A 43-year-old man was crossing the street when he was struck
by a car that, he estimated, was going about 10 miles per hour.
He was unsure which part of his body was hit, but he fell to the ground
landing on his right shoulder. He hit his head on the pavement and
may have had a brief loss of consciousness. He was able to stand
up and walk after the injury and came with his family to the hospital.
He complained of pain in his neck, back and right shoulder.
In the ED, the patient was placed on a stretcher and immobilized
with a hard plastic cervical collar. On examination, he appeared
well, fully alert, and in no distress. His vital signs were normal. There
was a small abrasion on the right occipital area and mild local
tenderness over C7. There was no hemotympanum. The chest, abdomen,
and pelvis were nontender. There was tenderness of the right deltoid
region, but the shoulder had full range of motion without pain.
The neurological examination, including upper and lower extremity
strength, sensation, and reflexes, was normal.
- Cervical spine radiographs were obtained
and are shown above (Figure 1).
- How would you interpret the radiographs?
- Are there any signs of an injury?
Good visualization of C1 and C2 could not be obtained with the
open mouth view. This was because the cervical collar was left in
place due to concern about moving the patient’s neck before all
of the radiographs were taken. The open mouth view was repeated,
but it was also suboptimal. A CT scan through C1 and C2 was therefore
The CT was read as normal and the patient was discharged home.
Several CT slices are shown in Figure 2.
- Is there a problem with this management?
- Are any additional studies needed?
The regions of the cervical spine where fractures are most often
missed are C7 and the cervicocranium. Injuries to the cervicocranium
are problematic due to their complex anatomy, the frequency that
radiographs are suboptimal in this region, the difficulty in localizing
pain or tenderness to that area, and the frequent lack of neurological
deficits—76% of patients with dens fractures have
no neurological deficits (Mower et al. 2000). Injuries to C7 are
missed because of poor visualization due to overlap by the shoulders.
After noting any obvious injuries, the radiographs must be systematically
examined to avoid overlooking subtle abnormalities. The mnemonic