Red Flags - Cervical Fractures - NEXUS & CCR

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One challenging aspect of being a primary contact practitioner, is being aware of red flags; fractures, infections, inflammatory conditions and tumors, which may enter your clinical door unknowingly.

Over the next few eZines, I will provide information and discuss clinical examples, in relation to fractures and tumors. In this eZine I focus on acute cervical blunt trauma screening.

About 5% of blunt trauma cervical injuries are severe injuries; fracture, dislocations or instabilities that require significantly different management to reassurance and pain medications. These cases often occur following a whiplash mechanism, so car accident, but could also occur in the sporting context; horse riding, surfing or a mountain bike fall .

Two protocols have been designed to screen these clinical groups to determine if an X-ray is appropriate, the NEXUS and Canadian Cervical Rule (CCR).

The National Emergency X radiography Utilization Study (NEXUS) criteria

normal alertness
no intoxication
no midline cervical tenderness
no focal neurological deficit (power, sensory, reflex)
no other painful distracting injury

If any of these criteria aren’t met, then a cervical x-ray is considered appropriate. You can take a NEXUS quiz here.

The Canadian Cervical Rule (CCR)

This rule requires an alert and stable client.

Question. Are there any high-risk factors (Age > 65 years or Dangerous mechanism of injury or Paresthesias in extremities)? If YES to any, then a cervical x-ray is considered appropriate.
Question. Are there any low-risk factors (simple rear-end motor vehicle collision or sitting position in ED, ambulatory at any time since injury or delayed onset of neck pain or absence of midline C-spine tenderness)? If No to any, then a cervical x-ray is considered appropriate.
Question. Is the patient able to actively rotate neck 45° to the left and right? If unable then a cervical x-ray is considered appropriate.

CCR & NEXUS - Head to Head

So which rule to use? Here we make it easier for you.

A just published study in the Canadian Medical Association Journal, compared these two rules and found the CCR was more sensitive than the NEXUS and more specific. Sensitivity was 99% and 91% respectively (meaning the CCR identified more people with a cervical fracture). The CCR also had a lesser false positive rate (meaning less x-rays were ordered unnecessarily and was therefore more specific).

It would seem prudent that as primary contact practitioners, we should be aware of the CCR details and be able to apply in our own clinical situations (clinic, sporting field or providing first aid). The exact details can be difficult to remember, but I have found a fantastic free app called 'Medical Calculator' that is available for iPhone, Android and Blackberry. Not only does it have the CCR and NEXUS, but also the Ottawa ankle and knee rules, plus host of other emergency department type rules and useful information. Links provided below.

Medical Calculator

Note - Select Orthopadic as specialty, when entering details.
Available for iPhone, iPad, Android and BlackBerry, See Here.

All the best,

Doug Cary FACP

Specialist Musculoskeletal Physiotherapist

email doug@aapeducation.com.au

ph/fx 08 90715055

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