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Taking a Chance With Improper Use of Seatbelts

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Spinal fractures from the improper use of seatbelts are associated with car accidents. Children are at risk for Chance spinal fractures when they are not properly restrained or only partially restrained with seatbelts. This report is the largest one of its kind examining Chance fractures in children.

Chance fractures are described as flexion-distraction fractures. They occur in the thoracic (mid) spine most often in children. The same type of fracture can occur in adults but usually affects the lumbar spine (low back).

Chance fractures are also referred to as a traumatic horizontal splitting of the spine. The force of the impact throws the child's weight forward against the seatbelt. The vertebral bone splits in half from side-to-side. The split goes through the main body of the vertebral bone and extends all the way back through the spinouts process (that's the bump you feel along the back of your spine).

There are usually other injuries that occur along with the Chance fracture. These associated injuries include abdominal injury (the "seat belt sign") and neurologic (nerve) damage. In accidents like these, there can also be other fractures and head injuries. According to this study of 35 children from three pediatric trauma centers, neurologic complications can be permanent.

Let's take a closer look at what they found with these 35 children. They ranged in ages from one year old to 17 years old. Almost half (43 per cent) had a neurologic problem at the time of examination following the accident. Some of those children recovered fully but many did not. Ten per cent of the children who were restrained recovered while 42 per cent of those who were not seat belted in at all reported continued pain and neurologic problems.

Type of treatment given may make a difference in the final results called outcomes. Yet, right now there doesn't appear to be a standard way to approach treatment for Chance fractures. Sometimes surgeons try placing the child in a cast or brace that holds the spine straight or in slight extension.

In other cases (usually in the case of more severe fractures and more forward flexion of the spine), surgery is done to fuse the spine. Rods, hooks, screws, and/or wires are used to hold the spine in good alignment during healing and recovery. According to the results of this study, children with a forward-flexed spine (called kyphosis) of more than 20 degrees are more likely to need surgery in order to have a good final outcome.

Thirty-five patients aren’t really enough to create a study that can provide specific guidelines. The authors say based on their observations that these rare injuries can be treated conservatively (nonoperatively). But in the presence of severe fractures accompanied by other serious injuries, surgery is advised as soon as the patient is stable.

Further studies are needed to compare the results of different treatment approaches. For example, it's possible that even one variable (e.g., location of the fracture(s), severity of fracture(s), age of the child, severity of kyphosis, presence of other injuries) could make a difference in selecting the most successful treatment.

In the meantime, education is a key factor in reducing Chance fractures. This is especially important for younger children who tend to be top heavy (their head and chest have greater volume and weight than the lower part of the body). The force of a sudden stop or collision in a car accident throwing the upper body forward puts them at greater risk of injury. Not using a shoulder strap or having difficulty placing the shoulder strap in the right position contributes to the risk of Chance spinal fractures.

At the same time, parents and guardians need to know that small or young children without enough muscle bulk or large enough pelvic and spinal bones are prone to this type of flexion-distraction injury. The risk of damaging the spinal cord (creating significant neurologic problems) is very real. This is because the underdeveloped bones and spinal ligaments stretch easily but the spinal cord does not.

The authors conclude that properly restraining our young children is the key to reducing the risk of Chance fractures. Once this type of injury does occur, surgery may be the best treatment of choice. All factors must be evaluated and considered when making the final decision about surgery.

Reference: Alexandre Arkader, MD, et al. Pediatric Chance Fractures: A Multicenter Perspective. In Journal of Pediatric Orthopaedics. October/November 2011. Vol. 31. No. 7. Pp. 741-744.

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