Pediatric Trauma C-Spine X-Ray
Ashlea Wilmott
PGY-1 Emergency Medicine
Objectives
• Approach to the c-spine film with notable
pediatric variations
• Ossification centre VS fracture
• Cases covering common pediatric injury
patterns
We will not cover
• Non-traumatic findings (ie: epiglottitis, foreign
body)
• Management of fractures
• Literature review of C-spine rules in children
Peds C-Spine Primers
• 2/3rds of pediatric spinal injuries occur in the
C-Spine
• Many have associated neurologic deficit
• Pediatric patients injure their c-spine higher
than adults
Anatomical Differences that Influence
C-Spine Injury
Big
Heads
Weak
Muscles and
Ligamentous
Laxity
Growth plates
and inherently
immature bones
Pediatric C-Spine
< 8-10 yrs
Your typical approach…
With some pediatric variations…
Pseudosubluxation
Ossification Centres
Oval Contour
Soft tissue
measurements
Pseudospread
C1
Loss of
Lordosis
Pre-dental
Space
dequacy
lignment
A- Anterior vertebral line
B- Posterior vertebral line
C- Spinolaminar line
D- Spinous processes
Loss of
Lordosis
Pseudosubluxation
Loss of Lordosis
• Distance
between spines
not > 1.5X
adjacent
• C1-2 normal up
to 10-12mm
Pseudosubluxation and Swischuk’s line
2mm
Child on a Spine board = flexion
Alignment - Odontoid
Normal up to 7mm of lateral displacement
Rotation = False displacement
one
• Oval contour and anterior wedging
• Ossification centres
Contour and Wedging
3mm
Ossification Centres
C1
7
7
3
Ossification Centres
C2
6
3
6
Odontoid age 4
Odontoid age 8
Ossification Centres
C3-C7
6
6
3
So many ossification centres…so little
memory…
• The spinous process
should be fused by 2-3
years
• This “wishbone” should
fuse with the body by
age 6 – can be later in
C1
• Extra caution with C2’s
late fusing centres:
– Base of the dens
– Top of the dens
Growth Plate
Smooth, regular
boarders
Predictable location
Sclerotic
Fracture
Irregular boarders
Un predictable location
Non-sclerotic
artilage
5 mm
e
n
s
oft Tissue
Summary
• Loss of lordosis, Pseudosubuxation, C1 spread
• Oval contour, Ant. Wedging, ossification
centres
• As in adults
• Pre-dental space, Tilt
• Changes with age
Cases to highlight a few points…
Something just
doesn’t look
right here…
Case
1
Powers Ratio
A-B/C-D
<1
A
C
D
B
Case Two
A normal Swischuk’s
line does not equal
pseudosubluxation!
Case
Three
A lucency at the
physis is not always
just the physis
Beware the
odontoid and all it’s
ossification centres
Case Four
The absence of a
visible neural arch
fracture does NOT
rule out hangman’s
fracture
Summary
• Loss of lordosis, Pseudosubuxation, C1 spread
• Oval contour, Ant. Wedging, ossification
centres
• As in adults
• Pre-dental space, Tilt
• Changes with age