Access Keys:
Skip to content (Access Key - 0)

Cervical fractures

Assessment of cervical cord injuries

Physical Exam

  • Assess for associated injury
  • BP decreases in quadriplegia (Neurogenic shock), due to
    • Disruption of sympathetic outflow
    • Unopposed vagal tone
  • Do not fluid overload
  • Bradycardia / arrhythmias may be present
  • May need tracheostomy if either :
    • Vital capacity is less than 20% predicted
    • Vital capacity is less than 1000 cc

Plain X-Ray

  • Direct evidence of instability
    • Increased angulation between spinous processes > 11° than in adjacent segments
    • Anterior / posterior translation of the vertebral bodies > 3.5 mm
    • Segmental disc space widening on lateral X-Ray
    • Facet joint widening
    • Malalignment of spinous processes on AP view
    • Rotation of the facets on lateral view
    • Tilt of vertebral body on AP view
  • Findings suggestive of unstable injuries
    • Increased retropharyngeal space
      • Anterior to C3 : normal < 3 mm
      • C4 and below : normal varies 8-10 mm
    • Minimal compression fracture of anterior vertebral bodies
    • Avulsion fracture at or near insertion of spinal ligaments
    • Nondisplaced fracture lines

Tomography

  • Good visualisation of posterior elements
  • Helpful for diagnosis of dens fracture

CT

  • Assesses bony encroachment on canal
  • Best method for accurate bone definition

MRI

  • Evaluates neural elements
  • Disc disruption
  • Ligamentous integrity

Stress X-Rays

  • Flexion-extension lateral view
  • Contraindicated in altered state of consciousness

The 3-column cervical spine

  • Denis first described the 3 column spine for thoracolumbar fractures
  • This 3 column concept has been extended to the cervical spine by Allen
  • Each cervical motion segment can be divided into :
    • Anterior
      • Resists compression by vertebral body centrum, anterior disc
      • Resists tension by anterior annulus, anterior longitudinal ligament
    • Middle
      • Resist compression by posterior vertebral body and the 2 unco-vertebral joints
      • There is no significant disc material in the middle column
      • Resists tension by posterior annulus, posterior longitudinal ligament
    • Posterior
      • Resists compression by R+L facet joints and lateral masses
      • Resists tension by facet joint capsules, interspinous ligaments

Unstable Cervical Injuries

  • Atlanto-occipital joint translation > 1 mm
  • Apex of dens to basion > 5 mm
  • Anterior translation of vertebrae > 3.5 mm
  • Flexion at any one level of > 11o
  • Facet joints subluxation of > 50%
  • Traumatic rupture of transverse (cruciate) ligament considered, if the atlanto-dens interval is
    • > 3 mm in an adult
    • > 5 mm in children
  • Jefferson fracture with lateral shift of the lateral masses of C1 on C2 of > 7 mm implies division of the transverse ligament allowing the two halves to separate
  • Retropharyngeal soft tissue should not be
    • > 3 mm at C3
    • > width of the vertebral bodies below the level of C4/C5
  • Unilateral facet dislocation classically leads to anterior subluxation of up to 25%, whereas bilateral dislocation results in anterior subluxation of at least 50%

Atlanto- Occipital Dislocation

  • Mechanism : hyperextension and distraction
  • The basion to posterior arch of C1 distance is < opisthion to anterior arch C1; if this is reversed, dislocation has occurred
  • Treatment
    • Often fatal
    • If patient has survived, avoid traction
    • Definitive treatment is fusion of occiput to C1

Transverse Ligament Rupture

  • Transverse ligament is the main restraint to anterior motion of C1
  • Normal distance between anterior ring of atlas and dens is < 3 mm
  • Injuries may be
    • Isolated
    • Associated with fractured atlas
    • Associated with atlanto-axial subluxation
  • Mechanism : flexion
  • Treatment
    • If there is bony avulsion, immobilise in SOMI until healed
    • Check flexion-extension views to assess transverse ligament competency
    • If there is midsubstance tear, perform primary atlanto-axial fusion

Atlanto-axial Rotatory Subluxation

  • Mechanism
    • Spontaneous
    • Traumatic
  • Presents with
    • Neck pain
    • Occipital neuralgia
    • Vertebrobasilar insufficiency symptoms
  • X-Ray
    • Odontoid view shows rotator malalignment
    • AP view shows C2 spine rotated off midline
  • CT 
    • Perform in R+L rotation
    • If C1 fails to reposition :
      • There is a fixed deformity
      • The dens separates from the anterior arch of C1 with increased rotation
  • Classification : based on Atlanto-dental interval
    • Type I : < 3 mm indicates intact transverse ligament
    • Type II : 3-5 mm
      • Failed transverse ligament
      • Intact alar ligaments
    • Type III : > 5 mm indicates both transverse ligament and alar ligament have failed
    • Type IV : Complete posterior dislocation of atlas
  • Treatment
    • All symptomatic subluxations should be reduced through light weight skeletal traction
    • If transverse ligament is insufficient, fuse C1 to C2 (types 2,3,4) after reduction

Atlas Fracture

  • Mechanism
    • Axial compression leads to forced widening of ring
    • Hyperextension causes posterior arch fracture
  • Classification
    • Stable fractures
      • Simple arch fracture
      • Nondisplaced lateral mass fracture
      • Fracture of TP
    • Unstable fractures
      • Combined overlap > 7 mm in odontoid view
      • Transverse ligament is insufficient
  • Treatment
    • Stable fracture : hard collar for 8 weeks
    • Unstable fracture : immobilise in SOMI / halo for 8 weeks

Odontoid Fracture

  • Classification: (Anderson & Alonzo)
    • Type I : Avulsion of the tip (avulsion fracture of alar ligament)
    • Type II : Waist fracture (junction of dens with body of axis)
      • 50% heal with immobilisation
      • Some series have reported 20 - 80% non-union rate
      • Increased risk of non union if
        • Initial displacement > 5 mm
        • Initial angulation >10 degrees
        • Posterior vs. anterior displacement
        • Age greater than 50 years 
        • Treatment with prolonged traction
        • No halo
    • Type III : Fracture into body of C2
  • Treatment
    • Type I : Stable
    • Type II : If high risk for non-union : SOMI for 8 weeks
    • Type III
      • High risk for non-union, if treated with hard collar alone
      • SOMI for 8 weeks 

Traumatic Spondylolisthesis of C2

  • Classification
    • Type I
      • No angulation
      • Up to 3 mm of anterior translation
      • Stable
    • Type II
      • Angulation > 10 degrees
      • Anterior translation > 3 mm
    • Type III
      • Very unstable
      • Severe angulation / displacement
      • Dislocation of one or both C2-C3 facets
  • Treatment
  • Type I : Hard collar for 8 weeks
  • Type II : SOMI for 8 weeks
  • Type III :
    • CR of dislocated facets may not be possible
    • May need ORIF with fusion

References


Peer Review

OrthopaedicsOne Peer Review Workflow is an innovative platform that allows the process of peer review to occur right within an OrthopaedicsOne article in an open, transparent and flexible manner. Learn more

Instructions for Authors

Read our Instructions for Authors to learn about contributing or editing articles on OrthopaedicsOne.

Content Partner

Learn about becoming an OrthopaedicsOne Content Partner.

Academic Resources

Resources on Cervical fractures from Pubget.

Error rendering macro 'rss' : The RSS macro is retrieving an HTML page.
Related Content

Resources on Cervical fractures and related topics in OrthopaedicsOne spaces.

Page: Cervical fractures (OrthopaedicsOne Articles)
Page: Wound coverage techniques (OrthopaedicsOne Articles)
Page: Lumbar spine fractures (OrthopaedicsOne Articles)
Page: Wrist fractures (OrthopaedicsOne Articles)
Page: Acromioclavicular joint injuries (OrthopaedicsOne Articles)
Page: Ankle sprains (OrthopaedicsOne Articles)
Page: Medial ankle sprains (OrthopaedicsOne Articles)
Page: Syndesmosis ankle sprains (OrthopaedicsOne Articles)
Page: Midfoot sprains (OrthopaedicsOne Articles)
Page: Posterior cruciate ligament sprain (OrthopaedicsOne Articles)
Showing first 10 of 186 results