Cervical Spine Fracture

Aka: Cervical Spine Fracture, C-Spine Fracture, Clay Shoveler's Fracture, Odontoid Process Fracture, Hangman's fracture, Jefferson Fracture, Cervical Wedge Compression Fracture, C1 Fracture, C2 Fracture, Cervical Teardrop Fracture, Cervical Spinous Process Fracture, Cervical Burst Fracture, Cervical Facet Dislocation, Cervical Fracture

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II. Anatomy

  1. See Cervical Spine Anatomy
  2. Image: Cervical Vertebrae
    1. orthoSpineVertebraeCervicalGrayBB84.gifLewis (1918) Gray's Anatomy 20th ed (in public domain at Yahoo or BartleBy)
  3. Three-Column Model
    1. Anterior column
      1. Anterior half of Vertebral body
      2. Anterior ligamentous complex
        1. Anterior portion of annulus fibrosus
        2. Anterior longitudinal ligament
    2. Middle column
      1. Posterior half of Vertebral body
      2. Ligaments
        1. Posterior portion of annulus fibrosus
        2. Posterior longitudinal ligament
    3. Posterior Column
      1. Facet joints (superior and inferior articular process)
      2. Laminae
      3. Spinous processes
      4. Posterior ligamentous complex
        1. Facet capsules
        2. Interspinous ligaments

III. Types: C1 Fractures

  1. Mechanism
    1. Axial load or Hyperextension injuries
  2. Jefferson Fracture (most common)
    1. Bilateral burst Fracture through posterior arch and lateral aspects
    2. Neurologic function is often spared

IV. Types: C2 Fractures

  1. Arch Fractures (hyperextension injury)
    1. Hangman's fracture (now typically due to MVAs)
      1. Fracture through both arches, pedicles
      2. C2 is dislocated from C1, and C2 subluxes anteriorly on C3
  2. Odontoid Fractures (forced flexion or extension)
    1. Fracture at junction of odontoid and Vertebral body
      1. Surgically managed
    2. Fracture of the odontoid tip
      1. Managed with Cervical Collar immobilization

V. Types: Facet Dislocation

  1. Unilateral facet dislocation
    1. Results from axial load with flexion and rotation
    2. Partial Vertebral subluxation <50% of Vertebral body width
    3. Stable injury
  2. Bilateral facet dislocation
    1. Severe flexion force to the middle and Posterior Columns
    2. Vertebral subluxation >50% of Vertebral body width
    3. Unstable injury

VI. Types: Wedge Compression Fracture

  1. Mechanism
    1. Flexion loading of the spine (even minor forces)
  2. Anterior Vertebral body end plate compression
    1. Posterior Vertebral height maintained (<25% wedge compression)
      1. Typically stable Fracture
      2. Evaluate with flexion-extension views for subluxation
    2. Posterior Vertebral height compressed more than 25%
      1. Associated with posterior ligamentous complex disruption

VII. Types: Flexion Teardrop Fracture

  1. Mechanism
    1. Flexion and compression injury (e.g. diving)
  2. Fracture dislocation which is highly unstable
    1. Small anteroinferior teardrop Fracture fragment
    2. Vertebral body or facet subluxation or spine angulation

VIII. Types: Translation-Rotation Fracture

  1. Severe, unstable injury almost always requiring Spine Surgery
  2. Mechanism
    1. Displacement of a Fracture in the horizontal plane (left-right, anterior-posterior or rotational)
  3. Findings
    1. Vertebral subluxation
    2. Unilateral or bilateral facet dislocation if rotational injury
    3. Associated rib or transverse process Fractures
    4. Posterior ligamentous complex disruption in all cases

IX. Types: Burst Fracture

  1. Mechanism
    1. Flexion and compression injury (e.g. diving)
  2. Comminuted Vertebral Fracture
    1. Disrupts anterior and middle columns
    2. Typically involves middle and lower Cervical Vertebrae
    3. Spinal Cord Injury if fragments are displaced
  3. Findings
    1. Vertebral height loss
    2. Posterior Ligamentous Complex Injury

X. Types: Spinous Process Fracture

  1. Mechanisms
    1. Direct spinous process Trauma
    2. Sudden deceleration
    3. High velocity Trauma with neck flexion
    4. Severe Muscle Contraction with secondary avulsion
  2. Spinous process tip avulsion (Clay Shoveler's Fracture)
    1. Occurs at C6 or C7
    2. Related to strong pull from neck and ShoulderMuscles with heavy physical work
    3. Stable Fracture (but confirm with flexion-extension XRay views)
    4. Differential Diagnosis
      1. Fracture of base of spinous process (disrupts posterior ligamentous complex)
      2. Nonfused, spinous process apophysis

XI. Imaging

  1. See Acute Cervical Spine Imaging

XII. Management

  1. See Cervical Spine Injury
  2. See Cervical Spine Immobilization
  3. Vertebral Fracture Stability
    1. Consider any cervical Vertebral Fracture unstable with the exception of those listed below
    2. Subaxial Injury Classification and Severity Scale (SLICS)
      1. https://www.mdcalc.com/calc/10085/subaxial-injury-classification-severity-scale-slics
    3. Unstable Cervical Spine Fracture (Mnemonic - "Jefferson Bit Off A Hangman's Tit")
      1. J - Jefferson Fracture (C1 Burst Fracture, axial loading injury)
      2. B - Bifacet dislocation or Fracture (flexion injury)
      3. O - Odontoid Fracture (Types 2 and 3, flexion injury)
      4. A - Any Fracture-dislocation, Atlantoaxial dislocation or atlanto-occipital dislocation (flexion injury)
      5. H - Hangman's fracture or bilateral C2 Pedicle Fracture (posterior C2 Fracture, extension injury)
      6. T - Teardrop Fracture (extension or flexion injury)
    4. Stable Fractures
      1. Spinous process Fracture
      2. Transverse process Fracture
      3. Unilateral facet dislocation
      4. Wedge Fracture (unless posterior Vertebral height compressed more than 25%)
      5. Vertebral burst Fracture (except C1 Jefferson Fracture, or if fragments are retropulsed)

XIII. References

  1. Dreis (2020) Crit Dec Emerg Med 34(7):3-21
  2. Eiff and Hatch (2018) Fracture Management for Primary Care, p. 187-96

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