Cervical Fracture

Question 1

Purpose of cervical spine

Answer 1

Support head

Protect spinal cord

Provide mobility

Due to its mobility it becomes very susceptible to injury + having relative small vertebral bodies

Question 2

Most commonly fracture vertebra

Answer 2

C2 (30%)

C7 (20%)

Question 3

Which is the most common classification system for cervical fractures?

Answer 3

AO classification

Question 4

AO classification of upper cervical fractures (C1 or C2)

Answer 4

Region
Type 1 - Occipital condyle and craniocervical junction
Type 2 - C1 ring and C1/2 joint
Type 3 - C2 and C2/C3 joint

Injury type
Type A - Bony injury only
Type B = Tension band injuries
Type C = Translation injuries

Question 5

AO classification of subaxial fractures

Answer 5

Type A - Compression injuries

Type B = Distraction injuries

Type C = Translation injuries

Type F = Facet joint injuries

Question 6

Answer 6

CT scan showing

(A) fracture at the base of the dens

(B) fracture of the C3 vertebral body

Question 7

Mechanism of injury

Answer 7

Young - High energy trauma

Older - Low impact injuries with associated osteoporosis

Question 8

Clinical features

Answer 8

Neck pain (sometimes no neck pain due to concurrent distracting injuries)

Can have neurological involvement depening on the level of the spinal cord the fracture is at.

Potential sensory and motor deficits.

Diaphragm and vasomotor tone can also be affected.

Any injury to vertebral artery from a cervical fracture can cause posterior circulation stroke.

Question 9

Dx

Answer 9

Cervical spondylosis

Cervical dislocation

Whiplash injury

Question 10

Explain Jefferson fracture

Answer 10

Burst fracture of the atlas caused by axial loading.

The occipital condyles are driven into lateral masses of C1

Usually unstable and account for 33% of all C1 fractures

Question 11

Explain Hangman’s fracture

Answer 11

Also called traumatic spondylolisthesis of the axis.

Fracture through pars interartcularis of C2 bilaterally.

Can also have subluxation of C2 vertebra on C3.

Caused by cervical hyperextension and distraction

Can be unstable and if so need surgical fixation

Question 12

Explain odontoid peg fractures.

Answer 12

Common cervical fractures especially in older patients

Low-impact injuries and neck pain is common.

Condition can be fatal especially with significant displacement of the odontoid.

Question 13

Answer 13

A) CT scan demonstrating a Jefferson Fracture

(B) Pain film radiograph demonstrating a Hangman’s Fracture

Question 14

Investigations

Answer 14

Any suspected cervical spine injury needs imaging

Canadian C-spine rules can help in assessment.

Perform CT scan in adults (if suggested by Canadian C-spine rules)

Perform MRI for children (if suggested by Canadian C-spine rules)

Only consider x-ray for those who done not fulfill criteria for MRI but clinical suspicion is still there.

MRI is also useful for assessment for concurrent injury.

Question 15

Explain Canadian C-Spine rules

Answer 15

Used to stratify risk of cervical spine injury after trauma and to decide imaging modalities required.

GCS 15/15 and stable is a requirement to carry out assessment

High-risk factors -> Immediate radiological imaging (including >65 yo)

Those who have low-risk factor present do not require radiological imaging prior to assessment.
(Rear-end motor vehicle collision, waiting in a sitting position, ambulatory at any time, delayed onset of neck pain, absence of midline C-spine tenderness)

Question 16

General management

Answer 16

Suspected cervical fracture must be managed per ATLS guidelines + 3-point C-spine immobilisation

Restrict movement of spine to prevent potential damage to spinal cord.

All cervical fractures need discussion with spinal specialist

Question 17

Indications for non-operative management

Answer 17

Stable injuries or may be needed for patients where surgery will pose a significant risk

Question 18

Non-operative managements

Answer 18

Rigid collars for immobilisation during extrication and initial assessment

Halo vest (image) if more rigid support is needed or if non-operative unstable fracture.

Traction devices can be used for definitive tratment when operative treatment is high risk.

Question 19

Indications of operative intervention

Answer 19

Unstable fractures (if surgery will not pose high risk)

Question 20

Operative management

Answer 20

Cervical fusion across injured segment of the spine to the uninjured segment above and below.

With or without decompression of the vertebral canal.

Stabilisation is done via a posterior approach

Patient is lying prone, fragments are then fixated using pedicle screws and rods.