Comprehensive programs for children who sustain traumatic spinal cord injury should incorporate optimizing hand and upper extremity function along with the other traditional pillars of rehabilitation. Children’s smaller anatomy, open growth plates, and future skeletal growth, combined with the age-related psychosocial impact of these injuries, require protocols suited to these age-related issues. There is a role for surgical reconstruction, as is the case for adults with traumatic tetraplegia, and surgical outcomes are equally beneficial and long lasting. Strict adherence to surgical indications, and surgical strategies and protocols that incorporate their age-related challenges, are the keys to successful management.