C1 Fractures Workup

  • Author: Mark R Foster, MD, PhD, FACS; Chief Editor: Mary Ann E Keenan, MD   more...
 
Updated: Jul 22, 2011
 

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. 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 as symmetrically centered between the lateral masses. A C1 fracture is often associated with lateral displacement, so 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 atlantooccipital membranes may be disrupted and an occipitoatlantal dislocation may be observed; the normal anatomy must be confirmed. If any suspicion of disruption and/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 atlantooccipital dislocation: a ratio greater than 1 of the basion to 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; CT scanning facilitates those investigations wherein thin cuts best demonstrate the pattern of disruption for evaluating the location and displacement of suspected fractures of C1.
    • 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 isdisrupted. 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.
Proceed to Treatment & Management
 
 
Contributor Information and Disclosures
Author

Mark R Foster, MD, PhD, FACS  President and Orthoedic 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, American College of Surgeons, American Physical Society, Christian Medical & Dental Society, Eastern Orthopaedic Association, North American Spine Society, Orthopaedic Research Society, and Pennsylvania Orthopaedic Society

Disclosure: Nothing to disclose.

Specialty Editor Board

James F Kellam, MD  Vice-Chair, Department of Orthopedic Surgery, Director of Orthopedic Trauma and Education, Carolinas Medical Center

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

Disclosure: Nothing to disclose.

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

Disclosure: Medscape Salary Employment

William O Shaffer, MD  Professor, Vice-Chairman and Residency Program Director, Department of Orthopedic Surgery, University of Kentucky at Lexington

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

Disclosure: DePuySpine 1997-2007 (not presently) Royalty Consulting; DePuySpine 2002-2007 (closed) Grant/research funds SacroPelvic Instrumentation Biomechanical Study; DePuyBiologics 2005-2008 (closed) Grant/research funds Healos study just closed; DePuySpine 2009 Consulting fee Design of Offset Modification of Expedium

Dinesh Patel, MD, FACS  Associate Clinical Professor of Orthopedic Surgery, Harvard Medical School; Chief of Arthroscopic Surgery, Department of Orthopedic Surgery, Massachusetts General Hospital

Dinesh Patel, MD, FACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons

Disclosure: Nothing to disclose.

Chief Editor

Mary Ann E Keenan, MD  Professor, Vice Chair for Graduate Medical Education, Department of Orthopedic Surgery, University of Pennsylvania School of Medicine; Chief of Neuro-Orthopedics Program, Department of Orthopedic Surgery, Hospital of the University of Pennsylvania

Mary Ann E Keenan, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Orthopaedic Surgeons, American Orthopaedic Association, American Orthopaedic Foot and Ankle Society, American Society for Surgery of the Hand, and Orthopaedic Rehabilitation Association

Disclosure: Nothing to disclose.

References

  1. North American Spine Society. Spinal cord injury. Available at: http://www.spine.org/fsp/prob_action-injury-cord.cfm. Accessed: November 13, 2006.

  2. White AA, Panjabi MM. Clinical Biomechanics of the Spine. 2nd ed. Philadelphia, Pa:. Lippincott, Williams & Wilkins;1990.

  3. Aebi M. Surgical treatment of upper, middle and lower cervical injuries and non-unions by anterior procedures. Eur Spine J. Oct 14 2009;[Medline].

  4. Elgafy H, Dvorak MF, Vaccaro AR, Ebraheim N. Treatment of displaced type II odontoid fractures in elderly patients. Am J Orthop. Aug 2009;38(8):410-6. [Medline].

  5. Platzer P, Thalhammer G, Krumboeck A, Schuster R, Kutscha-Lissberg F, Zehetgruber I, et al. Plate fixation of odontoid fractures without C1-C2 arthrodesis: practice of a novel surgical technique for stabilization of odontoid fractures, including the opportunity to extend the fixation to C3. Neurosurgery. Apr 2009;64(4):726-33; discussion 733. [Medline].

  6. Al Eissa S, Reed JG, Kortbeek JB, Salo PT. Airway compromise secondary to upper cervical spine injury. J Trauma. Oct 2009;67(4):692-6. [Medline].

  7. Jefferson G. Fracture of atlas vertebra. Report of four cases and a review of those previously recorded. Br J Surg. 1920;7:407-22.

  8. Grauer JN, Shafi B, Hilibrand AS, et al. Proposal of a modified, treatment-oriented classification of odontoid fractures. Spine J. Mar-Apr 2005;5(2):123-9. [Medline].

  9. Sugrue PA, Hage ZA, Surdell DL, Foroohar M, Liu J, Bendok BR. Basilar artery occlusion following C1 lateral mass fracture managed by mechanical and pharmacological thrombolysis. Neurocrit Care. Oct/2008;11:255-260.

  10. Li L, Teng H, Pan J, Qian L, Zeng C, Sun G, et al. Direct posterior c1 lateral mass screws compression reduction and osteosynthesis in the treatment of unstable jefferson fractures. Spine. Jul/2011;36:E1046-51.

  11. De Iure F, Donthineni R, Boriani S. Outcomes of C1 and C2 posterior screw fixation for upper cervical spine fusion. Eur Spine J. Jun / 2009;18 suppl:2-6.

  12. Gallie WE. Fractures and dislocations of the cervical spine. Am J Surg. 1939;46(3):495-9.

  13. Brooks AL, Jenkins EB. Atlanto-axial arthrodesis by the wedge compression method. J Bone Joint Surg Am. Apr 1978;60(3):279-84. [Medline].

  14. Richter M, Schmidt R, Claes L, et al. Posterior atlantoaxial fixation: biomechanical in vitro comparison of six different techniques. Spine. Aug 15 2002;27(16):1724-32. [Medline].

  15. Cornefjord M, Henriques T, Alemany M, et al. Posterior atlanto-axial fusion with the Olerud Cervical Fixation System for odontoid fractures and C1-C2 instability in rheumatoid arthritis. Eur Spine J. Feb 2003;12(1):91-6. [Medline].

  16. Alker GJ, Oh YS, Leslie EV, et al. Postmortem radiology of head neck injuries in fatal traffic accidents. Radiology. Mar 1975;114(3):611-7. [Medline].

  17. Anderson LD, D'Alonzo RT. Fractures of the odontoid process of the axis. J Bone Joint Surg Am. Dec 1974;56(8):1663-74. [Medline].

  18. Bucholz RW, Burkhead WZ. The pathological anatomy of fatal atlanto-occipital dislocations. J Bone Joint Surg Am. Mar 1979;61(2):248-50. [Medline].

  19. Budin E, Sondheimer F. Lateral spread of the atlas without fracture. Radiology. Dec 1966;87(6):1095-8. [Medline].

  20. Eismont FJ, Bohlman HH. Posterior atlanto-occipital dislocation with fractures of the atlas and odontoid process. J Bone Joint Surg Am. Apr 1978;60(3):397-9. [Medline].

  21. Eleraky MA, Theodore N, Adams M, et al. Pediatric cervical spine injuries: report of 102 cases and review of the literature. J Neurosurg. Jan 2000;92(1 Suppl):12-7. [Medline].

  22. Eubanks JD, Gilmore A, Bess S, et al. Clearing the pediatric cervical spine following injury. J Am Acad Orthop Surg. Sep 2006;14(9):552-64. [Medline].

  23. Evarts CM. Traumatic occipito-atlantal dislocation. J Bone Joint Surg Am. Dec 1970;52(8):1653-60. [Medline].

  24. Gabrielsen TO, Maxwell JA. Traumatic atlanto-occipital dislocation; with case report of a patient who survived. Am J Roentgenol Radium Ther Nucl Med. Jul 1966;97(3):624-9. [Medline].

  25. Garber JN. Abnormalities of the atlas and axis vertebrae--congenital and traumatic. J Bone Joint Surg Am. Dec 1964;46:1782-91. [Medline].

  26. Hamilton MG, Myles ST. Pediatric spinal injury: review of 174 hospital admissions. J Neurosurg. Nov 1992;77(5):700-4. [Medline].

  27. Hinchey JJ, Bickel WH. Fracture of the atlas: review and presentation of data on eight cases. Ann Surg. Jun 1945;121(6):826-32. [Full Text].

  28. Johnson RM, Hart DL, Simmons EF, et al. Cervical orthoses. A study comparing their effectiveness in restricting cervical motion in normal subjects. J Bone Joint Surg Am. Apr 1977;59(3):332-9. [Medline].

  29. Levine AM, Edwards CC. Fractures of the atlas. J Bone Joint Surg Am. Jun 1991;73(5):680-91. [Medline].

  30. Levine AM, Edwards CC. Treatment of injuries in the C1-C2 complex. Orthop Clin North Am. Jan 1986;17(1):31-44. [Medline].

  31. Lipson SJ. Fractures of the atlas associated with fractures of the odontoid process and transverse ligament ruptures. J Bone Joint Surg Am. Oct 1977;59(7):940-3. [Medline].

  32. McAfee PC. Jefferson's fracture. In: Frymoyer JW, Weinstein JN, Ducker TB, Kostuik JP, Hadler NM, eds. Adult Spine: Principles and Practice. 2nd ed. Philadelphia, Pa:. Lippincott Williams & Wilkins;1991:1067.

  33. No authors listed. Isolated fractures of the atlas in adults. Neurosurgery. Mar 2002;50(3 suppl):S120-4. [Medline].

  34. No authors listed. Management of combination fractures of the atlas and axis in adults. Neurosurgery. Mar 2002;50(3 suppl):S140-7. [Medline].

  35. Oda T, Panjabi MM, Crisco JJ 3rd, et al. Experimental study of atlas injuries. II. Relevance to clinical diagnosis and treatment. Spine. Oct 1991;16(10 suppl):S466-73. [Medline].

  36. Panjabi MM, Oda T, Crisco JJ 3rd, et al. Experimental study of atlas injuries. I. Biomechanical analysis of their mechanisms and fracture patterns. Spine. Oct 1991;16(10 suppl):S460-5. [Medline].

  37. Patel JC, Tepas JJ, Mollitt DL, et al. Pediatric cervical spine injuries: defining the disease. J Pediatr Surg. Feb 2001;36(2):373-6. [Medline].

  38. Penning L, Wilmink JT. Rotation of the cervical spine. A CT study in normal subjects. Spine. Oct 1987;12(8):732-8. [Medline].

  39. Pierce DS, Barr JS Jr. Fractures and dislocations at the base of the skull and upper cervical spine. In: Bailey RW, ed. The Cervical Spine. Philadelphia, Pa:. Lippincott, Williams & Wilkins;1983: 196-206.

  40. Richards PG. Stable fractures of the atlas and axis in children. J Neurol Neurosurg Psychiatry. Aug 1984;47(8):781-3. [Medline].

  41. Schellhas KP, Latchaw RE, Wendling LR, et al. Vertebrobasilar injuries following cervical manipulation. JAMA. Sep 26 1980;244(13):1450-3. [Medline].

  42. Sherk HH, Nicholson JT. Fractures of the atlas. J Bone Joint Surg Am. Jul 1970;52(5):1017-24. [Medline].

  43. Sherk HH, Schut L, Lane JM. Fractures and dislocations of the cervical spine in children. Orthop Clin North Am. Jul 1976;7(3):593-604. [Medline].

  44. Spence KF Jr, Decker S, Sell KW. Bursting atlantal fracture associated with rupture of the transverse ligament. J Bone Joint Surg Am. Apr 1970;52(3):543-9. [Medline].

  45. Wetzel SG, Martin JB, Somon T, et al. Painful osteolytic metastasis of the atlas: treatment with percutaneous vertebroplasty. Spine. Nov 15 2002;27(22):E493-5. [Medline].

  46. White AA 3rd, Panjabi MM. The clinical biomechanics of the occipitoatlantoaxial complex. Orthop Clin North Am. Oct 1978;9(4):867-78. [Medline].

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