the defor-
mity has been present for more than 3 months, posterior
arthrodesis is recommended to relieve muscle spasms
associated with the malrotation and produce normal
head appearance.
Hangmans Fracture
Bilateral spondylolisthesis of C2, or hangmans frac-
tures, are caused by forced hyperextension and are most
frequent in children younger than the age of 2 years,
probably because of the disproportionately large head,
poor muscle control, and hypermobility present in this
age group. The possibility of child abuse must be consid-
ered. Radiographs show a lucency anterior to the pedi-
cles of the axis, usually with some forward subluxation
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 Orthopaedic Knowledge Update 8
Figure 7 Fielding and Hawkins classification of atlantoaxial rotatory displacement showing four types of rotatory fixation. A, Type I, no anterior displacement and odontoid acting
as the pivot. B, Type II, anterior displacement of 3 to 5 mm and one lateral articular process acting as the pivot. C, Type III, anterior displacement of more than 5 mm.
D, Type IV, posterior displacement. (Reproduced with permission from Dormans JP: Evaluation of children with suspected cervical spine injury. Instr Course Lect 2002;51:403.)
of C2 on C3. This injury must be differentiated from a
persistent synchondrosis of the axis. Treatment is symp-
tomatic, with immobilization in a Minerva cast, halo, or
cervical orthosis for 8 to 12 weeks. If union does not oc-
cur, posterior or anterior arthrodesis can be done to sta-
bilize the fracture.
Subaxial Injuries
Fractures and dislocations involving C3 through C7 are
rare in children and infants. Because these injuries occur
most frequently in older children and adolescents and
have fracture patterns similar to those in adults, they
generally can be treated as in adults. Atlantoaxial screws
and lateral mass plates have been used successfully for
fixation of unstable fractures of the cervical spine in
children. Image-guided techniques make accurate place-
ment of these implants easier in a childs small verte-
brae.
Pediatric Halo Use
Halo vest immobilization is being used with increasing
frequency in children with cervical spine injuries. It af-
fords superior immobilization to a rigid cervical collar
and is easier to apply and more versatile than a Minerva
cast. It permits access for skin and wound care while
avoiding the skin problems (maceration, ulceration) typ-
ically associated with both hard collars and casts. How-
ever, complication rates as high as 68% have been re-
ported with pediatric halo use. The most common
problems are pin site infections; however, pin perfora-
tion and brain abscesses have also been reported. The
thickness of the skull in children is decreased and, in
children younger than age 6 years, it has been suggested
that CT of the skull to measure calvarial thickness can
be helpful in determining optimal sites for pin place-
ment.
In children older than 6 years, the standard adult
halo construct using four pins (two anterolaterally, two
posterolaterally) inserted at standard torques of 6- to 8-
American Academy of Orthopaedic Surgeons
Chapter 65 Pediatric Spine Trauma
inch-lb is generally successful. In younger children, more
pins (up to 12) placed with lower insertional torques (2-
to 4-inch-lb) have been advocated (Figure 8). Standard
pediatric halo rings fit most children, but infants and
toddlers usually require custom sizing. Although stan-
dard pediatric halo vests are available, custom vests or
body casts generally provide superior fit and immobili-
zation.
Spinal Cord Injury Without Radiographic
Abnormality
The possibility of spinal cord injury without radio-
graphic abnormality (SCIWORA) should be considered
in children, particularly in patients younger than 8 years.
SCIWORA is defined as spinal cord injury in a patient
in whom there is no visible fracture on plain radio-
graphs or CT scan. MRI may be diagnostic in showing
spinal cord edema or hemorrhage, soft-tissue or liga-
mentous injury, or apophyseal end plate or disk disrup-
tion, but is completely normal in approximately 25% of
patients. SCIWORA is the cause of paralysis in approxi-
mately 20% to 30% of children with injuries of the spi-
nal cord. Involvement of the cervical spine has been
found to be slightly more common than other levels in
most studies.
Potential mechanisms of SCIWORA include hyper-
extension of the cervical spine, which can cause com-
pression of the spinal cord by the ligamentum flavum
followed by flexion, which can cause longitudinal trac-
tion; transient subluxation without gross failure; or un-
recognized cartilaginous end plate failure (Salter-Harris
type I fracture). Ligamentous laxity, hypermobility of
the spine, and immature spinal vasculature are thought
to be contributing factors. Regardless of the specific
mechanism, injury to the spinal cord in this syndrome
occurs because of the variable elasticity of the elements
of the immature spinal column. Experimentally, it has
been shown that the bone, cartilage, and soft tissue in
the spinal column can stretch about 2 inches without
disruption but that the spinal cord ruptures after a 0.25-
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Pediatric Spine Trauma
Figure 8 Photograph of a 2-year-old patient showing a halo construct with a total of
10 pins placed with lower insertional torques (2- to 4-inch-lb).
inch displacement. Spinal cord injury occurs when de-
formation of the musculoskeletal structures of the spinal
column exceeds the physiologic limits of the spinal cord.
Neurologic injury may be complete or incomplete.
Partial spinal cord syndromes reported in SCIWORA
include Brown-Squard, anterior, and central cord syn-
dromes, as well as mixed patterns of injury. Incomplete
neurologic injuries have a good prognosis for recovery,
whereas complete injuries carry a dismal prognosis. Ap-
proximately 50% of patients have delayed onset of neu-
rologic symptoms or late neurologic deterioration after
an initially less severe degree of injury.
SCIWORA may also occur in the thoracolumbar
spine in association with high-energy thoracic or ab-
dominal trauma. The mechanisms of injury include vas-
cular insult to the watershed area of the spine associ-
ated with profound/prolonged hypotension, distraction
mechanism in the seatbelt-restrained patient, or hyper-
extension mechanism following a crush injury as most
often occurs when a child is rolled over by a car while in
the prone position, resulting in the spine collapsing into
the chest cavity.
Prognosis following SCIWORA is correlated to MRI
findings, if any are present, and to the severity of neuro-
logic injury. Children younger than 10 years are more
likely to have permanent paralysis than older children, re-
flecting differences in the types of injuries that occur in
these two age groups. SCIWORA in younger children is
usually the result of higher-energy trauma such as a mo-
tor vehicle crash, whereas in older children the mechanism
of injury is more likely to be the result of a lower-energy
event such as sports-related trauma or a fall.
Effective treatment requires careful evaluation of
the cervical spine to exclude osseous or cartilaginous in-
jury or mechanical instability, and stabilization of the
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Orthopaedic Knowledge Update 8
spine to prevent recurrent injury. Immobilization with a
rigid cervical collar for 2 to 3 months is usually ade-
quate treatment of SCIWORA. There have been no re-
ports of recurrent spinal cord injury when the cervical
spine has been immobilized in this manner. Surgery is
occasionally necessary for unstable injury patterns. The
prevalence of scoliosis following infantile paralysis is
more than 90% for patients with quadriplegia and 50%
for patients with paraplegia. Long-term follow-up to
monitor for spinal deformity is necessary.
Thoracic and Lumbar Fractures
Thoracic, lumbar, and sacral fractures are relatively un-
common in children. Most of these injuries are caused
by motor vehicle crashes or falls. The most common in-
juries are compression fractures and flexion-distraction
injuries. In infants and young children, nonaccidental
trauma (child abuse) may be a cause of significant spi-
nal trauma. Avulsion fractures of the spinous processes,
fractures of the pars or pedicles, or compression frac-
tures of multiple vertebral bodies are the most common
patterns of injury that usually occur from severe shaking
or battering. These injuries may be associated with other
signs of child abuse, including fractures of the skull, ribs,
or long bones and cutaneous lesions. Apophyseal end
plate fractures or slipped apophyses are injuries that are
unique to older children and teenagers whose symptoms
mimic disk herniation.
Compression fractures are caused by a combination
of hyperflexion and axial compression. Because the disk
in children is stronger than cancellous bone, the verte-
bral body is the first structure in the spinal column to
fail. It is common for children to sustain multiple com-
pression fractures. Compression rarely exceeds more
than 20% of the vertebral body. When loss of vertebral
body height exceeds 50%, the possibility of injury to the
posterior column of the spine should be considered and
is best evaluated with CT. Most of these fractures are
treated nonsurgically with rest, analgesics, and bracing.
Surgical stabilization may be indicated if there is poste-
rior column involvement and instability.
Flexion-distraction injuries (seat belt injuries) occur in
the upper lumbar spine in children wearing a lap belt.
With sudden deceleration, the belt slides up on the abdo-
men where it acts as a fulcrum. As the spine rotates
around this axis it fails in tension, resulting primarily in
disruption of the posterior column with variable patterns
of extension into the middle and anterior column. Four
patterns of injury have been described. Type A is a bony
disruption of the posterior elements extending to a vari-
able degree into the middle column. Type B is an avulsion
of the spinous process with facet joint disruption or frac-
ture and extension into the vertebral apophysis. Type C is
a disruption of the interspinous ligament with a fracture
of the pars interarticularis extending into the body. Type
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Orthopaedic Knowledge Update 8
D is a posterior ligamentous disruption with laminar frac-
ture and disruption of the vertebral apophysis. Because of
the transverse plane of orientation of this group of inju-
ries, abnormalities may be missed by thick-section CT and
may not be detected even with complementary thin sec-
tions, unless sagittal reconstructions are included. A lat-
eral radiograph showing widening of the interspinous
space is the most helpful study in diagnosing this fracture,
although increased distance between the spinous pro-
cesses may occasionally be seen on the AP radiograph.
MRI may be the single best imaging modality because it
can accurately identify soft-tissue and disk injury as well
as having predictive value in determining spinal cord and
neural injury.
Approximately two thirds of patients have intra-
abdominal injuries including ruptures of internal organs
and mesenteric tears, which may be life-threatening if
not diagnosed and treated appropriately. Neurologic in-
jury is unusual. Lap belt injuries with mostly bony in-
volvement and kyphosis less than 20 can be treated
with hyperextension casting. Those with posterior liga-
mentous disruption and soft-tissue injury require surgi-
cal stabilization with compression instrumentation and
posterior arthrodesis.
Fracture of the vertebral end plate (slipped vertebral
apophysis) usually occurs in teenagers and is character-
ized by traumatic disruption of the vertebral ring apo-
physis and disk into the spinal canal. The clinical symp-
toms are essentially the same as a herniated disk.
Patients may have muscle weakness, sensory changes,
absent reflexes, and root tension signs. This injury most
commonly involves the caudal end plate of L4, but may
occur at any level in the lumbar spine. The injuries may
be purely cartilaginous with herniation of the apophysis
and disk or osseous with fractures of the cortical and
cancellous rim of the vertebral body. This injury usually
cannot be identified on plain radiographs. CT or MRI is
needed to make the diagnosis. Treatment is removal of
the bony and cartilaginous fragments and usually re-
quires more extensive exposure (bilateral laminotomies)
than simple diskectomy.
Fracture-dislocations of the spine are unstable inju-
ries that usually occur at the thoracolumbar junction
and often are associated with neurologic deficits. They
are rare injuries in children that require surgical stabili-
zation and fusion. Burst fractures are also rare injuries
in children that result from axial compression and typi-
cally occur at the thoracolumbar junction or in the lum-
bar spine. The need for surgical treatment is determined
by the stability of the fracture and the presence of neu-
rologic deficits. Nonsurgical treatment is a viable option
in neurologically intact children, although most will de-
velop a progressive angular deformity during the first
year after the fracture. It has been shown that surgical
stabilization prevents kyphotic deformity and decreases
the length of hospitalization. Instrumentation should in-
American Academy of Orthopaedic Surgeons
Chapter 65 Pediatric Spine Trauma
clude two levels above and below the fracture. In chil-
dren with complete neurologic deficits, longer constructs
provide better stability and may prevent subsequent
paralytic spinal deformity from occurring.
Annotated Bibliography
Specific Cervical Spine Injuries
Flynn JM, Closkey RF, Mahboubi S, Dormans JP: Role
of magnetic resonance imaging in the assessment of pe-
diatric cervical spine injuries. J Pediatr Orthop 2002;22:
573-577.
In this study of 74 children, MRI confirmed the plain radi-
ography diagnosis in 66% and altered the diagnosis in 34%.
MRI is valuable in the evaluation of potential cervical spine
injury, especially in obtunded children or those with equivocal
plain radiographs.
Kenter K: Worley G, Griffin T, Fitch RD: Pediatric trau-
matic atlanto-occipital dislocation: Five cases and a re-
view. J Pediatr Orthop 2001;21:585-589.
Of five children with traumatic atlanto-occipital disloca-
tion, the three survivors had posterior occipitovertebral fu-
sions. The diagnosis was missed initially in three children. The
authors recommend detailed measurements of the initial cer-
vical spine radiographs in pediatric patients at risk for trau-
matic atlanto-occipital dislocation.
Lustrin ES, Karakas SP, Ortiz AO, et al: Pediatric cervi-
cal spine: Normal anatomy, variants, and trauma.
Radiographics 2003;23:539-560.
Knowledge of the normal embryologic development and
anatomy of the cervical spine is important to avoid mistaking
synchondroses for fractures and to correctly interpret imaging
studies. Familiarity with mechanisms of injury and appropriate
imaging modalities also aids in the correct interpretation of ra-
diographs of the pediatric cervical spine.
Thoracic and Lumbar Fractures
Clark P, Letts M: Trauma to the thoracic and lumbar
spine in the adolescent. Can J Surg 2001;44:337-345.
This article describes thoracolumbar fractures in adoles-
cents. The treatment of these injuries follows many of the
same principles as spinal fractures in adults. Nonsurgical treat-
ment is used more frequently because there is less spinal insta-
bility and better tolerance of bed rest and spinal immobiliza-
tion in this population.
Lalonde F, Letts M, Yang JP, Thomas K: An analysis of
burst fractures of the spine in adolescents. Am J Orthop
2001;30:115-120.
This article describes the results of treatment in 11 chil-
dren (average age 14.4 years) with burst fractures of the spine;
6 children were treated with posterior spinal fusion and instru-
mentation. Results showed that (1) mild progressive angular
deformity developed at the site of the fracture; (2) spinal in-
strumentation and fusion prevented kyphotic deformity and
773
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decreased the length of hospitalization without contributing to
further spinal cord injury; and (3) nonsurgical treatment was a
viable option in neurologically intact children, but progressive
angular deformity occurred during the first year after the frac-
ture.
Reddy SP, Junewick JJ, Backstrom JW: Distribution of
spinal fractures in children: does age, mechanism of in-
jury, or gender play a significant role? Pediatr Radiol
2003;33:776-781.
Of the 2,614 pediatric patients referred to a trauma center
over a 5-year period, 84 sustained vertebral fracture and 50
had neurologic injury without radiographic abnormality. A to-
tal of 164 fractures were identified. The thoracic region (T2-
T10) was most commonly injured, accounting for 47 fractures
(28.7%), followed by the lumbar region (L2-L5) with 38 frac-
tures (23.2%), the midcervical region with 31 fractures
(18.9%), the thoracolumbar junction with 24 fractures
(14.6%), the cervicothoracic junction with 13 fractures (7.9%),
and the cervicocranium with 11 fractures (6.7%). There was no
relationship to gender or mechanism of injury.
Sledge JB, Allred D, Hyman J: Use of magnetic reso-
nance imaging in evaluating injuries to the pediatric
thoracolumbar spine. J Pediatr Orthop 2001;21:288-293.
This study is a retrospective review of 19 children with
thoracolumbar fractures associated with neurologic deficits
from three level 1 trauma centers. The authors conclude that
MRI is the imaging modality of choice for these fractures be-
cause it can accurately classify injury to bones and ligaments
and because the cord patterns as determined by MRI have
predictive value of neurologic status.
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Orthopaedic Knowledge Update 8
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American Academy of Orthopaedic Surgeons