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Contents lists available at ScienceDirect

Orthopaedics & Traumatology: Surgery & Research

journal homepage: www.elsevier.com

Original article

Epidemiology of spinal fractures in children: Cross-sectional study

Roxane Compagnon a,∗ , Emmanuelle Ferrero b , Julien Leroux c , Yan Lefevre d , Pierre
Journeau e , Rapahël Vialle f , Christophe Glorion g , Philippe Violas h , Antoine Chalopin i ,
Thierry Odent j , Elie Haddad k , Jérémie Nallet l , Christophe Garin m , Elie Choufani n , Tristan
Langlais o , Jérôme Sales de Gauzy a , the French Society of Spinal Surgery (SFCR), French
Society of Pediatric Orthopedics (SOFOP)p
a
Hôpital des Enfants, Toulouse, France
b
Hôpital Robert-Debré, Paris, France
c
Hôpital universitaire de Rouen, Rouen, France
d
Hôpital Pellegrin, Bordeaux, France
e
Hôpital universitaire de Nancy, Nancy, France
f
Hôpital Armand-Trousseau, Paris, France
g
Hôpital Necker, Paris, France
h
Hôpital universitaire, Rennes, France
i
Hôpital universitaire, Nantes, France
j
Hôpital universitaire, Tours, France
k
Hôpital universitaire, Saint-Étienne, France
l
Hôpital universitaire, Besançon, France
m
Hôpital universitaire, Lyon, France
n
Hôpital La-Timone Enfants, Marseille, France
o
Fondation Lenval, Nice, France
p
Société française de chirurgie rachidienne (SFCR), Société française d’orthopedie pédiatrique (SOFOP), 56, rue Boissonade, 75014 Paris, France

a r t i c l e i n f o a b s t r a c t

Article history: Introduction: Epidemiological studies of fractures of the spine in children are all old, mostly single-centre,
Received 27 March 2020 with series spanning periods of 5 to 20 years.
Accepted 19 June 2020 Hypothesis: As lifestyle is constantly changing, notably with an increase in sports activities and improve-
Available online xxx
ments in the prevention of road and household accidents, epidemiology has likely changed.
Objective: To update the description of spinal trauma in children and adolescents compared to the existing
Keywords: literature.
Spinal fracture
Material and method: A multicentre cross-sectional study of spinal fracture, dislocation and spinal cord
Spinal trauma
Children and adolescents
injury without radiological abnormality (SCIWORA) in children was carried out in 15 French university
Epidemiology hospital centres, for a period of one year (2016).
SCIWORA Results: One hundred and sixty-five children were identified: 85 girls, 80 boys; mean age 11 years (range,
10 months–17 years); median, 12 years 6 months. One hundred and fifty-two children (92%) had fracture,
8 (5%) dislocation (including 7 C1-C2 rotary dislocations), and 5 (3%) SCIWORA. Fractures were multiple
in 80 cases (49%), contiguous in 73 cases (91%) and non-contiguous in 7 (9%). Locations were cervical in 25
cases (15%), thoracic in 85 (52%), lumbar in 75 and sacral in 4 (2%). Fracture types comprised 234 vertebral
compactions (78%), 25 burst fractures (8%), 5 chance fractures (2%), 2 odontoid fractures, and 33 other
lesions. Causes comprised fall in 77 cases (47%), sports accidents in 56 (34%), road accidents in 29 (18%),
and others in 3. In 52 cases (32%), there was ≥ 1 associated lesion: appendicular in 35 cases (67%), thoracic
or abdominal in 31 (60%), and head in 16 (31%). Twenty-one cases had multiple lesions (40%). Eighteen
cases showed neurological involvement (11%) including 5 SCIWORAs. Neurological complications were
more frequent before 9 years of age.

∗ Corresponding author at: Orthopédie, hôpital des Enfants, 330, avenue de Grande-Bretagne, 31059 Toulouse, France.
E-mail address: roxane.compagnon@gmail.com (R. Compagnon).

https://doi.org/10.1016/j.otsr.2020.06.015
1877-0568/© 2020 Elsevier Masson SAS. All rights reserved.

Please cite this article as: Compagnon R, et al, Epidemiology of spinal fractures in children: Cross-sectional study, Orthop Traumatol
Surg Res, https://doi.org/10.1016/j.otsr.2020.06.015
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R. Compagnon et al.
Conclusion: The epidemiology of spine fractures in children has slightly changed. There are now fewer
cervical lesions. Causes are less often road accidents and more often sports accidents. Multi-level lesions
remain frequent and the rate of neurological complications is around 10%. Compaction fracture is the
most common type.
1. Introduction
Spinal fracture is rare in children. Although incidence is hard to
determine, it is estimated that spinal fractures account for 1–5% of
all fractures in children [1–3], and that 1–10% of spinal fractures
are in children [3]. Several studies focused on the epidemiology
of childhood spinal fracture, but were all retrospective, quite old,
mainly single-centre, with heterogeneous series and study periods
ranging between 5 and 20 years [2–13].
Meanwhile, lifestyle is continually changing, notably with
increased sports activities and improved prevention of road and
household accidents.
It therefore seemed opportune to update the epidemiology of
childhood spinal fracture, comparing results with older reports.
A multicentre cross-sectional observational study was therefore
made, with the main objective of determining incidence, causes,
locations, types, complications and associations for childhood
spinal fracture and the secondary objective of analysing differences
according to patient age.
2. Material and method
A multicentre cross-sectional observational pediatric study was
sponsored by the French Society of Spinal Surgery (SFCR), based on a
standardised questionnaire sent to all members of the French Soci-
ety of Pediatric Orthopedics (SoFOP). For all admissions for spinal
lesion [fracture, dislocation, spinal cord injury without radiological
abnormality (SCIWORA)], items comprised: patient age and gender,
type of accident, fracture location and type, single or multiple frac-
ture, associated lesions, and neurologic status. The inclusion period
was February 1, 2016 to January 31, 2017.
“Compaction” fracture denoted types A1, A2 and A3.1 lumbar or
thoracic fracture, “burst” types A3.3 and A4, and “Chance” types B1
and B2 [14].
The inclusion criterion was diagnosis of traumatic spinal frac-
ture in patients aged 0–17 years. Incomplete files were excluded.
The study was registered with the CNIL data protection com-
mission: CNIL no 2217370.
Quantitative variables were reported as mean, median and
range.
3. Results
Fifteen pediatric orthopedic departments responded, all in
university hospitals: Besançon, Bordeaux, Debré (Paris), Lyon,
Marseille, Nancy, Nantes, Necker (Paris), Nice, Rennes, Rouen,
Saint-Etienne, Toulouse, Tours, and Trousseau (Paris).
Over the 1-year period, 165 cases were identified, all with com-
plete files: 85 girls, 80 boys; mean age, 11 years (range, 10 months
to 17 years); median, 12 years 6 months (i.e. adolescent predomi-
nance) (Fig. 1).
One hundred fifty-two children (92%) had ≥ 1 fracture, 8 (5%)
dislocation (including 7 C1-C2 rotational dislocations), and 5 (3%)
SCIWORA.
Fractures were multiple in 80 cases (49%), contiguous in 73 (91%)
and non-contiguous in 7 (9%).
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© 2020 Elsevier Masson SAS. All rights reserved.
3.1. Locations
Locations comprised cervical spine in 25 cases (15%), thoracic
spine in 85 (52%), lumbar spine in 75 (45%), and sacrum in 4 (2%).
Fractures were thoracolumbar (T12 and/or L1) in 61 patients (num-
ber of fractures exceeds number of patients due to multi-level
fractures).
3.2. Type of fracture
Fracture types comprised 234 vertebral compactions (78%), 25
burst fractures (8%), 5 chance fractures (2%), 2 odontoid fractures
and 33 others: 12 tear-drop, 19 type A0 (14) (spinal process, trans-
verse process, lamina), and 2 anterior arch.
3.3. Causes
Causes comprised falls in 77 cases (47%) (including 16 defen-
estrations), sports accidents in 56 (34%) [the most frequent sport
being horse-riding: 13 cases (23%)], road accidents in 29 (18%), and
direct trauma in 1; in 2 cases, the cause was not reported.
3.4. Associated lesions
There were ≥ 1 associated lesions in 52 cases (32%): in limbs in
35 cases (67%), thorax or abdomen in 31 (60%) and skull of face in
16 (31%). In 21 cases (40%), there were multiple lesions.
3.5. Neurologic involvement
Eighteen cases showed neurologic involvement (11%: 10 Frankel
A, 1 B, 3 C and 4 D), including 5 patients with SCIWORA. There were
6 medullary lesions, with clinical/MRI concordance, and 6 radicular
lesions; 6 clinical central deficits without MRI evidence all showed
complete recovery. Three patients died during the first week after
trauma.
3.6. Analysis according to age
Two age groups were distinguished: ≤ 8 years and ≥ 9 years, as
in previous reports [1–3,7,13]. Results are shown in Table 1.
Before 9 years of age, falls predominated, with road accidents
in second place, ahead of sports accidents (Table 2). Odontoid frac-
tures occurred exclusively in under-9 year-olds. There was only 1
burst fracture in the under-9s, versus 24 in the over-9s. In under-9s,
cervical spine lesions mainly comprised the 7 C1-C2 rotational dis-
locations, apart from which rates were identical in both age groups,
at 10%.
The rate of neurologic complications was 18% in under-9s and
9% in over-9s.
4. Discussion
Spinal fracture is rare in children. Incidence could not be pre-
cisely established, as the present study was not exhaustive; the
rarity of traumatic spinal lesions was, however, clear, with only 165
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Fig. 1. Age distribution of children with spine injuries.

Table 1
Spinal trauma lesion characteristics according to age.

Age ≤ 8 years (n) % Age > 8 years (n) % Total (n)

Number of patients 40 24.2 125 75.8 165

Number of lesions
Single 13 18.1 59 81.9 72
Multiple 17 21.3 63 78.8 80

Mechanism
Direct trauma 1 33.3 2 66.7 3
Road accident 13 44.8 16 55.2 29
Sport accident 11 19.6 45 80.4 56
Fall 15 19.5 62 80.5 77

Location
Cervical 11 44 14 56 25
Thoracic 24 28.2 61 71.8 85
Lumbar 12 16 63 84 75
Sacral 1 25 3 75 4

Type of lesion
Compaction 57 24.4 177 75.6 234
Chance 1 20 4 80 5
Burst 1 4 24 96 25
Odontoid 2 100 0 0 2
SCIWORA 3 60 2 40 5
Dislocation 7 87.5 1 12.5 8

Complications
Neurologic 7 38.9 11 61.1 18
Death 2 66.7 1 33.3 3

patients during the study year in 15 university hospital reference The present epidemiological findings were similar to those in
centres covering most of France. Such low incidence is reported the literature. Fractures were more frequent in adolescence in the
in all studies. Larger series were all retrospective, extending over main series. Mean age at fracture is 12 years; in the present series,
longer periods: 546 cases in 26 years [11], 749 in 20 years [15]. mean age was 11 years, median age 12 years and only 40 patients
Puisto et al. found constant annual incidence of 66 per 106 in under- (24%) were under 9 years of age.
18 year-olds over the period 1997–2006 [15]. Half of the present patients had multi-level fracture, in agree-
ment with literature rates of 35–53% [2,7,8,10,11]. Non-contiguous
fractures are rare: 9% in the present series, 7% for Carreon et al. [2],
12% for Kim et al. [5] and Firth et al. [4], 18% for Mahan et al. [7]
Table 2 and 39% for Rush et al. [10]. However, the whole spine should be
Road accidents.
explored for other lesions (preferably on MRI, to lessen the radia-
≤ 8 years > 8 years Total tion dose).
Pedestrian 1 0 1 Classically, it is the cervical spine that is most frequently injured
Bicycle 0 4 4 in young children, with rates of 30–50% [2,7,10,13,16], the higher,
Motorised 2-wheeler 0 6 6 the younger the children. Several reasons are given for this: the
Car (passenger) 12 6 18
weight of the head, the relative weakness of the cervical muscles,

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Table 3
Comparison of literature data.

Carreon et al. [2] Mahan et al. [7] Puisto et al. [15] Kim et al. [5] Compagnon et al. (current study)
Cases/years 137/10 years 195/10 years 749/10 years 275/23 years 165/1 year
Mean age (years) 12 12 ND 12 11
Multi-level lesions 34% 32% ND 27% 49%
Non-contiguous fractures 7% 6% ND 12% 9%
Cervical involvement 36% 38% 29% 32% 15%
Compaction 42% ND ND ND 78%
Falls 15% 38% 28% 13% 47%
Road accidents 58% 45% 35% 53% 18%
Sport accidents 7% 17% ND 28% 34%
Associated lesions 53% 59% ND 55% 32%
Neurologic deficit 19% 12% 3% 18% 20%
Mortality 8% 1% 3.5% 3% 2%

and the more horizontal orientation of the joint surfaces. Mahan
et al. reported 51% cervical locations in under-9 year-olds, versus
34% in older children [7], and 64% and 25%, respectively, accord-
ing to Puisto et al. [15]. In the present series, only 15% of cases
showed cervical involvement: 27.5% in under-9 year-olds and 11.2%
in over-9 year-olds. Improved road-safety rules for young children
probably account for this decrease.
The most frequent fracture type in the present series was com-
paction fracture, at 78%, compared to 42% for Carreon et al. [2].
Burst fractures were much more rare: 8% in both the present series
and that of Carreon et al. [2]; they mainly occur in adolescence,
and are exceptional in under-9 year-olds. Chance fractures have
become more rare, due to improved road safety: speed limitation
and improved safety equipment.
The most frequent etiology in the present series was falls, as in
most reports, where it sometimes accounts for more than half of
cases [11,13]. It can be difficult to differentiate between falls and
sports accidents; in the present study, only organised activities,
in competition or leisure, were counted for sports accidents, and
even so, the rate was 34%, in agreement with Kim et al. [5] and
Bilston et al. [3]. There are several possible reasons for this. One
is an increasing rate of at-risk sports: in the present study, horse
riding was the most frequently implicated sport; sports practices
are also changing, with more intense contact and risk of falling. In
the present series, road accidents ranked third, whereas in most
reports between 1990 and 2010, they ranked first [5,7,9,10].
In the present series, 32% of patients had associated lesions,
equally distributed between limbs, thorax, abdomen and head, and
multiple lesions in 20–40% of cases. Associated lesions were more
common in the previous literature, at rates between 55% and 62%
[7,10,12]. The difference may be due to the causes of the accidents,
road accidents being more frequent in older series, accounting for
the greater rate of multiple traumas.
There was an 11% rate of neurologic deficit, in agreement with
the literature rates of 7–19% for most series [2,5,7,8,10,12]. Only
Turgut et al. reported a substantially higher rate, at 47% [13], doubt-
less due to recruitment bias: their data came from a neurosurgery
department, with only 82 cases in 25 years.
Neurologic complications are more frequent in younger chil-
dren. In the present series, 20% of under-9 year-olds had neurologic
complications, compared to 8% of over-9 year-olds. Carreon et al.
[2] reported rates of 48% and 15%, respectively; Turgut et al. [13]
reported 59% and 44%, respectively.
The present series included 5 cases of SCIWORA; there were 2
in Kim et al.’s series, 5 in Carreon et al.’s [2] and 11 in Turgut et al.’s
[13].
The present 3% mortality was identical to that reported else-
where [10,12,13].
The main data are compared in Table 3.
The present series had several weaknesses. It was not exhaus-
tive. However, a large majority of university hospital departments
in France responded, and these are the departments mainly man-
aging spinal trauma. Some manage children only up to the age of 15
or 16 years, and the over-16 year-old age group was smaller. Some
patients may have been missed, being referred directly to ICU or
neurosurgery. We chose to include dislocations without fracture
and SCIWORA, so as to broaden recruitment in under-9 year-olds,
where there were 7 C1-C2 dislocations, as discussed above.
5. Conclusion
The epidemiology of childhood spinal fracture has slightly
changed with respect to the available literature. Cervical locations
are now less frequent. The rate of road accidents has decreased and
that of sports accidents increased, resulting in less multiple trau-
mas. Multi-level fracture is still frequent, and the rate of neurologic
complications is about 10%. Compaction fracture is now the most
frequent form.
Disclosure of interest
The authors declare that they have no competing interest.
Funding
None.
Author contributions
Compagnon R. contributed to the writing of the article and
investigation; Ferrero E., Lefevre Y., Journeau P., Glorion C., Vio-
las P., Chalopin A., Odent T., Haddad E., Nallet J., Garin C., Choufani
E., Langlais T., to the investigation and re-editing; Leroux J., to the
design and investigation; and Sales de Gauzy J., to the writing of
the article, study design and investigation.
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