A 4-Year-Old Who Fell from the Slide
Urgent message: Injuries sustained in playground falls are common
presentations to emergency departments and urgent care centers
alike. The urgent care physician should be alert to the keys to evaluation
and management of traumatic neck pain.
Muhammad Waseem, MD, Lalithambal Venugopalan, MD, and Gerard Devas, MD
Introduction
Cervical spine (C-spine) injuries occur infrequently in
children. This is especially true for fractures of atlas vertebra,
which is a rare injury in children. Its diagnosis may
easily be missed due to inconclusive C-spine radiographs and
absence of neurological signs.
Here, the authors present an illustrative case of a
patient with, and a review of, a fracture of atlas vertebra.
Case
A 4-year-old presented with neck pain one day after
he fell from a slide onto the top of his head. He was
complaining of pain in the back of his neck. There was
no history of loss of consciousness, headache, or vomiting.
He was immediately placed in a rigid cervical collar.
In the emergency department, he was alert and awake.
His Glasgow coma scale was 15. His vital signs were as
follows:
Temperature: 98.4°F
Heart rate: 119 beats/minute
Respiration: 22 breaths/minute
Oxygen saturation: 99%
The patient did not have any difficulty of breathing
but complained of diffuse neck pain.
On physical examination, he had torticollis and diffuse
tenderness over the back of his neck. There was no
subcutaneous emphysema. The pupils were equal and
reactive. There was no hemotympanum or cerebrospinal
fluid leak from his ears. His chest was clear, with bilateral
symmetric breath sounds. The abdomen was soft
and non tender. His neurologic examination was unremarkable.
Radiographs of the cervical spine (AP and lateral
views done in erect posture) showed pre-vertebral soft tissue
swelling of the upper cervical spine with reversal of
normal spine curvature (Figure 1).
Because of the persistent pain and indirect signs of
injury on the plain radiograph, a cervical collar was
applied and the patient underwent computed tomography
scan of the upper cervical spine, which showed a
fracture in the right anterior arch of the C1 vertebra with
a 9 mm separation (Figure 2). This fracture was considered
stable and managed with immobilization. He
improved and was well at follow-up.
Discussion
Cervical spine injuries are serious but relatively uncommon
in children, with a reported incidence of 1% to 2%.1
The typical mechanism of cervical spine injury is either
a fall onto the top of head or motor vehicle accident.
The fall onto the head causes the body weight to be
transmitted to the atlas, resulting in axial
loading.
Identification of the fractures of the
cervical spine by plain radiograph is
difficult and, therefore, can be missed
on plain radiographs.2,3 This is especially
true for upper cervical vertebrae—
including atlas, as most fractures of
the atlas, particularly the anterior
aspect, may remain occult.4
In addition, the open-mouth view,
which is usually pathognomonic for the
diagnosis, is often inadequate or not
obtained.5 An open-mouth view is helpful
to visualize the displacement of lateral
masses of atlas, but may not demonstrate
the site of fracture.
It is also important to look for any
indirect signs of injury, such as prevertebral
soft-tissue swelling, air in the
pre-vertebral space, an increased width
of the anterior atlantodental interval,
and overriding of the C1-C2 joint on
one side.6 Presence of any indirect signs
of injury on plain radiograph warrants
a CT scan to confirm the presence of fracture
of C-spine.
Younger children have a predilection for C-spine
injuries at the higher level, which may be related to
the biomechanical and anatomic features of the immature
pediatric C-spine.7 The child’s spine is more flexible
and mobile8 and, because of higher mobility and
elasticity of the spine and a lower body mass in children,
spinal injuries are relatively uncommon.9
It is especially rare in fractures of the atlas, as fracture of
the ring increases the space that is available for the dural
sac and, therefore, is unlikely to cause compression.10
Atlas fractures may be associated with other cervical
fractures, with odontoid fracture being the most common
associated fracture.
Management
The initial assessment of the patient must include maintenance
of the airway, breathing, and circulation.
A non-displaced fracture of atlas is considered stable.
11
Stable fractures usually heal within eight to 12 weeks.
Isolated stable fracture of the atlas can be treated
effectively with a rigid cervical collar alone for that
period.
12 A Philadelphia collar may provide sufficient
immobilization.
Generally, all displaced fractures are considered
unstable; more rigid or surgical stabilization is recommended
in unstable injuries in patients with displaced
fractures.13
Another option is halo-vest immobilization for a
period of 12 weeks.
Typically, cervical immobilization is sufficient for
an isolated fracture of the atlas with an intact transverse
atlantal ligament. However, cervical immobilization
with surgical fixation and fusion will be
required if transverse atlantal ligament is disrupted.14
The reported long-term outcome from the fracture of
atlas is good.15
Disposition of Case
The patient described in this case report was treated
conservatively with cervicothoracic brace; he recovered
without any neurological abnormalities.
In most reports, rigid collars, sternal occipital,
mandibular immobilizer, or "SOMI", braces and
halo ring-vest orthoses have all been used for a period
of eight to 12 weeks with good results.
No evidence has been reported favoring use of one
of these devices over the other.
Conclusion
It is important to consider fracture of the cervical
spine in a child with significant neck pain and neck
tilt after a fall on the top of the head. The presence
of indirect signs of injury on plain films, especially
in the presence of neck pain, should be taken
seriously and followed with a CT scan.
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