Lumbar (and thoracolumbar) fractures
Objectives- List the common injury mechanisms of injuries to the thoracolumbar and lumbar spine in children
- Discuss the role of the end plate in the anatomic features of
compression fractures of the lumbar spine in adolescents, and how the
pattern of injury differs from the adult
- Describe treatment for the compression fractures, flexion-distraction injuries, and burst fractures
- Describe indications for operative treatment of children's thoracolumbar and lumbar fractures
Discussion point
- In what way is a limbus fracture of the lumbar vertebra similar to a slipped capital femoral epiphysis?
Discussion
Although infrequent, fractures of the thoracolumbar and lumbar spine can present challenges in diagnosis and treatment. In general, the classification of Denis is used for analysis of injury. Compression fractures assume much more importance in the lumbar spine. Aufdermaur demonstrated conclusively that the growth plate was the primary site of failure in spinal injuries in adolescents, and a considerable literature has followed his publication. Prior to CT and MRI imaging, such injuries would have been classified as SCIWORA, but the pathology of growth plate failure and extrusion of the vertebral limbus into the spinal canal has been repeatedly and well demonstrated. With violent trauma, the translation and rotation of the fracture occurs at the growth plate, in which case the displacement is obvious; in limbus fractures the growth plate can displace posteriorly into the spinal canal, producing disc-like symptoms. Several patterns of displacement have been identified, CT myelography is reported as the most accurate imaging modality for diagnosis. Diagnosis is often delayed for weeks. The age of affliction for apophyseal fractures and the site of failure through the growth plate has led some to compare apophyseal fractures with slipped capital femoral epiphysis.
Burst fractures (failure of anterior and middle columns) can be unstable mechanically or neurologically. Both operative and nonoperative methods of treatment have been reported, recent work indicates that most of these injuries can be managed nonoperatively, even in adults. Small amounts of residual kyphosis have not been problematic in follow-up. Flexion-distraction injuries imply that posterior distraction forces predominate, and that pattern of injury depends on the fulcrum of rotation at the time of injury. With a seat belt the fulcrum will be anterior, and posterior failure from distraction is the predominant feature (Rumball and Jarvis). If the posterior injury is ligamentous, surgical stabilization of the separated spinous processes is indicated. If the injury is bony, healing of the fracture in a hyperextension cast will produce a stable spine. In general, operative treatment is only necessary when there is a worsening neurologic deficit, mechanical instability, or worsening deformity.
References
- Aufdermaur M. Spinal injuries in juveniles: Necropsy findings in 12 cases. J Bone Joint Surg (Br) 1974; 56: 513-19.
- Chow GH, Nelson BJ, Gebhard JS, Brugman JL, Brown CW, Donaldson DH. Functional outcome of thoracolumbar burst fractures managed with hyperextension casting or bracing and early mobilization [see comments]. Spine 1996; 21( 18): 2170-5.
- Denis F. Spinal instability as defined by the three column spine concept in acute spinal trauma. Clin Orthop 1984; 189: 65-76.
- Diamond P, Hansen CM, Christofersen MR. Child abuse presenting as a thoracolumbar spinal fracture dislocation: a case report. Pediatric Emergency Care 1994; 10( 2): 83-6.
- Domenicucci M, Preite R, Ramieri A, Ciappetta P, Delfini R, Romanini L. Thoracolumbar fractures without neurosurgical involvement: surgical or conservative treatment? Journal of Neurosurgical Sciences 1996; 40( 1): 1-10.
- Epstein N, Epstein J. Limbus lumbar vertebral fractures in 27 adolescents and adults. Spine 1991; 16: 962-66.
- Ghanayem AJ, Zdeblick TA. Anterior instrumentation in the management of thoracolumbar burst fractures. Clinical Orthopaedics & Related Research 1997( 335): 89-100.
- Glass RB, Sivit CJ, Sturm PF, Bulas DI, Eichelberger MR. Lumbar spine injury in a pediatric population: difficulties with computed tomographic diagnosis. Journal of Trauma-Injury Infection & Critical Care 1994; 37( 5): 815-9.
- Glassman SD, Johnson JR, Holt RT. Seatbelt injuries in children. J Trauma 1992; 33: 882-86.
- Greenwald TA, Mann DC. Pediatric seatbelt injuries: diagnosis and treatment of lumbar flexion-distraction injuries. Paraplegia 1994; 32( 11): 743-51.
- Haasbeek JF, Hedden DM. Unusual burst fracture in an adolescent involving the apophyseal plate. Journal of Pediatric Orthopedics 1994; 14( 4): 543-6.
- Handel SF, Twilford FW, Reigel DHL, Kaufman HH. Posterior lumbar apophyseal fractures. Radiology 1979; 130: 629-33.
- Phaltankar PM, Patel BR. Fracture-dislocation at the thoracolumbar junction in an infant with locked vertebrae. A case report. Spine 1997; 22( 16): 1933-5.
- Rumball K, Jarvis J. Seat-belt injuries of the spine in young children. J Bone Joint Surg( Am) 1992; 74: 571-74.
- Sovio OM, Bell HM, Beauchamp RD, Tredwell SJ. Fracture of the lumbar vertebral apophysis. J Pediatr Orthop 1985; 5: 550-52.
- Sturm PF, Glass RB, Sivit CJ, Eichelberger MR. Lumbar compression fractures secondary to lap-belt use in children. Journal of Pediatric Orthopedics 1995; 15( 4): 521-3.
May 16-19, 2012 in Denver, CO
