Clinical Features
- Children under about 8 years have a large head, lax ligaments and horizontal facets
- Injuries in young children cluster in the upper cervical spine
- SCIWORA is spinal cord injury without radiographic abnormality
- Distracting injuries and head injury reduce clinical reliability
Management
Immobilisation
- Collar, board and bolsters pending X-ray and clinical examination
- Board with a cut out for the occiput, or a pad under the torso
- Avoids forced neck flexion from the large occiput
Examination
- Primary survey under ATLS principles
- Palpate the whole spine for tenderness, step and swelling
- Check range of motion only when alert and cooperative
- Full neurological testing of motor, sensation and reflexes
- Rectal tone and perianal sensation
- Bulbocavernosus reflex to judge spinal shock
- Look for seatbelt sign with Chance fracture and abdominal injury
Investigations
- NEXUS or Canadian C spine rules are less validated in young children
- Lateral cervical radiograph first, adding AP and open mouth views where needed
- Pseudosubluxation of C2 on C3 and C3 on C4 is normal in young children
- Predental space up to 5 mm is normal in children
- CT for suspected fracture, limiting radiation where possible
- MRI for neurological deficit, SCIWORA or ligament injury
- Image the whole spine if one injury is found
Differential Diagnosis
- Non accidental injury
Reviewed by Professor Phong Tran, Head of Orthopaedic Surgery, Western Health. Last updated 10 October 2026.