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C1 Fractures Workup

  • Author: Mark R Foster, MD, PhD, FACS; Chief Editor: Jeffrey A Goldstein, MD  more...
 
Updated: Mar 09, 2015
 

Imaging Studies

Cervical spine radiographs are routinely obtained in the emergency department for patients with a history of pain or of trauma, and they are mandatory for the nonresponsive patient, who is unable to report pain. These radiographs specifically include the open mouth view (see the image below).

Fracture of C1 ring may result in lateral displace Fracture of C1 ring may result in lateral displacement and subsequent overhang on open mouth view in radiographs.

After confirmation that neutral rotation is present and the radiograph is reliable (eg, as determined by looking at the incisor teeth to confirm lack of rotation of the head), the odontoid should appear symmetrically centered between the lateral masses. A C1 fracture is often associated with lateral displacement; thus, if the ring of C1 overhangs or extends laterally more than 6.9 mm over the lateral mass, a fracture of the ring of C1 is established. However, less excursion does not exclude this fracture, particularly if minimally displaced in the supine patient.

The lateral view is also crucial because the atlanto-occipital membranes may be disrupted and an occipitoatlantal dislocation may be observed; the normal anatomy must be confirmed. If any suspicion of disruption or dislocation exists, traction must be avoided, as well as any subsequent flexion-extension maneuvers or inappropriate manipulation, until that possibility can be excluded.

The odontoid should be well imaged from the lateral view; any lack of alignment or discontinuity that suggests fracture also suggests instability of the upper cervical spine, which may be associated with a C1 fracture but indicates very significant instability, requiring immobilization of the occipitoatlantoaxial complex.

On the lateral view, the Power ratio may be used to evaluate for possible atlanto-occipital dislocation: a ratio greater than 1 of the basion to the posterior arch of C1 (BC) over the anterior arch of C1 to the opisthion (AO) is suspicious for anterior dislocation.

If the ring is not clearly observed to overhang but asymmetry is present between the atlas and the odontoid, a C1-2 problem may be present, particularly atlantoaxial rotary subluxation, which may be a result of one of the facets between these 2 vertebrae being displaced or locked in a dislocated position.

Unfortunately, a possible C1-2 instability, particularly the cock robin position of the head that may be present with displacement of C1 on one side (anteriorly is most common), makes obtaining the standard open mouth and other radiograph views difficult. Computed tomography (CT; see the images below) facilitates those investigations wherein thin cuts best demonstrate the pattern of disruption for evaluating the location and displacement of suspected fractures of C1.

Computed tomography is often best for visualizing Computed tomography is often best for visualizing C1 ring fractures. Note anterior disruption, which must be accompanied by another break in ring.
Computed tomography sagittal views can be used to Computed tomography sagittal views can be used to evaluate atlantodental (or atlantodens or atlas-dens) interval or to visualize C1 fractures.

Unilateral posterior displacement of the atlas also produces the cock robin position, but this displacement is usually without a fractured dens. In trauma cases, most commonly, a unilateral combined anterior and posterior subluxation occurs when the transverse ligament is disrupted. The C1 ring may displace anteriorly and reduce the space available for the spinal cord.

Arteriography may be essential and emergent for any suspected vascular compromise or symptoms consistent with a vascular insult to detect occlusion, thrombosis, or intimal tear. Subtraction angiography may also help evaluate collateral circulation. If any circulatory problems are diagnosed, immediate anticoagulation with heparin prevents further extension of thrombosis, and administration of oxygen maintains cerebral oxygenation.

 
 
Contributor Information and Disclosures
Author

Mark R Foster, MD, PhD, FACS President and Orthopedic Surgeon, Orthopedic Spine Specialists of Western Pennsylvania, PC

Mark R Foster, MD, PhD, FACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons, Orthopaedic Research Society, Pennsylvania Orthopaedic Society, American Physical Society, American College of Surgeons, Christian Medical and Dental Associations, Eastern Orthopaedic Association, North American Spine Society

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

William O Shaffer, MD Orthopedic Spine Surgeon, Northwest Iowa Bone, Joint, and Sports Surgeons

William O Shaffer, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Association, Kentucky Medical Association, North American Spine Society, Kentucky Orthopaedic Society, International Society for the Study of the Lumbar Spine, Southern Medical Association, Southern Orthopaedic Association

Disclosure: Received royalty from DePuySpine 1997-2007 (not presently) for consulting; Received grant/research funds from DePuySpine 2002-2007 (closed) for sacropelvic instrumentation biomechanical study; Received grant/research funds from DePuyBiologics 2005-2008 (closed) for healos study just closed; Received consulting fee from DePuySpine 2009 for design of offset modification of expedium.

Chief Editor

Jeffrey A Goldstein, MD Clinical Professor of Orthopedic Surgery, New York University School of Medicine; Director of Spine Service, Director of Spine Fellowship, Department of Orthopedic Surgery, NYU Hospital for Joint Diseases, NYU Langone Medical Center

Jeffrey A Goldstein, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American College of Surgeons, American Orthopaedic Association, North American Spine Society, Scoliosis Research Society, Cervical Spine Research Society, International Society for the Study of the Lumbar Spine, AOSpine, Society of Lateral Access Surgery, International Society for the Advancement of Spine Surgery, Lumbar Spine Research Society

Disclosure: Received consulting fee from Medtronic for consulting; Received consulting fee from NuVasive for consulting; Received royalty from Nuvasive for consulting; Received consulting fee from K2M for consulting; Received ownership interest from NuVasive for none.

Additional Contributors

James F Kellam, MD, FRCSC, FACS, FRCS(Ire) Professor, Department of Orthopedic Surgery, University of Texas Medical School at Houston

James F Kellam, MD, FRCSC, FACS, FRCS(Ire) is a member of the following medical societies: American Academy of Orthopaedic Surgeons, Orthopaedic Trauma Association, Royal College of Physicians and Surgeons of Canada

Disclosure: Nothing to disclose.

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Fracture of C1 ring may result in lateral displacement and subsequent overhang on open mouth view in radiographs.
Computed tomography is often best for visualizing C1 ring fractures. Note anterior disruption, which must be accompanied by another break in ring.
Computed tomography sagittal views can be used to evaluate atlantodental (or atlantodens or atlas-dens) interval or to visualize C1 fractures.
 
 
 
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