History and Physical Examination

Patients with C1 (atlas) fractures customarily present with a history of trauma and a symptom of pain in the neck. Among the massive number of patients who qualify as having this history and symptom, a few patients have an unstable C1 injury and may present in a neurologically intact state, but they are at grave risk for neurologic compromise if not promptly diagnosed and appropriately stabilized and treated.

Patients with a complete spinal cord injury (SCI) and no neurologic function continue to have only sensation on the face and motor control of the facial muscles from the cranial nerves. A tracheostomy is essential; the patient requires respiratory assistance and a volume respirator. If the C3-C5 area is intact, the phrenic nerve may often be stimulated to contract the diaphragm. If stimulation of the phrenic nerve does not contract the diaphragm, then the spinal cord is no longer functioning; the cell body is dead, and a phrenic electrical stimulator is not effective.

Classification

The Gehweiler classification is commonly used to categorize C1 fractures. This sytem divides fractures of the atlas into the following five types^[14]:

Type I - Fracture of the anterior arch
Type II - Fracture of the posterior arch
Type IIIa/ IIIb - Combined fracture of both the anterior and the posterior arch (Jefferson fracture), either nondisplaced (IIIa) or displaced (IIIb)
Type IV - Fracture of the massa lateralis
Type V - Fracture of the transverse process

Workup

Mead LB 2nd, Millhouse PW, Krystal J, Vaccaro AR. C1 fractures: a review of diagnoses, management options, and outcomes. Curr Rev Musculoskelet Med. 2016 Sep. 9 (3):255-62. [QxMD MEDLINE Link]. [Full Text].
Jefferson G. Fracture of atlas vertebra. Report of four cases and a review of those previously recorded. Br J Surg. 1920. 7:407-22.
Spinal cord injuries. North American Spine Society. Available at https://www.spine.org/KnowYourBack/Conditions/Injuries/Spinal-Cord-Injuries. 2022; Accessed: April 7, 2022.
Jonas R, Wilke HJ. The cervical spine. Galbusera F, Wilke HJ, eds. Biomechanics of the Spine: Basic Concepts, Spinal Disorders and Treatments. San Diego: Academic Press; 2018. 11-34.
Aebi M. Surgical treatment of upper, middle and lower cervical injuries and non-unions by anterior procedures. Eur Spine J. 2010 Mar. 19 Suppl 1:S33-9. [QxMD MEDLINE Link].
Elgafy H, Dvorak MF, Vaccaro AR, Ebraheim N. Treatment of displaced type II odontoid fractures in elderly patients. Am J Orthop (Belle Mead NJ). 2009 Aug. 38 (8):410-6. [QxMD MEDLINE Link].
Anderson LD, D'Alonzo RT. Fractures of the odontoid process of the axis. J Bone Joint Surg Am. 1974 Dec. 56 (8):1663-74. [QxMD MEDLINE Link].
Grauer JN, Shafi B, Hilibrand AS, Harrop JS, Kwon BK, Beiner JM, et al. Proposal of a modified, treatment-oriented classification of odontoid fractures. Spine J. 2005 Mar-Apr. 5 (2):123-9. [QxMD MEDLINE Link].
Roy-Camille R, Saillant G, Judet T, de Botton G, Michel G. [Factors of severity in the fractures of the odontoid process (author's transl)]. Rev Chir Orthop Reparatrice Appar Mot. 1980 Apr-May. 66 (3):183-6. [QxMD MEDLINE Link].
Desouza RM, Crocker MJ, Haliasos N, Rennie A, Saxena A. Blunt traumatic vertebral artery injury: a clinical review. Eur Spine J. 2011 Sep. 20 (9):1405-16. [QxMD MEDLINE Link].
Cusimano MD, Mascarenhas AM, Manoranjan B. Spinal cord injuries due to diving: a framework and call for prevention. J Trauma. 2008 Nov. 65 (5):1180-5. [QxMD MEDLINE Link].
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. 2009 Apr. 64 (4):726-33; discussion 733. [QxMD MEDLINE Link].
Al Eissa S, Reed JG, Kortbeek JB, Salo PT. Airway compromise secondary to upper cervical spine injury. J Trauma. 2009 Oct. 67 (4):692-6. [QxMD MEDLINE Link].
Lehman R, Riew D, Schnake K. Occipitocervical trauma. AO Foundation. Available at https://www2.aofoundation.org/wps/portal/surgery?showPage=diagnosis&bone=Spine&segment=TraumaUpperCervical. Accessed: April 7, 2022.
[Guideline] Ryken TC, Hadley MN, Walters BC, Aarabi B, Dhall SS, Gelb DE, et al. Radiographic assessment. Neurosurgery. 2013 Mar. 72 Suppl 2:54-72. [QxMD MEDLINE Link]. [Full Text].
Payabvash S, McKinney AM, McKinney ZJ, Palmer CS, Truwit CL. Screening and detection of blunt vertebral artery injury in patients with upper cervical fractures: the role of cervical CT and CT angiography. Eur J Radiol. 2014 Mar. 83 (3):571-7. [QxMD MEDLINE Link].
Bellabarba C, Bransford R, Shatsky J. Unstable C1 ring fractures managed with primary internal fixation without fusion: a retrospective review [abstr]. Global Spine J. 2017 May 18. 5 (1 Suppl):s-0035-1554200. [Full Text].
[Guideline] Kandziora F, Scholz M, Pingel A, Schleicher P, Yildiz U, Kluger P, et al. Treatment of Atlas Fractures: Recommendations of the Spine Section of the German Society for Orthopaedics and Trauma (DGOU). Global Spine J. 2018 Sep. 8 (2 Suppl):5S-11S. [QxMD MEDLINE Link]. [Full Text].
[Guideline] Trauma Quality Programs Best Practices Guidelines: spine injury. American College of Surgeons. Available at https://www.facs.org/-/media/files/quality-programs/trauma/tqip/spine_injury_guidelines.ashx. March 2022; Accessed: April 7, 2022.
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. 2009. 11 (2):255-60. [QxMD MEDLINE Link].
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 (Phila Pa 1976). 2011 Jul 1. 36 (15):E1046-51. [QxMD MEDLINE Link].
De Iure F, Donthineni R, Boriani S. Outcomes of C1 and C2 posterior screw fixation for upper cervical spine fusion. Eur Spine J. 2009 Jun. 18 Suppl 1:2-6. [QxMD MEDLINE Link]. [Full Text].
Krassnig R, Orlandi JA, Tackner E, Hohenberger G, Puchwein P. Computer-aided analysis for optimal screw insertion in lateral mass of C1: An anatomical study. Arch Orthop Trauma Surg. 2017 Jun. 137 (6):817-822. [QxMD MEDLINE Link].
Costa F, Ortolina A, Attuati L, Cardia A, Tomei M, Riva M, et al. Management of C1-2 traumatic fractures using an intraoperative 3D imaging-based navigation system. J Neurosurg Spine. 2015 Feb. 22 (2):128-33. [QxMD MEDLINE Link].
Singh PK, Garg K, Sawarkar D, Agarwal D, Satyarthee GD, Gupta D, et al. Computed tomography-guided C2 pedicle screw placement for treatment of unstable hangman fractures. Spine (Phila Pa 1976). 2014 Aug 15. 39 (18):E1058-65. [QxMD MEDLINE Link].
Gallie WE. Fractures and dislocations of the cervical spine. Am J Surg. 1939. 46(3):495-9.
Brooks AL, Jenkins EB. Atlanto-axial arthrodesis by the wedge compression method. J Bone Joint Surg Am. 1978 Apr. 60 (3):279-84. [QxMD MEDLINE Link].
Richter M, Schmidt R, Claes L, Puhl W, Wilke HJ. Posterior atlantoaxial fixation: biomechanical in vitro comparison of six different techniques. Spine (Phila Pa 1976). 2002 Aug 15. 27 (16):1724-32. [QxMD MEDLINE Link].
Cornefjord M, Henriques T, Alemany M, Olerud C. Posterior atlanto-axial fusion with the Olerud Cervical Fixation System for odontoid fractures and C1-C2 instability in rheumatoid arthritis. Eur Spine J. 2003 Feb. 12 (1):91-6. [QxMD MEDLINE Link].
Yu JC, Niemeier TE, Manoharan SR. Unstable C1 Fracture Managed with Internal Fixation Using Lateral Mass Screws: A Case Report. JBJS Case Connect. 2018 Jan-Mar. 8 (1):e9. [QxMD MEDLINE Link].
Simsek S, Yigitkanli K, Seçkin H, Comert A, Acar HI, Belen D, et al. Ideal screw entry point and projection angles for posterior lateral mass fixation of the atlas: an anatomical study. Eur Spine J. 2009 Sep. 18 (9):1321-5. [QxMD MEDLINE Link]. [Full Text].

Media Gallery

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.
Sagittal reformat of CT cervical spine showing posterior displacement and chronic nonunion of the dens.
Bilateral posterior arch fractures in the axial plane of the CT cervical spine in the same patient after a second fall.
Lateral radiograph after C1-2 posterior fusion.
AP radiograph showing hybrid C1-2 posterior fixation with bilateral C1 screws and right sided C2 pedicle screw with a left to right intralaminar or translaminar C2 screw.
Lateral radiograph after posterior C1-2 fusion.

of 8

Author

J Allan Goodrich, MD Staff Physician, Orthopaedic Spine Surgeon, Doctor's Hospital

J Allan Goodrich, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, North American Spine Society, Society of Lateral Access Surgery

Disclosure: Received income in an amount equal to or greater than $250 from: Globus medical<br/>Intellectual property Globus.

Coauthor(s)

Jonathan A Tuttle, MD, FAANS Neurological Surgeon, University Neurosciences, Augusta Back

Jonathan A Tuttle, MD, FAANS is a member of the following medical societies: American Association of Neurological Surgeons, AOSpine, Congress of Neurological Surgeons, 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 Former 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, International Society for the Study of the Lumbar Spine, Kentucky Medical Association, Kentucky Orthopaedic Society, North American Spine Society, Southern Medical Association, Southern Orthopaedic Association

Disclosure: Nothing to disclose.

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, AOSpine, Cervical Spine Research Society, International Society for the Advancement of Spine Surgery, International Society for the Study of the Lumbar Spine, Lumbar Spine Research Society, North American Spine Society, Scoliosis Research Society, Society of Lateral Access Surgery

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Globus, 3Spine<br/>Received income in an amount equal to or greater than $250 from: Globus, Nuvasive, Surgalign, 3Spine.

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.

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, American College of Surgeons, American Physical Society, Christian Medical and Dental Associations, Eastern Orthopaedic Association, North American Spine Society, Orthopaedic Research Society, Pennsylvania Orthopaedic Society

Disclosure: Nothing to disclose.

C1 (Atlas) Fractures Clinical Presentation

History and Physical Examination

Classification

References

Tables

Contributor Information and Disclosures

What would you like to print?