Cervical Spine Acute Bony Injuries in Sports Medicine Clinical Presentation

  • Author: George L Hertner, MD; Chief Editor: Sherwin SW Ho, MD   more...
 
Updated: Sep 23, 2011
 

History

Initially approach every injured athlete with the suspicion of a cervical spine injury. Consider ABCs (ie, airway, breathing, circulation) from the beginning.

Obtain the history before the physical examination or movement of the patient.

  • The mechanism of the injury defines the possible bony injuries, but this may not be possible to elicit, or it may be multifactorial.
  • Determine if the athlete has a history of neck injuries, spinal stenosis, spear tackler's spine, or other abnormalities (see Causes, below).
  • Ask the athlete if neck pain is present. Determine location and quality of any pain. Ask if the pain radiates distally or to the extremities.
  • Determine if the patient is experiencing paresthesias or weakness.
  • Determine if other distracting injuries are present.
  • Determine if the athlete is impaired by a head injury or the use of a legal or illicit drug.
Next

Physical

Address the patient's ABCs while protecting the cervical spine.

Palpate the neck, and specifically feel for midline bony pain, muscle spasm, step-off, and crepitus.

Determine if extremity sensation is intact.

Determine if the athlete can move all extremities without deficits.

Determine if the athlete can perform range of motion (ROM) in all directions without pain or symptoms. NOTE: Do not perform passive ROM of the neck.

Determine if head compression elicits pain or symptoms.

Before performing the Spurling maneuver to determine whether pain or symptoms are elicited, exclude the presence of any bony injury or instability first.

The Spurling maneuver is performed by passively forcing the athlete into cervical extension with lateral flexion toward the side of the symptoms. The maneuver reproduces symptoms of recurrent brachial plexus injuries by nerve root compression in the intervertebral foramen.[14] NOTE: This is an office-based examination to be performed after other injuries have been excluded.

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Causes

Collision sports are often associated with fractures. The occurrence of fractures increases with poor technique (eg, improper tackling techniques), poor conditioning, and substandard equipment. Previous injury may also predispose the athlete to new injury. The mechanism of injury determines the type of bony injury, and, historically, cervical spine fractures have been categorized by the mechanism of injury.[8, 12, 15, 16]

  • Flexion injuries
    • Simple wedge fracture (see the image below)
      • Fracture of the anterosuperior end plate of the vertebral body
      • Associated with posterior ligament disruption, which makes the injury unstable
      • Differs from a burst fracture because no vertical element to the fracture is presentChild with C6 flexion wedge fracture. Child with C6 flexion wedge fracture.
    • Anterior teardrop fracture
      • Teardrop fracture with an anteroinferior vertebral body fragment
      • Unstable fracture associated with complete disruption of ligaments
      • Associated with anterior cord syndrome
    • Clay shoveler's fracture (see the image below)
      • Avulsion of spinous process of the lower cervical vertebrae, usually C7
      • Stable fractureClay shoveler's fracture. Clay shoveler's fracture.
    • Atlantooccipital and atlantoaxial dislocation with fracture (see the image below)
      • High instability
      • High mortalityAnteroposterior view of atlantooccipital dislocatiAnteroposterior view of atlantooccipital dislocation.
    • Bilateral facet dislocation with fracture (see the image below)Bilateral facet fracture/dislocation at C6/C7. Bilateral facet fracture/dislocation at C6/C7.
  • Flexion with rotation injuries – Unilateral facet dislocation with fracture (The dislocation alone is stable. The fracture may occur at the base of the superior articular mass of the inferior cervical vertebrae, or the fracture may occur at the base of the inferior mass of the superior dislocated vertebrae.)
  • Extension with rotation injuries
    • Pillar fracture
      • Vertical or oblique fracture of the articular mass
      • Stable fracture
    • Pediculolaminar fracture
      • Variety of severities
      • Associated ligamentous injuries
  • Extension injuries
    • Anterior arch of the atlas (avulsion fracture) – Unstable fracture
    • Posterior arch of the atlas fracture
      • Compression between the axis and occiput
      • High association with other fractures
    • Hangman's fracture (see the image below)
      • C2 pedicles with anterior displacement
      • Common in diving accidents
      • NOTE: The patient may be without neurologic deficit, but this is an unstable fractureLateral view of hangman's fracture. Lateral view of hangman's fracture.
    • Laminar fracture (see the image below)
      • Subtle fracture associated with spinous process fractures
      • Stable fractureC7 lamina fracture. C7 lamina fracture.
    • Extension teardrop fracture
      • Anteroinferior vertebral body fracture from an avulsion by the anterior longitudinal ligament
      • Most common at C2
      • Unstable fracture
  • Lateral flexion injuries – Uncinate process fracture, resulting in transverse fracture of the base of the uncinate process by the superior vertebral body
  • Compression injuries
    • Jefferson fracture (see the image below)
      • The occipital condyles are driven into C1, forcing the lateral masses apart.
      • Often associated with rupture of the transverse ligament
      • Unstable fractureOdontoid view of a Jefferson fracture. Odontoid view of a Jefferson fracture.
    • Burst fracture (see the image below)
      • Axial lode causes the vertebral body to burst.
      • Involves both end plates and may intrude into the spinal canal
      • Unstable fractureC4 burst fracture. C4 burst fracture.
    • Spear tackler's spine
      • Associated with use of the head as the initial contact in football
      • Over time, athletes develop cervical stenosis, posttraumatic changes, and loss of cervical lordosis.
      • Traumatic axial compression can cause compression of the anterior column, followed by flexion, resulting in a fracture.
  • Other injuries
    • Odontoid fracture
      • Associated with other cervical fractures
      • Type I – At the tip superiorly. The transverse ligament remains intact, and the fracture is stable.
      • Type II – At the junction of the odontoid and the body. This is the most common type of odontoid fracture. See the image below. Odontoid type 2 fracture. Odontoid type 2 fracture.
      • Type III – Through the superior portion of C2 at the base of the odontoid. See the images below.Lateral view of type 3 odontoid fracture. Lateral view of type 3 odontoid fracture. Computed tomography scans of odontoid type 3 fractComputed tomography scans of odontoid type 3 fracture.
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Contributor Information and Disclosures
Author

George L Hertner, MD  Medical Director, Department of Emergency Medicine, Memorial Hospital North of Colorado Springs

George L Hertner, MD is a member of the following medical societies: American College of Emergency Physicians, American Medical Association, Colorado Medical Society, Undersea and Hyperbaric Medical Society, and Wilderness Medical Society

Disclosure: Nothing to disclose.

Coauthor(s)

Nathaniel Johnson Stewart Jr, MD, FACEP  Director for Education and Professional Services, Department of Emergency Medicine, Palmetto Health Richland Hospital

Nathaniel Johnson Stewart Jr, MD, FACEP is a member of the following medical societies: Alpha Omega Alpha, American College of Emergency Physicians, Society for Academic Emergency Medicine, and South Carolina Medical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Janos P Ertl, MD  Assistant Professor, Department of Orthopedic Surgery, Indiana University School of Medicine; Chief of Orthopedic Surgery, Wishard Hospital

Janos P Ertl, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Association, Hungarian Medical Association of America, and Sierra Sacramento Valley Medical Society

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Henry T Goitz, MD  Academic Chair and Associate Director, Detroit Medical Center Sports Medicine Institute; Director, Education, Research, and Injury Prevention Center; Co-Director, Orthopaedic Sports Medicine Fellowship

Henry T Goitz, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons and American Orthopaedic Society for Sports Medicine

Disclosure: Nothing to disclose.

Jon B Whitehurst, MD  Clinical Instructor of Surgery, University of Illinois College of Medicine; Partner, Rockford Orthopedic Associates; Orthopedic Chairman, Rockford Memorial Hospital

Jon B Whitehurst, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Society for Sports Medicine, and Arthroscopy Association of North America

Disclosure: Nothing to disclose.

Chief Editor

Sherwin SW Ho, MD  Associate Professor, Department of Surgery, Section of Orthopedic Surgery and Rehabilitation Medicine, University of Chicago

Sherwin SW Ho, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Society for Sports Medicine, Arthroscopy Association of North America, and Herodicus Society

Disclosure: Breg, Inc. Consulting fee Consulting; Biomet, Inc. Consulting fee Consulting; GMV, Inc. Arthroscopy Simulator Evaluation and teaching; Smith and Nephew Grant/research funds Fellowship funding; DJ Ortho Grant/research funds Course funding; Athletico Physical Therapy Grant/research funds Course, research funding

Additional Contributors

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous author coauthor Mark Leski, MD, to the development and writing of this article.

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Anteroposterior view of atlantooccipital dislocation.
Odontoid view of a Jefferson fracture.
Lateral view of a C2 fracture dislocation.
Odontoid type 2 fracture.
Lateral view of type 3 odontoid fracture.
Computed tomography scans of odontoid type 3 fracture.
Lateral view of a C3 spinous fracture.
Lateral view of hangman's fracture.
C3 flexion fracture.
C4 burst fracture.
Clay shoveler's fracture.
Unilateral locked facets on C5 and C6.
Bilateral facet fracture/dislocation at C6/C7.
Child with C6 flexion wedge fracture.
C7 lamina fracture.
 
 
 
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