American Journal of Emergency Medicine 33 (2015) 17501754

Contents lists available at ScienceDirect

American Journal of Emergency Medicine

journal homepage: www.elsevier.com/locate/ajem

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,
a
Carolinas Medical Center, Carolinas HealthCare System, Charlotte, NC
b
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
Cervical spine (C-spine) injury after trauma carries great morbidity,
with a subsequent lifetime cost of care often in excess of US $1 000 000
per affected patient [1]. Furthermore, a missed or delayed diagnosis of
C-spine injury results in up to 10 times the rate of neurologic injury,
with 29.4% of these cases resulting in permanent neurologic decit [2].
Missed or delayed diagnoses have been attributed commonly to
inadequate or misinterpreted radiographic evaluation [3]. A 2006
review of 367 spinal injuries described a 4.9% incidence of delayed or
missed diagnosis [4]. Ample literature highlights why C-spine injuries
are addressed in a conservative manner.
The cost and radiation effect associated with computed tomographic
(CT) imaging has called for a more judicious use of the technology.
The authors declare no source of funding for this study.
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.
E-mail address: ron.sing@carolinashealthcare.org (R.F. Sing).
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
than 2.8% and called into question the cost-effectiveness of blanket
CT scanning [5]. In addition, recent studies have brought radiation
consequences into consideration. Muchow et al [6] described in 2012
an estimated median excess relative risk of thyroid cancer after 1 CT
scan of the C-spine in pediatric patients at 13% for men and 25% for
women. Fortunately, a large body of literature suggests a high degree
of utility of clinical examination for C-spine injury [7-10], mitigating
the need for radiographic analysis.
The National Emergency X-Radiography Utilization Study (NEXUS)
clinical decision rule (CDR) is widely used to exclude C-spine injury in
blunt trauma patients and thereby avoid unnecessary imaging and the
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.
According to the criteria, distracting injury includes any or all of the
following: (1) a long bone fracture; (2) a visceral injury requiring surgi-
cal consultation; (3) a large laceration, degloving injury, or crush injury;

http://dx.doi.org/10.1016/j.ajem.2015.08.009
0735-6757/ 2015 Elsevier Inc. All rights reserved.
 R.T. Dahlquist et al. / American Journal of Emergency Medicine 33 (2015) 17501754
(4) large burns; or (5) any other injury producing acute functional
impairment or another injury determined based on clinician gestalt to
be potentially distracting. Despite the vague elements of the distracting
injury criteria, the interobserver reliability for the rule was acceptable in
the trial (, 0.73), and the NEXUS CDR has subsequently grown into
widespread use [11,12].
The distracting injury criteria, however, have been the subject of
much debate. In the original series, these criteria were the indication
for more than 30% of all cervical radiography tests. This CDR is based sci-
entically on the counterirritation phenomenon of pain, which suggests
that the perception of pain can be altered by other noxious neurologic
stimuli, if present simultaneously [13,14]. Studies have long shown
that the counterirritation effect is correlated to the proximity as well
as the amplitude of stimulus [15]. Recent published literature suggests
that upper torso injuries may have a greater effect than lower extremity
injuries on sensory inhibition of C-spine tenderness [11]; however, this
effect has not been scientically quantied nor fully explained,
and studies have shown conicting results, depending on the type of
stimulus [14].
Research has been conducted to further qualify the need for imaging
in the presence of distracting injury. Currently, conicting data exist. A
2001 study that assessed the performance of each individual NEXUS cri-
terion found that 39 patients with C-spine column injury met only the
distracting injury criteria. This suggests an unacceptably low CDR sensi-
tivity (93.5%) if the distracting injury criteria are removed [16]. In con-
trast, a 2005 investigation reviewing 4698 patients found that only
2.4% of patients with only distracting injury as an indication for imaging
had spinal fractures, with only 1 injury being cervical and none requir-
ing operative intervention. The investigators also evaluated the type of
distracting injury and found only bony fractures (such as femur frac-
ture) to impact the sensitivity of clinical screening [17]. Further evi-
dence has mounted to suggest minimal impact of distracting injury on
cervical examination, with Rose et al [18] demonstrating a sensitivity
and negative predictive value greater than 99% for the NEXUS criteria
in patients with distracting injuries.
Insufcient literature exists to evaluate the ability of the NEXUS
criteria to safely evaluate C-spine injury in the scenario of a lower ex-
tremity fracture requiring operative intervention. In patients with a
femur fracture, the rate of C-spine injury can be as high as 10%, and
treatment of femur fractures generally requires endotracheal intubation
and operative intervention [2]. Given the importance of bony fractures,
in particular, on cervical neck examination, our objective was to deter-
mine whether the NEXUS criteria would maintain sensitivity for blunt
trauma patients with femur fractures if the fracture is not considered
a distracting injury and an absolute indication for diagnostic imaging.
2. Methods
2.1. Study population
This retrospective study was conducted for consecutive adult and
pediatric patients presenting to the emergency department (ED) of a
large, level I trauma center in the southeastern United States between
2009 and 2011. All patients included in the study were consecutive
trauma activations after blunt trauma who were evaluated for C-spine
injury with imaging and who also had at least 1 femur fracture. Patients
with additional potentially distracting injuries were included in
the study.
Patients were included only if a complete documented examination
was performed sufciently to include all of the NEXUS criteria before
any imaging obtained. Patients were excluded upon (1) death before
imaging, (2) transferal from another hospital without documented
examinations before imaging, or (3) involvement in low-mechanism
trauma (falls from standing or injuries sustained from contact sports)
with no apparent clinical or radiographic evaluation for cervical injury.
Pediatric patients were included in this study as in the original NEXUS
1751
validation study. To date, the proportion of pediatric patients included
in such studies are low (2.5% age 8 years or younger in NEXUS). In addi-
tion, spinal cord injury without radiographic abnormality can go unde-
tected with CT or x-ray imaging alone. For this reason, although the
NEXUS criteria can be assessed and used in this population, a conservative
approach is taken at our institution that consists of C-spine immobiliza-
tion and serial examinations as adjuncts to radiographic evaluation.
The primary end point was the presence of C-spine injury requiring
operative intervention. The study population, methods, and protocol
were reviewed and approved by the institutional review board of our
institution. Because of the retrospective nature of the study and data
handling and protections undertaken, patient consent was waived.
2.2. Evaluation
Patients arrived to the ED in spinal immobilization per prehospital
provider protocols and subsequently underwent clinical evaluation. Pa-
tient evaluations were documented by either surgical or emergency
medicine residents or attending physicians. Results of these evaluations
were examined on review of the electronic medical record (CERNER
PowerNote). Pertinent data reviewed included all of the NEXUS criteria:
(1) any evidence of decit on neurologic examination, (2) presence or
absence of midline C-spine tenderness on examination, (3) evidence
of altered level of consciousness, (4) evidence of drug or alcohol
intoxication, and (5) presence of distracting injury. All subsequent ra-
diographic images were also reviewed for each patient, with interpreta-
tions provided by board-certied radiologists.
2.3. Outcome measures
The primary outcome was any C-spine injury requiring operative in-
tervention. For patients who did not require operative intervention,
other interventions that were prescribed (eg, cervical collar) were
gathered and recorded.
2.4. Data collection
Methodological strategies were used in accordance with the recom-
mendations of Gilbert et al [19] to enhance validity, reproducibility, and
overall quality of data collected from the ED medical records and the
institution-based trauma database by 2 abstractors (HD and AR). The
abstractors were trained in data collection and supervised by the pri-
mary investigator (RS) to ensure accuracy of data collection. Precisely
dened variables were used to collect data; these included patient de-
mographics, including age and sex; prehospital and ED Glasgow Coma
Scale score; presence or absence of intoxication, including blood ethanol
levels; ED vital signs; method of prehospital spine immobilization; re-
sult of physical examination that included the C-spine; type of radiogra-
phy performed and results; ultimate disposition; and neurosurgical or
orthopedic spine treatment (if applicable). Interrater reliability was
100% as determined by comparison of a subsample (10%) of charts ab-
stracted by both researchers.
2.5. Statistical analysis
Data were compiled into a spreadsheet (Microsoft Ofce Excel 2003;
Microsoft Corporation, Redmond, WA) and were subsequently analyzed
using standard statistical methods; P b .05 was considered to be statisti-
cally signicant. Descriptive statistics including mean SDs, counts,
and percentages were used to describe the study population on all var-
iables, and 95% condence intervals (CIs) were calculated to further de-
scribe sensitivities, specicities, and all predictive value calculations.
Comparisons of statistical performance were made between our
study and the original NEXUS validation trial using Fisher exact test.
The SAS System version 8.02 (Cary, NC) was used to complete all
statistical analyses.
1752 R.T. Dahlquist et al. / American Journal of Emergency Medicine 33 (2015) 17501754

3. Results
The study population included 566 trauma patients with at least 1
femur fracture. Of these 566 patients, 77 (13.6%) were younger than
18 years, and the age range was 2 months to 99 years (median age, 34
years). The population was 65.4% male. The mechanisms of injury
were as follows: 315 motor vehicle collisions (55.7%), 85 motorcycle
collisions (15.0%), 71 falls (12.5%), 41 pedestrians struck by motor
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-
ned as a score of 15 or greater [20].
All patients received C-spine imaging after clinical evaluation. In
almost all cases, the imaging modality was a C-spine CT scan, with the
exception of 9 pediatric patients, 7 of whom received plain lms of
the C-spine and 2 of whom received magnetic resonance imaging.
There were no cases of spinal cord injury without radiographic abnor-
mality in our study population. Overall, 53 patients (9.4%) were diag-
nosed with a C-spine injury. Ultimately, 8 of these patients (15.1%)
went to the operating room for spinal xation, but all of these had mul-
tiple positive NEXUS criteria in addition to distracting injury.
Of the initial 566 patients, 241 patients (42.6%) had positive NEXUS
ndings on examination, in addition to distracting injury, that is,
posterior C-spine tenderness, Glasgow Coma Scale score less than 15,
intoxication, or neurologic decit (Figure), and of these, 51 (21.2%)
had C-spine injuries. Of the 325 patients (57.4%) who were negative
by NEXUS criteria with the exception of their distracting injury (femur
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 application of the NEXUS criteria in this study population,
disregarding femur fracture as a distracting injury, had a sensitivity for
C-spine injury of 96.2% (95% CI, 85.9%-99.3%) and negative predictive
value of 99.4% (95% CI, 97.5%-99.9%) (Table 2). Compared with the perfor-
mance of the criteria in the original NEXUS study, sensitivity and negative
predictive value for detecting fracture did not differ signicantly different.
4. Discussion
These data support our hypothesis that femur fracture should not
qualify as a distracting injury by NEXUS criteria and should not be an
absolute indication for imaging of the C-spine. In this population, disregarding
the femur fracture as a distracting injury and imaging only those patients
with other positive NEXUS criteria would result in a 57% decrease in C-
spine CT usage with missed detection of 2 nonoperative C-spine fractures.
Statistically, this approach produced a sensitivity and negative predictive
value (96.2% and 99.4%, respectively) that performed well and were not sta-
tistically different from the sensitivity and negative predictive value of the
NEXUS validation study when compared with Fisher exact test (Table 2).
This patient population showed a higher incidence of C-spine injury
detected on radiography (9.4% overall) than that of the 34 069-patient
NEXUS cohort, where the incidence of fracture was 2.4%. This elevated
incidence is explained by the fact that trauma patients with femur frac-
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
of 5% to 11% of C-spine injury evidenced in admitted trauma patients at
other centers as previously described [21,22]. As originally described
with its distracting injury criteria, the NEXUS CDR demonstrated a sen-
sitivity of 99.6% (95% CI, 98.6%-100%) and negative predictive value of
99.9% (95% CI, 99.8%-100%). Our approach, disregarding femur fracture
as a distracting injury, produced sensitivity and negative predictive
values that were not signicantly different (P N .05) in performance
from the NEXUS validation study (Table 2). Obviously, all fractures
must be properly immobilized to allow for an appropriate clinical
evaluation of the neck and C-spine.
Furthermore, a relative strength of this study, in terms of ability to
demonstrate sensitivity and negative predictive value, is the higher
incidence of disease in this population. The difference in the positive
predictive value and specicity of our criteria compared to the NEXUS
validation study is explained by the substantial difference in disease
prevalence in the 2 populations.
4.2. Conclusions
These data support the assertion that if femur fracture were not con-
sidered a distracting injury, the NEXUS CDR would maintain acceptable
sensitivity and negative predictive value in excluding C-spine injury. In
this study population, the NEXUS CDR would have identied all unsta-
ble C-spine injuries requiring operative intervention and would have re-
duced the use of C-spine CT scans substantially. The NEXUS low-risk
criteria may allow for avoidance of C-spine radiography, even in pa-
tients with femur fracture, which would signicantly decrease radiation
exposure and unnecessary health care expenditure.
Funding source
The authors declare no source of funding for this study.
Acknowledgments

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

4.1. Limitations assistance with this manuscript.

This study has several limitations. First, a sample size of 566 patients References
is relatively small when compared with large trials such as the original
[1] Wyndaele M, Wyndaele JJ. Incidence, prevalence and epidemiology of spinal cord in-
NEXUS study. This study was conducted at a large level I trauma center,
jury: what learns a worldwide literature survey? Spinal Cord 2006;44:5239.
where ISSs and disease prevalence are higher than at smaller rural or [2] Reid DC, Henderson R, Saboe L, Miller JD. Etiology and clinical course of missed spine
community EDs. The relative experience of the providers in our institu- fractures. J Trauma 1987;27:9806.
[3] Davis JW, Phreaner DL, Hoyt DB, Mackersie RC. The etiology of missed cervical spine
tion in diagnosis and management of trauma is, therefore, a limitation
injuries. J Trauma 1993;34:3426.
and may call into question the applicability of this study to patients [4] Platzer P, Hauswirth N, Jaindl M, Chatwani S, Vecsei V, Gaebler C. Delayed or missed
and providers in centers who less commonly manage injured patients. diagnosis of cervical spine injuries. J Trauma 2006;61:1505.
Finally, this study is subject to the weaknesses inherent in any retro- [5] Blackmore CC, Ramsey SD, Mann FA, Deyo RA. Cervical spine screening with CT in
trauma patients: a cost-effectiveness analysis. Radiology 1999;212:11725.
spective investigation. [6] Muchow RD, Egan KR, Peppler WW, Anderson PA. Theoretical increase of thyroid
cancer induction from cervical spine multidetector computed tomography in pediat-
ric trauma patients. J Trauma Acute Care Surg 2012;72:4039.
[7] Gonzalez RP, Fried PO, Bukhalo M, Holevar MR, Falimirski ME. Role of clinical exam-
ination in screening for blunt cervical spine injury. J Am Coll Surg 1999;189:1527.
[8] Kreipke DL, Gillespie KR, McCarthy MC, Mail JT, Lappas JC, Broadie TA. Reliability of
Table 2
indications for cervical spine lms in trauma patients. J Trauma 1989;29:14389.
Performance of statistical variables [9] Roberge RJ, Wears RC. Evaluation of neck discomfort, neck tenderness, and neuro-
logic decits as indicators for radiography in blunt trauma victims. J Emerg Med
NEXUS performance NEXUS performance in
1992;10:53944.
without distracting injury original validation study
[10] Velmahos GC, Theodorou D, Tatevossian R, Belzberg H, Cornwell III EE, Berne TV,
criteria in this cohort et al. Radiographic cervical spine evaluation in the alert asymptomatic blunt trauma
Variable Performance 95% CI Performance 95% CI P victim: much ado about nothing. J Trauma 1996;40:76874.
[11] Heffernan DS, Schermer CR, Lu SW. What denes a distracting injury in cervical
Sensitivity 96.2% 85.9%-99.3% 99.0% 98.0%-99.6% .1195 spine assessment? J Trauma 2005;59:13969.
Specicity 63.0% 58.6%-67.1% 12.9% 12.8%-13.0% b.0001 [12] Hoffman JR, Wolfson AB, Todd K, Mower WR. Selective cervical spine radiography in
PPV 21.2% 16.3%-27.0% 2.7% 2.6%-2.8% b.0001 blunt trauma: methodology of the National Emergency X-Radiography Utilization
NPV 99.4% 97.5%-99.9% 99.8% 99.6%-100% .1521 Study (NEXUS). Ann Emerg Med 1998;32:4619.
Positive LR 2.60 2.30-2.94 1.14 1.13-1.15 [13] Price DD, McHafe JG. Effects of heterotopic conditioning stimuli on rst and second
Negative LR 0.06 0.01-0.25 0.08 0.04-0.15 pain: a psychophysical evaluation in humans. Pain 1988;34:24552.
[14] Bouhassira D, Danziger N, Attal N, Guirimand F. Comparison of the pain suppressive
Abbreviations: PPV, positive predictive value; NPV, negative predictive value; LR, effects of clinical and experimental painful conditioning stimuli. Brain 2003;126:
likelihood ratio. 106878.
1754 R.T. Dahlquist et al. / American Journal of Emergency Medicine 33 (2015) 17501754
[15] Bouhassira D, Le Bars D, Villanueva L. Heterotopic activation of A delta and C bres
triggers inhibition of trigeminal and spinal convergent neurones in the rat. J Physiol
1987;389:30117.
[16] Panacek EA, Mower WR, Holmes JF, Hoffman JR. Test performance of the individual
NEXUS low-risk clinical screening criteria for cervical spine injury. Ann Emerg Med
2001;38:225.
[17] Chang CH, Holmes JF, Mower WR, Panacek EA. Distracting injuries in patients with
vertebral injuries. J Emerg Med 2005;28:14752.
[18] Rose MK, Rosal LM, Gonzalez RP, Rostas JW, Baker JA, Simmons JD, et al. Clinical
clearance of the cervical spine in patients with distracting injuries: it is time to
dispel the myth. J Trauma Acute Care Surg 2012;73:498502.
[19] Gilbert EH, Lowenstein SR, Koziol-McLain J, Barta DC, Steiner J. Chart reviews in
emergency medicine research: where are the methods? Ann Emerg Med 1996;
27:3058.
[20] Baker SP, O'Neill B, Haddon Jr W, Long WB. The injury severity score: a method for
describing patients with multiple injuries and evaluating emergency care. J Trauma
1974;14:18796.
[21] Grossman MD, Reilly PM, Gillett T, Gillett D. National survey of the incidence of
cervical spine injury and approach to cervical spine clearance in U.S. trauma centers.
J Trauma 1999;47:68490.
[22] Robertson A, Branfoot T, Barlow IF, Giannoudis PV. Spinal injury patterns resulting
from car and motorcycle accidents. Spine (Phila Pa 1976) 2002;27:282530.
Reproduced with permission of the copyright owner. Further reproduction prohibited without
permission.