Abusive Pediatric Thoracolumbar Fracture Due to Forced Hyperextension: Case Report, Biomechanical Considerations, and Review of the Literature

Abstract

Pediatric thoracolumbar fractures are rare due to the physiological differences which afford greater resilience to the immature spine. Most pediatric thoracolumbar fractures occur as the result of high energy trauma, such as motor vehicle accidents, and modes of reasonable accidental injuries are limited by age and developmental capabilities of the child. These fractures can occur as the result of inflicted blunt force trauma and child abuse, and in most cases, the mechanism of injury to the spine is not known. We report the death of a 29-month-old man due to blunt force trauma to the back and forced hyperextension of the thoracolumbar spine causing fracture of the fourth lumbar (L4) vertebral body. A complete forensic examination revealed a previous healing fracture of the anterior aspect of the L4 vertebral body, with acute disruption of the anterior longitudinal ligament overlying the fracture site, complete fracture of the vertebral body, and fatal retroperitoneal hemorrhage. We present a review of the biomechanical considerations of the pediatric spine, a survey of pediatric spinal fractures, and a review of the literature on pediatric abusive thoracolumbar fractures. In this case, there was never a provided explanation for how the injury occurred; however, understanding the biomechanics of the pediatric spine allowed for the determination of the mechanism, force required to produce this specific pattern of abusive spinal injury, and the manner of death.

Thoracolumbar fracture-dislocation in a two-year-old female child following child abuse: A case report and literature review

“… Duffin et al [ 16 ] 2018 1 13 months Complete retrospondylolist-hesis of T12 on L1 Bilateral lower limb paralysis Child abuse T11-L1–instrumented fusion No neurologic recovery No follow up 10. Webb et al [ 17 ] 2020 1 29 months Fracture of the fourth lumbar (l4) vertebral body NA Child abuse NA Dead approximately two hours after arrival NA 11. Thornley et al [ 7 ] 2021 1 2 years Acute-on-chronic thoracolumbar fracture-subluxation Progressive neurologic dysfunction Child abuse Short-segment pedicle screw instrumentation 12 months Complete resolution of neurologic impairment …”

Child Abuse with Thoracolumbar Fracture-Dislocation Treated with Pedicle Screw Fixation in a 2-Year-Old

“…ediatric patients represent only 2% to 5% of the spine trauma population [1][2][3] . Pediatric thoracolumbar fracture is commonly associated with motor vehicle accidents and next most commonly with high-energy sporting injuries in adolescence 1,3 . Nonaccidental trauma is an additional mechanism of thoracolumbar fracture/subluxation.…”

“…Nonaccidental trauma (NAT) is an important mechanism of injury to consider in patients younger than 2 years because up to 38% of all pediatric spine patients in this cohort may have been abused 1,4,5 . There are less than 50 reported cases of NAT mechanisms for thoracolumbar fractures in infants and toddlers in the literature [1][2][3] . Largely these reports stem from radiology and pathology journals describing postmortem findings.…”

“…Nonaccidental trauma is an additional mechanism of thoracolumbar fracture/subluxation. Oftentimes, this mechanism of injury is nondiscernible but proposed to involve both an axial and flexion-distraction pattern 3,4 .…”