Anatomical background and injury mechanisms
The pediatric spine possesses phenomenal flexibility. This is due to the great height of the intervertebral discs, a significant amount of cartilage tissue within the vertebral bodies, and high elasticity of the vertebral arches, spinous processes, and ligamentous apparatus. As a consequence of these anatomical and physiological features, trauma most frequently results in crushing (compression) of the vertebral bodies specifically.
Injury typically occurs from a fall from a height (when axial load is combined with flexion or rotation) or from a fall on the back with a pronounced flexion mechanism. The level of injury directly depends on how the child fell:
- Fall on buttocks or back: thoracic vertebrae are affected. In about 50% of cases, this is the mid-thoracic spine, and in another 30%, the lower thoracic and upper lumbar spine.
- Fall on the head and shoulder girdle: the shock wave impacts the upper thoracic (Th5–Th6) and cervical (C3–C5) vertebrae.
Clinical presentation and diagnostics
Identifying an uncomplicated compression fracture in a child can be challenging due to the high plasticity of growing tissues. The patient's general condition usually remains satisfactory.
Main manifestations:
- Complaints: persistent back pain that noticeably worsens with any movement. If the thoracic spine is involved, the child may complain of labored breathing.
- Physical examination: the physician may visually determine a flattening of the physiological lordosis in the cervical or lumbar regions, an increase in thoracic kyphosis, and sometimes a scoliotic deformity in the impact zone.
- Palpation: pronounced tension of the trunk extensor muscles is detected. The spinous process of the fractured vertebra may slightly protrude, and pressing on it provokes severe pain.
- Specific tests: the key test is a graduated axial load. Light percussion on the patient's heels causes a sharp increase in pain strictly at the site of vertebral compression.
Radiological diagnostics
Radiography remains the gold standard for confirming the diagnosis. The examination must be performed in two standard projections.
Classic radiological signs of a fracture:
- Wedge-shaped deformity of the injured vertebral body.
- Step-off deformity of the anterior bone surface.
- Pathological compaction of the endplate shadow.
- Irregularity of the endplate contours.
Conservative treatment methods
The main objective of treatment is to completely offload the anterior spinal column.
At the first stage, axial offloading is applied:
- Longitudinal traction via the axillary regions: indicated for thoracic and lumbar fractures. The child is placed on a bed with a plywood board, with the head end elevated by 25–30 cm. The patient is secured to the head of the bed using special cotton-gauze straps.
- Glisson loop traction: used for cervical and upper thoracic vertebrae using a weight of about 2 kg.
Subsequently, tactics can proceed in three main directions:
- Gorinevskaya–Dreving method (functional): the most popular approach. Combines immobilization and active physical therapy (exercise therapy) to build a robust "muscle corset." Bed rest lasts for 4–5 weeks. It is important to remember that anatomical realignment of the vertebra does not occur with this method.
- Gradual repositioning using reclinators: aimed at the complete correction of the wedge-shaped deformity. The duration of bed rest is similar (4–5 weeks).
- Treatment in a lightweight extension brace: the spine is fixed in a hyperextension position. After pain relief, the child is allowed to walk in the brace. The device is removed at night, but sleeping exclusively on a firm bed is required for a whole year.
Important restriction: the patient is strictly forbidden to sit for up to 1.5–2 months from the moment of injury. In a sitting position, the load on the anterolateral parts of the vertebrae increases manifold, which can lead to secondary displacement.
Briefly: answers to topical questions
What degrees of vertebral body compression are distinguished on radiographs?
Radiographs distinguish two degrees of vertebral body compression depending on the height of the injury.
- Compression of less than 1/3 of the body height — refers to stable injuries.
- Compression of more than 1/3 of the body height — refers to unstable injuries and constitutes an absolutely unstable trauma.
What instrumental diagnostic methods, besides radiography, are used to confirm a spinal fracture in children?
To confirm a spinal fracture in children, in addition to radiography, highly informative tomographic methods are used.
- Computed tomography — allows clear visualization of the fracture line and identification of injuries in areas difficult for standard diagnostics.
- Magnetic resonance imaging — indispensable for visualizing soft tissues, demonstrating spinal cord edema, and determining the relationship of bone fragments.
Rule of injury localization: Head and shoulder girdle — Upper segments (cervical and upper thoracic) are affected. Buttocks and back — Lower segments (lumbar and mid/lower thoracic) are affected.
Class and exam questions
Why are compression fractures so common specifically in children?
This is due to the high flexibility of the spine, great disc height, ligament elasticity, and the abundance of cartilage tissue in the vertebral bodies, which easily compresses under axial load.
How is the axial load test checked?
The physician performs controlled, gentle percussion on the patient's heels. If a fracture is present, this action causes a sharp increase in pain at the site of the injured vertebra.
Why is sitting prohibited during treatment in an extension brace?
Sitting is strictly prohibited for 1.5–2 months, as this position maximizes the load on the anterolateral parts of the vertebral bodies, which hinders healing and can exacerbate compression.
What else to study on this topic
- Technique of applying the Glisson loop in neck injuries
- Stages of physical therapy according to the Gorinevskaya–Dreving method
- Jacobson's sign and diagnosis of metatarsal fractures in children
- Differential diagnosis of slipped capital epiphysis and phalangeal fractures of the foot
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Entire section "Specifics of bone and joint injuries in children"Prepared by WhiteCoat Pro faculty in accordance with the medical school curriculum. For educational purposes only.