High Yield Overview

TEARDROP FRACTURES

Flexion (Burst) vs Extension (Avulsion) | SLIC Classification | Anterior Corpectomy | Spinal Cord Injury

C5-C6most common level

FlexionUNSTABLE (3-column burst)

Extensionusually stable (avulsion)

SLIC 6+flexion teardrop score

Types of Teardrop Fractures

Flexion Teardrop

PatternAxial load + Flexion. Unstable burst. Often quad.

TreatmentAnterior Corpectomy + Fusion

Extension Teardrop

PatternHyperextension + Axial load. Avulsion of AIBL. Usually stable.

TreatmentCollar / Halo

Critical Must-Knows

Two Types: Flexion Teardrop (Unstable, Burst) vs Extension Teardrop (Usually Stable, Avulsion).
Flexion Teardrop: Catastrophic injury. Kyphosis, retropulsed fragment, ALL ligaments disrupted. Quadriplegia common.
Extension Teardrop: Elderly/Osteoporotic. Avulsion of anteroinferior vertebral body by ALL. Usually stable.
Imaging: CT to assess fragment and canal. MRI for discs/ligaments/cord.
Treatment: Flexion teardrop needs surgical stabilization. Extension teardrop often non-op.

Examiner's Pearls

"
The 'Teardrop' fragment is misleading - Flexion type is a BURST injury, not just an avulsion.
"
Flexion Teardrop has ALL THREE column disruption (Unstable).
"
Extension Teardrop is an avulsion at the ALL attachment (Stable unless severe).
"
Check for Sagittal Vertebral Body Fracture (Flexion Teardrop splits the body).

Teardrop Fracture Pitfalls

Confusing the Two

Flexion vs Extension. They have opposite stability profiles. Flexion = Unstable. Extension = Usually Stable. Know the difference.

Underestimating Flexion Teardrop

It's a BURST Injury. The fragment is just the tip of the iceberg. There is posterior ligamentous disruption and retropulsion.

Neurological Injury

Expect Cord Injury. Flexion teardrop often presents with quadriplegia or anterior cord syndrome.

Delayed Instability

Extension Teardrop Can Progress. If severe, may have delayed instability. Follow-up imaging.

At a Glance: Flexion vs Extension Teardrop

Feature	Flexion Teardrop	Extension Teardrop
Mechanism	Axial Load + Flexion (Diving)	Hyperextension + Axial Load
Patient	Young, High Energy	Elderly, Osteoporotic
Pathology	Burst (3-Column)	Avulsion (Anterior Column)
Stability	UNSTABLE	Usually STABLE
Cord Injury	Common (Quad/Anterior Cord)	Rare
Treatment	Surgery (ACDF/Corpectomy)	Collar / Halo

Mnemonic

BURSTFlexion Teardrop Features

Burst

Vertebral body comminuted (Burst injury)

Unstable

Three-column injury. Grossly unstable.

Retropulsion

Posterior fragment into canal

Sagittal Split

Sagittal fracture through vertebral body

Teardrop

Anteroinferior fragment (The 'Teardrop')

Memory Hook:Flexion Teardrop is a BURST injury.

Mnemonic

AVULSIONExtension Teardrop Features

ALL

Anterior Longitudinal Ligament avulses fragment

Vertebra Intact

Body is otherwise intact (Not comminuted)

Usually Stable

Anterior column injury only

Low Energy (Elderly)

Hyperextension in osteoporotic bone

Stable Usually

Conservative management often sufficient

Memory Hook:Extension Teardrop is an AVULSION.

Mnemonic

Dive InDiving Injury Pattern

Diving

Classic mechanism - Head strikes bottom

Impact

Axial load through vertex

Vertex Load

Force transmitted down spine

Extension then Flexion

Initial extension then flexion rebound

Memory Hook:Diving causes Flexion Teardrop.

Overview and Epidemiology

Why This Topic Matters

Teardrop fractures are cervical spine injuries with a triangular fragment from the anteroinferior vertebral body. There are TWO distinct types with opposite stability profiles: Flexion Teardrop (unstable burst injury, surgery needed) and Extension Teardrop (stable avulsion, usually conservative). Understanding the distinction is critical - flexion teardrop is a catastrophic 3-column injury often causing quadriplegia, while extension teardrop is usually stable with excellent prognosis.

Demographics

Flexion Teardrop: Young adults, high-energy trauma (diving, MVC, sports)
Extension Teardrop: Elderly, low-energy falls with hyperextension
Level: Most commonly C5 or C6
Gender: No specific predilection

Impact

Flexion: Catastrophic injury, high rate of quadriplegia, poor prognosis
Extension: Usually stable, excellent prognosis with conservative treatment
Neurological: Flexion teardrop often causes anterior cord syndrome or complete injury
Surgery: Flexion teardrop requires anterior corpectomy, extension rarely needs surgery

Anatomy and Pathophysiology

Flexion Teardrop (Burst Mechanism):

Axial Load: Force transmitted down the spine (head strike).
Flexion: Cervical spine flexed at moment of impact.
Burst: Vertebral body comminutes. Sagittal split common.
Posterior Element Disruption: Posterior ligamentous complex fails in tension.
Retropulsion: Posterior body fragment retropulses into canal.

Result: Three-column injury. Grossly unstable. Cord compression.

Extension Teardrop (Avulsion Mechanism):

Hyperextension: Cervical spine hyperextends.
Axial Load: Some axial component.
ALL Tension: Anterior Longitudinal Ligament fails, avulsing a fragment.

Result: Anterior column injury only. Stable (unless severe disc disruption).

Key Differentiator:

Flexion: Look for sagittal body fracture, posterior ligament injury, kyphosis.
Extension: Fragment is from anteroinferior body. Body otherwise intact. No kyphosis.

Classification Systems

Teardrop Fracture Types

Type	Mechanism	Pathology	Stability	Neurology	Treatment
Flexion Teardrop	Axial load + flexion (diving)	Burst (3-column injury)	UNSTABLE	Common (quad/anterior cord)	Surgery (ACCF)
Extension Teardrop	Hyperextension + axial load	Avulsion (anterior column)	Usually STABLE	Rare	Collar/halo (conservative)

Key Distinction

Flexion Teardrop is a BURST injury (3-column, unstable, surgery needed) - the teardrop fragment is just the tip of the iceberg. Extension Teardrop is an AVULSION (anterior column only, usually stable, conservative). The teardrop fragment looks similar but the injuries are vastly different.

Clinical Assessment

History

Mechanism: Diving (classic for flexion), MVC, fall with hyperextension (extension)
Neurology: Weakness, numbness, bowel/bladder issues
Pain: Neck pain, may radiate
Age: Young (flexion), elderly (extension)

Examination

Immobilization: Maintain C-spine precautions (collar)
Neurological: Full motor/sensory exam, rectal tone, anal wink
Cord syndromes: Anterior cord, central cord, complete injury
Stability: Do not test range of motion - maintain immobilization

Cord Syndromes

Flexion teardrop often causes:

Anterior Cord Syndrome: Motor loss, pain/temperature loss, preserved proprioception/vibration
Central Cord Syndrome: Upper limbs greater than lower limbs weakness
Complete Cord Injury: No motor/sensory below level

Extension teardrop rarely causes neurological injury.

Cord Syndrome Patterns

Syndrome	Motor	Sensory	Prognosis
Anterior Cord	Complete loss below level	Pain/temp lost, proprioception preserved	Poor - anterior spinal artery
Central Cord	Upper limbs greater than lower	Variable	Better - may recover function
Complete Cord	No motor below level	No sensation below level	Poor - unlikely recovery

Investigations

Imaging Protocol

First LinePlain Radiographs

AP, lateral, odontoid views - may show teardrop fragment.

Findings:

Teardrop fragment (anteroinferior corner)
Kyphosis (flexion teardrop)
Widening of interspinous distance (flexion teardrop)
Loss of vertebral body height (flexion teardrop)

Gold StandardCT Scan

Essential for assessment - 1mm cuts with reconstructions.

Assess:

Fragment size and location
Vertebral body comminution (flexion) vs intact (extension)
Sagittal split (flexion teardrop - key finding)
Retropulsed fragment (flexion teardrop)
Facet alignment
Canal compromise

EssentialMRI Scan

Required for soft tissue assessment.

Assess:

Spinal cord (edema, contusion, compression)
Disc herniation
Posterior ligamentous complex (PLC) integrity
Anterior longitudinal ligament (ALL)
DLC (disco-ligamentous complex) status

Imaging Key Findings

Flexion Teardrop: Sagittal vertebral body fracture (key!), body comminution, kyphosis, retropulsed fragment, PLC disruption. Extension Teardrop: Small fragment, body otherwise intact, no sagittal split, no kyphosis, posterior elements intact. CT is essential to differentiate - sagittal split is the key finding for flexion teardrop.

Management Algorithm

Flexion Teardrop Management

Surgical Stabilization Required.

Immediate: C-spine immobilization. ICU admission.
Traction: May be used for initial alignment (Gardner-Wells tongs).
Imaging: CT + MRI.
Surgery:
- Approach: Anterior (Corpectomy + Cage + Plate) OR Combined Anterior-Posterior.
- Anterior Corpectomy: Remove fractured vertebra. Structural graft. Plate fixation.
- Posterior Stabilization: Lateral mass screws/rods if significant kyphosis or posterior instability.
Post-op: ICU monitoring. Collar.

Anterior approach addresses the main pathology (burst body + disc). Posterior added if severe kyphosis.

Surgical Technique

Anterior Cervical Corpectomy and Fusion (ACCF)

For Flexion Teardrop.

Positioning: Supine, head neutral. Inline traction.
Approach: Standard anterior cervical (left-sided). Platysma, longus colli.
Discectomy: Remove discs above and below fractured level.
Corpectomy: Remove fractured vertebral body. Decompress canal.
Graft: Structural cage (titanium or PEEK) filled with bone graft.
Plate: Anterior cervical plate spanning levels above and below.
Closure: Hemostasis. Drain optional. Layered closure.

May add posterior stabilization if severe ligamentous injury.

Complications

Complication	Risk Factor	Management
Neurological Deterioration	Missed instability / Surgical	ICU monitoring / Revision
Non-union	Osteoporosis / Poor fixation	Revision surgery
Kyphosis	Inadequate correction	Extension osteotomy / Revision
Adjacent Segment Disease	Fusion	Surveillance / Revision
Dysphagia	Anterior approach	Usually transient / SLP

Postoperative Care and Rehabilitation

Rehabilitation Timeline

Immediate PostopWeeks 0-2

ICU monitoring: Especially if cord injury, MAP goals

Collar: Rigid cervical collar

DVT prophylaxis: Mechanical + chemical (if no contraindication)

Mobilization: Early mobilization if neurologically intact

Early RecoveryWeeks 2-6

Collar: Continue rigid collar

X-ray: 6-week check for fusion

Rehabilitation: Spinal cord rehab if injury

Activity: Avoid heavy lifting, contact sports

Progressive LoadingWeeks 6-12

If fusion: May remove collar

X-ray: Confirm fusion

Activity: Gradual return to activities

Follow-up: Flexion-extension X-rays

Outcomes and Prognosis

Type	Key Outcomes	Notes
Flexion Teardrop	Guarded prognosis, high permanent neurological deficit	Poor recovery even with surgery, anterior cord syndrome common
Extension Teardrop	Excellent prognosis with conservative care	95%+ heal with collar, rarely need surgery
Fusion Rates	90%+ with modern instrumentation (ACCF)	High success with anterior corpectomy and fusion

Predictors of Outcome

Neurological status at presentation is the strongest predictor of outcome. Flexion teardrop has guarded prognosis with high rate of permanent neurological deficit. Extension teardrop has excellent prognosis with conservative treatment. Fusion rates are high (90%+) with modern anterior corpectomy and fusion techniques.

Evidence Base and Key Trials

Flexion Teardrop - Original Description

Schneider RC et al • J Neurosurg (1956)

Key Findings:

Original description of the flexion teardrop injury
Identified it as a severe, unstable burst injury
Associated with anterior cord syndrome
Requires surgical stabilization

Clinical Implication: Flexion teardrop is a catastrophic 3-column burst injury requiring surgical stabilization. Original description established the severity of this injury pattern.

Limitation: Historical descriptive study, limited outcome data.

Extension Teardrop - Differentiation

Harris JH et al • Radiology (1994)

Key Findings:

Differentiated extension teardrop from flexion type
Extension teardrop is an avulsion injury at ALL attachment
Usually stable and managed conservatively
Body otherwise intact, no sagittal split

Clinical Implication: Extension teardrop is distinct from flexion type - avulsion injury, usually stable, excellent prognosis with conservative treatment.

Limitation: Descriptive study, limited outcome data.

SLIC Classification System

Vaccaro AR et al • Spine (2007)

Key Findings:

Developed the Subaxial Injury Classification (SLIC)
Three components: Morphology (0-4), DLC (0-2), Neurology (0-4)
SLIC greater than 4 = Surgery recommended
Provides score-based approach to management

Clinical Implication: SLIC score guides treatment decisions. Flexion teardrop typically scores 6+ (surgery required), extension teardrop scores 1-3 (usually conservative).

Limitation: Consensus-based classification, limited validation studies.

Anterior Corpectomy Outcomes

Dvorak MF et al • Spine (2007)

Key Findings:

Reviewed surgical outcomes for subaxial cervical injuries
ACCF effective for burst-type injuries
High fusion rates (90%+) with modern instrumentation
Combined anterior-posterior approach for severe 3-column injuries

Clinical Implication: Anterior corpectomy and fusion (ACCF) is effective for flexion teardrop fractures. High fusion rates with modern techniques. Combined approach may be needed for severe instability.

Limitation: Retrospective review, limited comparative studies.

Spinal Cord Injury Prognosis

Kirshblum SC et al • Spinal Cord (2011)

Key Findings:

Complete spinal cord injuries have poor recovery
Incomplete injuries (anterior cord syndrome) may have partial recovery
Early decompression (within 24 hours) may improve outcomes in incomplete injuries
Neurological status at presentation predicts outcome

Clinical Implication: Neurological status at presentation is the strongest predictor of outcome. Complete injuries have poor recovery. Incomplete injuries with compression may benefit from urgent decompression.

Limitation: Observational studies, limited randomized trials.

Exam Viva Scenarios

Practice these scenarios to excel in your viva examination

VIVA SCENARIOStandard

Scenario 1: Diving Injury with Quadriplegia (~2-3 min)

EXAMINER

"A 22-year-old male is brought in after diving into shallow water. He is quadriplegic with no motor or sensory function below C5. GCS 15, breathing spontaneously. What is your assessment and management?"

EXCEPTIONAL ANSWER

This presentation is highly concerning for a **flexion teardrop fracture** - a catastrophic 3-column burst injury. The key features are: diving mechanism (classic for flexion teardrop), quadriplegia (complete cord injury), and high-energy trauma. My approach would be: First, **ATLS primary survey** - secure airway if needed, maintain C-spine immobilization, assess breathing and circulation. Second, **neurological examination** - document complete cord injury (no motor/sensory below C5), assess rectal tone, document ASIA score. Third, **imaging** - CT C-spine to assess fracture pattern (expect burst at C5/C6, teardrop fragment, sagittal split, retropulsion), MRI to assess cord (edema, contusion, compression) and ligaments (PLC disruption). Fourth, **SLIC score** - likely 7+ (morphology 3-4 + DLC 2 + neurology 4), indicating surgical management. Fifth, **surgical planning** - anterior corpectomy and fusion (ACCF) to decompress cord and stabilize, consider posterior stabilization if severe kyphosis or posterior instability. Sixth, **ICU admission** - MAP goals for cord perfusion, monitor for complications. Prognosis is guarded - complete cord injury has poor recovery potential.

KEY POINTS TO SCORE

Recognize flexion teardrop - diving mechanism, quadriplegia, burst injury

ATLS approach - primary survey, C-spine immobilization

Imaging essential - CT for fracture pattern, MRI for cord and ligaments

SLIC score guides treatment - flexion teardrop scores 6+ (surgery required)

Anterior corpectomy and fusion - standard surgical treatment

ICU management - MAP goals, cord injury protocols

COMMON TRAPS

✗Underestimating the injury - it's a 3-column burst, not just an avulsion

✗Delaying imaging - urgent CT and MRI needed

✗Missing posterior instability - may need combined anterior-posterior fixation

✗Not addressing cord injury - MAP goals, ICU monitoring

LIKELY FOLLOW-UPS

"What is the difference between flexion and extension teardrop?"

"What is anterior cord syndrome and how does it differ from complete injury?"

"When would you add posterior stabilization to anterior corpectomy?"

VIVA SCENARIOStandard

Scenario 2: Elderly Fall with Extension Teardrop (~2-3 min)

EXAMINER

"A 78-year-old female presents after a fall with hyperextension of her neck. She has neck pain but no weakness or numbness. X-ray shows a small teardrop fragment at C5. What is your diagnosis and management?"

EXCEPTIONAL ANSWER

This presentation is consistent with an **extension teardrop fracture** - a stable avulsion injury. The key features are: hyperextension mechanism, elderly patient, neurologically intact, and small teardrop fragment. My approach would be: First, **confirm diagnosis** - CT to assess fracture pattern (expect small fragment, body otherwise intact, no sagittal split, posterior elements intact), MRI to assess disc and ligaments (confirm no significant disc injury, DLC intact). Second, **stability assessment** - extension teardrop is usually stable (anterior column only), SLIC score typically 1-3 (conservative). Third, **management** - if MRI shows stable pattern (intact DLC, no significant disc injury), rigid cervical collar for 6-8 weeks. If MRI shows significant disc injury or instability, consider halo vest or rarely ACDF. Fourth, **follow-up** - flexion-extension X-rays at 6 weeks to confirm stability, assess healing. The prognosis is excellent - over 95% heal with conservative treatment. This is distinct from flexion teardrop which is unstable and requires surgery.

KEY POINTS TO SCORE

Recognize extension teardrop - hyperextension mechanism, elderly, stable pattern

CT essential - body intact, no sagittal split (key differentiator)

MRI to assess disc and ligaments - determines if truly stable

Conservative treatment mainstay - collar usually sufficient

Excellent prognosis - 95%+ heal with conservative treatment

COMMON TRAPS

✗Confusing with flexion teardrop - extension is stable, flexion is unstable

✗Over-treating with surgery - extension teardrop rarely needs surgery

✗Missing disc injury on MRI - may indicate need for halo or surgery

LIKELY FOLLOW-UPS

"When would you operate on an extension teardrop?"

"What is the key CT finding that differentiates flexion from extension?"

"What is the SLIC score for extension teardrop?"

VIVA SCENARIOChallenging

Scenario 3: Differentiating Teardrop Types (~3-4 min)

EXAMINER

"You are shown two lateral C-spine X-rays both showing a teardrop fragment. One is from a 25-year-old diver, the other from a 75-year-old who fell. How do you differentiate flexion from extension teardrop?"

EXCEPTIONAL ANSWER

This is a critical distinction as the two types have **opposite stability profiles** and require different treatment. My differentiation would be: First, **patient factors** - young, high-energy (diving) suggests flexion teardrop; elderly, low-energy (fall) suggests extension teardrop. Second, **X-ray findings** - flexion teardrop shows kyphosis, loss of vertebral body height, widened interspinous distance (PLC disruption); extension teardrop shows no kyphosis (may be slight lordosis), body height preserved, posterior elements intact. Third, **CT findings** (most important) - flexion teardrop shows sagittal split through vertebral body (key finding!), body comminution/burst, retropulsed fragment, canal compromise; extension teardrop shows body otherwise intact, no sagittal split, no retropulsion, minimal canal compromise. Fourth, **MRI findings** - flexion teardrop shows PLC disruption, disc injury, cord compression; extension teardrop shows intact PLC, minimal disc injury, no cord compression. Fifth, **SLIC score** - flexion teardrop scores 6+ (surgery required), extension teardrop scores 1-3 (usually conservative). The key is: **Flexion = BURST (3-column, unstable, surgery)**, **Extension = AVULSION (anterior column, stable, conservative)**.

KEY POINTS TO SCORE

Patient factors - age, mechanism help differentiate

CT is key - sagittal split (flexion) vs intact body (extension)

X-ray findings - kyphosis and PLC widening (flexion) vs normal alignment (extension)

MRI findings - PLC disruption (flexion) vs intact (extension)

SLIC score - flexion 6+ (surgery), extension 1-3 (conservative)

COMMON TRAPS

✗Assuming all teardrops are the same - they have opposite stability

✗Treating extension teardrop surgically - usually not needed

✗Missing sagittal split on CT - key finding for flexion teardrop

✗Not assessing PLC on MRI - critical for stability

LIKELY FOLLOW-UPS

"What is the mechanism of each type?"

"What is the SLIC score breakdown for each?"

"What surgical approach would you use for flexion teardrop?"

MCQ Practice Points

Type Differentiation Question

Q: What is the key difference between flexion and extension teardrop fractures? A: Flexion teardrop is a BURST injury (3-column, unstable, surgery needed). Extension teardrop is an AVULSION (anterior column only, usually stable, conservative). The teardrop fragment looks similar but the injuries are vastly different.

Mechanism Question

Q: What is the classic mechanism for flexion teardrop fracture? A: Diving into shallow water - axial load through the vertex with the neck in flexion. This mechanism causes the burst injury pattern.

CT Finding Question

Q: What CT finding differentiates flexion from extension teardrop? A: Sagittal split through the vertebral body in flexion teardrop (key finding!). The body is comminuted/burst. In extension, the body is intact with just an avulsion fragment.

SLIC Score Question

Q: What is the typical SLIC score for flexion teardrop fractures? A: 6-10 points (morphology 3-4 + DLC 2 + neurology 2-4) - well above the surgical threshold of 4. Extension teardrop typically scores 1-3 (usually conservative).

Surgical Treatment Question

Q: What is the surgical treatment for flexion teardrop fractures? A: Anterior cervical corpectomy and fusion (ACCF) - remove fractured vertebra, decompress canal, structural graft, anterior plate. May add posterior stabilization if severe kyphosis or posterior instability.

Cord Syndrome Question

Q: What cord syndrome is commonly associated with flexion teardrop? A: Anterior cord syndrome - loss of motor, pain, and temperature below the level, preserved proprioception and vibration. Complete cord injury is also common.

Australian Context and Medicolegal Considerations

Australian Trauma Systems

Major trauma centers: Spine surgery capability required
Transfer protocols: For complex cervical injuries
C-spine clearance: Follow NEXUS/Canadian C-Spine rules, CT standard
Diving injuries: Important in Australian context (beaches, pools)

Medicolegal Considerations

Documentation: Mechanism, neurological status, imaging findings
Counseling: Surgical vs conservative options, outcomes, prognosis
Informed consent: Surgical risks, infection, nerve injury, dysphagia
Diving prevention: Public health campaigns, safety education

Medicolegal Considerations

Key documentation requirements:

Document mechanism (diving, fall, MVC) and neurological status at presentation
Classify type (flexion vs extension) and document rationale
Counsel about surgical vs conservative options and outcomes
Document informed consent for surgery including risks (infection, dysphagia, nerve injury)
Document prognosis - flexion teardrop has guarded prognosis, extension has excellent

TEARDROP FRACTURES

High-Yield Exam Summary

Key Anatomy

•Teardrop fragment = triangular anteroinferior vertebral body fragment
•Flexion = burst injury (3-column), extension = avulsion (anterior column)
•C5-C6 = most common level for both types
•Posterior ligamentous complex (PLC) = determines stability

Classification

•Flexion teardrop = BURST (unstable, surgery), extension = AVULSION (stable, conservative)
•SLIC score: Flexion 6+ (surgery), extension 1-3 (conservative)
•Sagittal split on CT = key finding for flexion teardrop
•Body intact on CT = extension teardrop

Treatment Algorithm

•Flexion teardrop: Anterior corpectomy and fusion (ACCF), may add posterior
•Extension teardrop: Rigid collar 6-8 weeks, excellent prognosis
•SLIC greater than 4 = surgery recommended
•MRI essential to assess DLC and cord

Surgical Pearls

•ACCF: Remove fractured vertebra, decompress canal, structural graft, anterior plate
•May add posterior stabilization if severe kyphosis or posterior instability
•Protect during positioning - Mayfield clamp, neutral alignment
•High fusion rates (90%+) with modern instrumentation

Complications

•Neurological deterioration: Missed instability, surgical complication
•Nonunion: Osteoporosis, poor fixation - revision surgery
•Kyphosis: Inadequate correction - extension osteotomy
•Dysphagia: Anterior approach - usually transient

Feature

Flexion Teardrop

Extension Teardrop

Mechanism

Axial Load + Flexion (Diving)

Hyperextension + Axial Load

Patient

Young, High Energy

Elderly, Osteoporotic

Pathology

Burst (3-Column)

Avulsion (Anterior Column)

Stability

UNSTABLE

Usually STABLE

Cord Injury

Common (Quad/Anterior Cord)

Rare

Treatment

Surgery (ACDF/Corpectomy)

Collar / Halo

Type

Mechanism

Pathology

Stability

Neurology

Treatment

Flexion Teardrop

Axial load + flexion (diving)

Burst (3-column injury)

UNSTABLE

Common (quad/anterior cord)

Surgery (ACCF)

Extension Teardrop

Hyperextension + axial load

Avulsion (anterior column)

Usually STABLE

Rare

Collar/halo (conservative)

Syndrome

Motor

Sensory

Prognosis

Anterior Cord

Complete loss below level

Pain/temp lost, proprioception preserved

Poor - anterior spinal artery

Central Cord

Upper limbs greater than lower

Variable

Better - may recover function

Complete Cord

No motor below level

No sensation below level

Poor - unlikely recovery

Complication

Risk Factor

Management

Neurological Deterioration

Missed instability / Surgical

ICU monitoring / Revision

Non-union

Osteoporosis / Poor fixation

Revision surgery

Kyphosis

Inadequate correction

Extension osteotomy / Revision

Adjacent Segment Disease

Fusion

Surveillance / Revision

Dysphagia

Anterior approach

Usually transient / SLP

Type

Key Outcomes

Notes

Flexion Teardrop

Guarded prognosis, high permanent neurological deficit

Poor recovery even with surgery, anterior cord syndrome common

Extension Teardrop

Excellent prognosis with conservative care

95%+ heal with collar, rarely need surgery

Fusion Rates

90%+ with modern instrumentation (ACCF)

High success with anterior corpectomy and fusion

Flexion Teardrop - Original Description

Schneider RC et al • J Neurosurg (1956)

Key Findings:

Original description of the flexion teardrop injury
Identified it as a severe, unstable burst injury
Associated with anterior cord syndrome
Requires surgical stabilization

Clinical Implication: Flexion teardrop is a catastrophic 3-column burst injury requiring surgical stabilization. Original description established the severity of this injury pattern.

Limitation: Historical descriptive study, limited outcome data.

Extension Teardrop - Differentiation

Harris JH et al • Radiology (1994)

Key Findings:

Differentiated extension teardrop from flexion type
Extension teardrop is an avulsion injury at ALL attachment
Usually stable and managed conservatively
Body otherwise intact, no sagittal split

Clinical Implication: Extension teardrop is distinct from flexion type - avulsion injury, usually stable, excellent prognosis with conservative treatment.

Limitation: Descriptive study, limited outcome data.

SLIC Classification System

Vaccaro AR et al • Spine (2007)

Key Findings:

Developed the Subaxial Injury Classification (SLIC)
Three components: Morphology (0-4), DLC (0-2), Neurology (0-4)
SLIC greater than 4 = Surgery recommended
Provides score-based approach to management

Clinical Implication: SLIC score guides treatment decisions. Flexion teardrop typically scores 6+ (surgery required), extension teardrop scores 1-3 (usually conservative).

Limitation: Consensus-based classification, limited validation studies.

Anterior Corpectomy Outcomes

Dvorak MF et al • Spine (2007)

Key Findings:

Reviewed surgical outcomes for subaxial cervical injuries
ACCF effective for burst-type injuries
High fusion rates (90%+) with modern instrumentation
Combined anterior-posterior approach for severe 3-column injuries

Limitation: Retrospective review, limited comparative studies.

Spinal Cord Injury Prognosis

Kirshblum SC et al • Spinal Cord (2011)

Key Findings:

Complete spinal cord injuries have poor recovery
Incomplete injuries (anterior cord syndrome) may have partial recovery
Early decompression (within 24 hours) may improve outcomes in incomplete injuries
Neurological status at presentation predicts outcome

Limitation: Observational studies, limited randomized trials.

Component	Flexion Teardrop	Extension Teardrop	Points
Morphology	Burst + translation	Compression/avulsion	Flexion: 3-4, Extension: 1-2
DLC Status	Disrupted	Intact/indeterminate	Flexion: 2, Extension: 0-1
Neurology	Complete/incomplete cord injury	Intact	Flexion: 2-4, Extension: 0
Total SLIC	6-10 (surgery required)	1-3 (usually conservative)	Greater than 4 = surgery

Component	Flexion Teardrop	Extension Teardrop	Points
Morphology	Burst + translation	Compression/avulsion	Flexion: 3-4, Extension: 1-2
DLC Status	Disrupted	Intact/indeterminate	Flexion: 2, Extension: 0-1
Neurology	Complete/incomplete cord injury	Intact	Flexion: 2-4, Extension: 0
Total SLIC	6-10 (surgery required)	1-3 (usually conservative)	Greater than 4 = surgery

Teardrop Fractures

Teardrop Fractures

TEARDROP FRACTURES

Types of Teardrop Fractures

Critical Must-Knows

Examiner's Pearls

Teardrop Fracture Pitfalls

Confusing the Two

Underestimating Flexion Teardrop

Neurological Injury

Delayed Instability

At a Glance: Flexion vs Extension Teardrop

BURSTFlexion Teardrop Features

AVULSIONExtension Teardrop Features

Dive InDiving Injury Pattern

Overview and Epidemiology

Demographics

Impact

Anatomy and Pathophysiology

Classification Systems

Teardrop Fracture Types

SLIC Score (Subaxial Injury Classification)

Clinical Assessment

History

Examination

Cord Syndromes

Cord Syndrome Patterns

Investigations

Imaging Protocol

Management Algorithm

Flexion Teardrop Management

Extension Teardrop Management

Surgical Technique

Anterior Cervical Corpectomy and Fusion (ACCF)

Posterior Cervical Fusion

Complications

Complications

Postoperative Care and Rehabilitation

Rehabilitation Timeline

Rehabilitation Timeline

Outcomes and Prognosis

Evidence Base and Key Trials

Flexion Teardrop - Original Description

Extension Teardrop - Differentiation

SLIC Classification System

Anterior Corpectomy Outcomes

Spinal Cord Injury Prognosis

Exam Viva Scenarios

Scenario 1: Diving Injury with Quadriplegia (~2-3 min)

Scenario 2: Elderly Fall with Extension Teardrop (~2-3 min)

Scenario 3: Differentiating Teardrop Types (~3-4 min)

MCQ Practice Points

Australian Context and Medicolegal Considerations

Australian Trauma Systems

Medicolegal Considerations

Medicolegal Considerations

TEARDROP FRACTURES

Key Anatomy

Classification

Treatment Algorithm

Surgical Pearls

Complications

Teardrop Fractures

Teardrop Fractures

TEARDROP FRACTURES

Types of Teardrop Fractures

Critical Must-Knows

Examiner's Pearls

Teardrop Fracture Pitfalls

Confusing the Two

Underestimating Flexion Teardrop

Neurological Injury

Delayed Instability

At a Glance: Flexion vs Extension Teardrop

BURSTFlexion Teardrop Features

AVULSIONExtension Teardrop Features

Dive InDiving Injury Pattern

Overview and Epidemiology

Demographics

Impact