Distracting Injury in NEXUS Criteria
A distracting injury in the NEXUS criteria is defined as any painful injury that could impair the patient's ability to perceive or report cervical spine pain, though the original NEXUS study intentionally left this as a clinical judgment without rigid definition. 1
Core Concept
The NEXUS criteria list "distracting injury" as one of five factors that mandates cervical spine imaging, but deliberately avoided providing a precise definition to allow clinical discretion. 1 The rationale is that certain injuries produce pain severe enough that patients may not notice or accurately report neck pain, even if a cervical spine injury is present.
Commonly Accepted Distracting Injuries
Based on clinical application and research validation, the following are typically considered distracting injuries:
Major Orthopedic Injuries
- Long bone fractures (femur, tibia, humerus) - though recent evidence suggests femur fractures alone may not truly distract from cervical spine assessment 2
- Multiple rib fractures (most common distracting injury at 21.6% in one series) 3
- Pelvic fractures
- Upper and lower extremity fractures 3
Significant Soft Tissue Injuries
- Large lacerations requiring repair
- Major burns
- Visceral injuries causing significant pain 1
Chest Wall Injuries
- Bruising and tenderness to the upper anterior chest - this specific location has been associated with missed cervical spine injuries in patients without neck tenderness 3
Critical Nuances and Pitfalls
What May NOT Be Truly Distracting
Femur fractures should be reconsidered as automatic distracting injuries. A 2015 study of 566 trauma patients with femur fractures found that when femur fracture was excluded as a distracting injury, NEXUS maintained 96.2% sensitivity for cervical spine injury, with only 2 of 325 otherwise NEXUS-negative patients having cervical spine injuries (both stable, non-operative). 2
Non-thoracic injuries generally do not impair cervical spine examination. A prospective study of 101 evaluable patients with cervical spine injury found that distracting injuries outside the upper chest region did not affect the sensitivity of clinical cervical spine examination. 3 Only patients with upper anterior chest bruising and tenderness had missed cervical spine injuries on initial examination. 3
Age-Related Considerations
The definition of distracting injury may need refinement in elderly patients (≥65 years). The NEXUS criteria sensitivity drops to 66-89% in patients ≥65 years old. 1 However, one study suggests NEXUS may maintain high sensitivity in the elderly if distracting injury is specifically defined as signs of trauma to the head/neck region. 1
Thoracolumbar Spine Context
When applied to thoracolumbar spine imaging, similar terminology is used but with slight variations:
- "Major distracting injury" in earlier criteria 1
- "Painful distracting injury" in more recent validation studies 1
Practical Clinical Application
Use clinical judgment to determine if an injury is severe enough to prevent reliable cervical spine assessment. 1 The key question is: Could this injury's pain prevent the patient from accurately perceiving or reporting neck pain?
Do not automatically image for isolated extremity fractures if the patient is alert, sober, neurologically intact, has no midline tenderness, and can reliably communicate about neck symptoms. 2, 3
Always image if there is upper chest wall trauma with tenderness, regardless of other injuries. 3
Consider imaging all patients ≥65 years old regardless of distracting injury status, as NEXUS sensitivity decreases significantly in this population. 1