Pediatric Cervical Trauma - Introduction

Author: Derek Moore

Topic updated on 04/07/13 7:48pm

Introduction

Cervical spine injuries are uncommon
Upper cervical injuries more common from birth to 8 years
- 87% of injuries at C3 or above
- due to
  - horizontal facets
  - large head size relative to trunk
  - increased physiologic motion
  - weak muscles
After eight years lower cervical injuries more common (adult injury patterns)

Imaging

Introduction
- pediatric cervical spine imaging interpretation complicated by
  - hypermobility
  - unique vertebral configurations
  - incomplete ossification
  - presence of apophyses
Radiographs
- mandatory trauma radiographs include
  - cross table lateral
    - normal findings
      - lines should follow smooth contour
        
        anterior vertebral bodies
        
        posterior vertebral bodies
        
        spinolaminar line (inside lamina)
        
        tips of spinous process
      - facet joints should be parallel
      - retropharyngeal space < 7mm
      - retrotracheal space < 14 mm
      - atlanto-dens interval < 5 mm (children) and < 3 mm adolescents and adults
  - AP
  - odontoid open mouth
- additional xrays (optional)
  - oblique
    - can help visualize facet disruption
  - flexion-extension
    - problematic and should only be performed under physician supervision
CT scan
- useful to identify
  - fractures of upper cervical spine
  - atlantoaxial rotatory subluxation
MRI
- useful in obtunded patients or patients with closed head injuries

Initial Treatment

Immobilization
- provide adequate initial immobilization
  - on pediatric spine board with head "cutout" to compensate for large head size
  - commercial collars often do not fit properly, may use sandbags
  - using an adult backboard for pediatric patients create a dangerous level of cervical flexion
Halo immobilization
- 8 to 12 pins
  - use low insertion torques (1 to 5 inch/lbs)
  - CT scan may help in pin placement to avoid cranial sutures and thin areas of skull increased complication rate compared to adults
- custom fitted vest

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(OBQ04.4) Proper immobilization is critical in young children with suspected cervical spine injuries. In this patient group, a dangerous level of cervical flexion has been associated with what immobilzation technique. Topic

Review Topic

1. pediatric cervical orthosis
2. halo immobilization
3. a pediatric backboard with in-line cervical traction
4. a pediatric backboard with a cervical orthosis
5. an adult backboard

PREFERRED RESPONSE ▶

DISCUSSION: Cervical spine injuries should be immobilized in a postion of relative extension in both children and adults. The reference by Herzenberg et al found that because of relatively large head size in children, an adult backboard can force a childs' cervical spine into a position of flexion. This might have catastrophic results and lead to spinal cord injury. Therefore, they recommend that pediatric backboards, or modified adult backboards, should be used in pediatric cervical injuries.

REFERENCES:

1. Herzenberg JE, Hensinger RN, Dedrick DK, Phillips WA. Emergency transport and positioning of young children who have an injury of the cervical spine. The standard backboard may be hazardous. J Bone Joint Surg Am. 1989 Jan;71(1):15-22. PMID:2912996 (Link to Abstract)

2. Wilber JH and Thompson GH. The multiply injured child, in Skeletal trauma in children, ed 3, pp. 73-103. 2003.

Question Authors:

Derek Moore,

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ABOS II: Pediatric Cervical Trauma - Introduction

General - Oral Boards Review

7/29/2011

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Evidence & References Show References

Textbooks

Review of Orthopaedics, 6th Edition, Mark D. Miller MD, Stephen R. Thompson MBBS MEd FRCSC, Jennifer Hart MPAS PA-C ATC, an imprint of Elsevier, Philadelphia, Copyright 2012
AAOS Comprehensive Orthopaedic Review, Jay R. Leiberman. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2009
Orthopaedic Knowledge Update 10, John M Flyn. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2011
Hoppenfeld SP. Surgical Exposures in Orthopaedics: The Anatomic Approach. Lipponcott, Williams, and Wilkins, Philadelphia, PA, Copyright 2009
Orthopaedic In-training Examination (OITE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012
Self-Assessment Examination (SAE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012

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Herzenberg JE, Hensinger RN, Dedrick DK, Phillips WA. Emergency transport and positioning of young children who have an injury of the cervical spine. The standard backboard may be hazardous. J Bone Joint Surg Am. 1989 Jan;71(1):15-22. PMID:2912996 (Link to Abstract)
Wilber JH and Thompson GH. The multiply injured child, in Skeletal trauma in children, ed 3, pp. 73-103. 2003.

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Pediatric Cervical Trauma - Introduction

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