Cervical fractures and dislocations

This page is for adult patients. For pediatric patients, see: cervical injury (peds)

Background

Sensation of cervical nerve roots

Three column concept of spinal fracture stability

Vertebral fractures and dislocations types

Vertebral anatomy.

Numbering order of vertebrae.

• Cervical fractures and dislocations
  • Atlanto-occipital dissociation
  • C1
    • Jefferson fracture
    • C1 isolated anterior arch fracture
    • C1 isolated posterior arch fracture
  • C2
    • Odontoid fracture
    • Hangman's fracture
  • C3-C7
    • Cervical burst fracture
    • Cervical spinous process fracture
    • Extension cervical teardrop fracture
    • Flexion cervical teardrop fracture
    • Anterior cervical wedge fracture
  • Cervical facet dislocation
  • Isolated transverse process fracture
• Thoracic and lumbar fractures and dislocations
  • Chance fracture
  • Thoracic burst fracture
  • Lumbar burst fracture
  • Isolated transverse process fracture
  • Thoracic and lumbar compression fractures

Clinical Features

C-spine injuries may present with

• Rarely neurogenic shock (bradycardia, hypotension)
• Posterior neck pain
• Pain on palpation of spinous processes
• Limited neck ROM with pain
• Weakness, numbness, or paresthesias

Differential Diagnosis

Neck Trauma

• Penetrating neck trauma
• Blunt neck trauma
  • Vertebral and carotid artery dissection
  • Strangulation
  • Whiplash injury
• Cervical injury
  • Cervical fractures and dislocations
  • Cervical injury (peds)
  • Cervical spine clearance
• Neurogenic shock
• Spinal cord injury

Neck pain

• Musculoskeletal
• Torticollis
• Dystonic reaction
• Cervical spondylosis
• Cervical stenosis
• Cancer
• Epidural abscess
• Vertebral osteomyelitis
• Transverse myelitis
• Temporal arteritis
• Epidural hematoma (anticoagulation, hemophilia)
• Cervical disk herniation
• Blunt neck trauma
• Anterior horn disease
• Cervical fractures and dislocations
• Cervical radiculopathy

Evaluation

Plain films lines

• See blunt neck trauma for general workup

Management

• Prehospital
  • See the NAEMSP National Guidelines for Spinal Immobilization
• Hospital
  • See page for specific fracture
  • Cervical spine clearance

Calculators

NEXUS Criteria

NEXUS Criteria for C-Spine Imaging

Criteria (ALL must be absent to clear)	Absent	Present
Posterior midline cervical tenderness	1
Focal neurologic deficit	1
Altered level of alertness	1
Intoxication	1
Distracting painful injury	1
Criteria Present	/ 5

Interpretation
0	C-spine can be cleared clinically — All 5 criteria absent. No imaging needed. Sensitivity 99.6% for clinically significant injury.
≥1	Cannot clear clinically — C-spine imaging indicated.

References
Hoffman JR, Mower WR, Wolfson AB, et al. Validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt trauma (NEXUS). N Engl J Med. 2000;343(2):94-99. PMID 10891516.

Canadian C-Spine Rule

Canadian C-Spine Rule

Step 1: Any High-Risk Factor? (mandates radiography)
Criteria	No	Yes
Age ≥65	1
Dangerous mechanism (fall ≥1m/5 stairs, axial load to head, MVC >100km/h or rollover/ejection, motorized recreational vehicle, bicycle collision)	1
Paresthesias in extremities	1
Step 2: Any Low-Risk Factor? (allows safe ROM assessment)
Simple rear-end MVC (excludes: pushed into traffic, hit by bus/large truck, rollover, hit by high-speed vehicle)	1
Sitting position in ED	1
Ambulatory at any time since injury	1
Delayed onset of neck pain (not immediate)	1
Absence of midline cervical tenderness	1
Step 3: Able to actively rotate neck 45° left and right?
Can rotate neck 45° L and R	1
High Risk Factors	/ 3
Low Risk Factors	/ 5

Interpretation (stepwise)
High risk ≥1	Radiography indicated — Do NOT assess ROM. Image the c-spine.
Low risk = 0	Cannot assess ROM safely — No low-risk factor present to allow safe assessment. Image.
Low risk ≥1 + ROM OK	C-spine can be cleared — At least one low-risk factor AND able to rotate neck 45°. No imaging needed.
Low risk ≥1 + no ROM	Radiography indicated — Low-risk factor present but unable to rotate. Image.

References
Stiell IG, Wells GA, Vandemheen KL, et al. The Canadian C-Spine Rule for radiography in alert and stable trauma patients. JAMA. 2001;286(15):1841-1848. PMID 11597285. Stiell IG, Clement CM, McKnight RD, et al. The Canadian C-Spine Rule versus the NEXUS low-risk criteria in patients with trauma. N Engl J Med. 2003;349(26):2510-2518. PMID 14695411.

See Also

• Blunt neck trauma
• Cervical spine clearance
• C-Spine (EAST)
• Penetrating neck trauma
• Spinal Cord Trauma
• Spinal Cord Compression (Non-Traumatic)
• Neurogenic Shock
• Unstable spine fractures‎
• Vertebral fractures
• Cervical injury (peds)