In a 24-year-old man involved in a high‑speed head‑on motor vehicle collision who presents with midline neck pain, complete loss of motor function and pain‑temperature sensation below the neck, and imaging showing posterior displacement of a vertebral body with posterior longitudinal ligament disruption, what is the most likely type of cervical spine injury?

Flexion Teardrop Fracture

This patient has sustained a flexion teardrop fracture, which is a devastating three-column injury characterized by posterior displacement of the vertebral body into the spinal canal, disruption of the posterior longitudinal ligament, and typically results in complete or near-complete spinal cord injury with quadriplegia. 1, 2

Mechanism and Pathophysiology

The injury pattern described—posterior displacement of a vertebral body with posterior longitudinal ligament disruption following a high-speed head-on collision—is pathognomonic for flexion teardrop fracture. 1, 2

Key biomechanical features:

• Results from combined axial compression and flexion forces, typically occurring when the head strikes an object with the neck in a pre-flexed position 3, 2
• Creates a characteristic three-part, two-plane fracture pattern: a frontal plane fracture separating an anterior triangular fragment, a sagittal plane fracture splitting the vertebral body, and often posterior arch fractures 1, 2
• The sagittal fracture occurs because axial loading increases disc hoop stress, which forces the uncinate processes to expand laterally, splitting the vertebral body into left and right halves 3
• C5 is the most frequently affected level 1

Clinical Presentation Matches Flexion Teardrop

This patient's complete motor loss and loss of pain/temperature sensation below the neck is consistent with the severe neurological injury pattern of flexion teardrop fractures:

• Three-part flexion teardrop fractures with posterior displacement are almost always associated with permanent quadriplegia 2
• Complete tetraplegia or anterior spinal cord injury syndrome occurs frequently when posterior dislocation and kyphosis exceed 20 degrees 1
• The posterior displacement of vertebral body fragments into the spinal canal directly compresses the spinal cord 1, 4

Why Other Options Are Incorrect

Clay-shoveler's fracture: This is a stable avulsion fracture of the spinous process (typically C6-T1) from muscular forces, not associated with neurological injury or vertebral body displacement 2

Extension teardrop fracture: This involves an anterior triangular fragment from hyperextension forces, typically at C2, and is generally stable without posterior ligamentous disruption or significant neurological injury 2

Jefferson fracture: This is a burst fracture of C1 (atlas) from axial loading, involving the anterior and posterior arches, not the vertebral body with posterior displacement 1

Unilateral facet dislocation: While this can cause neurological injury, it presents with rotational deformity and typically causes Brown-Séquard syndrome (asymmetric findings), not the complete motor and sensory loss described here 1

Imaging Confirmation

CT is the gold standard for identifying the bony fracture pattern with sensitivity approaching 100% 5

MRI is essential given the positive neurological examination and should be obtained to assess spinal cord injury, epidural hematoma, and the extent of ligamentous disruption 5, 6

Management Implications

This is a highly unstable injury requiring urgent surgical stabilization:

• Early surgical decompression within 24 hours is strongly recommended for incomplete spinal cord syndromes to improve neurological outcomes 6
• Both anterior and posterior approaches may be necessary given the three-column instability 4
• Immediate optimization of cardiorespiratory and hemodynamic parameters is essential to prevent secondary spinal cord injury 6