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A 37-year-old man lost his balance while standing on a subway platform and fell five feet, head first onto the tracks. He had consumed an alcoholic beverage prior to his fall. Fortunately, a train was not entering the station at the time. He was extricated from the tracks, immobilized, and brought to the ED.

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In the ED, the patient was hemodynamically stable. He had a deep, 5-cm scalp laceration, but no other external signs of trauma. He complained of neck pain and a painful burning sensation in his shoulders and upper arms. His neurological examination was remarkable for mild weakness of his hand grasp bilaterally. Lower extremity strength was normal. There was midline tenderness over his cervical spine, but no palpable deformity.

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The cervical spine radiograph is shown in Figure 1.

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Figure 1
Graphic Jump LocationGraphic Jump Location

A common clinical scenario causing an axial loading injury to the cervical spine—a dive head-first into a shallow body of water.

[From Galli et al: Emergency Orthopedics: The Spine. McGraw-Hill, 1989, with permission.]

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  • How would you interpret this radiograph?

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Lateral View—ABCS Approach

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The radiograph is technically inadequate because the seventh cervical vertebra is not visible (Figure 2). Nonetheless, several significant abnormalities are seen.

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The vertebrae are in good alignment, although the vertebral column as a whole appears straightened as is common in a supine portable cross-table lateral view of an immobilized trauma victim. In addition, the patient’s positioning was slightly rotated causing a lack of superimposition of the articular facets. The “ring of C2” is not clearly seen because of this rotation. The superior portion of the dens is obscured by the overlapping bone of the skull base.

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Examination of the bones reveals a tiny fragment adjacent to the anterior-inferior corner of C3 (Figure 2, arrow). This represents a small avulsion fracture due to traction by the anterior longitudinal ligament during forceful extension of the neck (Figure 3).

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Figure 3
Graphic Jump Location

Distractive-extension avulsion fracture

This is sometimes referred to as a hyperextension “teardrop” fracture.

[From Galli, et al: Emergency Orthopedics: The Spine. McGraw-Hill, 1989, with permission.]

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Examination of the prevertebral soft tissues reveals marked soft tissue swelling that measures 15 mm at C2 and C3 (Figure 2, arrowheads).

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When one injury is found (e.g., the C3 avulsion fracture), the search for others must continue. This patient, in fact, has two distinct injuries.

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