View source for Cervical fracture

{{More citations needed|date=January 2008}}
{{Infobox medical condition (new)
| name = Cervical fracture
| synonyms = Broken neck
| image = PdensfracCT.png
| caption = A fracture of the base of the dens (a part of C2) as seen on CT
| pronounce = 
| field = [[Emergency medicine]], [[neurosurgery]], [[orthopedic surgery]]
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A '''cervical fracture''', commonly called a '''broken neck''', is a [[fracture]] of any of the seven [[cervical vertebrae]] in the [[neck]]. Examples of common causes in humans are traffic collisions and diving into shallow water. Abnormal movement of neck bones or pieces of bone can cause a [[spinal cord injury]], resulting in loss of sensation, [[paralysis]], or usually death soon thereafter (~1 min.), primarily via compromising neurological supply to the respiratory muscles and innervation to the heart.

==Causes==
[[File:Karl Morgenschweis prays for condemned prisoner.jpg|thumb|Execution by hanging is intended to cause death from a cervical fracture.]]
Considerable force is needed to cause a cervical fracture. Vehicle collisions and falls are common causes.  A severe, sudden twist to the neck or a severe blow to the head or neck area can cause a cervical fracture.

Although high energy trauma is often associated with cervical fractures in the younger population, low energy trauma is more common in the geriatric population. In a study from Norway the most common cause was falls and the relative incidence of cervical spine fracture increased significantly with age.<ref>{{cite journal | vauthors = Fredø HL, Rizvi SA, Lied B, Rønning P, Helseth E | title = The epidemiology of traumatic cervical spine fractures: a prospective population study from Norway | journal = Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine | volume = 20 | issue = 1 | pages = 85 | date = December 2012 | pmid = 23259662 | pmc = 3546896 | doi = 10.1186/1757-7241-20-85 | doi-access = free }}</ref>

Sports that involve violent physical contact carry a risk of cervical fracture, including [[American football]], [[association football]] (especially the [[Goalkeeper (association football)|goalkeeper]]), [[ice hockey]], [[Rugby football|rugby]], and [[wrestling]]. [[Spearing (gridiron football)|Spearing]] an opponent in football or rugby, for instance, can cause a broken neck. Cervical fractures may also be seen in some non-contact sports, such as [[gymnastics]], [[skiing]], [[Diving (sport)|diving]], [[surfing]], [[powerlifting]], [[equestrianism]], [[mountain biking]], and motor racing.

Certain penetrating neck injuries can also cause cervical fracture which can also cause internal bleeding among other complications.

Execution by [[hanging]] is intended to cause a fatal cervical fracture. The [[Hangman's knot|knot]] in the noose is placed to the left of the condemned, so that at the end of the drop, the head is jolted sharply upwards and to the right. The force breaks the neck, causing an immediate loss of consciousness and death within a few minutes.

==Diagnosis==
[[File:Cervical fracture dislocation C6-C7.jpeg|thumb|Sagittal reconstruction of a CT scan showing a cervical fracture with dislocation at the level of C6/7]]
[[File:TeardropFractureC3CTMarked.png|thumb|Teardrop fracture of C3 (sagittal CT)]]
[[File:TreadropfractureC3.png|thumb|Teardrop fracture of C3 (lateral X ray)]]

===Physical examination===
{{See|Clearing the cervical spine}}
A [[medical history]] and [[physical examination]] can be sufficient in [[clearing the cervical spine]]. Notable [[clinical prediction rule]]s to determine which patients need [[medical imaging]] are [[Canadian C-spine rule]] and the National Emergency X-Radiography Utilization Study (NEXUS).<ref name="SaragiottoMaher2018">{{cite journal| vauthors = Saragiotto BT, Maher CG, Lin CW, Verhagen AP, Goergen S, Michaleff ZA |title=Canadian C-spine rule and the National Emergency X-Radiography Utilization Study (NEXUS) for detecting clinically important cervical spine injury following blunt trauma|journal=Cochrane Database of Systematic Reviews|year=2018|volume=2018 |issue=4 |pages=CD012989 |issn=1465-1858|doi=10.1002/14651858.CD012989|url=https://opus.lib.uts.edu.au/bitstream/10453/128267/1/Saragiotto_et_al-2018-Cochrane_Database_of_Systematic_Reviews.pdf|hdl=10453/128267|hdl-access=free | pmc = 6494628 }}</ref>

===Choice of medical imaging===
* In ''children'', a [[CT scan]] of the neck is indicated in more severe cases such as neurologic deficits, whereas [[projectional radiography|X-ray]] is preferable in milder cases, by both US<ref name=UpToDateChildren>{{cite web|url=https://www.uptodate.com/contents/evaluation-and-acute-management-of-cervical-spine-injuries-in-children-and-adolescents|title=Evaluation and acute management of cervical spine injuries in children and adolescents|author=Julie C Leonard|date=2018-02-12|website=UpToDate}}</ref> and UK<ref name=NICE>{{cite web|url=https://www.nice.org.uk/guidance/CG176|title=Head injury: assessment and early management|date=2014|website=National Institute for Health and Care Excellence (NICE)}} Updated in June 2017</ref> guidelines. Swedish guidelines recommend CT rather than X-ray in all children over the age of 5.<ref>{{cite web|url=https://vardgivare.skane.se/vardriktlinjer/medicinska-omraden/akutsjukvard/vardprogram-riktlinjer/traumamanual/#Nackskada|website=Region Skåne|title=Traumamanual}} Last updated: 2018-03-29</ref>
* In ''adults'', UK guidelines are largely similar as in children.<ref name=NICE/> US guidelines, on the other hand, recommend CT in all cases where medical imaging is indicated, and that X-ray is only acceptable where CT is not readily available.<ref>{{cite web|url=https://www.uptodate.com/contents/evaluation-and-acute-management-of-cervical-spinal-column-injuries-in-adults|title=Evaluation and acute management of cervical spinal column injuries in adults|date=2018-05-24|author=Amy Kaji, Robert S Hockberger}}</ref>

===Radiographic detection===
On [[CT scan]] or [[projectional radiography|X-ray]], a cervical fracture may be directly visualized. In addition, indirect signs of injury by the vertebral column are incongruities of the [[vertebral lines]],<ref name="RanigaMenon2014">{{cite journal | vauthors = Raniga SB, Menon V, Al Muzahmi KS, Butt S | title = MDCT of acute subaxial cervical spine trauma: a mechanism-based approach | journal = Insights into Imaging | volume = 5 | issue = 3 | pages = 321–338 | date = June 2014 | pmid = 24554380 | pmc = 4035495 | doi = 10.1007/s13244-014-0311-y }}</ref> and/or increased thickness of the [[prevertebral space]]:<ref name=Rojas2009>{{cite journal | vauthors = Rojas CA, Vermess D, Bertozzi JC, Whitlow J, Guidi C, Martinez CR | title = Normal thickness and appearance of the prevertebral soft tissues on multidetector CT | journal = AJNR. American Journal of Neuroradiology | volume = 30 | issue = 1 | pages = 136–141 | date = January 2009 | pmid = 19001541 | pmc = 7051716 | doi = 10.3174/ajnr.A1307 | doi-access = free }}</ref>

<gallery widths="185" heights="240">
File:X-ray of vertebral lines.jpg|[[Projectional radiography|X-ray]] of normal congruous [[vertebral lines]]
File:Vertebral lines.png|[[CT scan]] of normal congruous vertebral lines<ref name="RanigaMenon2014"/>
File:CT of prevertebral space.jpg|[[CT scan]] with upper limits of the thickness of the prevertebral space at different levels<ref name=Rojas2009/>
</gallery>

===Classification===
{{See|Spinal fracture}}
There are proper names for several types of cervical fractures, including:
* Fracture of ''[[Atlas (anatomy)|C1]]'', including [[Jefferson fracture]]
* Fracture of ''[[Axis (anatomy)|C2]]'', including [[Hangman's fracture]]
* [[Flexion teardrop fracture]] – a fracture of the anteroinferior aspect of a [[Cervical vertebrae|cervical vertebra]]

The [[AO Foundation]] has developed a descriptive system for cervical fractures, the ''AOSpine subaxial cervical spine fracture classification system''.<ref>{{cite web|url=https://www2.aofoundation.org/wps/portal/!ut/p/a0/04_Sj9CPykssy0xPLMnMz0vMAfGjzOKN_A0M3D2DDbz9_UMMDRyDXQ3dw9wMDAx8jfULsh0VAdAsNSU!/?bone=Spine&segment=TraumaLowerCervical&soloState=lyteframe&contentUrl=srg/popup/additional_material/52/X001_Classification.jsp|title=Classification|website=[[AO Foundation]]|access-date=2019-05-08}}</ref>

===Surgery indication===
The indication to surgically stabilize a cervical fracture can be estimated from the ''Subaxial Injury Classification'' (SLIC). In this system, a score of 3 or less indicates that [[conservative management]] is appropriate, a score of 5 or more indicates that surgery is needed, and a score of 4 is equivocal.<ref name=Brockmeyer2016>[https://books.google.com/books?id=r_gTDgAAQBAJ&pg=PA94 Page 94] and [https://books.google.com/books?id=r_gTDgAAQBAJ&pg=PA126 Page 126] in: {{cite book|title=Adult and Pediatric Spine Trauma, An Issue of Neurosurgery Clinics of North America|volume=28|issue=1|author=Douglas L. Brockmeyer, Andrew T. Dailey|publisher=Elsevier Health Sciences|year=2016|isbn=9780323482844}}</ref> The score is the sum from 3 different categories: morphology, discs and ligaments, and neurology:<ref name=Brockmeyer2016/>

{|class="wikitable"
|+SLIC system<ref name=Brockmeyer2016/>
! colspan=2 style="text-align:right"| Points
|-
!colspan=2|Morphology
|-
| No abnormality || 0
|-
| [[Vertebral compression fracture|Vertebral compression]] || 1
|-
| [[Burst fracture|Burst]] || +1 (=2)
|-
| Distraction (facet joint perch, hyperextension) || 3
|-
| Rotation / translation (facet joint dislocation, unstable [[Flexion teardrop fracture|teardrop]], advanced flexion-compression || 4
|-
!colspan=2| [[Intervertebral disc|Discs]] and ligaments
|-
| Intact || 0
|-
| Indeterminate (isolated widening between [[spinous process]]es, [[magnetic resonance imaging|magnetic resonance]] change) || 1
|-
| Disrupted (widened disc space, facet perch, dislocation) || 2
|-
!colspan=2| Neurology
|-
| No neurological symptoms || 0
|-
| Damaged [[nerve root]] || 1
|-
| Complete [[spinal cord injury]] || 2
|-
| Incomplete spinal cord injury<br> (risk of worsening without surgery) || 3
|-
| Continuous cord compression with neurological deficit || +1
|}

==Treatment==
Complete immobilization of the head and neck should be done as early as possible and before moving the patient. Immobilization should remain in place until movement of the head and neck is proven safe. ''In the presence of severe head trauma, cervical fracture must be presumed until ruled out.'' Immobilization is imperative to minimize or prevent further [[spinal cord injury]]. The only exceptions are when there is imminent danger from an external cause, such as becoming trapped in a burning building.

[[NSAIDs|Non-steroidal anti-inflammatory drugs]], such as [[aspirin]] or [[ibuprofen]], are contraindicated because they interfere with bone healing. [[Paracetamol]] is a better option. Patients with cervical fractures will likely be prescribed medication for pain control.

In the long term, [[physical therapy]] will be given to build strength in the muscles of the neck to increase stability and better protect the cervical spine.

[[cervical collar|Collars]], traction and surgery can be used to immobilize and stabilize the neck after a cervical fracture.

===Cervical collar===
Minor fractures can be immobilized with a [[cervical collar]] without need for traction or surgery. A soft collar is fairly flexible and is the least limiting but can carry a high risk of further neck damage in patients with [[osteoporosis]]. It can be used for minor injuries or after healing has allowed the neck to become more stable.

A range of manufactured rigid collars are also used, usually comprising a firm plastic bi-valved shell secured with [[hook-and-loop fastener|hook-and-loop fasteners]] and removable padded liners. Cervical collars can be used with additional chest and head extension pieces to increase stability.

===Rigid braces===
Rigid braces that support the head and chest are also prescribed.<ref>{{URL | http://emedicine.medscape.com/article/314921-overview | Shantanu S Kulkarni, DO and Robert H Meier III, "Spinal Orthotics", '''Medscape Reference'''}}.</ref>  Examples include the Sterno-Occipital Mandibular Immobilization Device (SOMI), Lerman Minerva and Yale types. Special patients, such as very young children or non-cooperative adults, are sometimes still immobilized in medical plaster of paris casts, such as the [[Orthopedic cast#Other casts|Minerva cast]].

===Traction===
[[Traction (orthopedics)|Traction]] can be applied by free weights on a pulley or a halo type brace. The [[Orthotics#Spinal orthoses|halo brace]] is the most rigid cervical brace, used when limiting motion to the minimum that is essential, especially with unstable cervical fractures. It can provide stability and support during the time (typically 8–12 weeks) needed for the cervical bones to heal.

===Surgery===
Surgery may be needed to stabilize the neck and relieve pressure on the spinal cord. A variety of surgeries are available depending on the injury. Surgery to remove a damaged [[intervertebral disc]] may be done to relieve pressure on the spinal cord. The discs are cushions between the vertebrae. After the disc is removed, the vertebrae may be fused together to provide stability. Metal plates, screws, or wires may be needed to hold vertebrae or pieces in place.

==History==
Arab physician and surgeon [[Ibn al-Quff]] (d. 1286 CE) described a treatment of cervical fractures through the oral route in his book ''Kitab al-ʿUmda fı Ṣinaʿa al-Jiraḥa'' (Book of Basics in the Art of Surgery).<ref>{{cite journal | vauthors = Aciduman A, Belen D | title = An Early Description of Using Oral Route for the Management of Cervical Vertebra Fracture by Ibn al-Quff in the Thirteenth Century | journal = World Neurosurgery | volume = 120 | pages = 476–484 | date = December 2018 | pmid = 30205224 | doi = 10.1016/j.wneu.2018.09.005 | s2cid = 52187620 }}</ref>

== See also ==
* [[Brown-Séquard syndrome]]
* [[Cervical dislocation]]
* [[Internal decapitation]]
* [[Spinal cord injury]]

== References ==

{{reflist}}

== External links ==
* {{cite journal | vauthors = Van Waes OJ, Cheriex KC, Navsaria PH, van Riet PA, Nicol AJ, Vermeulen J | title = Management of penetrating neck injuries | journal = The British Journal of Surgery | volume = 99 | issue = Suppl 1 | pages = 149–154 | date = January 2012 | pmid = 22441870 | doi = 10.1002/bjs.7733 | hdl-access = free | s2cid = 205512500 | hdl = 1765/37154 }}
{{Medical resources
|  DiseasesDB     = 2322
|  ICD10          = {{ICD10|S|12||s|10}}
|  ICD9           = {{ICD9|805.0}}
|  ICDO           =
|  OMIM           =
|  MedlinePlus    = 000029
|  eMedicineSubj  = emerg
|  eMedicineTopic = 189
|  MeshID         =
|  OrthoInfo      = A00414
}}

{{Fractures}}
{{Authority control}}

[[Category:Cervical spine fracture| ]]
[[Category:Bone fractures]]
[[Category:Injuries of neck]]