Epidemiology
- Motor vehicle accidents, as occupant or pedestrian, are the leading cause
- Falls predominate in younger children
- Sports, diving and recreational injuries predominate in adolescents
- Under about 8 years, a large head, lax ligaments and horizontal facets put the fulcrum at C2 to C3
- Younger children sustain upper cervical (occiput to C3) and more often ligamentous injuries
- After about 8 years the pattern becomes adult-like, with more subaxial fractures
Aetiology
- Down syndrome
- Klippel-Feil syndrome
- Skeletal dysplasias such as Morquio syndrome and achondroplasia
- Juvenile idiopathic arthritis
- Previous cervical surgery
- These predispose to instability and lower the threshold for imaging
Clinical Features
- Pain is the usual presentation, with frequent torticollis
- Ask specifically about weakness, sensory change and bowel or bladder dysfunction
- Young children may show only irritability or refusal to move the neck or limbs
- Transient paraesthesia, numbness or weakness at the scene, even if resolved, raises concern for SCIWORA
- Lap belt mechanism suggests a Chance injury with abdominal visceral injury
- Head and facial injuries are commonly associated
- Torticollis after URTI or head and neck surgery suggests Grisel syndrome
- Red flags are current or transient neurology, altered conscious state and distracting injuries
- Further red flags are high energy mechanism, torticollis after trauma and midline tenderness
- Spinal injury from abuse is uncommon but occurs in infants, often with other injuries
- Abuse features are delay, inconsistent or changing history, bruising, rib fractures or head injury
Investigations
- NEXUS and PECARN cervical spine rules guide imaging but are less reliable in preverbal children
- Skeletal survey and child protection referral when abuse is suspected
Reviewed by Professor Phong Tran, Head of Orthopaedic Surgery, Western Health. Last updated 10 October 2026.