What is your diagnosis?

This is a flexion teardrop fracture - the mechanism being hyperflexion and axial compression. It is associated with anterior and posterior ligamentous tears, injury to the ligamentum flavum, and posterior subluxation. It is generally seen in C4-C6 [1].

• Pearl: Four lines can be drawn to assist in reading cervical spine x-rays and CTs (Image 2). These include the anterior vertebral, posterior vertebral, spinolaminar, and posterior spinous lines. Note that all four are disrupted in Figure 1.

Image 2. Case courtesy of Dr Andrew Dixon, radiopaedia.org, rID: 32505

• Pearl: Don’t confuse this with an extension teardrop fracture, which has fewer ligament tears and is considered less severe (Image 3). It is generally seen in C2-C3.

Figure 3. Fracture at C2, note only the anterior line is disrupted. Case courtesy of Radswiki, radiopaedia.org, rID: 11268

Is this fracture stable or unstable? How do you remember the unstable cervical spine fractures?

Unstable. A common phrase used to remember unstable cervical fractures is “Jefferson Bit off a Hangman’s Thumb.” A brief description of each is as follows:

What neurological syndrome is associated with this fracture type?

A flexion teardrop fracture is most commonly associated with anterior cord syndrome [1]. This presents as loss of movement and pain/temperature below the level of the lesion with preservation of the dorsal columns (vibration, proprioception, and 2-point discrimination). 

What is your management in the ED? When do you consult orthopedics?

The patient should be maintained in strict C-spine precautions with a properly fitted collar at all times. CT imaging of the spine and other trauma work up should ensue. A surgical spine specialty should be emergently consulted as determined by institutional protocols.