Hangman's fracture in a 7-week-old infant

Posterior fixation for paediatric and adolescent unstable hangman's fracture: evolution to C1 sparing techniques

PURPOSE

The aim was to study surgical outcomes in hangman's fractures in paediatric and adolescent patients and to demonstrate evolution in posterior surgery from C1-C2-C3 fusion to C1 sparing techniques.

METHODS

Patients (aged ≤ 18 years) operated at a tertiary level centre between September 2011 to February 2018 with more than 1 year of follow-up were included. Neurological status, type of fracture, operating time, blood loss, follow-up, and complications were assessed.

RESULTS

Nine patients were included, with mean age mean of 16.45 years, with a mean follow-up of 42.78 months. Six patients having neurological deficit showed improvement. Two patients, one having undergone C1-C3 lateral mass screw rod fixation (LMSF) and other had C2 pedicle screw with C3 LMSF, developed kyphosis for which fixation was further extended caudally. One patient with an old hangman's fracture with reabsorbed axis pedicle underwent C2 body screw along with C3-C4 pedicle screw rod fixation and C2 pedicle reconstruction. All patients showed evidence of postoperative fusion.

CONCLUSION

Hangman's fractures in young patients can be successfully managed via posterior fixation. In our centre, we have evolved in the direction of motion preservation at C1 C2 joint, along with 3 column stable fixation of the C2 pedicle. C2 pedicle reformation has allowed motion preserving surgery in complex fracture types. Extension of construct till C4 in selected cases is important to prevent postoperative kyphosis.

En Bloc Examination of the Neck in Pediatric Homicide Cases: A Proper Way for Complete Assessment of Neck Trauma

The necks of infants and young children are not only anatomically different from adults, but are also supported by much weaker musculoskeletal systems and are therefore prone to trauma as a result of extension/flexion (shaking) or contact trauma to the head. Shaking cervical spine injuries can occur at much lower levels of head velocity and acceleration than those reported for shaken baby syndrome. The proper method for a comprehensive and detailed examination of the neck in pediatric homicide and suspected homicide cases is the en bloc examination of the neck, because the standard examination of the spinal cord not only distorts the anatomical relationship of the cord and osteocartilagenous structures, but also excludes the cervical nerves, ganglia, and the vertebral arteries from being evaluated. Interpretation of gross and microscopic findings using this method requires experience and knowledge of the anatomical relationship and common artifacts, such as epidural, focal intradural, or even isolated nerve hemorrhage to avoid misinterpretation. It is our opinion that this method should be applied to all pediatric homicide or suspected homicide cases, but is not suited for routine or nonsuspicious cases as it will add to the time and cost of medical examiner's operations.

Tensile failure properties of the perinatal, neonatal, and pediatric cadaveric cervical spine

STUDY DESIGN

Biomechanical tensile testing of perinatal, neonatal, and pediatric cadaveric cervical spines to failure.

OBJECTIVE

To assess the tensile failure properties of the cervical spine from birth to adulthood.

SUMMARY OF BACKGROUND DATA

Pediatric cervical spine biomechanical studies have been few due to the limited availability of pediatric cadavers. Therefore, scaled data based on human adult and juvenile animal studies have been used to augment the limited pediatric cadaver data. Despite these efforts, substantial uncertainty remains in our understanding of pediatric cervical spine biomechanics.

METHODS

A total of 24 cadaveric osteoligamentous head-neck complexes, 20 weeks gestation to 18 years, were sectioned into segments (occiput-C2 [O-C2], C4-C5, and C6-C7) and tested in tension to determine axial stiffness, displacement at failure, and load-to-failure.

RESULTS

Tensile stiffness-to-failure (N/mm) increased by age (O-C2: 23-fold, neonate: 22 ± 7, 18 yr: 504; C4-C5: 7-fold, neonate: 71 ± 14, 18 yr: 509; C6-C7: 7-fold, neonate: 64 ± 17, 18 yr: 456). Load-to-failure (N) increased by age (O-C2: 13-fold, neonate: 228 ± 40, 18 yr: 2888; C4-C5: 9-fold, neonate: 207 ± 63, 18 yr: 1831; C6-C7: 10-fold, neonate: 174 ± 41, 18 yr: 1720). Normalized displacement at failure (mm/mm) decreased by age (O-C2: 6-fold, neonate: 0.34 ± 0.076, 18 yr: 0.059; C4-C5: 3-fold, neonate: 0.092 ± 0.015, 18 yr: 0.035; C6-C7: 2-fold, neonate: 0.088 ± 0.019, 18 yr: 0.037).

CONCLUSION

Cervical spine tensile stiffness-to-failure and load-to-failure increased nonlinearly, whereas normalized displacement at failure decreased nonlinearly, from birth to adulthood. Pronounced ligamentous laxity observed at younger ages in the O-C2 segment quantitatively supports the prevalence of spinal cord injury without radiographic abnormality in the pediatric population. This study provides important and previously unavailable data for validating pediatric cervical spine models, for evaluating current scaling techniques and animal surrogate models, and for the development of more biofidelic pediatric crash test dummies.

Cervical spine trauma in the pediatric patient

Injuries to the pediatric cervical spine occur infrequently. Numerous unique anatomic and biomechanical features of the pediatric spine render it much more flexible than the adult spine. These features give rise to significant differences in the presentation, diagnosis, treatment, and prognosis of pediatric cervical trauma compared with adults. Younger children more often suffer injury to the upper cervical spine with greater neurologic injury and fewer fractures. Once the child reaches the age of 10 years, he or she develops a more adult-type spine, and injuries are thus more similar to those seen in the adult population. The unique anatomic and biomechanical differences in the pediatric spine are discussed, along with the various common and unique injuries.

An abused five-month-old girl: Hangman’s fracture or congenital arch defect?

Hangman's fractures are a rare finding in childhood. In case of suspected or proven child abuse, differentiation with a congenital defect of the posterior arch of C2 is essential. We present the case of a 5-month-old girl, who had a history of being physically abused by one of her caretakers. On the lateral view of the cervical spine, a defect of the posterior elements of C2 and an anterolisthesis of C2 on C3 was seen. CT scan showed a bilateral defect in the posterior elements of C2. No soft-tissue swelling of hematoma was noted. MRI showed a normal signal intensity of the intervertebral disc C2-C3. No haematoma was noted. Clinical examination revealed a slight head lag and local tenderness; there were no neurological deficits. This case shows that the differentiation between a congenital C2 arch defect and a hangman's fracture is precarious. In this case the findings on MRI and CT scan were interpreted as a congenital posterior arch defect (spondylolysis).

Second cervical vertebrae pedicle fractures versus synchondrosis in a child

Fractures of the second cervical vertebrae (C2) can be difficult to diagnose in young children. A 17-month-old infant sustained bilateral C2 pedicle fractures after minor trauma. The initial lateral radiograph showed pedicle defects, but even with computed tomography and a bone scan with single photon emission computed tomography this could not be differentiated from a congenital abnormality. One week after injury, repeat radiographs showed spondylolisthesis confirming the defects were fractures. The fractures were treated by closed reduction and a halo vest and healed uneventfully. This child is among a small number of patients with bilateral C2 pedicle fractures that occur predominantly in young children. Diagnosis can be difficult even with a high index of suspicion.

Direct injury to the cervical spine of a child by a lap-shoulder belt resulting in quadriplegia: case report

Most pediatric cervical spine injuries from seat-belt restraints result from hyperflexion of the neck without direct injury to the spine from the restraining device. We report what we believe to be the first case of direct injury to the cervical spine by the shoulder component of a lap-shoulder seat belt. This resulted in quadriplegia. The mechanism of injury and recommendations to obviate such injuries are discussed.

Infant involved in a motor vehicle accident

The authors present and discuss the differential diagnosis for a 7-month-old infant who was seen in the ED after having been involved in a motor vehicle accident. The infant was subsequently found to have an odontoid fracture. Strict attention to the mechanism of injury is emphasized for appropriate evaluation of this patient's condition. An infant who becomes airborne in a car that is extensively damaged deserves an aggressive workup. In a child of this age, examination for subtle or even quite significant injury is difficult. Therefore the focus should be on the potential for injury. This article addresses the rarity of this injury pattern and discusses factors involved in treatment of cervical spine injuries in pediatric patients. The development of the axis and radiography of the cervical spine in pediatric patients are reviewed also. Neurosurgical treatment options are presented. This case also reminds us to ensure parents understand the proper use of a car seat.

A review of cervical fractures and fracture-dislocations without head impacts sustained by restrained occupants

Crash injury reduction via lap-shoulder belt use has been well documented. Like any other interior car component, lap-shoulder belts may be related to injury in certain crashes. Relatively unknown is the fact that cervical fractures or fracture-dislocations to restrained front seat occupants occur where no head contact was evidenced by both medical records and car inspection. A review of the available literature on car crash injuries revealed more than 100 such cases. A review of the National Accident Severity Study (NASS) 80-88 file was also conducted, revealing more examples. Case capsule descriptions from the authors' files are also detailed along with examples of such injuries in infants and children in child restraints. However, cervical fractures or fracture dislocations are rare, as evidenced by the relatively few cases identified in the literature, in the author's files, and by an analysis of NASS 80-90 data that revealed a cervical spine injury frequency of only .4% at the AIS-3 level (Huelke, Morris, and Mackay 1992).