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.
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.
The cervical spine radiograph is shown in Figure 1.
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.]
- How would you interpret this radiograph?
The radiograph is technically inadequate because
the seventh cervical vertebra is not visible (Figure 2). Nonetheless,
several significant abnormalities are seen.
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.
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).
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.]
Examination of the prevertebral soft tissues reveals marked soft tissue swelling that measures
15 mm at C2 and C3 (Figure 2, arrowheads).
When one injury is found (e.g., the C3 avulsion fracture), the
search for others must continue. This patient, in fact, has two
The cervicocranium appears abnormal
(Figure 2). ...