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STUDY DESIGN: Observational. OBJECTIVE: The authors present a detailed description of 25 skeletally immature patients with Chance fractures with a mean follow-up of 6.4 years. SUMMARY OF BACKGROUND DATA: Since the legislation mandating seat belt usage in Canada was first introduced, the fatality rate of automobile collisions has decreased significantly. However, seat belts do not result in the complete elimination of injury. Fractures of the lumbar spine due to seat belts are well recognized in adolescents and adults but there are few reports in young children. METHODS: Radiographic images and patient records were analyzed for information on patient demographics and injury details. RESULTS: Treatment involved either posterior instrumentation (n = 16) or a conservative approach using casting or bracing (n = 9). Concomitant injuries were documented. A deformity index was developed as a simple value to take into account the severity of both anterior loss of vertebral height and posterior distraction. CONCLUSION: The deformity index was significantly higher in patients with a concomitants abdominal injury and significantly higher in patients managed operatively. Functional outcome scores were completed on 14 of the patients. Patients scored within the reported norms on the SF-36 version 2 but scored poorly on the pain and disability component of the AAOS lumbar specific questionnaire. These outcomes indicate a need for using an injury specific score to accurately quantify disability.

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PURPOSE: This study examined clinical and radiological outcomes following video-assisted thoracoscopic surgery (VATS) for anterior release and fusion in the correction of pediatric scoliotic deformities. METHODS: We undertook a detailed chart and radiographic review to determine the degree of correction and perioperative morbidity and complications, if any, of a sequential group of patients who underwent VATS between 2000 and 2004 at British Columbia's Children's Hospital. We used patients who underwent open thoracotomy immediately before the adoption of the VATS technique at the same hospital to evaluate the relative efficacy of VATS. RESULTS: There were 19 patients in each group, 17 with idiopathic scoliosis in the VATS group and 16 in the open thoracotomy group. Mean age, weight at surgery and preoperative Cobb angle were similar (p = 1.0, 0.8 and 0.05, respectively). There was no significant difference in operative time per level between the VATS group and the open thoracotomy group (37.2 v. 34.5 min, p = 0.2) or total blood loss (908 v. 823 mL, p = 0.5). There were no major complications encountered in the VATS group. One patient in the open thoracotomy group experienced atelectasis and subsequent lower lobe collapse. CONCLUSIONS: VATS has the potential to decrease postoperative morbidity while still allowing the same degree of correction as traditional open thoracotomies and is a good alternative in the pediatric population.

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C1-C2 instability is a challenging problem in the pediatric population. Small patient size and poor healing potential in the at-risk groups, such as patients with Down syndrome and os odontoideum, make fixation difficult. Instability in patients with Down syndrome is a common problem, and traditional methods of fixation have a high complication rate and are a challenge given the frequent anatomic abnormalities such as an incomplete or hypoplastic arch, os odontoideum, and incomplete passive reduction. The purpose of this study was to review our experience of transarticular screw use in pediatric patients and to define the potential applications of this technique in pediatric C1-C2 instability. Twelve patients, with C1-C2 instability managed with transarticular screws at the authors' institution, were reviewed. The youngest patient treated was 5 years old with a mean age for the group of 11.5 years. The group consisted of 3 patients with Down syndrome and 9 patients with os odontoideum. Three of the patients with os odontoideum failed previous posterior wiring. Two patients presented with an acute spinal cord injury in the setting of chronic instability. Preoperative computed tomography or magnetic resonance imaging was used in all patients to define the vascular and bony anatomy. No further surgery has been required at a mean follow-up of 5.1 years in all patients. Although vertebral size and congenital anomalies may make screw positioning challenging, the technique allows fixation in the absence of a complete posterior arch of C1 and eliminates the need for instrumentation in the canal. This technique also provides a high fusion rate in a complicated patient population.

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Injury to the abdominal aortic artery from blunt trauma is an infrequent event with few cases reported in either the adult or the pediatric literature. Injury to the thoracic aorta after blunt abdominal trauma is more common. It has been estimated that 95% to 99% of all aortic disruptions are in the thoracic region. Injury to the abdominal aorta is rarely seen in association with fractures of the lumbar spine secondary to seat belt use in motor vehicle accidents; there are few cases in the literature of these injuries in pediatric patients. Nevertheless, the overall mortality rate of this injury has been reported to be between 18% and 37%. It is therefore important to be aware of the possible association to allow prompt diagnosis and management of multitraumatized patients because extensive injuries to the abdominal viscera may mask aortic dissection and prognosis is significantly improved with early intervention.

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STUDY DESIGN: We present a descriptive case series outlining the surgical technique and outcome in six patients managed with a combined anterior neck and sternal splitting approach. OBJECTIVES: To describe a surgical approach used in the management of severe cervicothoracic kyphosis and/or scoliosis in pediatric patients. SUMMARY OF BACKGROUND DATA: There are few reports in the literature that address the problem of accessing multileveled spinal deformities around the cervicothoracic junction requiring stabilization in the pediatric population. METHODS: A detailed chart and radiographic review was completed of six consecutive patients managed at our center with a combined anterior neck and sternal splitting approach. The indications, surgical technique, and outcome are reviewed for each case. This technique was employed in 6 pediatric patients, aged 3-15 years, at the authors' institution. Diagnoses included Klippel-Feil Syndrome (2 patients), Proteus Syndrome, Larsen Syndrome, and neurofibromatosis type I (2 patients). All patients had severe cervicothoracic kyphosis requiring surgical instrumentation. This technique allowed surgical access from C5-T6. RESULTS: This approach was invaluable in gaining access to the cervicothoracic junction to address complex spinal deformities in pediatric patients. In one patient, a separate thoracotomy was performed to access the lower thoracic spine. The only significant complication related to the approach was recurrent laryngeal nerve palsy experienced by one patient. This approach allowed stabilization of severe scoliotic and/or kyphotic deformities to impede curve progression. CONCLUSIONS: This approach was invaluable in gaining multileveled access to the cervicothoracic junction to address complex spinal deformities in pediatric patients.

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Os odontoideum can lead to instability of the atlantoaxial joint and places the spinal cord at significant risk for acute catastrophic events after minor trauma or chronic neurological change. We present two cases of os odontoideum in pediatric patients that were not appreciated at earlier remote imaging but were, in retrospect, detectable. One patient presented with an acute spinal cord injury. Incorporating assessment of dens integrity into the evaluation algorithm for all pediatric cervical spine studies should lead to early detection of os odontoideum lesions and allow referral to appropriate clinical spinal services for evaluation, surveillance and possible surgery to prevent future complications.

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A pivotal point in most clubfoot management protocols is Achilles tendon lengthening or tenotomy to address hindfoot deformity. The effectiveness of botulinum A toxin (BTX-A) in attenuating the function of the triceps surae muscle complex as an alternative to tenotomy was investigated. Fifty-one patients with 73 idiopathic clubfeet were recruited. Outcome measures included surgical rate, Pirani clubfoot score, ankle dorsiflexion with knee in flexion and extension, and recurrences. Patients were divided according to age: group 1 (<30 days old) and group 2 (>30 days and <8 months old). Ankle dorsiflexion in knee flexion and extension remained above 20 degrees and 15 degrees, respectively, and Pirani scores below 0.5 following BTX-A injection for both groups. One of the 51 patients required limited posterior release and 9 patients required repeat manipulation and casting plus or minus BTX-A injection. The use of BTX-A as an adjunctive therapy in the noninvasive approach of manipulation and casting in idiopathic clubfoot is a safe and effective treatment.

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