Central Line Placement in Patients with Neck Fractures
In patients with neck fractures requiring central venous access, the femoral vein (groin) is the preferred site to avoid manipulation of the cervical spine and potential displacement of unstable fractures. 1
Rationale for Femoral Access
Cervical spine immobilization is paramount in patients with neck fractures, and attempts at internal jugular or subclavian central line placement require neck manipulation, positioning changes, and potential Trendelenburg positioning that could destabilize fractures and compromise the airway 2
The femoral approach eliminates cervical spine manipulation entirely, allowing maintenance of neutral spine alignment while establishing necessary central venous access for resuscitation, medication administration, and hemodynamic monitoring 1, 3
Critical Considerations for Neck Fracture Management
Airway management takes absolute priority in penetrating or unstable neck injuries, with rapid sequence intubation demonstrating 100% success rates when performed by experienced clinicians, avoiding the need for neck manipulation associated with fiberoptic approaches 2
Femoral neck fractures (hip fractures) require urgent surgical intervention within 24-48 hours to optimize outcomes and reduce mortality, making reliable central access essential for perioperative management 4, 1, 3
Elderly patients with hip fractures often have significant comorbidities including chronic kidney disease, atrial fibrillation, and diabetes that necessitate central venous access for fluid resuscitation, correction of anemia, and administration of perioperative medications 4, 3
Practical Implementation
Place the femoral central line immediately upon recognition of the need for central access in any patient with confirmed or suspected cervical spine injury, rather than attempting jugular or subclavian approaches that require repositioning 1
Maintain strict cervical spine precautions throughout all procedures, including airway management and line placement, until fracture stability is definitively established through imaging and surgical consultation 2
Coordinate with the surgical team regarding timing of central line placement relative to operative intervention, as femoral lines placed for resuscitation can remain in situ for perioperative management 4, 1
Common Pitfalls to Avoid
Never attempt internal jugular or subclavian access in patients with unstable cervical fractures, as the required neck extension, rotation, or Trendelenburg positioning can cause catastrophic spinal cord injury or fracture displacement 2
Do not delay necessary central access due to concerns about femoral site infection risk—in the acute trauma setting, the safety benefits of avoiding neck manipulation far outweigh infection concerns, and lines can be changed to alternative sites once spine stability is confirmed 1, 3
Avoid assuming cervical spine clearance based on limited imaging alone; maintain precautions until definitive evaluation is complete, particularly in elderly patients with osteoporotic bone who may have occult fractures 4, 1