Pediatric emergency medicine trisk 3597 3597
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information, and decreases the risk of missing a subtle injury. An algorithm for
considering radiographic evaluation is presented in Figure 112.15 . An MRI
should be considered to detect ligamentous, soft tissue, and/or spinal cord injuries.
Special consideration for MRI should be given to cases of nonaccidental trauma
due to the increased risk of cervical spine ligamentous injuries and spinal subdural
hematomas in this group compared to accidental injuries.
The next area of radiographic evaluation involves the cartilage. Cartilage is
radiolucent on plain radiographs. The cartilaginous areas include the
synchondroses or growth plates and intervertebral disc spaces ( Table 112.7 ). The
growth plates may mimic fractures and may be confusing to those who are
unaware of their presence. Growth centers in the anterior-superior vertebral bodies
cause a sloped appearance that may appear as a compression fracture to the
untrained eye. This anterior wedging on the radiographs can approach 3 mm and
still be considered normal. Vertebral disc abnormalities may indicate specific
types of injuries. A vertebral disc space that is narrowed anteriorly may indicate
disc extrusion, whereas a widened space suggests a hyperextension injury with
posterior ligamentous disruption.
Soft tissue evaluation is extremely important. Abnormal soft tissue spaces may
be the only clue to the underlying ligament, cartilage, or subtle bone injury, which
may not be obvious on the radiograph. The soft tissue widening may represent
blood or edema, which suggest an underlying injury. The prevertebral space at C3
should be less than one-half to two-thirds of the AP width of the adjacent
vertebral body ( Fig. 112.19 ). This space will double to approximately the width
of the adjacent vertebral body below C4 (the level of the glottis) because the
usually non–air-filled esophagus is present at this area. Care must be taken when
evaluating the prevertebral soft tissue space because crying, neck flexion, or the
expiratory phase of respiration may produce a pseudothickening in the
prevertebral space ( Fig. 112.20 ). Soft tissue abnormality should be reproducible
on repeated radiographs if an actual underlying injury exists.
