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208
13 Miscellaneous C2 Fractures
7. Hadley, M.N., Dickman, C.A., Browner, C.M., et al.: Acute
axis fractures: a review of 229 cases. J Neurosurg 71,
642–647 (1989)
8. Hahnle, U.R., Wisniewski, T.F., Craig, J.B.: Shear fracture
through the body of the axis vertebra. Spine (Phila Pa 1976)
24, 2278–2281 (1999)
9. Jakim, I., Sweet, M.B.: Transverse fracture through the body
of the axis. J Bone Joint Surg Br 70, 728–729 (1988)
10. Korres, D.S., Papagelopoulos, P.J., Mavrogenis, A.F., et al.:
Multiple fractures of the axis. Orthopedics 27, 1096–1099
(2004)
11. Korres, D.S., Zoubos, A.B., Kavadias, K., et al.: The “tear
drop” (or avulsed) fracture of the anterior inferior angle of
the axis. Eur Spine J 3, 151–154 (1994)
12. Leconte, P.: Fracture et luxation des deux premieres vertebres cervicales. In: Judet, R. (ed.) Luxation Congenitale de
la Hanche. Fractures du Cou-de-pied Rachis Cervical.
Actualites de Chirurgie Orthopedique de l’Hospital
Raymond-Poincare, vol. 3, pp. 147–166. Masson et Cie,
Paris (1964)
13. Lohnert, J., Latal, J.: Fracture of the axis–surgical treatment.
II. Axial isthmus. Acta Chir Orthop Traumatol Cech 60,
47–50 (1993)
14. Maki, N.J.: A transverse fracture through the body of the
axis. A case report. Spine (Phila Pa 1976) 10, 857–859
(1985)
15. Marotta, T.R., White, L., TerBrugge, K.G., et al.: An unusual
type of hangman’s fracture. Neurosurgery 26, 848–850
(1990). discussion 850–841
16. Okuchi, K., Fujioka, M., Konobu, T., et al.: A case of
Hangman’s fracture associated with vertebral arteriovenous
fistula treated with trapping. No Shinkei Geka 22, 55–59
(1994)
17. Pelker, R.R., Dorfman, G.S.: Fracture of the axis associated
with vertebral artery injury. A case report. Spine (Phila Pa
1976) 11, 621–623 (1986)
18. Signoret, F., Feron, J.M., Bonfait, H., et al.: Fractured odontoid with fractured superior articular process of the axis.
Report of three cases. J Bone Joint Surg Br 68, 182–184
(1986)
19. Simonsen, J.: Massive subarachnoid haemorrhage and fracture of the transverse process of the atlas. Med Sci Law 16,
13–16 (1976)
20. Starr, J.K., Eismont, F.J.: Atypical hangman’s fractures.
Spine (Phila Pa 1976) 18, 1954–1957 (1993)
21. Suchomel, P., Hradil, J., Barsa, P., et al.: Surgical treatment
of fracture of the ring of axis – “hangman’s fracture”. Acta
Chir Orthop Traumatol Cech 73, 321–328 (2006)
22. Takahashi, T., Tominaga, T., Ezura, M., et al.: Intraoperative
angiography to prevent vertebral artery injury during
reduction of a dislocated hangman fracture. Case report.
J Neurosurg 97, 355–358 (2002)
23. Taller, S., Suchomel, P., Lukas, R., et al.: CT-guided internal
fixation of a hangman’s fracture. Eur Spine J 9, 393–397
(2000)
Multiple Fractures of Axis and Atlas-Axis Fracture Combinations
P. Suchomel and J. Hradil
14
14.1 Multiple Fractures of the Axis
An attempt to classify multiple axis fractures based on
traditional approaches to categorizing spine fractures is
difficult due to the complexity of this particular vertebra
and the number of many different combinations of
fractures. Some of the “single” fractures (by tradition)
involve two separate fracture sites (hangman’s fracture,
sagittal body fracture) and some of the single fracture
lines run through multiple areas of the axis (coronal
fractures involving body, pedicles, superior facet joints,
and transverse processes). The exact incidence of multiple fractures, thus, depends on the number of categories distinguished by particular authors. The literature
addressing this topic is very limited and there is no evidence concerning treatment methods. All multiple fractures of the axis should, therefore, be evaluated on
strictly individual case-by-case basis. The treatment
should be tailored according to the opinion and personal
experience of the treating surgeon. The majority of
authors recommend conservative approach with external immobilization. However, several fracture types
allow and benefit from effective surgical intervention.
Korres et al. reported a combination of two or even
three distinct axis fracture types in a single patient in 5%
of their series [14]. There were combinations of hangman’s fracture and tear drop (three cases), odontoid
fracture and hangman’s fracture (two cases), odontoid
fracture and “lateral mass” fracture (two cases), and one
case of combined odontoid, tear drop, and hangman’s
fractures. Daum and Archer described a combination of
P. Suchomel and J. Hradil
Department of Neurosurgery,
Neurocenter, Regional Hospital Liberec,
Husova St. 10, 46063 Liberec, Czech Republic
odontoid and hangman’s fracture [3]. Signoret et al.
analyzed possible biomechanical background of odontoid fractures and compressive fractures of the superior
facet joints [15]. Lateral bending and lateromedial forces
leading to compressive fractures of the area supporting
superior facet joint and odontoid fracture are a frequent
finding in such cases. Hahnle et al. reported compressive fractures of the superior facet joint area with specific fractures of the odontoid base, resulting in dens tilt
off the mid-sagittal plane [12]. Iizuka et al. reported a
case of an atypical hangman’s fracture and additional
fracture of the spinous process [13].
14.1.1 Our Preference
The combination of teardrop fracture and hangman’s
fracture is probably the most common finding. Teardrop
fracture can change treatment rationale as it is strongly
suggestive of disc injury. In our opinion, anterior discectomy, interbody graft fusion, and plate fixation
(ACDF) should be performed in such situations
(Fig. 14.1). In questionable cases, dynamic lateral radio-
graphs should be obtained in cooperating patients, especially in otherwise “stable” type I hangman’s fractures.
The second most common scenario is a combination
of odontoid and hangman’s fractures. Since there is an
expected high rate of non-union in type II and shallow
type III odontoid fractures treated by external immobilization, we are convinced that surgical treatment is the
method of choice here. A combination of an odontoid
screw and C2-3 ACDF is a viable and simple option in this
situation (Fig. 14.2). This approach is also suitable for the
treatment of a “triple” hangman-tear drop-odontoid fracture. Other fracture combinations can be seldom seen and
therefore, require individual evaluation of the degree of
P. Suchomel and O. Choutka, Reconstruction of Upper Cervical Spine and Craniovertebral Junction,
DOI: 10.1007/978-3-642-13158-5_14, © Springer-Verlag Berlin Heidelberg 2011
209
210
Fig. 14.1 C2 tear drop
fracture with simultaneous
hangman type fracture.
(a) Lateral radiograph.
(b) Postoperative picture
showing graft and plate
anterior fusion. Note triple
screw introduction into C3
body to increase the strength
of plate lever arm.
14 Multiple Fractures of Axis and Atlas-Axis Fracture Combinations
instability, their healing potential, and individual patient
characteristics. When conservative treatment is selected
in borderline or unclear cases, the need for a frequent and
close patient follow-up cannot be stressed enough.
14.2 Combined Atlas-Axis Fractures
Virtually, any fracture of axis can be accompanied by
atlas fracture and vice versa. The published frequency
of combined C1-2 fractures is approximately 3% of all
acute cervical spine injuries [5, 9]. Their treatment is
strictly individual. Most authors are in favor of external immobilization, but there are cases that may benefit
from early surgical solution [1, 2, 4, 9].
Gleizes et al. [7] provided a comprehensive analysis of cervical spine fractures associated with upper
cervical spine (UCS) trauma. A total of 784 cervical
spine injuries were evaluated and of those, 116 (14.8%)
involved the UCS. Nineteen cases (16.4% of UCS
injuries) of combinations of C1-C2 fracture were
found in this series. Double fractures were found in 17
and triple fractures in the remaining 2 patients. Within
the pool of 19 UCS fracture combinations, hangman’s
with odontoid fractures were present in 21.0%, odontoid with C1 posterior arch in 31.6%, odontoid with a
Jefferson fracture in 10.5%, and odontoid with a C2
superior facet fracture in 10.5%. Remaining 26.4% of
cases were of a unique fracture pattern.
Dickman et al. [5] presented 25 cases of atlas-axis
combinations that represented 43% of all atlas fractures and 16% of all axis fractures. Atlas fractures
included Jefferson type fractures in 40%, posterior
arch in 28%, unilateral ring in 24%, and lateral mass
in 8%. Axis fractures were represented by odontoid
type II injuries in 40%, miscellaneous fractures in
28%, odontoid type III in 20%, and hangman’s fractures in 12%. Neurological deficit was higher than in
isolated atlas or axis fractures and reached 12% across
all comers with combined C1/2 fractures. A large
series of patients with axis traumatic injuries accumulated in the same center by Hadley et al. and Greene
et al. did not deal with fracture combinations in detail,
nevertheless, they described atlas fractures in 41% of
axis injuries [8, 10, 11].
We found 17.5% of atlas fractures in a published
series of hangman’s fractures [16]. In his fundamental
piece, Effendi registered posterior atlas arch fractures
in 6.0% and odontoid fractures in 1.5% together with
fractures of the ring of axis [6].
14.2.1 Our Preference
The general principles of treatment of combined atlasaxis fractures are not based on any available evidence,
series analyses, or outcome measures yet. They are
based mostly on individual surgeon’s understanding
14.2 Combined Atlas-Axis Fractures
211
Fig. 14.2 Combination of a shallow odontoid type III and hang-
man’s fractures treated with single anterior odontoid screw and
subsequent C2-3 ACDF. (a) Plain lateral film. (b) Axial CT scan
and interpretation of the injury impact on biomechanical
properties of the bony and discoligamentous apparatus
of the AA complex.
If both the atlas and axis injuries are evaluated as
stable and non-displaced, external bracing can lead to
a successful union. However, if the fracture of any one
or even both vertebrae is considered to be unstable or
displaced, or if the discoligamentous apparatus is not
showing hangman type fracture. (c) Sagittal CT reconstruction
depicting odontoid type II fracture Postoperative lateral (d) and
AP (e) view of screw and plate fixation
able to maintain adequate spinal alignment, surgical
stabilization (usually following traction reduction) can
increase the chance of healing quicker and in an appropriate UCS balance.
The location of major instability often guides our
treatment approach selection. As most of the combinations include odontoid and hangman type fractures,
their fixation, if indicated, has to be done first. If the
212
14 Multiple Fractures of Axis and Atlas-Axis Fracture Combinations
concomitant atlas ring injury is stable (anterior, posterior arch) a hard collar for 6–12 weeks with regular
radiological follow-up can be sufficient. However, if
the atlas fracture is unstable (transverse atlantal ligament dysfunction etc.) or not maintaining alignment,
Fig. 14.3 Combination UCS
injury in a 64 year-old man
including shallow odontoid
type III, hangman and
Jefferson like fractures treated
with anterior fixation in single
stage. (a) Preoperative plain
laterogram. (b) Axial CT scan
of hangman like coronal
fracture of C2. (c) Plain
lateral view of C2-3 graft and
plate fixation together with
single anterior screw odontoid
osteosynthesis and double
transarticular screw AA
fusion. (d) The same patient
on AP film
simultaneous AA fixation can be performed. The combined procedure can often be done from a single anterior approach (Fig. 14.3). Combination of unstable atlas
and axis fractures can also be treated with posterior AA
or OC fixation and fusion (Figs. 14.4. and 14.5).
14.2 Combined Atlas-Axis Fractures
Fig. 14.4 Case of miscella-
neous C2 fracture combined
with AA instability caused
by TAL attachment abruption
treated with posterior
transarticular AA fusion.
(a) Axial CT of C2 lateral
pillar fracture. (b) Axial CT
showing the fragments of
abrupted TAL. (c) dynamic
lateral radiogram radioraph in
flexion documenting
increased AADI confirming
the AA instability. (d)
Posterior C1-2 transarticular
instrumentation supplemented with graft and wire
sublaminar fixation
213
Fig. 14.5 Rotatory
atlanto-axial subluxation with
concomitant C2 articular
pillar and odontoid process
type II fracture treated with
posterior fusion according
to Goel-Harms. (a) Axial CT
showing abnormal odontoid
position in rotatory C1
subluxation. (b) Coronal
plane CT (c) 3D CT anterior
view of fracture of C2
articular process. (d) Lateral
plain film of posterior
fixation
214
14 Multiple Fractures of Axis and Atlas-Axis Fracture Combinations
References
1. Agrillo, U., Mastronardi, L.: Acute combination fracture of atlas
and axis: “triple” anterior screw fixation in a 92-year-old man:
technical note. Surg Neurol 65, 58–62 (2006)
2. Apostolides, P.J., Theodore, N., Karahalios, D.G., et al.:
Triple anterior screw fixation of an acute combination atlasaxis fracture. Case report. J Neurosurg 87, 96–99 (1997)
3. Daum, W., Archer, C.R.: Fracture of the odontoid associated
with pedicle fracture of the axis: a previously undescribed
entity. J Trauma 17, 381–386 (1977)
4. Dean, Q., Jiefu, S., Jie, W., et al.: Minimally invasive technique of triple anterior screw fixation for an acute combination atlas-axis fracture: case report and literature review.
Spinal Cord 48, 174–177 (2010)
5. Dickman, C.A., Hadley, M.N., Browner, C., et al.:
Neurosurgical management of acute atlas-axis combination
fractures. A review of 25 cases. J Neurosurg 70, 45–49
(1989)
6. Effendi, B., Roy, D., Cornish, B., et al.: Fractures of the ring
of the axis. A classification based on the analysis of 131
cases. J Bone Joint Surg Br 63, 319–327 (1981)
7. Gleizes, V., Jacquot, F.P., Signoret, F., et al.: Combined injuries in the upper cervical spine: clinical and epidemiological
data over a 14-year period. Eur Spine J 9, 386–392 (2000)
8. Greene, K.A., Dickman, C.A., Marciano, F.F., et al.: cute axis
fractures. Analysis of management and outcome in 340 consecutive cases. Spine (Phila Pa 1976) 22, 843–1852 (1997)
9. Guiot, B., Fessler, R.G.: Complex atlantoaxial fractures.
J Neurosurg Spine 91, 139–143 (1999)
10. Hadley, M.N., Browner, C., Sonntag, V.K.: Axis fractures: a
comprehensive review of management and treatment in 107
cases. Neurosurgery 17, 281–290 (1985)
11. Hadley, M.N., Dickman, C.A., Browner, C.M., et al.: Acute
axis fractures: a review of 229 cases. J Neurosurg 71,
642–647 (1989)
12. Hahnle, U.R., Wisniewski, T.F., Craig, J.B.: Shear fracture
through the body of the axis vertebra. Spine (Phila Pa 1976)
24, 2278–2281 (1999)
13. Iizuka, H., Shimizu, T., Hasegawa, W., et al.: Fractures of the
posterior part of the body and unilateral spinous process of the
axis: a case report. Spine (Phila Pa 1976) 26, 528–530 (2001)
14. Korres, D.S., Papagelopoulos, P.J., Mavrogenis, A.F., et al.:
Multiple fractures of the axis. Orthopedics 27, 1096–1099
(2004)
15. Signoret, F., Feron, J.M., Bonfait, H., et al.: Fractured odontoid
with fractured superior articular process of the axis. Report of
three cases. J Bone Joint Surg Br 68, 182–184 (1986)
16. Suchomel, P., Hradil, J., Barsa, P., et al.: Surgical treatment
of fracture of the ring of axis – “hangman’s fracture”. Acta
Chir Orthop Traumatol Cech 73, 321–328 (2006)
Acute Traumatic Atlantoaxial Dislocation (AAD) in Adults
P. Suchomel and R. Fricˇ
15
Traumatic atlantoaxial dislocation (AAD) occurs less
frequently than AOD. This, usually fatal injury, [1, 2]
is commonly found as a consequence of high velocity
trauma. Generally, due to traumatic impact, the atlas
can be displaced in any direction in respect to C2 vertebra. C1 dislocation is frequently accompanied by a
fracture of the odontoid process but other UCS fractures can also be present. However, AAD as a result of
pure ligamentous injury is very rare.
Traumatic AADs can be divided into three categories: translational (AP and lateral), rotatory, and distractive [34].
The adult traumatic translational AAD is most frequently caused by AA instability related to odontoid or
other C2 fractures (Fig. 14.4, Chap. 14) and or atlas
fractures (Fig. 10.12, Chap. 10). The pure incompetence of transverse atlantal ligament (TAL) is much less
frequent (Figs. 10.3 and 10.11, Chap. 10) [24].
The isolated ligamentous rotatory traumatic dislocations are extremely rare in adults [4, 6, 20, 27, 33]
and most of the reported cases are combined with C2
fractures (Fig. 14.5, Chap. 14) [8, 13, 17, 21, 26, 34].
The classification dividing nontraumatic AA rotatory fixations in children and young adults into two
(often four) categories [10, 31] can be used to classify
the degree of traumatic rotatory displacement in adults
as well; however, one has to be aware not to overestimate the rotational displacement as it can be, in fact,
P. Suchomel
Department of Neurosurgery,
Neurocenter, Regional Hospital Liberec,
Husova St. 10, 46063 Liberec, Czech Republic
R. Fricˇ
Department of Neurosurgery, Rikshospitalet,
Oslo University Hospital, Sognsvannsveien 20,
0027 Oslo, Norway
within normal range of AA joint movement. Recently,
Mönckeberg et al. [25] reported CT analysis performed
on 40 healthy volunteers (actually, colleagues from
author’s own institution) clearly documenting that during maximal voluntary rotation (38° on an average) to
one side, 70% of AA joint facet surface is uncovered
on an average, and that the full facetal contact is
achieved only in neutral position.
Often, distractive force can also cause the AAD
without vertebral fractures, however, a very important
warning case of concomitant fracture was reported by
Przybylski and Welsch [30]. They had a patient
referred from another hospital with type III odontoid
fracture. Quadriplegia developed with 5 lbs of traction
used, to reduce the angular odontoid process displacement. Horizontal AA complex disruption simultaneous with type III odontoid fracture revealed on CT
was responsible for this significant vertical instability
with AAD.
The first who described distractive AAD without
concomitant fractures were Haralson and Boyd in
1969 [16]. Until 1980, only two other similar cases
were published [28, 32]. With improved rescue services and development of modern imaging more cases
of pure ligamentous AA disruption were reported later
on [7, 11, 18, 19, 22, 29, 36, 37]; nevertheless, this
often fatal injury is still a rarity. Such AA distraction
is possible only with simultaneous disruption of alar
and apical ligaments. Tectorial membrane can be torn
and a dural tear can be detected [37]. Although not
ruptured, the TAL is always suspected of being also
seriously damaged.
Cases of dual AOD and AAD injury have been
reported even less frequently (only three cases up to
now) [14, 15, 22].
A congenital atlanto-occipital coalition, various
CVJ anomalies and particularly hypoplastic odontoid
P. Suchomel and O. Choutka, Reconstruction of Upper Cervical Spine and Craniovertebral Junction,
DOI: 10.1007/978-3-642-13158-5_15, © Springer-Verlag Berlin Heidelberg 2011
215
216
15 Acute Traumatic Atlantoaxial Dislocation (AAD) in Adults
process are thought to be a predisposing factor for AA
instability [35]. In these cases, only mild trauma can
cause significant AAD.
As mentioned previously, competence of TAL and
integrity of odontoid process are crucial factors for
maintaining atlantoaxial stability. However, the other
ligaments, membranes, and joint capsules also play
an important role especially in purely traumatic rotatory, uni- or bilateral AA joint dislocations. If reduced
during the emergent investigations after injury, a
purely ligamentous injury can be missed and the
patient can come back later with chronic AA
instability.
Adult traumatic AAD represents a substantially different topic from atlantoaxial rotatory subluxation/
fixation commonly diagnosed in children (“cockrobin” posture) usually presenting with orofacial
infections, minor trauma, ocular problems, and genetic
diseases. Also, other pathologies can lead to AA displacement and if trauma is superimposed onto tumor,
RA or infection, the diagnosed AA displacement is
certainly also not a typical AAD.
15.1 Etiology and Epidemiology
AAD resulting from trauma occurs in only 1–2% of
patients admitted to hospitals with acute cervical injuries [5, 12].
The mechanisms responsible for translational and
rotatory AAD with or without simultaneous UCS fractures can be complex with some predilection for flexion in anterior dislocations and lateral bending and/or
rotation in rotatory displacements.
The probable mechanism of distractive AAD is the
hyperextension of UCS with consequent rupture of alar,
apical, and accessory ligaments, but the tectorial membrane and ALL must, in principle, be damaged also.
Until this moment the mechanism of disruption is similar to AOD; however, instead of capsular AO disruption
the AA joint capsule and its ligaments are crushed with
subsequent distraction and/or dislocation. Exceptionally,
both UCS joints can also be involved creating dual
AAD/AOD injury. An actual injury mechanism reported
in the majority of cases is the sudden hyperextension of
relaxed spine not prepared to resist, with typical example of a relaxed pedestrian walking on the street hit by a
car from behind.
15.2 Clinical Diagnosis
Probably, half of trauma victims suffering from AAD
die at the place of accident; however, the majority of
survivors fortunately do not have major neurologic deficit. The symptoms vary from nonspecific pain with
blocked UCS movement to fixed head rotation away
from anteriorly displaced AA joint in rotational AAD.
Some can also have suboccipital neuralgia due to an
overstretched C2 nerve root. Exceptionally, the signs of
VB insufficiency can be seen if the VA is compromised.
As in other UCS injuries, approximately in 20% of
admitted patients, the specific clinical picture can be
clouded by coincident symptomatology of cerebral
injury or polytrauma.
15.3 Radiology
Plain films are seldom obtained as a first assessment.
Lateral projections are often without signs of pathology (if fracture or posterior atlas dislocation are not
present) and transoral pictures can show only asymmetric odontoid position. Dynamic films can reveal
AA instability in cooperating patients but are never
performed as the primary investigation.
Currently, trauma patients pass through the emergency department with a helical CT performed primarily. The diagnosis is thus reached earlier than in the past.
It is usually easy to visualize the fractures but the rotatory dislocation needs a specific protocol. The scanner
gantry angle adopted to respect the axial plane of atlas
and images superimposed by computer are necessary to
quantify the amount of AA rotation [3]. Recently, the 3D
CT can demonstrate the amount of displacement much
better. To assess TAL, alar ligaments as well as the space
available for spinal cord, the MRI should be done in all
cases. In those with marked AA dislocation, VA can be
overstretched and thus CTA can be indicated to elucidate
its patency.
15.4 Treatment Strategy
The goals of AAD treatment are to restore or prevent
possible neurological compromise, to stabilize the
dangerous instability and if possible in minor, purely
References
217
ligamentous injuries, to restore normal, pain-free
motion of AA joint.
In translational injuries with fractures, it is the fracture pattern that determines whether conservative or
operative treatment should be undertaken [17, 34]. If
TAL is damaged, the majority of surgeons perform
posterior AA fusion [9, 24]. The controlled traction –
reduction nearly always precedes the final surgical
procedure.
The pure rotatory dislocations can be treated primarily by manipulation (also finger through mouth pressure
was recommended), by traction or their combinations
with subsequent hard bracing for 6 weeks–3 months
[23]. However, if the conservative approach fails, posterior AA fusion should be considered.
In fracture-associated rotational dislocation, the
stability of the fracture often is the most important
point in the decision process. The indications were
described in detail in previous chapters. For example,
the odontoid type II fracture should be fixed by direct
screw osteosynthesis and the AA instability often heals
without further problems.
In pure distractive injury with posterior atlas displacement, the reduction often consisting of closed distraction,
reduction, and release, with [16, 18, 36, 37] or without
[32] posterior fusion was reported as efficient treatment.
In one case, the transoral odontoid resection was chosen
to release the dislocation [11] and in another the high
anterolateral approach and partial odontoid resection
with C1 reduction followed by anterior AA screw fixation was performed [19]. During any reduction manipulation, one has to take care not to overdistract the AA
joint. Some authors prefer closed maneuvers to reduce
the AAD but if this is not easily possible the head manipulation controlled by direct “open” visibility of posterior
elements seems to be safer. Also, the open reduction
maneuvers can be very effective. Yoon et al. reported that
caudally oriented pressure to C2 spinous process under
simultaneous traction can be effective in AAD reduction
[37]. Certainly, all such manipulations have to be controlled by lateral fluoroscopy and IOM.
15.5 Our Preference
As humans are standing and walking beings, the spine head fixation system is not adapted to pure distraction
and in any injury where the distractive force is
suspected (e.g., gliding of passenger under the seat
belts with submandibular excoriations, violent combat sports, rugby, etc.), full investigation of potential
distractive injury has to follow. Despite a very limited
experience with this topic we suppose that the CT
and/or MRI assessment of AA but also of AO joints
should be done under mild distractive force either
during the diagnostic process or later at follow-up
checks to recognize the inadequate joint fissure distraction. It seems doubtful that the ligaments will heal
with sufficient capacity to resist the head traction,
especially when considering the age and lifestyle of
each individual.
As described previously, we are surgically active in
cases of unstable fracture dislocations as well as in
cases of confirmed TAL damage. In the case of pure
rotational ligamentous injury without marked TAL
damage, the question remains what extent of rotation
exceeds the normal physiological range. Reduction by
traction and collar fixation is probably a good solution
for majority of these.
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