Fracture of the Neck

Overview

A fracture of the neck, medically termed a cervical fracture, refers to a break in any of the seven cervical vertebrae (C1-C7) that form the upper portion of the spine. These injuries range from minor compression fractures to severe, life-threatening breaks that can damage the spinal cord and lead to paralysis or death. The cervical spine is particularly vulnerable due to its mobility and the relatively small size of the vertebrae compared to the weight of the head they support.

The severity and consequences of a neck fracture depend on several factors, including the specific vertebra involved, the type of fracture, and whether the spinal cord or nerve roots are affected. High cervical fractures (C1-C2) can be immediately life-threatening as they may affect breathing centers, while lower cervical fractures (C3-C7) more commonly result in varying degrees of paralysis or neurological dysfunction.

Modern trauma care has significantly improved outcomes for neck fracture patients, with advances in imaging, surgical techniques, and rehabilitation. However, these injuries remain medical emergencies requiring immediate stabilization and expert care. Early recognition and appropriate management are crucial for preventing secondary injury and optimizing long-term recovery. The annual incidence of cervical spine fractures is approximately 12,000 cases in the United States, with young adults and elderly populations being most affected.

Symptoms

The symptoms of a neck fracture can vary dramatically based on the location and severity of the injury, ranging from localized pain to complete paralysis. It's crucial to recognize that not all neck fractures present with obvious symptoms immediately, and some may worsen over time if left untreated.

Primary Symptoms at Injury Site

• Severe neck pain that worsens with movement
• Tenderness and swelling at the fracture site
• Visible deformity or abnormal positioning of the head
• Muscle spasms in the neck and upper back
• Restricted range of motion or inability to move the neck

Neurological Symptoms

When the spinal cord or nerve roots are affected:

• Numbness or tingling in arms, hands, legs, or feet
• Weakness or paralysis in one or more limbs
• Loss of bladder or bowel control
• Difficulty breathing (with high cervical injuries)
• Changes in sensation, including loss of temperature or pain perception

Referred Pain Patterns

Neck fractures often cause pain that radiates to other areas:

• Leg pain - May indicate spinal cord compression affecting lower body nerve signals
• Hip pain - Can result from altered gait or compensatory postures
• Low back pain - Often develops from protective posturing and muscle tension
• Elbow pain - May occur with nerve root compression affecting arm innervation
• Lower body pain - General discomfort from neurological involvement

Associated Symptoms

• Headache - Common with upper cervical fractures
• Dizziness or vertigo
• Difficulty swallowing
• Hoarseness or voice changes
• Blurred vision
• Ringing in the ears (tinnitus)

Signs of Spinal Shock

In severe cases, patients may experience:

• Complete loss of sensation below the injury level
• Flaccid paralysis
• Loss of reflexes
• Low blood pressure and slow heart rate
• Inability to regulate body temperature

Causes

Neck fractures typically result from high-energy trauma that exceeds the strength of the cervical vertebrae. Understanding the mechanisms of injury helps in prevention and guides treatment approaches.

Motor Vehicle Accidents

The leading cause of cervical spine fractures:

• Whiplash mechanisms: Rapid flexion-extension movements
• Direct impact: Head striking windshield or steering wheel
• Rollover accidents: Complex forces on the neck
• Ejection from vehicle: Extreme trauma forces
• Motorcycle accidents: High-speed impacts without protection

Falls

Particularly dangerous in certain populations:

• Elderly falls: Often from standing height onto hard surfaces
• Falls from height: Construction accidents, ladder falls
• Diving accidents: Shallow water injuries causing compression
• Slip and fall: Backward falls with head impact

Sports Injuries

High-risk activities include:

• Contact sports: Football, rugby, hockey
• Gymnastics: Falls during routines
• Diving: Pool and cliff diving accidents
• Horseback riding: Falls from horses
• Skiing/snowboarding: High-speed collisions
• Mountain biking: Over-the-handlebar accidents

Violence

• Gunshot wounds to the neck
• Stab wounds affecting vertebrae
• Physical assault with blunt force trauma
• Strangulation injuries

Pathological Fractures

Fractures occurring in weakened bone:

• Osteoporosis: Age-related bone density loss
• Cancer metastases: Tumors weakening vertebrae
• Infection: Osteomyelitis or tuberculosis
• Rheumatoid arthritis: Inflammatory bone damage
• Osteogenesis imperfecta: Genetic bone fragility

Specific Fracture Mechanisms

• Flexion injuries: Forward bending causing compression
• Extension injuries: Backward bending with posterior element fractures
• Rotation injuries: Twisting forces causing facet fractures
• Axial loading: Vertical compression from head impact
• Distraction injuries: Pulling forces separating vertebrae

Risk Factors

Several factors increase the likelihood of sustaining a neck fracture or experiencing worse outcomes from such injuries:

Age-Related Factors

• Elderly individuals (>65 years):
  • Decreased bone density
  • Higher fall risk
  • Slower reflexes
  • Pre-existing spine degeneration
• Young adults (15-35 years):
  • High-risk behaviors
  • Sports participation
  • Motor vehicle accidents

Medical Conditions

• Osteoporosis - Weakened bones fracture more easily
• Rheumatoid arthritis - Cervical spine instability
• Ankylosing spondylitis - Rigid spine prone to fractures
• Cancer with bone metastases
• Vitamin D deficiency
• Previous spine surgery or injury

Lifestyle Factors

• Participation in high-risk sports without proper protection
• Occupation involving heights or heavy machinery
• Alcohol or substance abuse affecting coordination
• Not wearing seatbelts or helmets
• Living in areas with icy conditions

Anatomical Factors

• Congenital spine abnormalities
• Previous neck injuries or surgeries
• Cervical stenosis (narrow spinal canal)
• Ligamentous laxity conditions

Diagnosis

Prompt and accurate diagnosis of neck fractures is critical to prevent secondary injury and guide appropriate treatment. The diagnostic process must balance thoroughness with the need to minimize movement of potentially unstable injuries.

Initial Assessment

Emergency evaluation follows trauma protocols:

• Primary survey: Airway, breathing, circulation assessment
• Cervical spine immobilization: Collar and backboard
• Neurological examination: Motor, sensory, and reflex testing
• NEXUS criteria: Clinical clearance protocol
• Canadian C-spine rule: Decision tool for imaging

Imaging Studies

Plain Radiographs (X-rays)

• Lateral, anteroposterior, and odontoid views
• Initial screening tool
• May miss up to 20% of fractures
• Useful for alignment assessment

Computed Tomography (CT)

• Gold standard for detecting bony injuries
• Multiplanar reconstructions for detailed visualization
• CT angiography if vascular injury suspected
• Faster than MRI in emergency settings

Magnetic Resonance Imaging (MRI)

• Best for soft tissue evaluation
• Identifies spinal cord injury
• Detects ligamentous damage
• Evaluates disc herniation
• Essential for surgical planning

Clinical Classification

Fractures are classified by:

• Location: Which vertebra(e) affected (C1-C7)
• Stability: Stable vs. unstable patterns
• Morphology: Compression, burst, flexion-distraction
• Neurological status: ASIA impairment scale

Specialized Tests

• Flexion-extension radiographs: For ligamentous instability (delayed)
• Electromyography (EMG): Nerve function assessment
• Somatosensory evoked potentials: Spinal cord function
• Bone density scan: If pathological fracture suspected

Common Fracture Types

• Jefferson fracture: C1 ring fracture
• Hangman's fracture: C2 pedicle fracture
• Odontoid fracture: C2 dens fracture
• Compression fracture: Vertebral body collapse
• Burst fracture: Vertebral body explosion
• Teardrop fracture: Flexion-compression injury

Treatment Options

Treatment of neck fractures depends on fracture type, stability, neurological involvement, and patient factors. The goals are to protect the spinal cord, restore alignment, promote healing, and maximize functional recovery.

Immediate Management

• Spinal immobilization: Rigid collar and spine board
• Airway management: May require intubation
• Hemodynamic stabilization: IV fluids, vasopressors if needed
• High-dose steroids: If given within 8 hours (controversial)
• Pain management: Careful use of analgesics

Non-Surgical Treatment

For stable fractures without neurological compromise:

Cervical Collar

• Soft collar for comfort in minor injuries
• Rigid collar (Philadelphia, Miami J) for 6-12 weeks
• Regular X-rays to monitor healing
• Gradual weaning with physical therapy

Halo Vest Immobilization

• External fixation device
• Pins in skull connected to vest
• Provides maximum stability
• Worn for 8-12 weeks typically
• Allows early mobilization

Cervical Traction

• Gardner-Wells tongs or halo ring
• Reduces fracture-dislocations
• Decompresses neural elements
• Usually temporary before surgery

Surgical Treatment

Indicated for unstable fractures or neurological compromise:

Anterior Approach Surgery

• Anterior cervical discectomy and fusion (ACDF): Removes disc, places bone graft
• Corpectomy: Removal of vertebral body
• Plate fixation: Internal stabilization
• Better for lower cervical injuries

Posterior Approach Surgery

• Posterior fusion: Bone grafting between vertebrae
• Lateral mass screws: For C3-C6 fixation
• C1-C2 fusion: For upper cervical instability
• Laminectomy: Decompression of spinal cord

Combined Approaches

• 360-degree fusion for severe instability
• Staged procedures for complex injuries
• Occipitocervical fusion for high injuries

Rehabilitation

Critical for optimal recovery:

• Physical therapy: Range of motion, strengthening
• Occupational therapy: Daily living skills
• Pain management: Multimodal approaches
• Psychological support: Coping with injury impact
• Vocational rehabilitation: Return to work planning

Complications Management

• Deep vein thrombosis prevention: Anticoagulation, compression devices
• Pressure ulcer prevention: Regular positioning
• Respiratory therapy: Prevent pneumonia
• Bladder/bowel programs: For neurological deficits
• Spasticity management: Medications, therapy

Long-term Management

• Regular follow-up imaging
• Monitoring for late instability
• Management of chronic pain
• Bone health optimization
• Activity modification counseling

Prevention

While not all neck fractures can be prevented, many injuries can be avoided through safety measures and risk reduction strategies.

Vehicle Safety

• Always wear seatbelts: Properly positioned across chest and lap
• Adjust headrests: Top at ear level, close to head
• Airbag safety: Maintain proper distance from steering wheel
• Child safety seats: Age-appropriate restraints
• Avoid distracted driving: No phones or other distractions
• Defensive driving: Maintain safe following distances

Sports Safety

• Wear appropriate protective equipment
• Learn proper tackling and falling techniques
• Strengthen neck muscles
• Follow rules designed for safety
• Avoid heading in soccer when possible
• Check water depth before diving

Fall Prevention

Especially important for elderly:

• Remove home hazards (rugs, clutter)
• Install grab bars and railings
• Improve lighting throughout home
• Regular vision and balance checks
• Review medications affecting balance
• Wear appropriate footwear
• Use assistive devices when needed

Workplace Safety

• Follow OSHA guidelines
• Use proper fall protection equipment
• Maintain three points of contact on ladders
• Regular safety training
• Report unsafe conditions

Bone Health

• Adequate calcium and vitamin D intake
• Regular weight-bearing exercise
• Avoid smoking and excessive alcohol
• Bone density screening when appropriate
• Treatment of osteoporosis

When to See a Doctor

Neck fractures are medical emergencies. Any suspicion of neck injury requires immediate medical attention.

Call 911 Immediately For

• Any significant trauma to head or neck
• Severe neck pain after injury
• Inability to move neck normally
• Numbness, tingling, or weakness in arms or legs
• Loss of bladder or bowel control
• Difficulty breathing after neck injury
• Visible deformity of neck
• Loss of consciousness with neck trauma

Do NOT Move the Person If

• They complain of severe neck pain
• There's obvious head or neck trauma
• They have any neurological symptoms
• They're unconscious after trauma
• The mechanism suggests possible neck injury

While Waiting for Help

• Keep the person still
• Place towels on both sides of neck
• Hold head and neck in position found
• Do not remove helmets
• Monitor breathing and consciousness
• Keep person warm

Follow-up Care Needed For

• Persistent neck pain after initial treatment
• New neurological symptoms
• Difficulty with prescribed collar or brace
• Signs of infection at surgical sites
• Problems with breathing or swallowing

Related Conditions

Several conditions are associated with or may complicate neck fractures:

Spinal Injuries

• Spinal cord injury
• Whiplash
• Herniated disc
• Spinal stenosis
• Spondylolisthesis

Associated Traumatic Injuries

• Traumatic brain injury
• Skull fracture
• Facial fractures
• Chest trauma
• Vertebral artery dissection

Degenerative Conditions

• Cervical spondylosis
• Osteoporosis
• Rheumatoid arthritis
• Ankylosing spondylitis

Complications

• Chronic pain syndrome
• Complex regional pain syndrome
• Post-traumatic arthritis
• Syringomyelia

References

1. Fehlings MG, Tetreault LA, Wilson JR, et al. A Clinical Practice Guideline for the Management of Acute Spinal Cord Injury: Introduction, Rationale, and Scope. Global Spine J. 2017;7(3 Suppl):84S-94S.
2. Theodore N. Updated Guidelines for the Management of Acute Cervical Spine and Spinal Cord Injury. Neurosurgery. 2013;72(Suppl 2):1.
3. Schroeder GD, Kepler CK, Kurd MF, et al. A Systematic Review of the Treatment of Geriatric Type II Odontoid Fractures. Neurosurgery. 2015;77(Suppl 4):S6-14.
4. Aarabi B, Walters BC, Dhall SS, et al. Subaxial Cervical Spine Injury Classification Systems. Neurosurgery. 2013;72(Suppl 2):170-186.
5. Joaquim AF, Patel AA. Subaxial Cervical Spine Trauma: Evaluation and Surgical Decision-Making. Global Spine J. 2014;4(1):63-70.
6. American Spinal Injury Association. International Standards for Neurological Classification of Spinal Cord Injury. Richmond, VA: ASIA; 2019.
7. Hadley MN, Walters BC, Grabb PA, et al. Guidelines for the management of acute cervical spine and spinal cord injuries. Clin Neurosurg. 2002;49:407-498.
8. Hoffman JR, Mower WR, Wolfson AB, et al. Validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt trauma. N Engl J Med. 2000;343(2):94-99.
9. Stiell IG, Wells GA, Vandemheen KL, et al. The Canadian C-spine rule for radiography in alert and stable trauma patients. JAMA. 2001;286(15):1841-1848.
10. Gelb DE, Hadley MN, Aarabi B, et al. Initial closed reduction of cervical spinal fracture-dislocation injuries. Neurosurgery. 2013;72(Suppl 2):73-83.