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American Journal of Emergency Medicine 33 (2015) 17501754

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Original Contribution

Femur fractures should not be considered distracting injuries for cervical

spine assessment
Robert T. Dahlquist, MD a, Peter E. Fischer, MD a, Harsh Desai, BS b, Amelia Rogers, BS b,
A. Britton Christmas, MD a, Michael A. Gibbs, MD a, Ronald F. Sing, DO a,
Carolinas Medical Center, Carolinas HealthCare System, Charlotte, NC
University of Maryland School of Medicine, Baltimore, MD

a r t i c l e i n f o a b s t r a c t

Article history: Introduction: The National Emergency X-Radiography Utilization Study (NEXUS) clinical decision rule is extremely
Received 10 October 2014 sensitive for clearance of cervical spine (C-spine) injury in blunt trauma patients with distracting injuries.
Received in revised form 7 August 2015 Objectives: We sought to determine whether the NEXUS criteria would maintain sensitivity for blunt trauma patients
Accepted 7 August 2015 when femur fractures were not considered a distracting injury and an absolute indication for diagnostic imaging.
Methods: We retrospectively analyzed blunt trauma patients with at least 1 femur fracture who presented to our
emergency department as trauma activations from 2009 to 2011 and underwent C-spine injury evaluation. Presence
of C-spine injury requiring surgical intervention was evaluated.
Results: Of 566 trauma patients included, 77 (13.6%) were younger than 18 years. Cervical spine injury was diagnosed in
53 (9.4%) of 566. A total of 241 patients (42.6%) had positive NEXUS ndings in addition to distracting injury; 51 (21.2%)
of these had C-spine injuries. Of 325 patients (57.4%) with femur fractures who were otherwise NEXUS negative, only 2
(0.6%) had C-spine injuries (95% condence interval [CI], 0.2%-2.2%); both were stable and required no operative inter-
vention. Use of NEXUS criteria, excluding femur fracture as an indication for imaging, detected all signicant injuries
with a sensitivity for any C-spine injury of 96.2% (95% CI, 85.9%-99.3%) and negative predictive value of 99.4% (95%
CI, 97.6%-99.9%).
Conclusions: In our patient population, all signicant C-spine injuries were identied by NEXUS criteria without
considering the femur fracture a distracting injury and indication for computed tomographic imaging.
Reconsidering femur fracture in this context may decrease radiation exposure and health care expenditure
with little risk of missed diagnoses.
2015 Elsevier Inc. All rights reserved.

1. Introduction A recent analysis noted a cost of greater than US $50 000 per quality-
adjusted life-year for populations with a fracture incidence of less
Cervical spine (C-spine) injury after trauma carries great morbidity, than 2.8% and called into question the cost-effectiveness of blanket
with a subsequent lifetime cost of care often in excess of US $1 000 000 CT scanning [5]. In addition, recent studies have brought radiation
per affected patient [1]. Furthermore, a missed or delayed diagnosis of consequences into consideration. Muchow et al [6] described in 2012
C-spine injury results in up to 10 times the rate of neurologic injury, an estimated median excess relative risk of thyroid cancer after 1 CT
with 29.4% of these cases resulting in permanent neurologic decit [2]. scan of the C-spine in pediatric patients at 13% for men and 25% for
Missed or delayed diagnoses have been attributed commonly to women. Fortunately, a large body of literature suggests a high degree
inadequate or misinterpreted radiographic evaluation [3]. A 2006 of utility of clinical examination for C-spine injury [7-10], mitigating
review of 367 spinal injuries described a 4.9% incidence of delayed or the need for radiographic analysis.
missed diagnosis [4]. Ample literature highlights why C-spine injuries The National Emergency X-Radiography Utilization Study (NEXUS)
are addressed in a conservative manner. clinical decision rule (CDR) is widely used to exclude C-spine injury in
The cost and radiation effect associated with computed tomographic blunt trauma patients and thereby avoid unnecessary imaging and the
(CT) imaging has called for a more judicious use of the technology. associated expense and radiation risk. As originally described, the
NEXUS guidelines suggest cervical radiography for blunt trauma pa-
tients with any of the following high-risk criteria: (1) a focal neurologic
decit, (2) midline C-spine tenderness on examination, (3) altered level
of consciousness, (4) intoxication, and (5) presence of distracting injury.
The authors declare no source of funding for this study.
According to the criteria, distracting injury includes any or all of the
Corresponding author at: Carolinas Medical Center, 1000 Blythe Blvd, MEB 6th Floor,
Charlotte, NC 28204. Tel.: +1 704 355 6904; fax: +1 704 355 5619. following: (1) a long bone fracture; (2) a visceral injury requiring surgi-
E-mail address: (R.F. Sing). cal consultation; (3) a large laceration, degloving injury, or crush injury;
0735-6757/ 2015 Elsevier Inc. All rights reserved.
R.T. Dahlquist et al. / American Journal of Emergency Medicine 33 (2015) 17501754 1751

(4) large burns; or (5) any other injury producing acute functional validation study. To date, the proportion of pediatric patients included
impairment or another injury determined based on clinician gestalt to in such studies are low (2.5% age 8 years or younger in NEXUS). In addi-
be potentially distracting. Despite the vague elements of the distracting tion, spinal cord injury without radiographic abnormality can go unde-
injury criteria, the interobserver reliability for the rule was acceptable in tected with CT or x-ray imaging alone. For this reason, although the
the trial (, 0.73), and the NEXUS CDR has subsequently grown into NEXUS criteria can be assessed and used in this population, a conservative
widespread use [11,12]. approach is taken at our institution that consists of C-spine immobiliza-
The distracting injury criteria, however, have been the subject of tion and serial examinations as adjuncts to radiographic evaluation.
much debate. In the original series, these criteria were the indication The primary end point was the presence of C-spine injury requiring
for more than 30% of all cervical radiography tests. This CDR is based sci- operative intervention. The study population, methods, and protocol
entically on the counterirritation phenomenon of pain, which suggests were reviewed and approved by the institutional review board of our
that the perception of pain can be altered by other noxious neurologic institution. Because of the retrospective nature of the study and data
stimuli, if present simultaneously [13,14]. Studies have long shown handling and protections undertaken, patient consent was waived.
that the counterirritation effect is correlated to the proximity as well
as the amplitude of stimulus [15]. Recent published literature suggests 2.2. Evaluation
that upper torso injuries may have a greater effect than lower extremity
injuries on sensory inhibition of C-spine tenderness [11]; however, this Patients arrived to the ED in spinal immobilization per prehospital
effect has not been scientically quantied nor fully explained, provider protocols and subsequently underwent clinical evaluation. Pa-
and studies have shown conicting results, depending on the type of tient evaluations were documented by either surgical or emergency
stimulus [14]. medicine residents or attending physicians. Results of these evaluations
Research has been conducted to further qualify the need for imaging were examined on review of the electronic medical record (CERNER
in the presence of distracting injury. Currently, conicting data exist. A PowerNote). Pertinent data reviewed included all of the NEXUS criteria:
2001 study that assessed the performance of each individual NEXUS cri- (1) any evidence of decit on neurologic examination, (2) presence or
terion found that 39 patients with C-spine column injury met only the absence of midline C-spine tenderness on examination, (3) evidence
distracting injury criteria. This suggests an unacceptably low CDR sensi- of altered level of consciousness, (4) evidence of drug or alcohol
tivity (93.5%) if the distracting injury criteria are removed [16]. In con- intoxication, and (5) presence of distracting injury. All subsequent ra-
trast, a 2005 investigation reviewing 4698 patients found that only diographic images were also reviewed for each patient, with interpreta-
2.4% of patients with only distracting injury as an indication for imaging tions provided by board-certied radiologists.
had spinal fractures, with only 1 injury being cervical and none requir-
ing operative intervention. The investigators also evaluated the type of 2.3. Outcome measures
distracting injury and found only bony fractures (such as femur frac-
ture) to impact the sensitivity of clinical screening [17]. Further evi- The primary outcome was any C-spine injury requiring operative in-
dence has mounted to suggest minimal impact of distracting injury on tervention. For patients who did not require operative intervention,
cervical examination, with Rose et al [18] demonstrating a sensitivity other interventions that were prescribed (eg, cervical collar) were
and negative predictive value greater than 99% for the NEXUS criteria gathered and recorded.
in patients with distracting injuries.
Insufcient literature exists to evaluate the ability of the NEXUS 2.4. Data collection
criteria to safely evaluate C-spine injury in the scenario of a lower ex-
tremity fracture requiring operative intervention. In patients with a Methodological strategies were used in accordance with the recom-
femur fracture, the rate of C-spine injury can be as high as 10%, and mendations of Gilbert et al [19] to enhance validity, reproducibility, and
treatment of femur fractures generally requires endotracheal intubation overall quality of data collected from the ED medical records and the
and operative intervention [2]. Given the importance of bony fractures, institution-based trauma database by 2 abstractors (HD and AR). The
in particular, on cervical neck examination, our objective was to deter- abstractors were trained in data collection and supervised by the pri-
mine whether the NEXUS criteria would maintain sensitivity for blunt mary investigator (RS) to ensure accuracy of data collection. Precisely
trauma patients with femur fractures if the fracture is not considered dened variables were used to collect data; these included patient de-
a distracting injury and an absolute indication for diagnostic imaging. mographics, including age and sex; prehospital and ED Glasgow Coma
Scale score; presence or absence of intoxication, including blood ethanol
2. Methods levels; ED vital signs; method of prehospital spine immobilization; re-
sult of physical examination that included the C-spine; type of radiogra-
2.1. Study population phy performed and results; ultimate disposition; and neurosurgical or
orthopedic spine treatment (if applicable). Interrater reliability was
This retrospective study was conducted for consecutive adult and 100% as determined by comparison of a subsample (10%) of charts ab-
pediatric patients presenting to the emergency department (ED) of a stracted by both researchers.
large, level I trauma center in the southeastern United States between
2009 and 2011. All patients included in the study were consecutive 2.5. Statistical analysis
trauma activations after blunt trauma who were evaluated for C-spine
injury with imaging and who also had at least 1 femur fracture. Patients Data were compiled into a spreadsheet (Microsoft Ofce Excel 2003;
with additional potentially distracting injuries were included in Microsoft Corporation, Redmond, WA) and were subsequently analyzed
the study. using standard statistical methods; P b .05 was considered to be statisti-
Patients were included only if a complete documented examination cally signicant. Descriptive statistics including mean SDs, counts,
was performed sufciently to include all of the NEXUS criteria before and percentages were used to describe the study population on all var-
any imaging obtained. Patients were excluded upon (1) death before iables, and 95% condence intervals (CIs) were calculated to further de-
imaging, (2) transferal from another hospital without documented scribe sensitivities, specicities, and all predictive value calculations.
examinations before imaging, or (3) involvement in low-mechanism Comparisons of statistical performance were made between our
trauma (falls from standing or injuries sustained from contact sports) study and the original NEXUS validation trial using Fisher exact test.
with no apparent clinical or radiographic evaluation for cervical injury. The SAS System version 8.02 (Cary, NC) was used to complete all
Pediatric patients were included in this study as in the original NEXUS statistical analyses.
1752 R.T. Dahlquist et al. / American Journal of Emergency Medicine 33 (2015) 17501754

3. Results fracture), only 2 (0.6%) had C-spine injuries (95% CI, 0.2%-2.2%); both in-
juries were stable and did not require operative intervention (Table 1).
The study population included 566 trauma patients with at least 1 The application of the NEXUS criteria in this study population,
femur fracture. Of these 566 patients, 77 (13.6%) were younger than disregarding femur fracture as a distracting injury, had a sensitivity for
18 years, and the age range was 2 months to 99 years (median age, 34 C-spine injury of 96.2% (95% CI, 85.9%-99.3%) and negative predictive
years). The population was 65.4% male. The mechanisms of injury value of 99.4% (95% CI, 97.5%-99.9%) (Table 2). Compared with the perfor-
were as follows: 315 motor vehicle collisions (55.7%), 85 motorcycle mance of the criteria in the original NEXUS study, sensitivity and negative
collisions (15.0%), 71 falls (12.5%), 41 pedestrians struck by motor predictive value for detecting fracture did not differ signicantly different.
vehicle, (7.2%), and 58 (10.2%) other mechanism (eg, all-terrain vehicle
accidents, industrial accidents, assault). The average Injury Severity
Score (ISS) for the cohort was 18.5, with a major trauma commonly de- 4. Discussion
ned as a score of 15 or greater [20].
All patients received C-spine imaging after clinical evaluation. In These data support our hypothesis that femur fracture should not
almost all cases, the imaging modality was a C-spine CT scan, with the qualify as a distracting injury by NEXUS criteria and should not be an
exception of 9 pediatric patients, 7 of whom received plain lms of absolute indication for imaging of the C-spine. In this population, disregarding
the C-spine and 2 of whom received magnetic resonance imaging. the femur fracture as a distracting injury and imaging only those patients
There were no cases of spinal cord injury without radiographic abnor- with other positive NEXUS criteria would result in a 57% decrease in C-
mality in our study population. Overall, 53 patients (9.4%) were diag- spine CT usage with missed detection of 2 nonoperative C-spine fractures.
nosed with a C-spine injury. Ultimately, 8 of these patients (15.1%) Statistically, this approach produced a sensitivity and negative predictive
went to the operating room for spinal xation, but all of these had mul- value (96.2% and 99.4%, respectively) that performed well and were not sta-
tiple positive NEXUS criteria in addition to distracting injury. tistically different from the sensitivity and negative predictive value of the
Of the initial 566 patients, 241 patients (42.6%) had positive NEXUS NEXUS validation study when compared with Fisher exact test (Table 2).
ndings on examination, in addition to distracting injury, that is, This patient population showed a higher incidence of C-spine injury
posterior C-spine tenderness, Glasgow Coma Scale score less than 15, detected on radiography (9.4% overall) than that of the 34 069-patient
intoxication, or neurologic decit (Figure), and of these, 51 (21.2%) NEXUS cohort, where the incidence of fracture was 2.4%. This elevated
had C-spine injuries. Of the 325 patients (57.4%) who were negative incidence is explained by the fact that trauma patients with femur frac-
by NEXUS criteria with the exception of their distracting injury (femur tures have higher ISSs than those associated with any other fracture.

566 trauma activations with femur

fractures (all NEXUS positive
by distracting injury)

241 (42.6%) with

325 (57.4%)
positive NEXUS
otherwise NEXUS criteria in addition to
negative distracting injury

241 (100%) received

325 (100%) received
cervical imaging, 4
cervical imaging, 3 pediatric X-rays and 2
pediatric X-ray only pediatric MRI

2 (0.6%) cervical
323 (99.4%) no 51 (21.2%) cervical 190 (78.8%) no
spine injury, non-
cervical spine injury spine injury cervical spine injury
operatively treated

8 (15.7%) requiring
operative fixation

Figure. Distribution of patients by NEXUS nding and cervical injury status.

R.T. Dahlquist et al. / American Journal of Emergency Medicine 33 (2015) 17501754 1753

Table 1
Cervical spine injuries in patients with distracting injury but otherwise NEXUS negative

Demographics Mechanism of injury Cervical injury Other injuries Management ISS

Female, 42 y Motorcycle crash Type I C2 pedicle fracture (stable) Right femur fracture Aspen collar 6 wk 13
Right tibia/bula fracture
Fifth nger fracture
Middle nger fracture
Clavicle fracture
Male, 49 y Left C2 superior articular surface fracture T2 vertebral body fracture Aspen collar 6 wk 22
Motorcycle crash Left C6 superior facet fracture L1 compression fracture
Small amount of possible epidural hemorrhage Left humerus fracture
C2-C3 without mass effect Left femur fracture
Right bular fracture
Right rib fracture
Right scapular fracture
Right hemothorax

Abbreviations: C, cervical; T, thoracic; L, lumbar.

This rate of C-spine injury in this study population is similar to the rates 4.2. Conclusions
of 5% to 11% of C-spine injury evidenced in admitted trauma patients at
other centers as previously described [21,22]. As originally described These data support the assertion that if femur fracture were not con-
with its distracting injury criteria, the NEXUS CDR demonstrated a sen- sidered a distracting injury, the NEXUS CDR would maintain acceptable
sitivity of 99.6% (95% CI, 98.6%-100%) and negative predictive value of sensitivity and negative predictive value in excluding C-spine injury. In
99.9% (95% CI, 99.8%-100%). Our approach, disregarding femur fracture this study population, the NEXUS CDR would have identied all unsta-
as a distracting injury, produced sensitivity and negative predictive ble C-spine injuries requiring operative intervention and would have re-
values that were not signicantly different (P N .05) in performance duced the use of C-spine CT scans substantially. The NEXUS low-risk
from the NEXUS validation study (Table 2). Obviously, all fractures criteria may allow for avoidance of C-spine radiography, even in pa-
must be properly immobilized to allow for an appropriate clinical tients with femur fracture, which would signicantly decrease radiation
evaluation of the neck and C-spine. exposure and unnecessary health care expenditure.
Furthermore, a relative strength of this study, in terms of ability to
demonstrate sensitivity and negative predictive value, is the higher Funding source
incidence of disease in this population. The difference in the positive
predictive value and specicity of our criteria compared to the NEXUS The authors declare no source of funding for this study.
validation study is explained by the substantial difference in disease
prevalence in the 2 populations. Acknowledgments

The authors thank Jennifer C. Barnes, PhD, ELS, for editorial

4.1. Limitations assistance with this manuscript.

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