Cervical Fracture

Spine

Overview

Cervical fractures represent breaks in the cervical vertebrae (C1-C7) resulting from trauma, pathological processes, or degenerative disease, with potential for serious neurological compromise. These injuries range from stable, minimally displaced fractures to unstable patterns involving multiple columns and ligamentous disruption. Immediate immobilization and medical imaging are essential to prevent catastrophic spinal cord injury.

Pathophysiology

Cervical fractures occur when compressive, tensile, shear, or rotational forces exceed the structural integrity of vertebral bone and associated ligaments. The mechanism determines fracture type and stability: axial compression typically produces burst fractures, hyperextension causes posterior element fractures, hyperflexion creates teardrop or facet dislocations. Unstable fractures disrupt the anterior longitudinal ligament, posterior ligaments, or involve multiple vertebral columns, compromising the spinal canal and risking spinal cord compression, contusion, or transection with resulting neurological deficit.

Patient Education

Cervical fractures are serious injuries requiring immediate medical evaluation and immobilization; never attempt self-treatment or manipulation without definitive imaging and specialist clearance, as inappropriate movement can convert a stable fracture into a catastrophic neurological injury.

Typical Presentation

Site

Posterior and lateral neck pain at fracture level; may radiate to occiput, shoulders, or upper limbs if nerve root compression present

Quality

Sharp, localised pain at fracture site; burning or radiating pain if neural involvement; may be absent in severe spinal cord injury

Intensity

Highly variable; can range from mild localised discomfort in stable fractures to severe pain with neurological symptoms in unstable injuries; pain may be masked by spinal shock in acute cord injury

Aggravating

Any neck movement, particularly flexion, extension, or rotation; palpation over fracture site; Valsalva maneuver; coughing or sneezing

Relieving

Complete immobilization in rigid collar or halo; recumbent position; analgesics; reduction of unstable fractures

Associated

Muscle guarding, reduced cervical range of motion, neurological deficits (weakness, sensory loss, areflexia or hyperreflexia depending on cord level), autonomic dysfunction (bradycardia, hypotension) in high cervical injuries, respiratory compromise in C3-C5 fractures affecting phrenic nerve

Orthopaedic Tests

Cervical Spine Palpation for Step-Off Deformity

Procedure

Patient seated or supine; examiner palpates spinous processes of C3–C7 along the midline, feeling for discontinuity, bony prominence, or step-off suggesting vertebral body displacement or fracture.

Positive Finding

Palpable step-off, tenderness over a spinous process, or deviation in the normal contour of the cervical spine

Sensitivity / Specificity

Unknown / Unknown

Interpretation

Suggests possible cervical fracture or significant structural injury; warrants imaging (CT or MRI) to rule out fracture and instability.

Cervical Spine Immobilization & Neurological Screening (NEXUS Criteria Component)

Procedure

Assess patient for presence of midline tenderness, focal neurological deficit, altered alertness, or intoxication. Perform bilateral upper limb strength and reflex testing (C5–T1 myotomes and dermatomes).

Positive Finding

Midline cervical tenderness, motor weakness, sensory loss, hyperreflexia, or absent reflexes consistent with cord compromise

Sensitivity / Specificity

99.6% (for clinically significant cervical spine injury) / 12.9% (NEXUS criteria—low specificity necessitates imaging)

Hoffman et al., 2000, JAMA

Interpretation

High sensitivity means negative findings reduce fracture likelihood; positive findings or midline pain require immediate imaging and cervical collar immobilization.

Lhermitte Sign

Procedure

Patient seated or standing; examiner passively flexes the cervical spine by bringing chin toward chest. Patient reports any symptoms that occur.

Positive Finding

Sharp, electric shock-like sensation radiating down the spine or into the limbs during passive cervical flexion

Sensitivity / Specificity

Unknown / Unknown

Interpretation

Suggests cervical myelopathy or spinal cord irritation/compression; indicates need for urgent MRI and imaging to assess for fracture with cord involvement.

Cranial Nerve & Upper Motor Neuron Assessment

Procedure

Test CN IX–XII (gag reflex, tongue protrusion, shoulder shrug). Assess deep tendon reflexes (biceps, triceps, brachioradialis) and check for hyperreflexia, clonus, or Babinski sign indicating upper motor neuron involvement.

Positive Finding

Abnormal reflexes, hyperreflexia, clonus, positive Babinski sign, or cranial nerve deficits; weakness in C5–T1 distribution

Sensitivity / Specificity

Unknown / Unknown

Interpretation

Indicates possible cervical cord compression or myelopathic involvement; fracture with neurovascular compromise is a medical emergency requiring immediate imaging and immobilization.

Canadian Cervical Spine Radiography Rule (CCR)

Procedure

Assess alert, stable patient for age ≥65, mechanism of injury (fall >1 m or ejection from vehicle), paresthesia in extremities, and inability to rotate neck 45° bilaterally. If any factor present, imaging is indicated.

Positive Finding

Presence of one or more criteria: age ≥65, dangerous mechanism, paresthesia, or limited cervical rotation

Sensitivity / Specificity

100% (for detecting significant cervical spine injury) / 42.5% (triggers imaging but has moderate specificity)

Stiell et al., 2001, CMAJ

Interpretation

Highly sensitive rule; positive findings warrant plain radiographs ± CT to exclude fracture. Negative findings in low-risk patients may allow safe cervical collar removal without imaging.

Axial Load Test (Spurling Test for Cervical Compression)

Procedure

Patient seated; examiner applies gentle axial compression to the head in neutral and then extended positions, with and without ipsilateral lateral flexion. Note any radicular or neck pain reproduction.

Positive Finding

Reproduction of arm pain, paraesthesia, or sharp pain radiating into the arm on the side of compression

Sensitivity / Specificity

47–73% (for cervical radiculopathy; lower sensitivity for fracture detection) / 73–98% (for cervical radiculopathy with nerve root involvement)

Tong et al., 2007, Spine

Interpretation

Primarily used for cervical radiculopathy rather than acute fracture; positive finding in trauma suggests nerve root irritation or compression secondary to fracture or disc herniation. Requires imaging confirmation.

⚠ Red Flags

  • •Acute traumatic mechanism including motor vehicle accident, fall from height, diving injury, or assault
  • •Severe neck pain with neurological symptoms including weakness, sensory loss, or bowel/bladder dysfunction
  • •Respiratory distress or need for ventilatory support
  • •Spinal shock presenting as flaccid paralysis, absent reflexes, and loss of sensation below fracture level
  • •Imaging confirmation of fracture, particularly unstable patterns including burst, teardrop, facet dislocation, or ligamentous disruption
  • •Haemodynamic instability with bradycardia and hypotension suggesting neurogenic shock

⚡ Yellow Flags

  • •High-impact mechanism with significant trauma anxiety
  • •Catastrophizing beliefs about permanent disability or paralysis
  • •Delayed presentation or minimization of injury severity
  • •Fear of movement or re-injury leading to prolonged immobility
  • •Secondary gain from injury including litigation or compensation claims
  • •Maladaptive coping strategies or substance misuse post-injury
  • •Depression or anxiety comorbidities common in spinal cord injury survivors
  • •Social isolation or loss of employment due to perceived disability

Osteopathic Techniques

Region

Cervical spine and proximal thoracic spine (ONLY after medical clearance and imaging exclusion of instability)

Technique

Soft Tissue

Rationale

Gentle soft tissue mobilisation to cervical paraspinal musculature, trapezius, and sternocleidomastoid in recovery phase reduces muscle guarding and promotes circulation, facilitating healing without imposing mechanical stress on fracture site; appropriate only after fracture union confirmed by imaging

Region

Thoracic spine and ribcage

Technique

Articulation

Rationale

Thoracic articulation and rib mobilisation preserves respiratory mechanics and reduces compensatory tension in patients with cervical immobilisation, particularly important in high cervical fractures affecting respiratory function

Region

Lumbar spine and pelvis

Technique

Soft Tissue

Rationale

Treatment of lower spine and pelvic structures prevents development of secondary compensatory dysfunction during prolonged cervical immobilisation; promotes overall spinal alignment and proprioception

Region

Upper extremities (shoulders, arms, hands)

Technique

Soft Tissue

Rationale

Mobilisation of upper limbs reduces tension, maintains circulation, and preserves neuromuscular function in cervical dermatomes; prevents contracture development during immobilisation phase

Region

Cranium and cervicobrachial plexus region

Technique

Soft Tissue

Rationale

Gentle cranial soft tissue release and neuromuscular facilitation around brachial plexus reduces neural tension and promotes normal axonal transport in post-acute recovery phase

Region

Cervical spine

Technique

Functional

Rationale

Functional osteopathic techniques using gentle positioning and isometric contraction patterns facilitate motor control and proprioceptive restoration during late-phase rehabilitation without imposing directional forces

Add-On Approaches

Chinese Medicine

Acupuncture to relevant meridians (Bladder, Governor Vessel) and local points around fracture site may support pain management and circulation; moxibustion cautiously applied to promote Qi flow; herbal remedies for bone healing (e.g., supplements containing calcium, vitamin D) appropriate in recovery phase

Chiropractic

Contraindicated in acute phase; spinal manipulation absolutely forbidden until fracture union confirmed. Post-recovery chiropractic care limited to gentle mobilisation under strict imaging-guided protocols with specialist medical clearance

Physiotherapy

Essential component of management: early cervical stability exercises, progressive range-of-motion training, postural re-education, gait training if lower limb dysfunction present, neuromuscular re-education for spinal cord injury survivors, vestibular rehabilitation if balance affected

Remedial Massage

Gentle remedial massage to paraspinal muscles, upper trapezius, and shoulder girdle in recovery phase reduces muscle tension and improves circulation; avoid direct pressure over fracture site until consolidation confirmed; beneficial for managing secondary myofascial pain syndrome

Rehabilitation Exercises

Cervical Spine Neutral Alignment - Supine

PosturalBeginner

Cervical Gentle Isometric Contraction - Flexion

Range of MotionBeginner

Cervical Gentle Isometric Contraction - Extension

Range of MotionBeginner

Cervical Gentle Isometric Contraction - Lateral Flexion (Bilateral)

Range of MotionBeginner

Deep Cervical Flexor Activation - Supine Chin Tuck

StrengtheningIntermediate

Cervical Stabiliser Endurance - Supine Head Float

StrengtheningIntermediate

Shoulder Retraction Against Resistance - Prone

StrengtheningIntermediate

Progressive Cervical Rotation in Gravity-Reduced Positions

Range of MotionIntermediate

Oculomotor Stability Training - Gaze Stabilisation Exercises

BalanceIntermediate

Upper Thoracic Extension - Prone Support

PosturalIntermediate

Gentle Upper Trapezius Stretch - Seated Neutral

StretchingBeginner

Advanced Cervical Proprioception - Seated Dynamic Control

StrengtheningAdvanced

Referral Criteria

  • •All acute cervical fractures require immediate referral to emergency department with spinal precautions and imaging
  • •Referral to spinal surgeon if fracture is unstable or associated with neurological deficit
  • •Referral to neurologist if spinal cord injury confirmed or neurological examination abnormal
  • •Referral to spinal rehabilitation specialist for management of spinal cord injury including bladder/bowel dysfunction
  • •Referral to pain management specialist if post-injury chronic pain syndrome develops
  • •Referral to physiotherapist for evidence-based rehabilitation and functional recovery
  • •Referral to psychologist if psychological distress, depression, or post-traumatic stress evident
  • •Referral to vocational rehabilitation if return-to-work assessment needed
  • •Referral back to medical team if neurological deterioration, new symptoms, or signs of non-union develop
  • •Consultation with orthotist for specialised spinal immobilisation devices during healing phase