Teardrop Fractures

A teardrop fracture is a cervical spine injury with a triangular fragment from the anteroinferior corner of the vertebral body. The name covers two distinct injuries with opposite stability profiles, and the fragment looks similar in both. Confusing them is the classic error: the flexion teardrop is a catastrophic three-column injury that often causes quadriplegia, while the extension teardrop is usually stable with an excellent prognosis.

The flexion teardrop. An unstable burst injury of young adults in high-energy trauma, from diving, motor vehicle collisions and sports, and predominantly an injury of young males. It carries a high rate of quadriplegia, often as an anterior cord syndrome or a complete injury, and a poor prognosis. It requires surgical stabilisation with anterior corpectomy.

The extension teardrop. An avulsion injury of elderly, osteoporotic patients after a low-energy fall with hyperextension. It is usually stable, rarely needs surgery and has an excellent prognosis with conservative treatment.

Level. Teardrop fractures most commonly occur at C5 or C6.

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The flexion teardrop is a burst. The classic mechanism is a dive into shallow water: the head strikes the bottom and the axial load passes through the vertex and down the spine, with the neck flexed at the moment of impact. The load compresses the anterior body until a triangular anteroinferior fragment shears off, while the posterior ligaments fail in distraction. The vertebral body comminutes, a sagittal split is common, the posterior ligamentous complex fails in tension and the posterior part of the body retropulses into the canal, while the anteroinferior fragment remains tethered by the anterior longitudinal ligament. The result is a three-column injury, grossly unstable, with cord compression.

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The extension teardrop is an avulsion. The spine hyperextends, with some axial component, and the anterior longitudinal ligament fails in tension, avulsing a small fragment from the anteroinferior body. The body is otherwise intact and not comminuted, and the posterior elements are intact; the injury is confined to the anterior column. Imaging shows prevertebral soft tissue swelling with subtle anterior disc space widening. It is stable unless there is severe disc disruption, and a severe injury may develop delayed instability, which is why it is followed up with imaging.

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Telling them apart. Fragment size, the alignment of the vertebra behind it and the mechanism separate the two:

• Flexion: sagittal body fracture, posterior ligament injury, kyphosis
• Extension: small fragment from the anteroinferior body, body otherwise intact, no kyphosis

History. The mechanism and age point to the type. Diving is classic for the flexion teardrop, which motor vehicle collisions also cause, and a fall with hyperextension points to the extension teardrop. The flexion patient is young, the extension patient elderly. Ask about weakness, numbness and bowel or bladder symptoms, and about neck pain, which may radiate.

Examination. Maintain cervical spine precautions in a collar and do not test range of motion. The neurological examination is full motor and sensory, including rectal tone and the anal wink. Chart light touch and pinprick by dermatome and motor power by key myotome on the ASIA chart, with the sacral examination for sparing, at presentation and serially: serial charts are what demonstrate recovery or deterioration objectively.

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Cord syndromes. A flexion teardrop often causes an anterior cord syndrome, a central cord syndrome or a complete cord injury. An extension teardrop rarely causes neurological injury.

Spinal shock is neurological. It is the transient loss of all reflex activity below the injury immediately after cord injury, with flaccid paralysis, areflexia and loss of the bulbocavernosus and anal reflexes, and it resolves over hours to days. Return of the bulbocavernosus reflex (S2-S4) marks its end. You cannot accurately classify an injury as ASIA A (complete) while the patient is still in spinal shock, because apparent total loss may partly recover.

Neurogenic shock is haemodynamic. It is seen in cervical and high-thoracic (above T6) cord injury, where loss of sympathetic outflow causes hypotension with bradycardia and warm, vasodilated peripheries. That is the opposite of the tachycardic, vasoconstricted picture of haemorrhagic shock.

Associated injuries. The flexion teardrop is a high-energy injury and rarely travels alone. Look for a second non-contiguous spinal fracture, vertebral artery injury, and concurrent head, chest and abdominal trauma; an injury at C3 to C5 additionally threatens respiratory function.

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Differential diagnosis. Several entities put a fragment at the anteroinferior corner of a cervical body:

Radiographs. AP, lateral and odontoid views come first and may show the teardrop fragment at the anteroinferior corner. The findings of a flexion teardrop are:

• Retrolisthesis and kyphosis
• Widening of the interspinous distance
• Loss of vertebral body height

CT. The gold standard and essential for assessment, with 1mm cuts and reconstructions. CT is what differentiates the two types, and the key finding is the sagittal split through the body of a flexion teardrop. Assess:

• Fragment size and location
• Vertebral body comminution (flexion) or an intact body (extension)
• Retropulsed fragment (flexion)
• Facet alignment
• Canal compromise

MRI. Required for soft-tissue assessment, and mandatory before reduction or surgery. A disc extruded behind the vertebral body changes the approach from posterior to anterior. Assess:

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

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Algorithm

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Flexion teardrop: surgical stabilisation. Surgery is required, and the sequence is:

1. Immediate cervical spine immobilisation and ICU admission
2. Traction may be used for initial alignment (Gardner-Wells tongs)
3. Imaging: CT and MRI
4. Surgery: anterior corpectomy with cage and plate, or a combined anterior-posterior approach
5. Postoperative ICU monitoring and a collar

The exception is the one the SLIC section describes: with an intact neurological examination the composite score may not reach the operative tier, and conservative management can be chosen.

Choosing the approach. The anterior approach addresses the main pathology, the burst body and the disc. The fractured vertebra is removed, which decompresses the retropulsed fragment directly, and a structural graft and plate are placed. Posterior stabilisation with lateral mass screws and rods is added for significant kyphosis or posterior instability, making the fixation circumferential when the posterior ligaments have failed or the anterior construct alone will not hold in a severely kyphotic, three-column injury.

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Extension teardrop: usually non-operative. Most extension teardrops heal with immobilisation, and treatment is graded by severity:

• Mild (stable MRI): rigid cervical collar for 6-8 weeks
• Moderate (disc concern): halo vest for 8-12 weeks
• Severe (instability): rarely, ACDF if there is significant disc disruption or delayed instability

Flexion-extension radiographs at 6 weeks confirm stability.

Neurological status at presentation is the strongest predictor of outcome.

Flexion teardrop. The prognosis is guarded, with a high rate of permanent neurological deficit and poor recovery even with surgery; anterior cord syndrome is common. Fusion rates are high, 90%+ with modern instrumentation and anterior corpectomy and fusion.

Extension teardrop. The prognosis is excellent with conservative care: 95%+ heal in a collar, and surgery is rarely needed.

Timing of decompression. STASCIS supports decompression within 24 hours, but it was a non-randomised cohort and the benefit is clearest in incomplete injuries. The practical "ultra-early" (under 12h) target and its benefit in complete injuries remain debated, and logistics often dominate real-world timing.

Anterior or combined approach. A single anterior corpectomy addresses the burst body and retropulsion, but the threshold for adding posterior fixation (degree of kyphosis, facet injury, PLC failure, osteoporosis) is not standardised and varies by surgeon and registry.

Defining a "stable" extension teardrop. There is no validated cut-off separating a benign avulsion from an unstable hyperextension injury. MRI assessment of the disc and ALL is operator-dependent, and delayed instability is occasionally reported, justifying interval flexion-extension films.

Steroids in acute spinal cord injury. High-dose methylprednisolone remains contentious. Several guidelines no longer recommend it routinely because the marginal neurological benefit is outweighed by infective and metabolic complications, and practice varies widely between regions.