SPINAL FRACTURES

QUESTIONS AND ANSWERS

Types of Spinal Fractures

Spinal fractures are typically classified based on both the type of break and the specific location within the spine. Your healthcare provider will also determine whether the fracture is stable—meaning the spine can still support normal body weight—or unstable, which is more serious and may risk nerve damage or paralysis.

The primary regions where spinal fractures occur include:

• Cervical spine (neck)
• Thoracic spine (upper back, from your neck to the bottom of your ribs)
• Lumbar spine (lower back)

Let’s take a closer look at common types of spinal fractures:

Compression Fracture

Compression fractures can cause the vertebrae to collapse, making the spine shorter in height. Furthermore, this collapse can make the pieces of bone press on the spinal cord and nerves. Consequently, this can decrease the amount of blood and oxygen supply to the spinal cord.

Causes Of a Compression Fracture

• Osteoporosis
• Injuries to the spine
• Tumors in the spine, etc.

Symptoms of a Compression Fracture

In the initial phase, compression fractures may not have any symptoms. Sometimes, a healthcare provider may discover them on an X-ray while doing it for other reasons. Later, the symptoms may come up as:

• Slowly worsening back pain
• A decrease in your height, limited spine movement
• A gradually developing stooped-over posture
• Numbness or tingling, problems in walking, weak muscles
• Trouble in controlling your bowels or bladder as a result of nerve damage
• In case you get a sudden fracture, you may have sudden, severe, and disabling back pain.

Axial Burst Fracture

An axial fracture typically refers to a fracture of the axis (C2 vertebra) in the cervical spine.  This often involvs the odontoid process (dens) or other structures like the neural arch. Below, are the causes and symptoms of an axial fracture,

Causes of Axial Fracture

Axial fractures, particularly of the C2 vertebra, result from specific mechanisms of injury that apply force to the upper cervical spine. Common causes include:

Trauma from High-Energy Impact:

• Motor Vehicle Accidents: Sudden deceleration or impact can cause hyperextension or hyperflexion of the neck. This can lead to C2 fractures, especially in children involved in car crashes.
• Falls: Falling from a height (e.g., playground equipment, sports) and landing on the head or neck can transmit force to the axis.  This can cause fractures like odontoid fractures.
• Sports Injuries: Contact sports (e.g., football, gymnastics) or activities with a risk of neck impact can result in axial fractures. This can occur with children with developing spines.

Hyperextension or Hyperflexion Injuries:

• Hyperextension: Backward motion of the head (whiplash) can fracture the posterior elements of C2, such as the neural arch.  This can lead to conditions like hangman’s fracture (bilateral pedicle fractures).
• Hyperflexion: Forward motion (diving into shallow water) can cause odontoid fractures. This is cause by compressing or shearing the dens against the C1 vertebra (atlas).

Pediatric-Specific Factors:

• Immature Bone Structure: Children’s cervical spines are more flexible and have less ossified bones.  This makes children susceptible to unique fracture patterns, such as odontoid fractures at the synchondrosis (cartilaginous junction) in young patients.
• Congenital Anomalies: Pre-existing conditions like os odontoideum (a congenital separation of the odontoid) can predispose children to fractures with minor trauma.
• Child Abuse: Non-accidental trauma (shaking or blunt force) can cause axial fractures in infants or young children.

Low-Energy Trauma in Rare Cases:

• In children with underlying conditions (e.g., osteogenesis imperfecta, connective tissue disorders), even minor trauma can lead to C2 fractures due to weakened bone integrity.

Symptoms of Axial Fracture

Symptoms of an axial fracture vary depending on the fracture type (e.g., odontoid, hangman’s), severity, and whether there’s associated spinal cord or nerve injury. Common symptoms include:

Neck Pain and Stiffness:

• Localized pain in the upper neck (cervical spine) is a hallmark symptom, often worsened by movement or palpation.
• Children may hold their head in a fixed position or resist turning it, similar to guarding seen in scoliosis cases (as noted in the Juvenile Scoliosis webpage).

Restricted Range of Motion:

• Limited ability to rotate, flex, or extend the neck due to pain or instability caused by the fracture.
• In pediatric patients, this may present as reluctance to participate in activities like sports or play.

Neurological Symptoms (if spinal cord or nerves are involved):

• Numbness or Tingling: Radiating sensations in the arms, hands, or shoulders if nerve roots are compressed, especially in fractures causing instability.
• Weakness: Muscle weakness in the upper or lower limbs, indicating potential spinal cord involvement, particularly in severe odontoid fractures.
• Loss of Coordination: Difficulty with fine motor skills or walking, seen in cases with cord compression.
• Rare but Severe: Paralysis or loss of bowel/bladder control in high-grade injuries with significant cord damage.

Headache or Occipital Pain:

• Pain at the base of the skull or radiating to the head, often due to muscle spasms or irritation of cervical nerves.
• Common in hangman’s fractures or posterior element injuries.

Swelling or Tenderness:

• Localized swelling or bruising over the upper neck, though this may be subtle in children due to soft tissue coverage.
• Tenderness on palpation of the C2 region during physical examination.

Pediatric-Specific Symptoms:

• Irritability or Distress: Young children may not articulate pain but show fussiness, crying, or discomfort when the neck is moved.
• Postural Changes: Holding the head tilted or forward, resembling compensatory postures in scoliosis (as described in the webpage).
• Refusal to Move: Reluctance to engage in activities requiring neck motion (e.g., looking up, turning head).

Associated Injuries:

• Symptoms of concurrent injuries, such as head trauma (e.g., concussion, headache) or other cervical fractures (e.g., C1 or lower vertebrae), may be present, especially in high-energy trauma.
• In non-accidental trauma, additional signs like bruising or fractures elsewhere may raise suspicion.

Chance Fracture

A Chance fracture, also known as a seat-belt injury, is a specific type of spinal fracture typically involving the thoracolumbar spine (T10-L2 vertebrae). It is characterized by a horizontal splitting of the vertebra, often affecting the vertebral body, pedicles, and posterior elements, caused by a flexion-distraction mechanism. Below, I outline the causes and symptoms of a Chance fracture, tailored to the pediatric context of Medical City Children’s Orthopedics and Spine Specialists, drawing on general medical knowledge and aligning with the Juvenile Scoliosis webpage’s focus on pediatric spinal conditions and early intervention.

Causes of Chance Fracture (Seat-Belt Injury)

Chance fractures are primarily associated with high-energy trauma that causes a flexion-distraction injury, where the spine is forcibly flexed around a pivot point (often a seat belt) while being distracted (pulled apart). Common causes include:

Motor Vehicle Accidents (Improper Seat-Belt Use):

• Primary Cause: The hallmark cause is a lap-only seat belt (without a shoulder harness) worn improperly during a car crash, particularly in frontal collisions. The seat belt acts as a fulcrum across the abdomen, causing the spine to flex forward while the posterior elements are distracted.
• Pediatric Context: Children are at higher risk due to improper seat-belt fit (e.g., belts riding up over the abdomen instead of the pelvis) or being seated in adult seat belts without booster seats. High-speed crashes or sudden deceleration amplify the force on the thoracolumbar spine.
• Example: A child in a lap belt during a head-on collision experiences rapid forward flexion, fracturing the vertebra horizontally.

High-Energy Trauma:

• Falls from Height: Falling from significant heights (e.g., playground equipment, trees) and landing in a seated or flexed position can cause a Chance fracture, especially in children with flexible, developing spines.
• Sports Injuries: High-impact sports (e.g., motocross, skiing, or diving) involving falls or collisions can lead to flexion-distraction injuries, though less common in pediatrics.
• Example: A child falling from a trampoline in a seated position, causing a sudden forward bend.

Child Abuse (Non-Accidental Trauma):

• In infants or young children, Chance fractures can result from non-accidental trauma, such as forceful shaking or slamming, where the spine is subjected to extreme flexion forces.
• This is a critical consideration in pediatric cases, often accompanied by other injuries (e.g., rib fractures, bruising).

Pediatric-Specific Factors:

• Immature Bone Structure: Children’s vertebrae are less ossified and more cartilaginous, making them susceptible to unique fracture patterns. The flexibility of the pediatric spine can lead to Chance fractures even with relatively lower force compared to adults.
• Improper Restraint Systems: Booster seats or car seats not used correctly increase the risk of seat-belt syndrome, where the lap belt causes abdominal and spinal injuries.
• Underlying Conditions: Rare conditions like osteogenesis imperfecta or Ehlers-Danlos syndrome can predispose children to fractures with minimal trauma due to weakened bone or connective tissue.

Associated Injuries (Seat-Belt Syndrome):

• Chance fractures are often part of “seat-belt syndrome,” which includes abdominal injuries (e.g., bowel perforation, mesenteric tears) due to the belt’s pressure. These associated injuries are common in pediatric cases, as children’s softer tissues are more vulnerable to compression.

Symptoms of a Chance Fracture (Seat-Belt Injury)

Symptoms of a Chance fracture depend on the fracture’s severity, stability, and whether there’s associated spinal cord, nerve, or abdominal injury. In children, symptoms may be subtle or nonspecific due to difficulty articulating pain or discomfort. Common symptoms include:

Back Pain:

• Localized Pain: Severe pain in the thoracolumbar region (mid to lower back), often sharp or aching, exacerbated by movement, sitting, or standing.
• Pediatric Presentation: Young children may express pain indirectly through irritability, crying, or refusal to move, similar to compensatory behaviors in scoliosis (as noted in the Juvenile Scoliosis webpage).

Tenderness and Swelling:

• Tenderness over the thoracolumbar spine is often detected during a physical exam.
• Mild swelling or bruising in the back, though this may be less visible in children due to deeper spinal structures.

Restricted Range of Motion:

• Limited ability to bend, twist, or extend the spine due to pain or instability from the fracture.
• Children may avoid activities requiring back movement (e.g., playing, bending over), resembling the restricted motion seen in scoliosis cases.

Neurological Symptoms (if Spinal Cord or Nerves Involved):

• Numbness or Tingling: Sensations in the lower limbs or buttocks occur if nerve roots are compressed, particularly in unstable fractures.
• Weakness: Muscle weakness in the legs, indicating potential spinal cord involvement, though less common in Chance fractures (10–15% have neurological deficits).
• Paralysis (Rare): Severe cases with significant cord compression may cause partial or complete paralysis below the injury level.
• Bowel/Bladder Dysfunction: Loss of control, a red flag for cord injury, requiring urgent evaluation.

Abdominal Symptoms (Seat-Belt Syndrome):

• Abdominal Pain: Common due to associated intra-abdominal injuries (e.g., bowel or mesenteric trauma), often presenting as diffuse or localized pain.
• Bruising or Seat-Belt Sign: A visible bruise or abrasion across the abdomen where the lap belt was positioned, a key indicator of seat-belt syndrome.
• Nausea/Vomiting: May indicate internal injuries like bowel perforation, especially in pediatric patients.
• Pediatric Consideration: Children may not verbalize abdominal pain clearly, presenting with fussiness or lethargy instead.

Deformity or Postural Changes:

• Kyphosis: A visible forward tilt or hump in the mid-back due to the fracture’s flexion component, similar to spinal deformities in scoliosis.
• Guarding: Children may hold their backs rigidly or adopt a protective posture to minimize pain.

Pediatric-Specific Symptoms:

• Irritability or Distress: Young children may cry, be unusually fussy, or refuse to sit or stand due to pain.
• Refusal to Engage: Reluctance to participate in physical activities (e.g., sports, play), mirroring scoliosis-related behavioral changes noted in the webpage.
• Delayed Presentation: Symptoms may not be immediately apparent in children, as minor fractures can initially be mistaken for muscle strain.

When to Seek Immediate Medical Attention

It’s important to recognize when a spinal fracture is an emergency. If your child experiences persistent back pain that doesn’t improve, or if the pain is accompanied by warning signs such as numbness, tingling, loss of sensation, or difficulty moving their arms or legs, these can be red flags of a more severe injury. Immediate medical help should be sought if you notice:

• Sudden weakness or inability to move limbs
• Numbness or tingling in the arms, legs, or torso
• Loss of bladder or bowel control
• Severe pain following trauma, such as a fall or accident

These symptoms may indicate spinal cord involvement and require urgent evaluation by a medical professional. Prompt action can help prevent further complications and ensure your child receives the safest care possible.

How are Spinal Fractures Diagnosed?

When a spinal compression fracture is suspected, particularly after a fall, sports injury, or accident, prompt diagnosis is critical for ensuring timely and appropriate care. Doctors begin by asking about the child’s symptoms, details of how the injury occurred, and any relevant medical history.

A careful physical examination follows, where the physician will look for tenderness along the spine, observe for abnormal curvatures, and assess for neurological symptoms such as weakness or numbness. To confirm the diagnosis and determine the extent of the injury, medical imaging is essential:

• X-rays: Often the first step, X-rays help reveal bone breaks and changes in vertebral height.
• MRI scans: These provide a detailed look at the spinal cord and nerves, helping to assess for soft tissue injuries or compression that may not appear on X-rays.
• CT scans: These offer a more detailed image of the bone and can be useful for planning treatment if surgery is considered.

Based on the findings, your healthcare provider can accurately diagnose the type of spinal fracture and develop a treatment plan that addresses the specific needs and safety of your child.

Treatment of Spinal Fractures

Treatment may include some combination of the following:

Brace:

Our doctors use this for immobilizing the injured area and promoting bone alignment and healing. Also, this helps in reducing the eventual height loss and improving the angulation of the fracture. Most spinal fractures are initially managed with a back brace, along with nonsurgical options such as rest and over-the-counter pain medications like ibuprofen or naproxen to ease discomfort and inflammation.

Reduction:

It helps in realigning the fractured bone. Specialists do this with open reduction (by making an incision into the fracture site) or closed reduction (by external manipulation with no incision).

Traction:

In this procedure, doctors apply a force to stretch particular parts of the body in a certain direction. This treatment comprises pulleys, strings, weights, as well as a metal frame attached over the bed. The objective is to stretch the muscles and tendons around the broken bone. It allows the bone to align and heal.

Physical Therapy:

Physical therapy often plays a key role during recovery, helping patients regain strength, mobility, and function as the fracture heals.

Surgery:

Surgery might be necessary to put certain types of fractured bones back into place. Sometimes, internal fixation or external fixation devices are used to hold the bone fragments in place and thus allowing the right alignment and healing. If the spinal fracture is severe, or pain persists despite conservative measures, surgical procedures may be considered and could include:

• Vertebroplasty: Vertebroplasty is a minimally invasive procedure often used to treat compression fractures in the spine. Especially, when they cause significant pain or instability. During this procedure, a doctor uses a small needle to inject special bone cement into the fractured vertebra. This cement quickly hardens, helping to stabilize the bone, restore some of its original height, and relieve pain. The goal of vertebroplasty is to support the weakened vertebra and also to improve mobility and reduce discomfort so your child can return to their usual activities sooner.
• Kyphoplasty: Kyphoplasty is a minimally invasive surgical procedure designed to treat certain spinal compression fractures, often caused by trauma. During the procedure, a small balloon is carefully inserted into the fractured vertebra and gently inflated. This helps restore the vertebra’s lost height and relieves pressure on the spine. Once the bone is in the correct position, the balloon is removed and the space is filled with a special bone cement, which hardens quickly to stabilize the vertebra and reduce pain. Kyphoplasty can improve mobility, decrease spinal deformity, and provide rapid pain relief for many patients.

The specific approach depends on factors such as the type and location of the fracture, as well as the underlying cause. Your care team will tailor treatment to your needs, focusing on both immediate pain relief and long-term recovery.

Determining The Right Treatment 

So, basically, the overall goal of spinal fracture treatment is to restore the normal length and alignment of the vertebrae. Our doctors will determine the specific treatment for a fracture, considering:

• • The age of your child, overall health, and medical history
  • The severity of the fracture
  • The tolerance of your child for specific therapies, medications, or procedures
  • Your preferences and opinions
  • Expectations for the course of the fracture

  Bottom Line

  How your child will heal from a compression fracture depends on how severe the damage is and the cause of the damage. As a parent, you can help your child get the best result by not missing any of the follow-up doctor visits, giving proper meds as directed, and following the doctor’s instructions regarding activities.  Finally, our doctors at Medical City Children’s Orthopedics and Spine Specialists, with offices in Dallas,  Arlington, Flower Mound, Frisco, and McKinney, TX, understand the importance of maintaining your child’s health. In addition, our experts and specialists have the training, knowledge, and experience required to take care of a fractured spine that is causing pain to your child. If your child experiences a spinal Fracture, don’t hesitate to call our office at 214-556-0590 to schedule an appointment at one of our five locations.

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  Footnote:

  American Academy of Orthopaedic Surgeons: Fracture of the Spine