Cervical Spine Assessment: What are "distracting injuries"?

The NEXUS definition of "distracting injury" is vague

(Hoffman et al., NEJM, 2000)

Defined as “a condition thought by the clinician to be producing pain sufficient to distract the patients from a second (neck) injury. Examples may include, but are not limited to the following:

• A long bone fracture
• A visceral injury requiring surgical consultation
• A large laceration, degloving injury, or crush injury
• Large burns
• Any other injury producing acute functional impairment

Physicians may also classify any injury as distracting if it is thought to have the potential to impair the patient’s ability to appreciate other injuries"

Distracting injury alone accounted for 30% of all radiographic studies ordered for the 818 NEXUS patients

Injuries to the upper torso may be considered distracting injuries

(Heffernan et al., J Trauma, 2005)

Study design:

• Prospective study of blunt trauma patients
• Exclusion criteria: patient age <18 years, prolonged ICU care, non-English speaking

Results: (n=40 patients with cervical spine injury out of 406 patients)

• 7 of 40 patients (18%) had no neck pain or tenderness
• All 7 patients had upper torso injuries.

Severe pain or injuries in the chest may be considered distracting injuries

(Konstantinidis et al, J Trauma, 2011)

Study design:

• Prospective study of blunt trauma patients
• Exclusion criteria: GCS <13, intoxication, patient age ≤16 years

Results: (n =101 patients with a cervical spine injury out of 9,103 blunt trauma patients)

• 4 of 101 (4%) patients had no neck pain or tenderness
• All 4 patients had rib fractures or severe chest tenderness.

References

• Konstantinidis A, Plurad D, Barmparas G, Inaba K, Lam L, Bukur M, Branco BC, Demetriades D.The presence of nonthoracic distracting injuries does not affect the initial clinical examination of the cervical spine in evaluable blunt trauma patients: a prospective observational study.J Trauma. 2011 Sep;71(3):528-32. doi: 10.1097/TA.0b013e3181f8a8e0. [PubMed]
• Hoffman JR, Mower WR, Wolfson AB, Todd KH, Zucker MI. Validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt trauma. National Emergency X-Radiography Utilization Study Group.N Engl J Med. 2000 Jul 13;343(2):94-9. [PubMed]
• Heffernan DS, Schermer CR, Lu SW. What defines a distracting injury in cervical spine assessment? J Trauma. 2005 Dec;59(6):1396-9. [PubMed]