FIGURE 111.58 A,B: Fracture of the third (L3) and fourth (L4) vertebrae in a 12-year-old girl, the result of a shear injury in a motor vehicle collision C: Permanent paralysis of the lower extremities resulted, as suggested by the degree of spinal canal collapse seen on the computed tomography scan Shear Fractures Although the cervical spine is most vulnerable to shear injuries, violent trauma can also cause such injuries in the thoracic and the lumbar spine ( Fig 111.58 ) Unfortunately, neurologic deficits are common in this setting All shear fractures should be considered unstable injuries that will need stabilization procedures to avoid progressive deformity and enhance any possibility of neurologic recovery Neurologic Injuries Without Fractures Anatomically, the immature spine is more flexible than the spinal cord As a result, injuries causing hyperflexion or extension may induce damage to the cord and neurologic injury while leaving the bony, cartilaginous, and ligamentous structures intact Trauma causing spinal cord injury without radiographic abnormality (SCIWORA) is much more common in children younger than years, particularly affecting the cervical and thoracic spine Both incomplete and complete neurologic deficits can occur Any history of neurologic deficit following spinal trauma should prompt consideration of a