Specific Fractures and Joint Injuries in

Children (Specific fractures and dislocations) :

The spine

Presentator:
dr. Afifurrahman
Tutor:
dr. Kiagus Zulkarnain Muslim, SpOT(K)
BASIC SCIENCE TUTORIAL FOR ORTHOPAEDIC &
TRAUMATOLOGY RESIDENTS
Spine in Children
• The spine column is more flexible in children than adults 
less fracture / dislocation, but be careful with ” spinal cord
injuries without radiographic abnormality“ (SCIW-ORA)
• Important :
• clinical by local tenderness, muscle spasm, and deformity must be
thorough
• at least four projections are required (antero-posterior, lateral, right
and left oblique)
• Sometimes special projections, CT scans, MRI, or even
cineradiography are indicated.
Anatomical Difference
• Anatomical differences in children to be considered in treating spinal injury
include the following:
• Interspinous ligaments and joint capsules are more flexible.
• Vertebral bodies are wedged anteriorly and tend to slide forward with flexion.
• The facet joints are flat.
• Children have relatively large heads compared with their necks. Therefore, the
angular momentum is greater, and the fulcrum exists higher in the cervical
spine, which accounts for more injuries at the level of the occiput to C3.
• Growth plates are not closed, and growth centres are not completely formed.
Spinal Cord Injury without Radiographic
Abnormality (SCIWORA)
• Cervical spine is more flexible than the spinal
cord in children
• Can have traction injury to spinal cord in a
child with normal radiographs
• Usually occurs in upper C spine, in children
younger than 8
• MRI can diagnose injury to spinal cord and
typically posterior soft tissues
Occiput – C1 Sciwora
Cervical Spine
1. Rotatory Subluxation of the Atlantoaxial joint
• Rotatory subluxation
• Locked position due to forced beyond its normal range of rotation by a sudden twisting type of injury.
• Incidence, relatively common
• Acute & painful Wry-neck deformity ec. Muscle spasm
• The clinical features, the child prefer to support his head with the hands to lie down
• In several days it will self resolves
• With cervical “ruff” support will make comfort
• Open mouth X-ray usually reveals persistent asymmetry at the atlantoaxial joint
• Treatment
• Mild continuous traction through a head halter
• Spasm soon subsides and the subluxation is reduced in few days than support with cervical “ruff” for a few weeks
Cervical Spine
2. Anterior Subluxation of the Atlantoaxial Joint
• Severe fall on the top of the head  forward subluxation of tl1e atlas ( C-1) on the axis (C-2)
• Reduction :
• Reduction of the subluxation and maintenance of the reduction
• Reduction is more effectively obtained by continuous traction through a " halo" than head halter

• After reduction
• C l -2 joint should be stabilized by arthodcsis (fusion) to prevent recurrence of the subluxation, or even a dislocation , from a
subsequent injury.
Cervical Spine
3. Subluxations at Other Levels of the Cervical Spine
• Mobility increased in child’s cervical spine  produce an appearance of subluxation,
particularly between C2 and C3.
• Reduced by " halo“ traction .
• The reduction is maintained by ''halo vest" or a " halocast" for 8 weeks.
• If the injured segment is still unstable  local posterior spinal arthrodesis
 When it comes to fractures o the C2 in children,
nonoperative treatment is a good option even
with unstable cervical spine fractures or
luxation. Minerva/Diadem casts are
 considered most effective

Diadem Cast in 4 Years old

boy Dresing K and Peter T. Casts, Splits, and Support Bandages – Nonoperative Treatment and Perioperative Protection. 1 st Edition. New York: Thieme. 2014.
Cervical Spine
3. Subluxations at Other Levels of the Cervical Spine
 Occipitocervical Trauma

AO Surgery Reference. Spine Trauma: Occipitocervical, Subaxial cervical, Thoracic and Lumbar, Sacropelvic [Accessed on 5 th January 2021] Available From:
https://surgeryreference.aofoundation.org/spine/trauma
 Occipitocervical Trauma

AO Surgery Reference. Spine Trauma: Occipitocervical, Subaxial cervical, Thoracic and Lumbar, Sacropelvic [Accessed on 5th January 2021] Available From: https://surgeryreference.aofoundation.org/spine/trauma
Subaxial Cervical Trauma

AO Surgery Reference. Spine Trauma: Occipitocervical, Subaxial cervical, Thoracic and Lumbar, Sacropelvic [Accessed on 5 th January 2021] Available From:
https://surgeryreference.aofoundation.org/spine/trauma
Cervical Spine: C0 Fractures and Atlanto occipital dissociation

AO Surgery Reference. Spine Trauma: Occipitocervical, Subaxial cervical, Thoracic and Lumbar, Sacropelvic [Accessed on 5th January 2021] Available From: https://surgeryreference.aofoundation.org/spine/trauma
Cervical Spine: Atlas Fractures type I

Type I fractures are stable. These fractures can be treated with

cervical spine immobilization with a soft cervical collar for 6
months.

AO Surgery Reference. Spine Trauma: Occipitocervical, Subaxial cervical, Thoracic and Lumbar, Sacropelvic [Accessed on 5 th January 2021] Available From:
https://surgeryreference.aofoundation.org/spine/trauma
Cervical Spine: Atlas Fractures type II

Type II fractures are stable. These fractures can be treated with

cervical spine immobilization with a soft cervical collar for 6
months.

AO Surgery Reference. Spine Trauma: Occipitocervical, Subaxial cervical, Thoracic and Lumbar, Sacropelvic [Accessed on 5 th January 2021] Available From:
https://surgeryreference.aofoundation.org/spine/trauma
 ATLAS type IIIA

AO Surgery Reference. Spine Trauma: Occipitocervical, Subaxial cervical, Thoracic and Lumbar, Sacropelvic [Accessed on 5 th January 2021] Available From: https://surgeryreference.aofoundation.org/spine/trauma
 ATLAS type IIIb

AO Surgery Reference. Spine Trauma: Occipitocervical, Subaxial cervical, Thoracic and Lumbar, Sacropelvic [Accessed on 5 th January 2021] Available From: https://surgeryreference.aofoundation.org/spine/trauma
 ATLAS Type IV

AO Surgery Reference. Spine Trauma: Occipitocervical, Subaxial cervical, Thoracic and Lumbar,
Sacropelvic [Accessed on 5th January 2021] Available From:
https://surgeryreference.aofoundation.org/spine/trauma
ATLAS Type V

AO Surgery Reference. Spine Trauma: Occipitocervical, Subaxial cervical, Thoracic and Lumbar, Sacropelvic [Accessed on 5 th January 2021] Available From:
https://surgeryreference.aofoundation.org/spine/trauma
C1-C2 Rotatory Subluxation

AO Surgery Reference. Spine Trauma: Occipitocervical, Subaxial cervical, Thoracic and Lumbar,
Sacropelvic [Accessed on 5th January 2021] Available From:
https://surgeryreference.aofoundation.org/spine/trauma
C1-C2 Dislocation

AO Surgery Reference. Spine Trauma: Occipitocervical, Subaxial cervical, Thoracic and Lumbar, Sacropelvic [Accessed on 5 th January 2021] Available From:
https://surgeryreference.aofoundation.org/spine/trauma
Anderson d’Alonzo Type I

AO Surgery Reference. Spine Trauma: Occipitocervical, Subaxial cervical, Thoracic and Lumbar, Sacropelvic [Accessed on 5 th January 2021] Available From:
https://surgeryreference.aofoundation.org/spine/trauma
 Anderson d’Alonzo Type II

AO Surgery Reference. Spine Trauma: Occipitocervical, Subaxial cervical, Thoracic and Lumbar, Sacropelvic [Accessed on
5th January 2021] Available From: https://surgeryreference.aofoundation.org/spine/trauma
 Anderson d’Alonzo Type III

AO Surgery Reference. Spine Trauma: Occipitocervical, Subaxial cervical, Thoracic and Lumbar, Sacropelvic [Accessed on 5 th
January 2021] Available From: https://surgeryreference.aofoundation.org/spine/trauma
 C2 body fractures

AO Surgery Reference. Spine Trauma: Occipitocervical, Subaxial cervical, Thoracic and Lumbar, Sacropelvic
[Accessed on 5th January 2021] Available From: https://surgeryreference.aofoundation.org/spine/trauma
Effendi Type I

AO Surgery Reference. Spine Trauma: Occipitocervical, Subaxial cervical, Thoracic and Lumbar, Sacropelvic [Accessed on 5 th January 2021] Available From:
https://surgeryreference.aofoundation.org/spine/trauma
 Effendi Type II

AO Surgery Reference. Spine Trauma: Occipitocervical, Subaxial cervical, Thoracic and Lumbar, Sacropelvic [Accessed on 5 th
January 2021] Available From: https://surgeryreference.aofoundation.org/spine/trauma
 Levine Modification type IIA

AO Surgery Reference. Spine Trauma: Occipitocervical, Subaxial cervical, Thoracic and Lumbar, Sacropelvic [Accessed on 5th
January 2021] Available From: https://surgeryreference.aofoundation.org/spine/trauma
Effendi Type III

AO Surgery Reference. Spine Trauma: Occipitocervical, Subaxial cervical, Thoracic and Lumbar, Sacropelvic [Accessed on 5 th January 2021] Available From:
https://surgeryreference.aofoundation.org/spine/trauma
Subaxial Cervical Trauma: A0 – Minor
Nonstructural Fractures

AO Surgery Reference. Spine Trauma: Occipitocervical, Subaxial cervical, Thoracic and Lumbar, Sacropelvic [Accessed on 5 th January 2021] Available From:
https://surgeryreference.aofoundation.org/spine/trauma
 Subaxial Cervical Trauma: A1 Compression fracture single endplate

AO Surgery Reference. Spine Trauma: Occipitocervical, Subaxial cervical, Thoracic and Lumbar, Sacropelvic [Accessed on 5 th
January 2021] Available From: https://surgeryreference.aofoundation.org/spine/trauma
 Subaxial Cervical Trauma: A2 Coronal
split/pincer fracture

AO Surgery Reference. Spine Trauma: Occipitocervical, Subaxial cervical, Thoracic and Lumbar, Sacropelvic [Accessed on 5 th
January 2021] Available From: https://surgeryreference.aofoundation.org/spine/trauma
 Subaxial Cervical Trauma: A3 Burst fracture
of single endplate

AO Surgery Reference. Spine Trauma: Occipitocervical, Subaxial cervical, Thoracic and Lumbar, Sacropelvic [Accessed on 5 th
January 2021] Available From: https://surgeryreference.aofoundation.org/spine/trauma
Subaxial Cervical Trauma: A4 Burst fracture or sagittal split
involving both endplates

AO Surgery Reference. Spine Trauma: Occipitocervical, Subaxial cervical, Thoracic and Lumbar, Sacropelvic [Accessed on 5 th January 2021] Available From:
https://surgeryreference.aofoundation.org/spine/trauma
Subaxial Cervical Trauma: B1 Posterior
tension band injury (bony)

AO Surgery Reference. Spine Trauma: Occipitocervical, Subaxial cervical, Thoracic and Lumbar, Sacropelvic [Accessed on 5 th January 2021] Available From:
https://surgeryreference.aofoundation.org/spine/trauma
 Subaxial Cervical Trauma B2 Posterior tension band injury (bony
capsuloligamentous, ligamentous)

AO Surgery Reference. Spine Trauma: Occipitocervical, Subaxial cervical, Thoracic and Lumbar,
Sacropelvic [Accessed on 5 th January 2021] Available From:
https://surgeryreference.aofoundation.org/spine/trauma
 Subaxial Cervical Trauma: B3 Anterior tension band injury

AO Surgery Reference. Spine Trauma: Occipitocervical, Subaxial cervical, Thoracic and Lumbar, Sacropelvic
[Accessed on 5th January 2021] Available From: https://surgeryreference.aofoundation.org/spine/trauma
 Subaxial Cervical Trauma: C Translational Injury

AO Surgery Reference. Spine Trauma: Occipitocervical, Subaxial cervical, Thoracic and Lumbar,
Sacropelvic [Accessed on 5th January 2021] Available From:
https://surgeryreference.aofoundation.org/spine/trauma
Thoracic Spine
• Uncommon in childhood  possibility pathological type

• Compression fracture may caused from a severe fall

• The posterior longitudinal ligaments of the spine remain intact and

there is no injury to spinal cord

• Treatment : uninhibited children to immobilize the spine in a body

cast for 8 weeks

• Prognosis : excel­lent and no attempt at reduction of the slight

deformity is necessary
 Sagging patient positioning in thoracic and lumbar spine fracture

Dresing K and Peter T. Casts, Splits, and Support Bandages – Nonoperative Treatment and Perioperative Protection. 1st Edition. New York: Thieme. 2014.
Lumbar Spine
• Caused of Violent Trauma  produce a fracture-dislocation of the lumbar spine with
resultant injury to the cauda equina

• "Chance" fracture : Child wearing a lap seat belt, is involved in a head-on automobile
accident, the resultant acute flexion of the lumbar spine, produce a flexion-distraction
fracture that shears off a vertebral body end-plate and fracture the pedicles

• Treatment :
• Closed reduction
• After reduction, immobilization in a body cast for 8 weeks
• Residual instability  indication for spinal instrumentation and arthrodesis
• For older children  alternatively spinal instrumentation and arthrodesis within a few days of the
injury.
Lumbar Spine
• Severe fracture-dislocation of the
lumbar spine
 Lumbar Spine
• Spondylolysis refers to a defect (stress fracture) in the pars
interarticularis, usually located in the lumbar spine.
• Spondylolisthesis occurs when the pars defects are bilateral at the
same level and there’s subsequent forward slip- page, or subluxation,
of the upper vertebral segment on the one below. This most
commonly occurs when the fifth lumbar vertebra slips forward on the
sacrum.

Herring, J.A. Tachdjian’s Pediatric Orthopaedics from the Texas Scottish Rite Hospital for Children. Philadelphia: Elsevier. 2014.
 A, Radiograph features of spondylolysis showing lytic defect (arrow) in the pars
interarticularis. B, In isthmic defects, this appears as the collar (arrow) of the
“Scotty dog” sign. C, Collar of “Scotty dog” sign outlined on film.

Herring, J.A. Tachdjian’s Pediatric Orthopaedics from the Texas Scottish Rite Hospital for Children. Philadelphia: Elsevier. 2014.
 Lumbar Spine
• Treatment of spondylolysis and type 1 spondylolisthesis (<25% slip)
starts with hamstring stretching. The patient is restricted from sports
participation until the symptoms resolve. 

Herring, J.A. Tachdjian’s Pediatric Orthopaedics from the Texas Scottish Rite Hospital for Children. Philadelphia: Elsevier. 2014.
 Thoracic and Lumbar Trauma

AO Surgery Reference. Spine Trauma: Occipitocervical, Subaxial cervical, Thoracic and Lumbar, Sacropelvic [Accessed on 5th January 2021] Available From: https://surgeryreference.aofoundation.org/spine/trauma
A0 Minor, nonstructural fractures

AO Surgery Reference. Spine Trauma: Occipitocervical, Subaxial cervical, Thoracic and Lumbar, Sacropelvic
[Accessed on 5th January 2021] Available From: https://surgeryreference.aofoundation.org/spine/trauma
A1 Wedge-compression fractures

AO Surgery Reference. Spine Trauma: Occipitocervical, Subaxial cervical, Thoracic and Lumbar, Sacropelvic
[Accessed on 5th January 2021] Available From: https://surgeryreference.aofoundation.org/spine/trauma
A2 Split fractures
 A3 Incomplete Burst Fracture

AO Surgery Reference. Spine Trauma: Occipitocervical, Subaxial cervical, Thoracic and Lumbar, Sacropelvic
[Accessed on 5th January 2021] Available From: https://surgeryreference.aofoundation.org/spine/trauma
 A3 Incomplete Burst Fracture

AO Surgery Reference. Spine Trauma: Occipitocervical, Subaxial cervical, Thoracic and Lumbar, Sacropelvic
[Accessed on 5th January 2021] Available From: https://surgeryreference.aofoundation.org/spine/trauma
 A4 Complete burst fractures

AO Surgery Reference. Spine Trauma: Occipitocervical, Subaxial cervical, Thoracic and Lumbar, Sacropelvic
[Accessed on 5th January 2021] Available From: https://surgeryreference.aofoundation.org/spine/trauma
 A4 Complete burst fractures

AO Surgery Reference. Spine Trauma: Occipitocervical, Subaxial cervical, Thoracic and Lumbar, Sacropelvic
[Accessed on 5th January 2021] Available From: https://surgeryreference.aofoundation.org/spine/trauma
 A4 Complete burst fractures

AO Surgery Reference. Spine Trauma: Occipitocervical, Subaxial cervical, Thoracic and Lumbar, Sacropelvic
[Accessed on 5th January 2021] Available From: https://surgeryreference.aofoundation.org/spine/trauma
 B1 Transosseous tension band disruption / Chance fracture

AO Surgery Reference. Spine Trauma: Occipitocervical, Subaxial cervical, Thoracic and Lumbar, Sacropelvic
[Accessed on 5th January 2021] Available From: https://surgeryreference.aofoundation.org/spine/trauma
 B2 Posterior tension band disruption

AO Surgery Reference. Spine Trauma: Occipitocervical, Subaxial cervical, Thoracic and Lumbar, Sacropelvic
[Accessed on 5th January 2021] Available From: https://surgeryreference.aofoundation.org/spine/trauma
 B2 Posterior tension band disruption

AO Surgery Reference. Spine Trauma: Occipitocervical, Subaxial cervical, Thoracic and Lumbar,
Sacropelvic [Accessed on 5th January 2021] Available From:
https://surgeryreference.aofoundation.org/spine/trauma
 B3 Hyperextension

AO Surgery Reference. Spine Trauma: Occipitocervical, Subaxial cervical, Thoracic and Lumbar,
Sacropelvic [Accessed on 5th January 2021] Available From:
https://surgeryreference.aofoundation.org/spine/trauma
C Displacement or Dislocation

AO Surgery Reference. Spine Trauma: Occipitocervical, Subaxial cervical, Thoracic and Lumbar, Sacropelvic [Accessed on 5 th January 2021]
Available From: https://surgeryreference.aofoundation.org/spine/trauma
Sacral Trauma
• Three basic categories (Types) were used to describe primary injury
morphology.
• Type A injuries are lower sacrococcygeal fractures which have no impact on the
posterior pelvic or spinopelvic stability.
• Type B injuries are unilateral longitudinal (vertical) sacral fractures which
primarily result in posterior pelvic instability. There is no impact on spino-pelvic
stability. These injuries have also been classified as Denis Zone I through III.
• Type C injuries include unilateral B injuries with L5-S1 facet involvement,
bilateral longitudinal (vertical) sacral fractures and U fracture variations
resulting in spinopelvic instability. Sacral U-fracture variations have also been
classified according to Roy-Camille.

AO Surgery Reference. Spine Trauma: Occipitocervical, Subaxial cervical, Thoracic and Lumbar, Sacropelvic [Accessed on 5 th January 2021]
Available From: https://surgeryreference.aofoundation.org/spine/trauma
Sacral Trauma

AO Surgery Reference. Spine Trauma: Occipitocervical, Subaxial cervical, Thoracic and Lumbar, Sacropelvic [Accessed on 5 th January 2021]
Available From: https://surgeryreference.aofoundation.org/spine/trauma
A1 Coccygeal/sacral compression or ligamentous avulsion
fractures

AO Surgery Reference. Spine Trauma: Occipitocervical, Subaxial cervical, Thoracic and Lumbar, Sacropelvic [Accessed on 5 th January 2021]
Available From: https://surgeryreference.aofoundation.org/spine/trauma
A2 Non-displaced transverse fracture below S-I joint

AO Surgery Reference. Spine Trauma: Occipitocervical, Subaxial cervical, Thoracic and Lumbar, Sacropelvic [Accessed on 5 th January 2021]
Available From: https://surgeryreference.aofoundation.org/spine/trauma
A3 Displaced transverse fracture below the S-I joint

AO Surgery Reference. Spine Trauma: Occipitocervical, Subaxial cervical, Thoracic and Lumbar, Sacropelvic [Accessed on 5 th January 2021]
B1 Central Fracture

AO Surgery Reference. Spine Trauma: Occipitocervical, Subaxial cervical, Thoracic and Lumbar, Sacropelvic [Accessed on 5 th January 2021]
Available From: https://surgeryreference.aofoundation.org/spine/trauma
B2 Transalar Fracture

AO Surgery Reference. Spine Trauma: Occipitocervical, Subaxial cervical, Thoracic and Lumbar, Sacropelvic [Accessed on 5 th January 2021]
Available From: https://surgeryreference.aofoundation.org/spine/trauma
B3 Transforaminal fracture

AO Surgery Reference. Spine Trauma: Occipitocervical, Subaxial cervical, Thoracic and Lumbar, Sacropelvic [Accessed on 5 th January 2021]
Available From: https://surgeryreference.aofoundation.org/spine/trauma
C0 Nondisplaced U-fracture

AO Surgery Reference. Spine Trauma: Occipitocervical, Subaxial cervical, Thoracic and Lumbar, Sacropelvic [Accessed on 5 th January 2021]
Available From: https://surgeryreference.aofoundation.org/spine/trauma
C1 B fracture with ipsilateral superior S1 facet discontinuous with
medial part of sacrum

AO Surgery Reference. Spine Trauma: Occipitocervical, Subaxial cervical, Thoracic and Lumbar, Sacropelvic [Accessed on 5 th January 2021]
Available From: https://surgeryreference.aofoundation.org/spine/trauma
C2 Bilateral type B injury

AO Surgery Reference. Spine Trauma: Occipitocervical, Subaxial cervical, Thoracic and Lumbar, Sacropelvic [Accessed on 5 th January 2021]
Available From: https://surgeryreference.aofoundation.org/spine/trauma
C3 Displaced sacral U-type fracture

AO Surgery Reference. Spine Trauma: Occipitocervical, Subaxial cervical, Thoracic and Lumbar, Sacropelvic [Accessed on 5 th January 2021]
Available From: https://surgeryreference.aofoundation.org/spine/trauma
 • CT and MRI scans should not be used as routine
• screening modalities for evaluation of the paediatric cervical spine

Herring, J.A. Tachdjian’s Pediatric Orthopaedics from the Texas Scottish Rite Hospital for Children. Philadelphia: Elsevier. 2014.
Reference
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4. Apley, A. G., & Solomon, L.  Apley's system of orthopaedics and trauma. 10th Ed London: Arnold. 2018.
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Neurotrauma: 2011;28:1515
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1st Edition. New York: Thieme. 2014.
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Elsevier. 2014.
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