Initial Management of Pediatric Spine Compression Fractures (F1-F4)
Immediate Assessment and Imaging
For pediatric patients with suspected spine compression fractures classified as F1-F4, initial management should be stratified by fracture severity: F0-F1 fractures require conservative management with early mobilization, F2 fractures require bracing or crutches for 6-12 weeks, and F3-F4 fractures require consideration of surgical consultation followed by protected mobilization. 1
Imaging Protocol by Fracture Grade
- F0 fractures: Two orthogonal view X-rays are sufficient; MRI is not routinely indicated 1
- F1 fractures: X-ray is mandatory, with MRI considered based on patient age and injury extent 1
- F2 and F3 fractures: X-ray followed by MRI confirmation is required; F3 fractures also require CT scan 1
- Important caveat: In children under 6 years of age, MRI requiring general anesthesia should not be routinely performed 1
The lateral cervical spine radiograph alone has 73% sensitivity for detecting cervical spine injury in children, while CT has superior sensitivity for bony abnormalities 2. However, normal variants in young children (<8 years) such as pseudosubluxation of C2-C3 and widening of the atlantodental interval can complicate CT interpretation 2.
Conservative Management Strategy
F0 Fractures (Minimal Compression)
F1 Fractures (Mild Compression)
- Verticalization using crutches or brace should be considered based on patient age and injury extent 1
- Duration of spinal load reduction: 3-6 weeks, increasing with patient age (minimum 3 weeks) 1
- Sports activities should be restricted during this period 1
F2 Fractures (Moderate Compression)
- Verticalization using crutches or brace is mandatory 1
- Duration of spinal load reduction: 6-12 weeks, increasing with patient age (minimum 6 weeks) 1
- Long-term bed rest is contraindicated as it leads to deconditioning, bone loss, and increased mortality 1
F3 Fractures (Severe Compression)
- Surgical treatment should be considered first 1
- If conservative treatment is chosen, apply the same protocol as F2 fractures with verticalization using crutches or brace for 6-12 weeks 1
Evidence on Bracing Efficacy
The role of bracing in pediatric thoracolumbar compression fractures remains controversial. A study of 72 pediatric patients with type A 1.2 impaction fractures demonstrated significant remodeling capacity regardless of bracing, with the sagittal index improving from 0.76 at injury to 0.92 at mean 7.9-year follow-up 3. Bracing did not influence the remodeling capacity or long-term outcome 3. However, current treatment protocols still recommend bracing for F2 and F3 fractures based on expert consensus 1.
Surgical Consultation Indications
Surgical intervention should be reserved for:
- F3-F4 fractures with significant vertebral collapse 1
- Neurological deficits present on examination 2
- Spinal instability or significant deformity 2
- Canal compromise with cord compression 2
Children have a higher risk of spinal cord injury without radiological abnormality (SCIWORA), particularly in those under 8 years of age due to incomplete ossification, ligamentous laxity, and large head-to-body ratio 2.
Critical Pitfalls to Avoid
- Never prescribe prolonged bed rest: This causes deconditioning, decreased bone mineral density, muscle strength loss, and increased mortality 1, 4
- Avoid missing neurological deficits: Perform thorough neurological examination in all patients, as 83% of children with cervical spine fractures may present with no demonstrable neurological deficit initially 5
- Do not overlook SCIWORA: Children can have clinical symptoms of traumatic myelopathy with no radiographic or CT features of spinal fracture 2
- Avoid routine MRI in young children: In patients under 6 years requiring general anesthesia for MRI, the risks may outweigh benefits for minor fractures 1