Femur fractures should not be considered distracting injuries for cervical spine assessment.
BACKGROUND
The National Emergency X-Radiography Utilization Study (NEXUS) clinical decision rule is extremely sensitive for clearance of cervical spine (C-spine) injury in blunt trauma patients with distracting injuries.


OBJECTIVE
We sought to determine whether the NEXUS criteria would maintain sensitivity for blunt trauma patients 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 findings 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% confidence interval [CI], 0.2%-2.2%); both were stable and required no operative intervention. Use of NEXUS criteria, excluding femur fracture as an indication for imaging, detected all significant 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 significant C-spine injuries were identified 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.
Carolinas Medical Center, Carolinas HealthCare System, Charlotte, NC.
Robert T
RT
Dahlquist
Carolinas Medical Center, Carolinas HealthCare System, Charlotte, NC.
Peter E
PE
Fischer
University of Maryland School of Medicine, Baltimore, MD.
Harsh
H
Desai
University of Maryland School of Medicine, Baltimore, MD.
Amelia
A
Rogers
Carolinas Medical Center, Carolinas HealthCare System, Charlotte, NC.
A Britton
AB
Christmas
Carolinas Medical Center, Carolinas HealthCare System, Charlotte, NC.
Michael A
MA
Gibbs
Carolinas Medical Center, Carolinas HealthCare System, Charlotte, NC. Electronic address: ron.sing@carolinashealthcare.org.
Ronald F
RF
Sing
D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002574:Cervical Vertebrae / Q000293:injuries*; D002648:Child; D002675:Child, Preschool; D004636:Emergency Service, Hospital; D005260:Female; D005264:Femoral Fractures / Q000150:complications* / Q000175:diagnosis; D006801:Humans; D007223:Infant; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D012680:Sensitivity and Specificity; D013124:Spinal Injuries / Q000150:complications / Q000175:diagnosis*; D014949:Wounds, Nonpenetrating / Q000150:complications / Q000175:diagnosis*; D055815:Young Adult