by Samantha Giles
Description
The cervical vertebrae are the bones that comprise the neck area of the body. There are seven cervical bones and if any of these become fractured or severely dislocated, the neck can be described as broken. In some cases, the fractured or dislocated vertebrae can cause compression and damage to the spinal cord resulting in neurological symptoms or paralysis.
Any part and any number of cervical vertebrae can be broken for someone to have a broken neck but there are some specific patterns:
Hangman's Fracture
A fracture of the pars interarticularis on the pedicle of the C2 vertebrae (axis) is often called a “hangman’s” fracture. This term was coined by Scheider et al. based on the observation that these were the types of fractures seen in hanged criminals.1 This type of fracture is the most common of all cervical spine fractures and it is often caused by extreme hyperextension to the neck when the face forcibly strikes a hard surface. As a result, facial fractures can also be seen with these types of cervical fractures.2
Jefferson Fracture:
A burst fracture of the C1 vertebrae (atlas) is often called a Jefferson fracture and is not commonly associated with spinal cord damage. The most common Jefferson fractures are from axial compression caused by diving into shallow water, falling from a height onto the head, or motor vehicle accidents that cause the head to be thrown into the windshield. The transverse ligament is often implicated in the Jefferson Fracture.3,4
Teardrop fractures
A tear drop fracture is a flexion compression injury often associated with diving accidents. It is characterized by an anteroinferior bone fragment that rotates anteriorly because of pull from the intact anterior longitudinal ligament. The vertebral body is fractured in a coronal plane and the posterior portion can push into the vertebral canal, decreasing space for the spinal cord.4
Information about other types of fractures in the cervical spine:
-The odontoid process on the C2 (axis) vertebrae can be fractured and is associated with a high rate of non-union. An x-ray view through the mouth is most important for detecting this type of fracture.4
-Fractures of C1/C2 together are not uncommonly seen and occur due to both forced hyperextension and axial compression type injuries.5 Their unique positioning make them more likely to fracture together than other vertebrae.
-Fractures of the C3 vertebrae, although uncommon, have been linked to a higher mortality rate than other cervical fractures. The phrenic nerve can be damaged in a C3 fracture and subsequently paralyze the diaphragm. This is probably the cause for higher mortality.6
-Below C3, the vertebral canal is narrower in comparison to the diameter of the spinal cord itself, so spinal cord injuries occur more frequently in cervical fractures below C3.6
Anatomy:
Indications:
Any patient admitted to a trauma center or emergency care center with a mechanism of injury that fits the etiology described below should be evaluated for a cervical spine fracture or injury. This is especially true in cases where the patient is experiencing a high amount of neck pain or neural issues.
According to the criteria developed by the American National Emergency X-radiography Utilization Study(NEXUS), conscious, coherent patients with no midline cervical pain, no neurological signs, and no severe distracting injuries, only need a simple physical evaluation to rule out fracture.7 If there are cervical symptoms, imaging is indicated.
According to the same criteria, if the patient is intoxicated, unconscious, or uncooperative, they should be considered high risk for cervical fracture and imaging should be done as soon as possible and the use of a CT scan is indicated because it has been shown to be more reliable than x-ray in this population. 7
Incidence
Cervical spine fractures make up 20% of all spinal fractures.8 A research study that gathered data on over a million patients admitted to trauma centers found that 4.45 % of those patients sustained a cervical fracture.2 Another study reported that cervical spine fractures occur in only 1-3% of trauma cases.5
In the cervical vertebrae, C2 fractures occur most frequently and 55% of those have involvement of the dens or odontoid process.5
Clinical Presentation
If a patient with a broken neck came to clinic, it would most likely be after the fracture has healed and been cleared by a physician as ready for rehabilitation.
However, in light of direct access, it is relevant to mention that if a patient does come in complaining of neck pain following a traumatic injury to the head or neck, DO NOT TREAT THEM without medical clearance by a physician. X-ray imaging or a CT scan needs to be performed in order to clear the neck for treatment and rule out possible fractures.
Potential Etiologies:
The mechanism of injury in cervical fractures is often forced hyperextension or extreme flexion. Straight axial compression to the head and direct trauma to the neck can also cause fractures. A combination of hyperextension or flexion with axial compression is the best recipe for a cervical fracture.
According to Canadian cervical spine criteria, a cervical spine injury should be suspected and evaluated for in injuries when the mechanism is:8
- A fall from an elevation greater than 1 meter or 5 stairs
- An axial load to the head (diving)
- Motor vehicle crash (MCV) with high speed (≥100 km/hr), rollover, or ejection
- Motorized recreational vehicle accident
- Bicycle collision
Diagnostic Tests:
The most widely accepted diagnostic tool is x ray specifically the 3 view series:7
1. Lateral view of entire c-spine from base of skull to top of T1 vertebrae
2. Open-mouth odontoid (also important to capture the integrity of the transverse ligament)
3. Anteroposterior view
If the patient is unconscious, it can be difficult to capture the x-ray images and in this case a CT scan is the best diagnostic tool.7,9
If there is no fracture visible on the x-ray or CT and there are neurological deficits or severe pain, an MRI is indicated for its ability to show imaging of the spinal cord.7,9
The sensitivity for 3-view x-ray imaging is about 35-72% but this includes high-risk patients. Obtaining x-rays in high risk patients can be tricky and often results in poor quality images. CT scans are 96% sensitive for fractures and osseous issues. MRI is only 55% sensitive for fractures.7
Evaluation/Special Orthopedic Tests:
After a patient’s fractured has healed and been cleared by a physician, they may be referred to rehabilitation for range of motion, strengthening and pain relief.
As a part of the initial evaluation, it would be appropriate to include cervical ligament stress tests, a vertebral artery test and a neurological exam if any nerve damage or spinal cord injury is suspected.
Click on the following tests for a link to a video on how to perform them.
Cervical Ligament Tests:
Alar Ligament Test
Transverse Ligament Test
Vertebral Artery Test
Neurological Tests
Dermatomes
Myotomes
Reflexes
Babinkski
Clonus
Treatment:
Treatments for cervical spine fractures vary greatly depending on the stability of the fracture, the location, and involvement of the spinal cord, spinal nerves, and vertebral artery.
For a Hangman’s C2 (axis) fracture, the most widely used grading system was devised by Effendi et al and later revised by Edwards and Levine.10,11
Type I: Caused by axial loading and hyperextension. There is less than 3mm of subluxation of C2 on C3 and no angulation. This fracture is stable because the anterior longitudinal ligament (ALL) and posterior longitudinal ligaments (PLL) are intact along with the C2/C3 disk.
Type I fractures of C2 can sometimes be treated conservatively with a cervical collar. These collars just help support the head while the neck is healing but they do not prevent movement so they are not good for unstable fractures.
Cervical Collars
Type II: Caused by axial loading and hyperextension followed by a rebound flexion and axial loading. There is subluxation of C2 on C3 greater than 4mm or 11° angulation. There is some damage to the ALL and significant structural damage to the PLL and C2/C3 disk. This fracture is unstable.
Most Type I, II, and some IIA hangman fractures are treated effectively with a halo vest.11,4 This brace utilizes pins placed in the skull attached to metal braces that prevent any neck movement. It is not well tolerated in the elderly or patients with respiratory problems so alternative treatments have to be used.4
Halo Vest:
Type IIA: Caused by flexion with distraction. These have no anterior displacement, but there is severe angulation. The C2/C3 disk is damaged along with the PLL. This fracture is unstable
Type III: Caused by initial flexion and rebound extension with axial compression. There is severe displacement and severe angulation. This injury is accompanied by C2/C3 disk dislocation, and unilateral or bilateral c2/c3 facet dislocation. There is also injury to the ALL and PLL. This fracture is considered unstable.
Type IIA and III often have to be treated with surgery because of the angulation needing correction.11,4 This can be done either through an anterior or posterior approach with similar outcomes for both.11 The 2nd cervical vertebrae can be fused with the 1st and 3rd surgically for stabilization.
Treatments for other cervical fractures can be found in the additional web based resources as well as in the following journal articles
Timothy J, Towns G, Girn HS. (i) Cervical spine injuries. Current Orthopaedics. 2004;18(1):1-16.
Jiang T, Ren X, Wang W, Zhang X, Li C, Hao Y. Operative treatment for cervical fracture and dislocation with blunt unilateral vertebral artery injury. Chinese Journal Of Traumatology = Zhonghua Chuang Shang Za Zhi / Chinese Medical Association. October 1, 2010;13(5):279-283.
Physical Agents
The use of physical agents has not been researched in this specific population. However, the use of low level laser and light therapy has been shown to maybe aid in tissue healing and bone growth12. This may help fracture healing.
The best parameters to use for light and laser therapy are still inconclusive at this time. It is considered safe to administer infrared or red light in a range from 4-16 J/cm2. More research will have to be done in order to understand what the best method is in this population.
If pain is a problem for the patient, thermal agents such as heat and cold can be applied. The application of cold packs falls into the category of cryotherapy. For reduction of pain, the application of a cold pack for 10-20 minutes can help increase pain tolerance, decrease muscle spasm, and lower nerve conduction velocity.12 The application of hot packs can also relieve pain through different modes and also should be applied for 10-20 minutes. The patient should always be checked to make sure the ice or heat are not causing any skin damage and If there is sensory nerve damage, ice and heat are contraindicated as the patient may not be able to detect how hot or cold the treatment is.
Additional Web Based Resources:
C2 fractures:
http://emedicine.medscape.com/article/1267150-overview
Neck Injuries:
http://www.nlm.nih.gov/medlineplus/neckinjuriesanddisorders.html
http://orthoinfo.aaos.org/topic.cfm?topic=A00414
http://www.sld.cu/galerias/pdf/sitios/rehabilitacion/examination_of_the_upper_cervical_spine.pdf
C1 Fractures:
http://www.learningradiology.com/archives06/COW%20188-Jeffersons%20Fx/jeffersonfxcorrect.htm
http://emedicine.medscape.com/article/1263453-overview
References
1. Schneider R, Livingston K, Cave A, Hamilton G. "Hangman's" fracture of the cervical spine. Journal Of Neurosurgery. February 1965;22:141-154.
2. Mulligan R, Friedman J, Mahabir R. A nationwide review of the associations among cervical spine injuries, head injuries, and facial fractures. Journal of Trauma. March 2010;68(3):587-592
3. Jefferson G. Fracture of the atlas vertebra. Br J Surg1920;7:407–22.
4. Timothy J, Towns G, Girn HS. (i) Cervical spine injuries. Current Orthopaedics. 2004;18(1):1-16.
5. Pratt H, Davies E, King L. Traumatic injuries of the c1/c2 complex: computed tomographic imaging appearances. Current Problems In Diagnostic Radiology. January 2008;37(1):26-38.
6. Pull ter Gunne A, Aquarius A, Roukema J. Risk factors predicting mortality after blunt traumatic cervical fracture. Injury. December 2008;39(12):1437-1441.
7. Saltzherr T, Fung Kon Jin P, Beenen L, Vandertop W, Goslings J. Diagnostic imaging of cervical spine injuries following blunt trauma: A review of the literature and practical guideline. Injury August 2009;40(8):795-800.
8. Leucht P, Fischer K, Muhr G, Mueller E. Epidemiology of traumatic spine fractures. Injury. February 2009;40(2):166-172.
9. Richards P. Cervical spine clearance: a review. Injury. February 2005;36(2):248-269. Available from: MEDLINE, Ipswich, MA.
10. Effendi B, Roy D, Cornish B, Dussault RG, Laurin CA. Fractures of the ring of the axis: a classification based on analysis or 131 cases. J Bone Joint Surg Br 1981;63 B: 319–27.
11. Li X, Dai L, Lu H, Chen X. A systematic review of the management of hangman's fractures. European Spine Journal: Official Publication Of The European Spine Society, The European Spinal Deformity Society, And The European Section Of The Cervical Spine Research Society. March 2006;15(3):257-269.
12. Cameron M. Physical Agents in Rehabilitation, From Research to Practice. 3rd ed. St. Louis, MO: Saunders Elslevier; 2009: 136-161,355.
