Purpose: A single level spine fracture can be dangerous, however a second spine fracture at a different level can add complexity to patient management, and if missed, can result in a significant adverse outcome. Higher rates of multiple noncontiguous spinal injury (MNCSI) have been reported in patients who die from injuries, and with more unstable spinal injuries. The reported incidence in adults is 1.6–34%, but to our knowledge there are no studies examining multiple spine injuries in a pediatric population.

Method: A retrospective review of charts at an academic pediatric level 1 trauma center over a 15 year period identified a population with MNCSI.

Results: Twenty five (11.8%) out of 211 patients were identified with MNCSI and complete charts and radiographs. The mean age was 10.7 years old. MVC (motor vehicle collision) was the most common mechanism of injury for ages 0–9, while a fall was most common for ages 10–17 years. The mean number of vertebral levels injured was 3.2 and the most common region was the thoracic spine. Patients had a mean of 5.4 (range 1 to 22) intact vertebral levels between injuries. Twenty-four percent of patients with MNCSI had a neurologic deficit compared to 9.7% in patients with single level or contiguous injuries. This was statistically significant; risk ratio was 2.48 [1.09, 5.65]. Seven (78%) of 9 patients aged 0–9 suffered an associated injury; most commonly a visceral injury. The mortality rate was 8.0% in patients with MNCSI compared to 2.7% in patients with a single level injury.

Conclusion: We report a 12 % incidence of MNCSI in a pediatric trauma population. Children with NCSI were more likely to suffer neurologic injury than with a single level injury. Younger patients with MNCSI’s had a high rate of associated injuries. A higher mortality rate was seen in patients with MNCSI (not statistically significant). MNCSI’s can occur in conjunction with SCIWORA’s in the flexible pediatric spine. Clinicians must be aware of the incidence of NCSI’s in children, as well as their associations.

To compare the clinical and radiographic outcomes of Type III supracondylar fractures of the humerus in children managed either by open reduction and internal fixation versus those treated by closed reduction and percutaneous pinning. The indications for open reduction included an inability to obtain a satisfactory reduction by closed means; open fractures and fractures with vascular compromise after closed reduction.

Retrospective chart and radiograph review over a ten year period (1995–2005), with two hundred and thirty-six children with Type III fractures treated at a Level One pediatric hospital within a universal health-care system.

One hundred and seventy by closed reduction and percutaneous pinning and sixty-six by open reduction. The left arm was involved in one hundred and forty-eight cases and twenty-five patients had vascular compromise at presentation but no cases required vascular repair. There were ten open fractures in the open reduction group. The anterior approach was employed in twenty-nine patients, anteromedial in twenty-two and anterolateral, medial and lateral in equal preference. Entrapped structures included brachialis muscle in thirty-four patients, periosteum in eighteen, radial nerve in two, medial nerve in two, and the brachial artery in one. According to Flynn’s criteria, the open reduction group had an excellent or good outcome in 90% of cases while the closed reduction group had an 80% excellent or good outcome.

In this study of displaced Type III supracondylar fractures, there was a higher rate of open reduction than was initially anticipated. There was a higher rate of excellent and good outcomes in the ORIF group but this may be due to a relatively short follow-up in the closed reduction group. Post reduction stiffness would likely dissipate and allow a higher rate of excellent and good outcomes in the closed reduction group. An anterior approach or variation of an anterior approach is best suited to visualise the anatomy and structures hindering the reduction. Despite this, there was no clinical or radiographic difference between the approaches employed. In conclusion, open reduction and internal fixation if displaced Type III supracondylar fractures is a safe and effective procedure. An anterior approach is recommended to identify and relieve the soft tissue obstacles to a suitable reduction. Significance: This study furthers the literature that proposes to lower the threshold for open versus closed reduction of displaced supercondylar fractures in children.