SplintER Series: Neck Pain Tears Me Up

A 40-year-old male presents with neck pain after a high-speed head-on motor vehicle collision. You obtain cervical spine x-rays (Figure 1).

Figure 1. Case courtesy of Dr Muhammad Asadullah Munir, Radiopaedia.org. From the case rID: 78890


Figure 1. Case courtesy of Dr Muhammad Asadullah Munir, Radiopaedia.org. From the case rID: 78890



This is a flexion teardrop fracture – the mechanism of injury is 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 (Figure 2). These include the anterior vertebral, posterior vertebral, spinolaminar, and posterior spinous lines. Note that all four are disrupted in Figure 1.

Figure 2. Case courtesy of Dr Andrew Dixon, Radiopaedia.org. From the case rID: 32505

  • Pearl: Don’t confuse this with an extension teardrop fracture, which has fewer ligament tears and is considered less severe (Figure 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. From the case rID: 11268

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:

Name Location Mechanism
Jefferson Fracture C1 burst fracture Axial Loading
Bilateral Facet Dislocation Vertebral body anterior translocation Hyperflexion
Odontoid Fracture C2 Dens (Zone II) Flexion or Extension
Atlanto-Occipital Dislocation Cranial dislocation from C1, i.e. decapitation Flexion or Extension
Hangman’s Fracture C2 Pars Interarticularis Hyperextension
Flexion Teardrop Fracture C4-6 Flexion

A flexion teardrop fracture is most commonly associated with anterior cord syndrome [1]. This syndrome 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).

The patient should be maintained in strict C-spine precautions with a properly fitted collar at all times. A spine surgeon should be emergently consulted as determined by institutional protocols.


Resources & References:

Check out ALiEM’s Paucis Verbis cards to brush up on other can’t miss adult neck and cervical spine injuries.

  1. Kim, Kwang S., et al. “Flexion teardrop fracture of the cervical spine: radiographic characteristics.” American Journal of Roentgenology 152.2 (1989): 319-326.

Author information

Mark Hopkins, MD

Mark Hopkins, MD

Loma Linda University Health

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