Flexion Teardrop Fracture of the Cervical Spine: Causes, Symptoms, Diagnosis, Treatment and Prognosis — Comprehensive Medical Guide

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Introduction

Flexion teardrop fracture of the cervical spine is one of the most severe and unstable cervical spine injuries encountered in trauma medicine and neurosurgery. Recognizing this injury and applying timely treatment is essential for preventing catastrophic neurological deficits. This comprehensive guide covers the causes, pathophysiology, epidemiology, clinical symptoms, imaging diagnosis, differential diagnosis, treatment strategies, and long-term prognosis of flexion teardrop fractures. 

Pathophysiology of Flexion Teardrop Fracture

A cervical flexion teardrop fracture occurs due to extreme hyperflexion combined with axial compression. This force produces shearing and compressive stresses that damage both bony and ligamentous structures:

  • Avulsion of the anteroinferior vertebral body corner fragment (the “teardrop”).

  • Rupture of the anterior longitudinal ligament (ALL).

  • Disruption of the posterior ligamentous complex (supraspinous, interspinous, ligamentum flavum).

  • Potential posterior displacement of fragments into the spinal canal, leading to severe spinal cord compression.

Key point: Unlike extension teardrop fractures (common at C2, stable, and caused by hyperextension), flexion teardrop fractures at C4–C6 are unstable and often associated with permanent neurological injury.

Epidemiology

Flexion teardrop fractures are relatively uncommon but disproportionately severe:

  • Represent ~8% of all cervical spine fractures.

  • Most frequently occur at C4, C5, and C6 vertebrae.

  • Strongly linked to high-energy trauma: motor vehicle accidents, sports injuries, and falls.

  • Predominantly affect young adult males, though elderly patients with cervical degeneration may also sustain these fractures.

Clinical Symptoms and Presentation

Patients with a flexion teardrop fracture typically present with:

  • Severe neck pain immediately following trauma.

  • Neurological deficits ranging from radiculopathy to quadriplegia.

  • Up to 60% of cases involve acute spinal cord injury.

  • Elderly patients with degenerative cervical spondylosis may have subtle symptoms but carry higher instability risk.

Imaging Features

Radiography and CT findings:

  • A distinct triangular bony fragment at the anteroinferior vertebral body margin.

  • Abnormal cervical spine alignment, often with kyphotic angulation.

  • Widening of interspinous distance.

  • Posterior displacement of vertebral body and fracture fragments.

MRI findings:

  • Crucial for assessing ligamentous injury and spinal cord compression.

  • Reveals cord edema, contusion, or hemorrhage.


Figure 1. Cervical Spine CT — Demonstrates a displaced C5 flexion teardrop fracture with posterior translation compromising the spinal canal.

Differential Diagnosis

When interpreting cervical spine imaging, flexion teardrop fractures should be differentiated from:

  1. Extension teardrop fractures (C2, stable, hyperextension mechanism).

  2. Avulsion of anterior osteophytes.

  3. Cervical burst fractures.

  4. Chance fractures.

Diagnosis

A proper diagnosis combines:

  • History of high-energy flexion trauma.

  • CT scan for bony detail.

  • MRI for soft tissue and cord evaluation.

  • Recognition of instability is critical, as conservative management is rarely sufficient.

Treatment and Management

Treatment options for flexion teardrop fractures vary by stability and neurological involvement:

  • Conservative (rare): Reserved for neurologically intact patients with stable injury patterns. Involves rigid cervical collar or halo vest.

  • Surgical management (standard of care):

    • Anterior decompression and fusion to remove compressive fragments.

    • Posterior instrumentation for multi-column instability.

    • Combined anterior-posterior approach in complex or comminuted injuries.

Early surgery is recommended to minimize secondary neurological deterioration.

Prognosis

  • Patients with complete spinal cord injury at presentation have poor prognosis.

  • Those with incomplete deficits may experience partial neurological recovery with timely decompression.

  • Mortality and morbidity are higher in elderly patients and polytrauma cases.

Quiz

Q1: What is the most common mechanism of injury for flexion teardrop fractures?

A) Hyperextension

B) Hyperflexion with axial compression

C) Twisting motion

D) Vertical distraction

Q2: Which imaging modality best detects ligamentous disruption in flexion teardrop fractures?

A) X-ray

B) CT scan

C) MRI

D) Ultrasound

Q3: Which cervical levels are most vulnerable to flexion teardrop fractures?

A) C1–C2

B) C3

C) C4–C6

D) T1

Q4: How does a flexion teardrop fracture differ from an extension teardrop fracture?

A) Level involved

B) Stability

C) Mechanism of injury

D) All of the above

Q5: Why are flexion teardrop fractures considered unstable injuries?

A) Only anterior involvement

B) Associated ligamentous disruption and posterior displacement

C) Minimal displacement

D) Occurs only in elderly

Answer and Explanation

1. Answer: B) Hyperflexion with axial compression. Explanation: The classic mechanism is severe flexion with compression, leading to anterior vertebral body corner fracture.

2. Answer: C) MRI. Explanation: MRI is superior for visualizing ligaments and cord pathology.

3. Answer: C) C4–C6. Explanation: These vertebral levels sustain the greatest flexion-compression forces.

4. Answer: D) All of the above.
Explanation: Extension teardrop fractures (C2, stable, hyperextension) differ significantly from flexion teardrop fractures (C4–C6, unstable, hyperflexion).

5. Answer: B) Associated ligamentous disruption and posterior displacement. Explanation: The combination of osseous and ligamentous failure produces spinal instability and high risk of cord injury.

References

[1] K. S. Kim, H. H. Chen, E. J. Russell, and L. F. Rogers, “Flexion teardrop fracture of the cervical spine: Radiographic characteristics,” AJR Am J Roentgenol, vol. 152, no. 2, pp. 319–326, 1989.
[2] H. J. Kim, K. Y. Lee, and W. C. Kim, “Treatment outcome of cervical teardrop fracture,” Asian Spine J, vol. 3, no. 2, pp. 73–79, 2009.
[3] D. S. Korres, K. Stamos, A. Andreakos, S. Spyridonos, and K. Kavadias, “The anterior inferior angle fracture of a lower cervical vertebra,” Eur Spine J, vol. 3, no. 4, pp. 202–205, 1994.
[4] A. Vaccaro, M. Hulbert, P. Patel, et al., “The subaxial cervical spine injury classification system,” Spine, vol. 32, no. 21, pp. 2365–2374, 2007.
[5] R. F. Heary and T. F. Vaccaro, “Management of flexion teardrop fractures,” Neurosurg Focus, vol. 25, no. 5, pp. E8, 2008.
[6] J. Liu, X. Deng, Y. Wang, “Surgical treatment of unstable cervical spine injuries: A comparative study,” J Spinal Disord Tech, vol. 27, no. 1, pp. 15–20, 2014.
[7] C. M. Bono and A. R. Garfin, “Cervical spine trauma,” Spine J, vol. 4, no. 6, pp. 602–613, 2004.

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