Cervical Teardrop Fracture
(Redirected from Cervical Burst Fracture)
Other Names
- Teardrop fracture
- Extension teardrop fracture (ETF)
- Flexion teardrop fracture (FTF)
- Quadrangular fracture
- Teardrop Vertebral Fracture
- Cervical Spine Teardrop Injury
- Anterior Inferior Vertebral Body Fracture
- Cervical Avulsion Fracture (Teardrop Type)
- Unstable Cervical Teardrop Injury
Background
- This page describes triangular fracture fragments of the Vertebral Body, commonly referred to as teardrop fractures
History
- First described by Kahn and Schneider in 1956[1]
Epidemiology
- Both ETF and FTF are rare and not well documented in the literature
- ETF estimated to 11-15% of upper cervical spine fractures[2]
Introduction
General
- Characterized by a triangular fragment avulsed from the anteroinferior corner of a cervical vertebral body
- Occur due to high energy trauma such as hyperflexion or axial loading, associated with high risk of neurological deficit
- Can be described as occuring from either a flexion mechanism (unstable) or extension mechanism (stable)
- Management requires prompty evaluation by a spinal surgeon and depends on stability and neurological status
Location
- Flexion: Most commonly due to flexion with axial load
- Anterior column fails in flexion with compression
- Subsequently, retropulsion of vertebral body segment
- Most commonly occur at mid or lower cervical spine C4, C5, C6[6]
- This is more unstable, severe
- Extension: Less comonly due to extension with axial load
- Commonly C2 vertebral body in older patients
- Stable in flexion, unstable in extension
- This is considered an stable, less severe
Etiology
- Flexion injuries classically occur due to severe flexion with axial compression load
- Diving impact, deceleration during MVC
- Extension injuries
Anatomy of the Anterior Longitudinal Ligament (ALL)
- Covers the anterolateral surface of the vertebral bodies and intervertebral discs
- Attaches superiorly to the occipital bone, foramen magnum, anterior tubercle of C1
- Extends distally to the anterior surface of the sacrum
- In ETF, ALL is disrupted avulsing off anteroinferior fragment
Associated Injuries
- Spinal Cord Injury
- Cervical Spine Fractures
- Central Cord Syndrome
Risk Factors
Differential Diagnosis
Differential Diagnosis Neck Pain
- Fractures
- Subluxations and Dislocations
- Neuropathic
- Muscle and Tendon
- Pediatric/ Congenital
- Other Etiologies
Clinical Features
History
- Important to characterize mechanism of trauma
- Often includes MVC, fall, sport injury with axial load, hyperflexion
- Patient will complain of neck pain
- Acute and severe
- Restricted range of motion
- Isolated teardrop fractures are typically neurologically intact
- There may be parasthesias or weakness of upper/lower extremities depending on level of spinal cord involvement
Physical Exam: Physical Exam Neck
- Depending on mechanism of action, may need to follow ATLS
- They may be tender at the level of the injury
- Range of motion is restricted
- Neurological examination may reveal deficits ranging from mild sensory changes to complete tetraplegia[7]
- In elderly patients or those with extension mechanism, defecits are typically more mild[8]
Evaluation
Radiographs
- Standard Radiographs Cervical Spine
- Begin with standard 3 view cervical spine
- Flexion Teardrop Fracture Findings
- Most commonly at C6-C6
- Fracture of the anteroinferior lip of vertebral body (triangular fragment or 'teardrop')
- Posterior displacement of the posterior vertebral body
- Extension Teardrop Fracture findings
- Often at C2
- Avulsion fracture due to ALL
- Anterior disc space widening
- Fragment is smaller, less involvement of the posterior element
CT
- Indicated in all cases of fractures on standard radiographs
- Also indicated in all high energy trauma
- Much more sensitive for osseous injuries of the cervical spine
- Findings
- Anteroinferior corner fracture of the vertebral body
- Triangular or "teardrop"-shaped fragment
MRI
- Can be useful to help distinguish flexion type injury
- Evaluate integrity of posterior longitudinal ligament (PLL)
- Evaluate other soft tissue injuries, esepcially spinal cord and nerve roots
Classification
- N/A
Management
Nonoperative
- Indications: Flexion Teardrop Fractur
- Few. most are unstable and surgical
- Immobilized in hard Cervical Collar for 6-12 weeks or external halo
- Serial radiographs to monitor for healing/ displacement
- Indications: Extension Teardrop Fracture
- Vast majority of cases
- Nondisplaced without neurological deficits
- Need to be immobilized in hard Cervical Collar for 6-12 weeks
- Serial radiographs to monitor for healing/ displacement
Operative Management
- Indications
- Most flexion teadrop fractures
- Rarely indicated for extension teadrop fractures
- Unstable fractures
- Neurological deficits
- Significant displacement
- Failure of conservative management
- Technique
- Anterior or posterior decompression
- Corpectomy and plating
- Anterior cervical discectomy and fusion (ACDF)
- Direct fragment osteosynthesis
- Posterior reduction/fixation
Rehab and Return to Play
Rehabilitation
- Therapeutic exercise programs can help
- Restore strength
- Balance
- Functional status
- Evidence for specific protocols is limited
Return to Play
- Essential RTP criteria include[11]
- Radiographic evidence of fracture healing or solid fusion
- Pain-free, full cervical range of motion
- Absence of neurological deficits
- Restoration of sport-specific skills
- No persistent instability or cord signal changes on imaging
- Psychological readiness and ability to perform safely
- Contraindications for RTP[12]
- Persistent instability
- Ongoing neurological symptoms
- Multilevel fusion
- Abnormal cord signal on MRI
- RTP should follow a graded, outcome-based progression[13]
- Return to participation: Begin light training once healing is confirmed
- Return to sport: Resume non-contact activities, progressing to contact as tolerated
- Return to performance: Full competition only after meeting all criteria
Prognosis and Complications
Prognosis
- General
- Best in isolated, stable fractures without neurological involvement
- Worst in unstable, complex flexion teardrop fractures with cord injury
- Nonsurgical
- Surgical
- Superior to halo vest immobilization for restoring and maintaining sagittal alignment, reducing kyphosis, and promoting neurological recovery in unstable cases[16]
Complications
- Spinal Cord Injury
- Cervical Spine Fractures
- Central Cord Syndrome
- Persistent Pain
- Nonunion
- Surgical treatment failure
- Pseudarthrosis
- Postoperative infection
See Also
Internal
References
- ↑ Kahn EA, Schneider RC: Chronic neurological sequelae of acute trauma to the spine and spinal cord. I. The significance of the acute-flexion or tear-drop fracture-dislocation of the cervical spine. J Bone Joint Surg Am 38-A:985–997, 1956
- ↑ Watanabe, Masahiko, et al. "Clinical features of the extension teardrop fracture of the axis: review of 13 cases." Journal of Neurosurgery: Spine 14.6 (2011): 710-714.
- ↑ Image courtsey of radiologyassistant.nl/
- ↑ Kim, Kwang S., et al. "Flexion teardrop fracture of the cervical spine: radiographic characteristics." American Journal of Roentgenology 152.2 (1989): 319-326.
- ↑ Ahn, Jae-Sung. "Journal of Musculoskeletal Trauma." Journal of Musculoskeletal Trauma 24.1 (2011): 100-113.
- ↑ Kim KS, Chen HH, Russell EJ et-al. Flexion teardrop fracture of the cervical spine: radiographic characteristics. AJR Am J Roentgenol. 1989;152 (2): 319-26.
- ↑ Torg, Joseph S., et al. "The axial load teardrop fracture: a biomechanical, clinical, and roentgenographic analysis." The American journal of sports medicine 19.4 (1991): 355-364.
- ↑ Watanabe, Masahiko, et al. "Clinical features of the extension teardrop fracture of the axis: review of 13 cases." Journal of Neurosurgery: Spine 14.6 (2011): 710-714.
- ↑ 9.0 9.1 Jain, Anil K. "ISCOS-Textbook on comprehensive management of spinal cord injuries." Indian Journal of Orthopaedics 50.2 (2016): 223.
- ↑ 10.0 10.1 Maharaj, Monish, Kevin Phan, and Ralph J. Mobbs. "Management of hyper-flexion injury-related teardrop fracture in an adolescent." Case Reports 2016 (2016): bcr2015211876.
- ↑ Zuckerman, Scott L., et al. "Return-to-Sport Recommendations for Athletes With Cervical Spine Trauma: A Modified Delphi Consensus Survey of Expert Opinion." Neurosurgery (2022): 10-1227.
- ↑ Zuckerman, Scott L., et al. "Return-to-Sport Recommendations in Athletes Requiring Cervical Spine Surgery: A Modified Delphi Consensus Survey of Expert Opinion." Spine (2025): 10-1097.
- ↑ White, Michael D., et al. "Return to play in professional football players following traumatic cervical spine injury: expert opinions from the National Football League spine surgeons: Presented at the 2024 AANS/CNS Joint Section on Disorders of the Spine and Peripheral Nerves." Journal of Neurosurgery: Spine 1.aop (2024): 1-10.
- ↑ Watanabe, Masahiko, et al. "Clinical features of the extension teardrop fracture of the axis: review of 13 cases." Journal of Neurosurgery: Spine 14.6 (2011): 710-714.
- ↑ Fisher, Charles G., et al. "Comparison of outcomes for unstable lower cervical flexion teardrop fractures managed with halo thoracic vest versus anterior corpectomy and plating." Spine 27.2 (2002): 160-166.
- ↑ Koivikko, M. P., et al. "Conservative and operative treatment in cervical burst fractures." Archives of orthopaedic and trauma surgery 120.7 (2000): 448-451.