Teardrop Fracture¶
Definition¶
Teardrop fractures of the cervical spine are characterized by a triangular bone fragment avulsed from the anteroinferior corner of a vertebral body. Despite their similar radiographic appearance, flexion teardrop fractures and extension teardrop fractures have fundamentally different mechanisms, stability profiles, and clinical significance.
Flexion Teardrop Fracture¶
Mechanism¶
Severe hyperflexion with axial compression — the classic scenario is diving into shallow water or a motor vehicle collision with a direct blow to the vertex of the head.
This is an unstable fracture and one of the most devastating cervical spine injuries. The axial-flexion force causes:
- A triangular fragment to shear from the anteroinferior vertebral body
- Comminution of the vertebral body with retropulsion of the posterior body into the spinal canal
- Complete disruption of the posterior ligamentous complex, disc, and usually the posterior longitudinal ligament
- The posterior vertebral body fragment compresses the anterior spinal cord
Imaging Findings¶
CT:
- Triangular fragment from the anteroinferior vertebral body
- Sagittal vertebral body fracture (a key distinguishing feature) — the body is split in the sagittal plane
- Retropulsion of the posterior vertebral body into the canal
- Widening of the facet joints and interspinous distance posteriorly
- Kyphotic angulation at the fracture level
MRI:
- Spinal cord compression and edema/hemorrhage
- Posterior ligamentous complex disruption
- Disc disruption
- Epidural hematoma
Clinical Significance¶
Flexion teardrop fractures are strongly associated with anterior cord syndrome — loss of motor function and pain/temperature sensation below the level of injury, with preservation of posterior column function (proprioception, vibration, deep pressure). This occurs because the retropulsed bone fragment damages the anterior two-thirds of the spinal cord.
Clinical Pearl
The sagittal vertebral body fracture is a critical distinguishing feature of the flexion teardrop fracture. If you see a triangular anteroinferior fragment AND a sagittal body fracture on coronal CT AND distraction of the posterior elements, this is a flexion teardrop injury — an unstable, three-column injury — not a benign extension teardrop.
Extension Teardrop Fracture¶
Mechanism¶
Hyperextension — the anterior longitudinal ligament (ALL) avulses a triangular fragment from the anteroinferior vertebral body as the spine extends.
Imaging Findings¶
CT:
- Small triangular fragment from the anteroinferior vertebral body (similar location to flexion teardrop)
- No sagittal vertebral body fracture
- No retropulsion or posterior element disruption
- The fragment's vertical height is typically equal to or greater than its transverse dimension
- Most common at C2
Clinical Significance¶
Extension teardrop fractures are generally stable injuries. The posterior ligamentous complex is intact, and there is no retropulsion into the canal. They are most common in elderly patients with degenerative spines.
Distinguishing Flexion from Extension Teardrop¶
| Feature | Flexion Teardrop | Extension Teardrop |
|---|---|---|
| Mechanism | Hyperflexion + axial load | Hyperextension |
| Stability | Unstable (3-column) | Stable |
| Sagittal body fracture | Present | Absent |
| Retropulsion | Present | Absent |
| Posterior elements | Disrupted | Intact |
| Most common level | C4–C6 | C2 |
| Neurological deficit | Common (anterior cord syndrome) | Rare |
| Management | Surgical | Cervical collar |
Key Points¶
- Flexion teardrop fractures are highly unstable three-column injuries with frequent anterior cord syndrome
- Extension teardrop fractures are stable single-column injuries that mimic flexion teardrop on lateral view
- The sagittal vertebral body fracture on coronal CT distinguishes the unstable flexion teardrop from the benign extension teardrop
- Retropulsion of the posterior body into the canal is the hallmark of flexion teardrop injuries
- MRI is essential in flexion teardrop fractures to evaluate cord injury and posterior ligamentous disruption
References¶
- Kim KS, Chen HH, Russell EJ, Rogers LF. Flexion teardrop fracture of the cervical spine: radiographic characteristics. AJR Am J Roentgenol. 1989;152(2):319-326. https://pubmed.ncbi.nlm.nih.gov/2783508/
- Cirillo I, Blanco S, Cabello S, Ricciardi G, Guiroy A, Yurac R. Flexion teardrop fracture of the cervical spine: a narrative review. EFORT Open Rev. 2025;10(10):806-814. https://pmc.ncbi.nlm.nih.gov/articles/PMC12497533/
- Flexion teardrop fracture. Radiopaedia. https://radiopaedia.org/articles/flexion-teardrop-fracture-1
- Extension teardrop fracture of C2. Radiopaedia. https://radiopaedia.org/cases/extension-teardrop-fracture-of-c2
- Extension teardrop fracture cervical spine. Orthobullets. https://www.orthobullets.com/spine/12102/extension-teardrop-fracture-cervical-spine
- Flanders A, Smithuis R. Spine — cervical injury. The Radiology Assistant. 2008. https://radiologyassistant.nl/neuroradiology/spine/cervical-injury