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148
9 Occipital Condyle Fractures
Fig. 9.5 Broad condyle avulsion – more skull base fracture
passing through the jugular foramen (Type II Anderson and
Montesano). (a) Axial scan showing the fracture passing through
be recommended (Fig. 9.6). Type I comminution of
the condyle and/or shallow based type III avulsion
(Fig. 9.7) can be prone to settling and displacement
and therefore, hard collar treatment should be worn
for at least 6 weeks with appropriate radiographic
follow-up. Transoral images can show progressive
asymmetry caused by dislocation of the condyle
which has to be confirmed by CT during the followup. The final status of alignment and fracture healing
should be evaluated by CT approximately 3–6 months
after the injury.
jugular foramen. (b) coronal view showing some degree of
displacement. (c) 3D CT internal view
Fig. 9.6 Mild avulsion of the occipital condyle at the place of
alar ligament attachment (Type III Anderson and Montesano),
note the simultaneous fracture of C1 lateral mass
Fig. 9.7 Typical occipital condyle avulsion with mild disloca-
tion (Type III Anderson and Montesano). (a) Reconstruction in
frontal plane. (b) Anterior 3D view
We do not have our own experience with acute or
delayed instability and/or deformity in OCF requiring
surgical intervention. We suppose that, in some bilateral condyle fractures (Fig. 9.8), circular foramen mag-
num breach, atlanto-occipital joint disruption, and
asymmetric condylar collapse, surgical intervention
limited to the damaged segments has to be considered.
References
Fig. 9.8 Bilateral condyle avulsion depicted on coronal CT
reconstruction
References
1. Anderson, P.A., Montesano, P.X.: Morphology and treatment of occipital condyle fractures. Spine (Phila Pa 1976)
13, 731–736 (1988)
2. Anonymous: Occipital condyle fractures. Neurosurgery 50,
S114–S119 (2002)
3. Aulino, J.M., Tutt, L.K., Kaye, J.J., et al.: Occipital condyle
fractures: clinical presentation and imaging findings in 76
patients. Emerg Radiol 11, 342–347 (2005)
4. Bell, C.: Surgical observations. Middlesex Hosp J 4, 469–
470 (1817)
5. Blacksin, M.F., Lee, H.J.: Frequency and significance of
fractures of the upper cervical spine detected by CT in
patients with severe neck trauma. AJR Am J Roentgenol
165, 1201–1204 (1995)
6. Bloom, A.I., Neeman, Z., Slasky, B.S., et al.: Fracture of the
occipital condyles and associated craniocervical ligament
injury: incidence, CT imaging and implications. Clin Radiol
52, 198–202 (1997)
7. Bolender, N., Cromwell, L.D., Wendling, L.: Fracture of the
occipital condyle. AJR Am J Roentgenol 131, 729–731 (1978)
8. Clayman, D.A., Sykes, C.H., Vines, F.S.: Occipital condyle
fractures: clinical presentation and radiologic detection.
AJNR Am J Neuroradiol 15, 1309–1315 (1994)
149
9. Deeb, Z.L., Rothfus, W.E., Goldberg, A.L., et al.: Occult
occipital condyle fractures presenting as tumors. J Comput
Tomogr 12, 261–263 (1988)
10. Demisch, S., Lindner, A., Beck, R., et al.: The forgotten condyle: delayed hypoglossal nerve palsy caused by fracture of
the occipital condyle. Clin Neurol Neurosurg 100, 44–45
(1998)
11. Hanson, J.A., Deliganis, A.V., Baxter, A.B., et al.: Radiologic
and clinical spectrum of occipital condyle fractures: retrospective review of 107 consecutive fractures in 95 patients.
AJR Am J Roentgenol 178, 1261–1268 (2002)
12. Legros, B., Fournier, P., Chiaroni, P., et al.: Basal fracture of
the skull and lower (IX, X, XI, XII) cranial nerves palsy:
four case reports including two fractures of the occipital
condyle – a literature review. J Trauma 48, 342–348 (2000)
13. Leone, A., Cerase, A., Colosimo, C., et al.: Occipital condylar fractures: a review. Radiology 216, 635–644 (2000)
14. Link, T.M., Schuierer, G., Hufendiek, A., et al.: Substantial
head trauma: value of routine CT examination of the cervicocranium. Radiology 196, 741–745 (1995)
15. Maserati, M.B., Stephens, B., Zohny, Z., et al.: Occipital
condyle fractures: clinical decision rule and surgical management. J Neurosurg Spine 11, 388–395 (2009)
16. Orbay, T., Aykol, S., Seckin, Z., et al.: Late hypoglossal
nerve palsy following fracture of the occipital condyle. Surg
Neurol 31, 402–404 (1989)
17. Pang, D., Nemzek, W.R., Zovickian, J.: Atlanto-occipital
dislocation – part 2: The clinical use of (occipital) condyleC1 interval, comparison with other diagnostic methods, and
the manifestation, management, and outcome of atlantooccipital dislocation in children. Neurosurgery 61, 995–1015
(2007). discussion 1015
18. Pang, D., Nemzek, W.R., Zovickian, J.: Atlanto-occipital
dislocation: part 1 – normal occipital condyle-C1 interval
in 89 children. Neurosurgery 61, 514–521 (2007). discussion 521
19. Savolaine, E.R., Ebraheim, N.A., Jackson, W.T., et al.:
Three-dimensional computed tomography in evaluation of
occipital condyle fracture. J Orthop Trauma 3, 71–75
(1989)
20. Spencer, J.A., Yeakley, J.W., Kaufman, H.H.: Fracture of the
occipital condyle. Neurosurgery 15, 101–103 (1984)
21. Su, T.M., Lui, C.C., Cheng, M.H., et al.: Occipital condyle
fracture with hypoglossal nerve palsy: case report. J Trauma
49, 1144–1146 (2000)
22. Tuli, S., Tator, C.H., Fehlings, M.G., et al.: Occipital condyle fractures. Neurosurgery 41, 368–376 (1997). discussion 376–367
23. Urculo, E., Arrazola, M., Arrazola Jr., M., et al.: Delayed
glossopharyngeal and vagus nerve paralysis following
occipital condyle fracture. Case report. J Neurosurg 84,
522–525 (1996)
Atlas Fractures
P. Suchomel and R. Brabec
10
Fractures of the atlas comprise approximately 2–13%
of cervical spine injuries and about 1–3% of the fractures of the entire spinal column [13, 14, 29, 39]. They
are either isolated or occur in 23–57% as combined
with other UCS but also subaxial cervical spine injuries [3, 10, 14, 24, 26, 27]. The first description of atlas
fracture was an autopsy report by Cooper, in 1823 [4].
Sir Geoffrey Jefferson was the first who comprehensively described the atlas “burst” fracture that bears his
name in 1920 [22]. He stated that: “If the atlas was
morphologically similar to the other vertebrae, death
would be the common result of fracture.” Nevertheless,
in his own series of four cases (two patients and two
museum specimens) analyzed together with literature
survey of 42 others, he found only in 50% of patients a
consequent neurological symptomatology and thus as
the first also validated the relative clinical benignity of
C1 isolated fractures. From those times many large
series of patients with atlas fractures were published;
however, a conclusive statement giving us the therapeutic guidance on higher level of evidence is not
available up to now [10, 13, 14, 26, 29, 39].
10.1 Classification
There is no uniformly accepted classification system
of atlas fractures to date. Many attempts to classify C1
fractures were published. Levine and Edwards [28, 29]
divided their series of 34 patients into three groups.
P. Suchomel and R. Brabec
Department of Neurosurgery,
Neurocenter, Regional Hospital Liberec,
Husova St. 10, 46063 Liberec, Czech Republic
Most frequently, the posterior arch fracture was seen,
then the lateral mass area fractures often causing asymmetric single mass displacement were described as
second category, and the last group was three and/or
four fragmental Jefferson type fractures.
More precise is the classification proposed by
Landels and Van Peteghem from Vancouver dividing
the fractures into three types [26]. Type I are the isolated fractures of single arch not crossing the equator
of atlas. Type II are the fractures of arches crossing the
equator having two and more fragments including the
four-fragmental Jefferson fracture. Unstable were evaluated as those type II fractures with summarized lateral
mass overhang more than 6.9 mm, according to Spence
[41]. Type III are those fractures involving lateral mass
and maximally one arch. In their analyzed series of 35
patients having atlas fracture, they found the concomitant other level cervical spine injury in 57%. No one
patient had neurological deficit related to C1 fracture.
Another and even more complex classification was
proposed by Aebi and Nazarian [1]. Also, case studies
describing unusual horizontal fracture of anterior arch
probably caused by hyperextension together with
counter action of anterior tubercle attachment of longus colli muscle were reported [23, 32, 42].
Dickman and Green suggested the most descriptive
classification system respecting the therapeutic consequences [5]. They divided the fractures of C1 into
6 categories:
Type A: fracture of the anterior arch
Type B: fracture of the posterior arch
Type C: simple lateral mass fracture
Type D: comminuted lateral mass fracture
Type E: four-part ring fracture (Jefferson type)
Type F: two-part ring fracture
P. Suchomel and O. Choutka, Reconstruction of Upper Cervical Spine and Craniovertebral Junction,
DOI: 10.1007/978-3-642-13158-5_10, © Springer-Verlag Berlin Heidelberg 2011
151
152
10 Atlas Fractures
The fractures were recommended for treatment successively from A to F depending also on the status of TAL with
increasing stiffness of external support or even surgery.
Perhaps, currently, the most widely accepted is the
classification of Gehweiler et al. interestingly proposed
as one of the first but accepted as the last because of its
printed presentation in radiological literature [12].
This classification describes five types of atlas fractures
(Fig. 10.1):
Type I: fracture of the anterior arch
Type II: fracture of the posterior arch
Type III: combined fracture of both anterior and posterior
arch (Jefferson incl.)
Type IV: isolated simple or burst fracture of massa lateralis
Type V: fracture of transverse process
For all the previously mentioned authors, the crucial
point how to define the stability of atlas fractures was
the functional integrity of TAL. Initially, most of the
surgeons accepted the “rule of Spence” saying that
summarized overhang of dislocated lateral masses over
C2 superior facets should not exceed 6.9 mm on the
transoral radiogram (Fig. 10.2). This idea came from
the work of Spence et al. [41] who tested the distractive
force causing TAL rupture on ten cadaveric isolated
specimens cut like in Jefferson four-part fractures. They
found that the TAL can tear under distractive force of
average 580 N (380–1,040 N) having the mean distance
6.9 mm (4.8–7.6 mm) above the normal value. However,
their results were criticized by Dickman and Sonntag
because of important flaws related to laboratory conditions of testing [8]. In their words, the testing force did
not reflect the clinical mechanism and also, the elastic
recoil normally oriented against the distraction was lost
due to devoid muscular and soft tissue in the experiment. The other drawback of the “rule of Spence” was
defined by Heller et al. [18]. Simply, the radiographic
Fig. 10.2 Overhang of C1 over C2 in summary larger than
8 mm suspicious of TAL disruption (“rule of Spence”)
Fig. 10.1 Types of atlas fractures according to Gehweiler. (a) Posterior arch fracture (exceptional single). (b) Anterior arch fracture.
(c) Three piece fracture of both arches. (d) Comminuted fracture of lateral mass. (e) fracture extending to transverse process
10.2 Etiology
Fig. 10.3 Negative Spence measurement despite TAL abruption. (a) Coronal CT reconstruction analog to transoral radiogram
showing no C1-overhang. (b) MRI clearly showing TAL attachment abruption in the same patient
153
magnification of +18% has to be calculated during evaluation of transoral pictures. They suggested to increase
the critical summarized distance of both sides overhang
measured on transoral images from 6.9 to 8.1 mm.
Dickman et al. in their series of direct MRI assessment of TAL integrity has demonstrated that the “rule
of Spence” would have missed 60% of transverse ligament disruptions (Fig. 10.3). They classified those disruptions into two subtypes: type I with pure ligament
disruption; type II with an avulsion fracture of the
attaching tubercle or the lateral mass comminution.
They advocated an early surgical fixation of type I
fractures due to subsequent C1-2 instability and poor
potential of TAL matrix healing [6].
Fig. 10.4 Sagittal split fracture of lateral mass described by
Bransford. Note the avulsion fracture of condyle
Recently, Bransford et al. added the sagittal split
fracture of lateral mass to classification systems as a
specific entity prone to nonunion with painful defor-
10.2 Etiology
mity sequelae in the long term [3]. This intra-articular
fracture, in fact, completely disconnects the lateral
part of C1 mass from the C1 ring but it does not influence the attachment and function of TAL (Fig. 10.4).
The authors found 6 (11%) of previously described
fractures in their series of 54 admitted to the hospital.
Three of them died due to unrelated causes; however,
in three surviving individuals they have demonstrated
unsuccessful conservative treatment in rigid external
supports (2 × rigid collar, 1 × halo-vest) resulting in
painful deformity accompanied by cranial settling,
craniolateral odontoid migration, and finally necessitating traction-reduction followed by surgical occipitocervical fusion.
Like in other spine injuries, the incidence of atlas fractures peaks in the second and third decades of life with
almost twice male predominance. Vehicle accidents,
falls, and miscellaneous other reasons often caused by
either heavy object falling on the individual’s head or
indirect axial head compression are the common causes
of C1 fracture. Most frequently seen is an isolated fracture of the posterior C1 arch (approx 60% of all),which
is nearly always bilateral and usually caused by hyperextension and axial load when the arch is compressed
between occiput and spinous process of C2. The fracture
almost always occurs through its thinnest part in the VA
groove. It is obviously visible on lateral radiograph.
154
10 Atlas Fractures
On lateral plain film also easily visible isolated fracture of anterior arch is usually caused by the direct
impact of odontoid process or by hyperextension with
counteraction of longus colli muscle attached to anterior
tubercle. Jefferson was the first who hypothesized that
the axial load transmitted via occipital condyles to the
wedge-shaped lateral masses of atlas can cause their lateral dislocation followed by the ring fracture [22]. This
“bursting” mechanism is still accepted. The classic
Jefferson fracture as four-point fracture of the atlas is
rare; however, two- or three-point variants are much
more common [17]. These fractures result from axial
loading and usually, are not associated with neurological
injury. Different positions of head during the axial load
(flexion, rotation, lateral bending, etc.) can be responsible for variations of fracture pattern. For example, asymmetric lateral mass burst fracture with or without
concomitant asymmetric disconnection of both arches
can be a result of axial load in lateral bending. The functional integrity of TAL is considered as the most critical
factor determining the stability of C1 fractures [10, 13,
14, 26, 29, 39]. Transverse process fractures are caused
almost exclusively by direct blunt impact and can be
accompanied by VA tear or thrombosis [21]. Also, open
injury caused by sharp object penetration, knife violence,
and/or gunshot can involve the atlas [38, 39]. In such
trauma, cervical CTA might be necessary to exclude an
AV fistula or thrombosis.
10.3 Clinical Symptoms
Published mortality rate related to atlas fracture differs
depending on the source of analysis. If all trauma
patients admitted to a hospital with the C1 fracture are
analyzed retrospectively the mortality is as high as
30% [3], but if only those with isolated atlas fractures
referred for a specific treatment are included, the mortality is almost zero, and neurological deficit is rarely
detected [10, 14]. These observations confirming relative benignity of isolated C1 fractures are certainly
influenced by eventual inclusion of polytrauma patients
and/or those with combined UCS injuries in the survey. The clinical picture can be also modified by concomitant craniocerebral trauma in approximately 20%
of patients [14].
Nevertheless, in the patients with isolated C1 injury,
the clinical symptoms are usually nonspecific and any
neurological deficit clearly related to C1 trauma is
observed very rarely. Patients can complain of cervical
spine tenderness or pain radiating to the occiput. Also,
decreased sensation in occipital nerve region can be registered sometimes in combination with paravertebral
reactive muscular spasms limiting the cervical spine
motion. If the anterior arch is dislocated or prevertebral
hematoma present, the patient can also have swallowing
difficulties. Dislocated lateral masses and/or direct injury
of vertebral foramen can cause symptoms of vertebrobasilar insufficiency. There are numerous case reports
describing VA injuries associated with C1 fractures
[3, 31, 40, 48];however, only one case where the C1 fracture caused bilateral VA obliteration [47]. This patient
suffered from posterior fossa stroke but survived.
10.4 Diagnosis
As mentioned previously, most atlas fractures are
detected by spiral CT during admittance of acutely
traumatized patient; however, if the patient presents on
outpatient basis with nonspecific symptoms, then the
lateral, AP, and transoral radiographs are performed as
a first choice. Unfortunately, up to 25% of C1 fractures
might be missed on plain radiographs [7, 14] and there-
fore, if any suspicion of UCS injury arise from plain
films, CT always follows and thereafter, the MRI is
eventually performed to evaluate the status of TAL and
exclude neural structure compromise. The stability of
atlantal fractures, sometimes hypothetic, although for
further treatment decision crucial, can be confirmed by
physician-guided flexion–extension skiascopy in cooperating patients. Despite that, it is not widely accepted
since a dynamic CT or MRI can also be done for the
same purpose with more accuracy today.
Often, the first suspicion of instability comes from
transoral images if the atlantoaxial joint lateral summarized overhang is more than 8 mm [18, 41]. This
always leads to thin sliced CT imaging not only to
exactly depict the fracture and bone dislocation extend
but especially to see if the TAL tubercle is not detached
(Fig. 10.5) as an indirect sign of TAL deficiency [6].
Also, some comminuted lateral mass fractures are not
able to hold the ligamental tubercle avulsion (LTA)
strength to fix the dens in correct position (Fig. 10.6).
The most specific method to evaluate the LTA status is
MRI (Fig. 10.6).
10.5 Treatment Strategy
155
Fig. 10.5 Unstable two part C1 ring fracture with detachment
of TAL treated surgically with temporary lateral mass compression by custom made internal fixator fixed behind the C2
spinous process by the interconnecting rod. (a) Axial CT showing the fracture and TAL tubercle avulsion. (b) Perioperative
Fig. 10.6 (a) axial MRI
showing intact TAL, (b) axial
scan at the different level
demonstrating burst TAL
attachment
10.5 Treatment Strategy
Irrespective of the type of treatment, the goal of therapy in fractures of the atlas is to achieve bony healing,
maintain atlantoaxial stability, and prevent any neurological or painful sequelae of nonunion or malunion
picture, note the rod behind the C2 spinous process. (c)
Transoral postoperative view showing the achieved partial lateral mass compression. (d) Laterogram with internal fixator of
C1 fixed to spinous process of C2 by the rod
with good functional outcome. In the past, the treatment began with external bracing almost always [15,
39, 49]. The dislocations were reduced by traction,
sometimes lasting more than 6 weeks, followed by
hard external support with Minerva plaster or halocast and later, halo-vest [26, 29]. Most of the authors
156
Fig. 10.7 Pure ligamentous tear of TAL near to its insertion
depicted on axial MRI
described successful outcome in nearly all cases with
fusion rate round 95–100% and without delayed AA
instability regardless of the TAL integrity status [10,
14, 24, 39]. Surgery was indicated only if the conser-
vative approach failed. Due to contemporary technical
development, the surgical fixation was often not stable
enough and thus, uncomfortable halo-vest wearing continued for another 12 weeks after the operation [3, 26].
Dickman et al. started the era of more active surgical approach promoting to operate on all acute C1 fractures with MRI-proven traumatic intrasubstance
disintegration of TAL (their type I) to prevent subsequent AA instability. They have also reported that LTA
(their type II TAL injury) can heal conservatively in
only 74% [6].
Segal et al. [37] found positive relationship
between the degree of fracture displacement and nonunion and noticed that nonunions only occurred in
comminuted fractures involving the lateral mass with
osteoperiosteal avulsion of the transverse ligament. It
was also reported that those patients did not return to
full level of activity and were classed as poor clinical
outcome. As well others, including Jefferson’s initial
review [22], concluded that poor functional outcomes
may occur in 56–80% of conservatively treated
patients when the articular surface of lateral mass is
fractured and displaced [26, 29]. Usual argument is
that, incongruity of articular surface is responsible
for late pain and limited mobility in lateral mass fractures. Recently, Dvorak et al. retrospectively studied
a group of 34 patients treated (91% conservatively)
10 Atlas Fractures
for isolated Jefferson type fractures [9]. They psychometrically compared the follow-up status with the
normative and found out that the functional ability
did not achieve the preinjury state of health approximated to the normal population. The patient’s functional status was much worse in those with lateral
mass residual displacement more than 7 mm.
Potential risks of all surgical treatments are clear;
however, external immobilization techniques are not
without their risks. Halo-vest may be associated with
extra- or intracranial infections, while rigid collars
and braces (Minerva, SOMI) may result in cutaneous ulceration or inadequate immobilization [11, 19,
30, 34, 45]. Although immobilization techniques can be
adequate, 12 weeks in a halo-vest may not be acceptable
to every patient especially if alternatives exist [43].
Moreover, the halo seems not to be superior in terms of
rigidity to Philadelphia collar fixation in the UCS region
[25, 36].
Traditionally, unstable atlas fractures have been
treated surgically through a variety of different fusion
techniques ranging from posterior onlay occipitocervical fusions through wiring or screw methods [6,
27, 35]. Currently, the modular screw systems for AA
fixation with the ability to reduce atlantal fracture and/
or dislocation are the most effective surgical alternative [16, 44, 46]. Nevertheless, any AA fixation
substantially reduces the UCS mobility and therefore,
it is reasonable to look for better alternatives. Motionpreserving surgical treatment of isolated atlas fractures
is not a novel idea. Böhm et al. recently presented eight
patients with unstable Gehweiler Type III atlas fractures treated with an open direct osteosynthesis [2].
They reconstructed the C1 ring and avoided not only
fusion to C2 or occiput but also postoperative immobilization. Another method of preserving the AA motion
is, to fix the lateral masses together with construct
introduced transorally [20, 33]. When associated with
other fractures of the cervical spine, it is usually the
concomitant injury (most frequently, odontoid fracture) that determines the type of treatment [13, 24].
10.6 Our Preference
All our patients with suspected UCS injury have thin
sliced CT and MRI to obtain maximal information about
the “hard” and “soft” morphology of the injury. More
sophisticated investigations like dynamic films, dynamic
10.7 Our Treatment Algorithm
157
MRI, MRA, and/or CTA are added if necessary for finetuning of the diagnosis or planning of surgery.
We see isolated atlas fractures less frequently than
C1-2 combination injuries. This can be caused by
preferable admitting of patients referred for surgical
intervention from other hospitals. Apart from frequent single arch fractures the four-part Jefferson
fracture is extremely rarely seen; however, three- or
two-part ring disconnection is more often admitted.
In a similar frequency, we are encountering intraarticular fractures and lateral mass comminutions.
We believe that intra-articular fracture extent, the
joint incongruence caused by dislocation and the C1
ring functional disintegrity are the most important
factors influencing the patient’s outcome in isolated
C1 injuries. We have accepted the “Spence rule” as
an orientation warning about TAL status. Nevertheless,
the negative results seen on TO image should be confirmed by more precise methods (MRI, CT to see the
tubercle, dynamic films) of TAL integrity investigation in all C1 ring disconnecting fractures. Generally,
the stability of the fracture is dependent on the integrity of the C1 ring itself, in our opinion. The other
fact supporting our conviction of C1 ring integrity
importance is that the anterior transoral C1 laminectomy can lead to odontoid vertical migration in the
long term because the disintegrated ring is not able to
hold the weight of head and the wedge-shaped lateral
masses are prone to displace laterally. Any shift or
rotation of disconnected ring fragments can cause the
AA joint incongruence. Moreover, the sagittal split of
lateral mass described by Bransford et al. [3] is, in
fact, an unstable intra-articular fracture.
In summary, we suppose that if the fracture disconnecting the C1 ring heals under influence of vertical force on wedge-shaped lateral masses, the
displacement with joint incongruence can be the
result. In such situations, the later onset of posttraumatic arthritis with consecutive pain and movement
limitation can be anticipated. Jefferson fracture is not
a “burst fracture” in the usual sense of the term but
this is an atlas-bursting injury.
There are three most important points in decision
process choosing between surgery and conservative
treatment of atlas fractures, in our opinion. First, to
establish if the fracture is isolated or a part of combined USC injury. Most often, we can see the combination with odontoid process fracture and the C1
breach itself is not the key point to decide; however, if
it is unstable, more complex surgery can be involved
(e.g., triple anterior screw).
As second point, the stability of atlas fracture has to
be evaluated, which means that the functional integrity
of TAL has to be judged. We believe that also comminution of lateral mass cannot hold the TAL strength in
normal values. As a third important point in our decision process, is the expected long-term result and
patient’s satisfaction. Dislocated fractures not reducible with traction, intra-articular fractures (especially,
comminuted) – in summary, all those who cannot heal
conservatively with acceptable congruence of AA joint
are, at least, candidates for surgical consideration. The
busiest joint of the whole spine having healed in incorrect position can cause a whole life’s worth of problems for our patient.
10.7 Our Treatment Algorithm
Depending on pain generated by soft tissue injury, the
soft or hard collar should be stiff enough for successful
treatment of isolated posterior arch fractures.
Philadelphia collar for 12 weeks is sufficient to
immobilize the anterior arch fractures but more
frequent, radiological follow-up including dynamic
films is necessary to monitor eventual posterior C1
displacement.
In nondislocated fractures of both sides of the ring
with intact TAL confirmed by MRI also, the hard collar is used as initial treatment. Nonetheless, the fracture can heal slowly (sometimes, more than 6 months)
and this process has to be verified by CT and the
dynamic films should confirm the AA stability.
The same therapeutic regime can be used if the
“Jefferson-like” arch disconnection has more than two
fragments. Dislocated fractures without intra-articular
extend with intact TAL can be reduced by traction.
The weight of traction should be increased gradually
starting on 2 kg and the reduction effect controlled by
TO X-rays, or better by CT (with all the difficulties
accompanying the traction during patient’s transport
and positioning). If the fracture does not redislocate
after gradual traction release, the Philadelphia collar
with 14 days follow-up transoral radiographic control
can be applied, in our opinion.
Fractures of C1 lateral masses can be treated similarly to the previous group with hard collar if