A Paediatric Spinal Injury

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A Paediatric Spinal Injury

• Andreas Crede
• Emergency Medicine Registrar

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Introduction

• 5 Year old male
• Involved in MVA as restrained passenger near
  Beaufort West
• Head on collision, no history about other
  passengers
• Referred because of abdominal pain and distension
  - ?blunt abdominal organ injury

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Introduction

• Arrived via AMS
• Immobilised on spine board
• No significant past medical history

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Introduction

• Clinical examination
• ABCs stable
• Chest, CVS NAD
• Abdo soft, suprapubic distension and
  discomfort. Urinary catheter drained 900ml
  clear urine

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Introduction

• CNS
• GCS 15/15.
• No signs of head injury
• T12 Sensory level on right
• L1 Sensory level on left
• Lower limbs complete motor deficit, bilateral
  unresponsive plantar reflexes
• Absent anal tone
• Right upper limb C4-T2 sensory deficit, no motor
  deficit

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Investigations

• Bloods normal
• Lodox normal, incl c-spine views
• Thoraco lumbar spine x-rays

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MRI findings

• Extensive haematoma T11 L2
• Multiple ligament tears, mainly posterior complex
• L2 vertebral body fracture
• Additional haematoma C7 with extensive cervical
  spine oedema

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Mechanism of Injury
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3 Column Model of Denis
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Column Model

• 3 columns required to maintain spinal stability
• Wedge fracture stable
• Wedge fracture with ligamentous rupture
  unstable
• Predictors of soft tissue injury Angulation gt20
  or translation gt3,5mm

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Adult Classification

• A Classic Chance Fracture
• B Fulcrum Fracture
• C Soft tissue flexion-distraction injury

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Paediatric Classification

• Different to adults
• Presence of growth plate
• Different characteristics of intervertebral disc
  allowing greater deformity
• more water content of nucleus pulposus
• more elastic content

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Paediatric Classification

• Type I physeal injury of the superior growth
  plate associated with posterior lesion above the
  pedicle (soft tissue injury or superior facet
  fracture).
• Type II osseous type. Fracture through the
  vertebral body, pedicle, lamina and spinous
  process.
• Type III physeal injury of the inferior growth
  plate associated with posterior lesion below the
  pedicle (soft tissue injury or inferior facet
  fracture).

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Type I

• Physeal injury of the superior growth plate
  associated with posterior lesion above the
  pedicle (soft tissue injury or superior facet
  fracture).

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Type II

• Osseous type. Fracture through the vertebral
  body, pedicle, lamina and spinous process.

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Type III

• Physeal injury of the inferior growth plate
  associated with posterior lesion below the
  pedicle (soft tissue injury or inferior facet
  fracture).

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Alternate Classification

• Rumball and Jarvis A-D (X-ray classification)
• A Disruption of Posterior Column extending into
  middle column
• B Avulsion of Posterior elements with facet
  joint disruption
• C Posterior ligament disruption with fracture
  line extending into vertebra
• D Posterior ligament rupture with fracture line
  through lamina extending into physis of adjacent
  vertebral body

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Imaging

• Standard X-rays view boney components/ alignment
• X-rays cannot view soft tissues
• MRI can identify ligamentous/ soft tissue and
  growth plate injuries
• Absent epiphysis in human spines
• CT scan not indicated unless MRI not available or
  intra-abdominal injury suspected

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Chance Fractures

• Unique to thoracolumbar spine (T10 L2)
• Variant of flexion-distraction injury
• Due to lap belt injury without shoulder belt
  restraint
• Fulcrum of flexion lies anterior to vertebral
  column allowing no compression of vertebral body
• Flexion results in either ligamentous tear or
  combination of ligament, bone and disc injuries

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Chance Fractures

• 15-42 chance intra-abdominal organ injury
  pancreas, duodenum and prox small bowel
• 79 hollow viscus injury in New Zealand case
  series
• 25-83 neurologic deficit/vertebral injury
• 1/3 patients have Type II fracture
• 2/3 Type I or III fracture
• 96 patients bone and soft tissue injury, 4 soft
  tissue injury alone
• Almost all patients have extensive soft tissue
  oedema and posterior osteo-ligamentous complex
  disruption

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Management

• ABCs
• Prevent secondary injury
• High index of suspicion in patients restrained by
  lap seat belts
• Regular reassessment for abdo injuries
• Unstable fracture requires immobilisation/
  stabilisation

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Management

• Conservative reduction of dislocation
  application of TLSO 2-3 months
• Surgical large body habitus, polytrauma, failure
  to stabilise conservatively.

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References

• www.radiologyassistant.nl
• www.imaging.consult.com
• www.emedicine.medscape.com
• Ceroni, Mousny, Lironi, Kaelin. Paediatric seat
  belt injuries Unusual Chances fracture
  associated with intra-abdominal lesions in a
  child. Eur Spine J 2004 13167-171
• De Gauzy et al. Classification of Chance Fracture
  in Children Using Magnetic Resonance Imaging.
  Spine 2007 32 E89-E92
• Sheperd, Hamill, Segedin. Paediatric lap-belt
  injury A 7 year experience. Emergency Medicine
  Australasia 2006 18 57-63
• Leonard M, Sproule J, McCormack D. Paediatric
  Spinal Trauma and Associated Injuries. Injury
  2007 38 188-193
• Groves CJ et al. Chance type flexion-extension
  injuries in the thoracolumbar spine MR imaging
  characteristics. Radiology 2005 236 601-8

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Also Check

• Seatbelt syndromes
• Google/pubmed etc it
• Soft tissue injuries associated with seat belt
  sign