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Cervical Teardrop Fracture

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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

Teardrop fracture of C2 (arrow)
Illustration of mechanism of injury of extension teardrop fracture[3]
Diagram of flexion teadrop injury[4]
Flexion teardrop fracture of C5. Lateral radiographs (A, B) of the cervical spine show typical flexion teardrop fracture with anteriorly displaced triangular fracture fragment ("teardrop") of the anterior-inferior aspect of vertebral body of C5 (white arrow in B) and retropulsion of its posterior vertebral body fragment into spinal canal (black arrow in B). Note a subtle localized kyphotic angulation at C5-6 and widening of the interspinous distance at C5-6 ("fanning") (white double arrow in B).[5]

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

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

Plain radiograph and sagittal CT cervical spine reformat reveal a triangular teardrop fracture at the anteroinferior margin of C5 vertebra. The central vertebral body is compromising the spinal canal due to its posterior displacement.[9]
Spinal cord injury associated with a flexion teardrop fracture. Sagittal T1-and T2-weighted cervical spine images (in the same patient) demonstrate a spinal cord compression with a long-segment diffuse increase in caliber and poorly marginated hyperintensity within the cervical cord suggestive of cord edema.[9]

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

Artistic impression of surgical technique. (A) Loading during injury. (B) Teardrop fracture. (C) Surgical approach. (D) Fusion between fractured segment and adjacent level.[10]
Postoperative anterior and lateral radiographs illustrating C5/6 anterior fusion at 1-month follow-up.[10]

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
    • Most extension-type teardrop fractures have good outcomes, low risk of persistent pain or instability[14]
    • In flexion-type, higher risk of kyphosis and treatment failure[15]
  • 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

  1. ↑ 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
  2. ↑ 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.
  3. ↑ Image courtsey of radiologyassistant.nl/
  4. ↑ Kim, Kwang S., et al. "Flexion teardrop fracture of the cervical spine: radiographic characteristics." American Journal of Roentgenology 152.2 (1989): 319-326.
  5. ↑ Ahn, Jae-Sung. "Journal of Musculoskeletal Trauma." Journal of Musculoskeletal Trauma 24.1 (2011): 100-113.
  6. ↑ 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.
  7. ↑ 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.
  8. ↑ 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. ↑ 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. ↑ 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.
  11. ↑ 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.
  12. ↑ 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.
  13. ↑ 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.
  14. ↑ 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.
  15. ↑ 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.
  16. ↑ Koivikko, M. P., et al. "Conservative and operative treatment in cervical burst fractures." Archives of orthopaedic and trauma surgery 120.7 (2000): 448-451.
Created by:
John Kiel on 4 July 2019 09:28:36
Authors:
Last edited:
25 November 2025 21:27:39
Categories:
Trauma | Neck | Fractures | Spine - Cervical | Acute
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