Atlas fracture

Transverse ligament injury

Atlas Fractures & Transverse Ligament Injuries are
traumatic injuries usually caused by high-energy trauma
with axial loading in young patients (Jefferson Fracture)
or low-energy falls in elderly. Due to the capacious nature
of the spinal canal at this level these injuries usually
present with neck pain without neurological deficits.
Diagnosis is often missed with plain radiographs so a CT
scan may be required to make the diagnosis. An open-
mouth odontoid radiograph is useful to evaluate for
disruption of the transverse ligament which leads to lateral
displacement of the lateral masses relative to each other.
Stable injuries can be treated with immobilization in a
cervical collar. Unstable injuries require either halo-vest
immobilization or surgical stabilization with a fusion.
EPIDEMIOLOGY Incidence
make up ~7% of cervical spine fractures
atlas fractures make up to 25% of the injuries of the craniovertebral junction
1-3% of all spinal injuries
commonly missed due to inadequate imaging of occipitocervical junction
Demographics
bimodal age distribution
early adulthood (20-30s)
high-energy axial loading mechanism
elderly
low-energy, ground-level fall
predisposed to injury from
osteoarthritic bone changes
limited mobility
gait imbalance
Pathophysiology
mechanism
most commonly associated with high-
energy injury mechanisms
~85% of cases associated with MVC
ground level falls in elderly patients
osteoporosis predisposes to low energy
fractures
injury biomechanics
hyperextension
forehead blow injury
posterior arch remains static
anterior arch continues to move
posterior arch injury
higher occurence with low-energy falls
higher association with odontoid
fractures
30% less energy requirement to cause
atlas fracture when cervical spine is in
extension compared to neutral
lateral compression
anterior arch fractures
lateral distraction
comminuted lateral mass fracture
axial compression
blow to the vertex
leads to Jefferson burst fracture
Associated conditions due to large space for the
spine fracture spinal cord at this level
50% have an associated injuries tend to increase
spine injury the area availabe for
40% associated with axis spinal cord at C1
fx
closed head injuries
neurologic injury
risk of neurologic injury
is low
Bony anatomy
Atlas osteology
atlas (C1) is a ring containing
two articular lateral masses
it lacks a vertebral body or a
spinous process
embryology
forms from 3 ossification
centers
anatomic variation
incomplete formation of the
posterior arch is a relatively
common anatomic variant and
does not represent a traumatic
injury
C1 transverse foramen
houses vertebral artery
makes acute posteromedial
bend around Occ-C1 joint and
crosses sulcal groove
sulcal groove is a common site
for posterior arch
injuries/fractures
Ligamentous anatomy
occipital-cervical junction and
atlantoaxial junction are coupled
intrinsic ligaments are located within the apical ligament
spinal canal, provide most of the
ligamentous stability. They include
transverse ligament
primary stabilizer of atlantoaxial
junction
prevents posterior migration of the
odontoid into the spinal canal
connects the posterior odontoid to the
anterior atlas arch, inserting laterally on
bony tubercles of the lateral mass
paired alar ligaments
connect the odontoid to the occipital
condyles
relatively strong and contributes to
occipitalcervical stability
relatively weak midline structure
runs vertically between the odontoid and
foramen magnum.
tectorial membrane
connects the posterior body of the axis to
the anterior foramen magnum and is the
cephalad continuation of the PLL
Articulations aticulation between the dens (C2) and
occipitoatlantal joint (Occ-C1) the anterior arch of the atlas
occipital condyles articulate with C1 enable ~50% of cervical spine rotation
superior articular processes
provides ~50% of cervical spine flexion
and extension range of motion
true synovial joint
contains anterior and posterior joint
capsules
atlantoaxial joints (C1-2)
facet joints
articulation between the inferior facet of
C1 and superior facet of C2
biconcave synovial joint
atlantodens joint
synovial joint
 •  Landells Atlas Fractures Classification

•Isolated anterior or posterior arch fracture.Most

common injury pattern
•"Plough" fracture is an isolated anterior arch fracture
•Type 1 caused by a force driving the odontoid through the
anterior arch. 
•Stable injury
•Treat with hard collar. 

•Jefferson burst fracture with bilateral fractures of

anterior and posterior arch resulting from an axial
load.Stability determined by the integrity of transverse
ligament. 
•Type 2
•If intact, treat with a hard collar. 
•If disrupted, halo vest (for bony avulsion) or C1-2
fusion (for intrasubstance tear)(see Dickman
classification below).

•Unilateral lateral mass fx. Stability determined by the

integrity of the transverse ligament. 
•Type 3
•If stable, treat with a hard collar. 
•If unstable, halo vest.

• Dickman Transverse Ligament Injuries Classification

•Intrasubstance tear.
•Type 1
•Treat with C1-2 fusion.

•Type 2 •Bony avulsion at tubercle on C1 lateral mass. Treat with

halo vest (successful in 75%)
PRESENTATION History Physical exam
high-energy injury neuro deficits uncommon in isolated C1
MVC fractures
fall from ladder associated C2 fractures have a higher risk of
ground level fall neuro deficit
elderly patients vertebral artery injury
Symptoms vertigo
neck pain diploplia
cervical spinal muscle spasms blindness
limited neck motion ataxia
C2 nerualgia/palsy bilateral weakness
occipital neuralgia dysphagia
occipital numbess nausea
occipital alopecia (rare) C2 nerve palsy
vertebral artery dissection decreased sensation in the occipital region
loss of consciousness neck flexion and extension weakness
double vision
vertigo
IMAGING views
Radiographs < 3 mm = normal in adult (< 5mm normal in child)
recommended views 3-5 mm = injury to transverse ligament with intact alar and
lateral radiographs apical ligaments
oblique radiographs > 5 mm = injury to transverse, alar ligament, and tectorial
60-degree oblique radiographs to indetify posterior arch membrane
fractures
open-mouth odontoid
open-mouth odontoid view important to identify atlas sum of lateral mass displacement (LMD)
fractures measured on open-mouth odontoid views
optional views if sum of lateral mass displacement is > 6.9 mm (rule of
flexion-extension views Spence) or 8.1mm with radiographic magnification (rule of
identify late instability following nonoperative treatment Heller) then a transverse ligament rupture is assured and
findings the injury pattern is considered unstable
increased widening of C1 lateral masses compared to C2
(LMD) retropharyngeal soft tissue
increased distance of the atlantodental interval (ADI) measured on lateral radiographs
fracture involving the posterior or anterior arch increased thickening of retropharyngeal soft tissue (>9.5
concomitant spine injuries mm) suggests an anterior arch injury
C2 injuries sensitivity
subaxial spine injuries radiographs have a lower sensitivity of detecting unstable
occipitocervical distraction/dissociation atlas fractures than CT and MRI
measurements
atlantodens interval (ADI)
measured on lateral radiographs and flexion-extension
CT increased radial displacement of the C1 fracture fragments
indications (unstable)
should be ordered for every case of suspected cervical spine bone avulsion injuries of the tubercle (TAL insertion)
injury sagittal split fractures of the lateral mass
study of choice to delineate fracture pattern and identify sensitivity
associated injuries in the cervical spine highly sensitive at detecting fractures
lower sensitivity than MRI at detecting TAL injuries
good study to assess for pseudospread of the atlas in
pediatric patients
thin slices parallel to the C1 arch
represents asymmetric growth of the atlas compared to the
axis
greater atlantal overhang of the lateral masses
views
sagittal reconstructions
occult horizontal fractures of the anterior arch
axial reconstructions
identify Dickman II injuries to the TAL
coronal reconstructions
determine total lateral mass displacement
angiogram
assess the presence of a vertebral artery injury
findings
fractures involving the anterior and posterior ring
lateral mass fractures
MRI hematoma
indications depends on age of injury
should be ordered in any case there is a prevertebral soft tissue swelling
confirmed fracture of the atlas increased prevertebral soft tissue T2 signal
rule out associated unstable ligamentous intensity at C1-2
injuries more sensitive at detecting injury to
views transverse ligament
sagittal and coronal views increaed T2 signal intensity in the TAL is
increased T2 signal in the TAL suggests suggestive of injury
intrasubstance injury
findings
TAL injuries
increased T2 signal intensity in the TAL on
the sagittal and coronal views
spinal cord injury
edema
increased T2 signal intensity in the spinal
cord
TREATMENT -unstable Type II (controversial)
Nonoperative -unstable Type III (controversial)
hard collar vs. halo immobilization for 6-12 weeks - Dickman type I TAL injuries
- combined C1 and C2 fractures
indications most often type II odontoid and hangman's fractures
- stable Type I fx (intact transverse ligament) higher association with neurologic injury
- stable Jefferson fx (Type II) (intact transverse ligament) some authors prefer Occ-C2 fusion as opposed to C1-2
- stable Type III (intact transverse ligament) fusion
- Dickman type II TAL injuries no significant downside and lower risk of revision
technique surgery
controversy exists around optimal form of technique
immobilization may consider preoperative traction to reduce displaced
hard cervical collar lateral masses
typically used in stable fracture patterns with intact C1 internal fixation
transverse ligament indications
halo vest - C1 lateral mass split fractures (controversial)
typically used in the transverse ligament is compromised described in a few small case serioes
reduce with halo traction before immobilization preserves C1-2 motion
immobilization for 3 months technique
require post treatment flexion-extension radiographs to anterior and posterior techniques described
assess for late instability transoral approach
Operative further randomized trials needed to ascertain role of this
posterior C1-C2 fusion vs. occipitocervical fusion treatment
indications
COMPLICATIONS Stiffness
Vertebral artery injury loss of ~50% of cervical rotation with C1-2 arthrodesis
rare complication with displaced posterior ring fractures loss of ~50% cervical flexion with Occ-C2 arthrodesis
fractures involving the sulcal groove Infection
Neurologic injury a complication of surgical treatment
rare in isolated atlas fractures higher infection rates in patients treated with posterior
radial displacement of fracture increased the surface area approaches
of the spinal canal'
Cock robin deformity
displaced unilateral sagittal split lateral mass fracture
occipital condyle settles onto the C2 superior articular
facet
treat with occipitocervical fusion +/- osteotomy to
correct the deformity
Nonunion
~20% of cases treated nonoperatively
Neck pain
present in 20-80% of patients after immobilization
Delayed C-spine clearance
higher rate of complications in patients with delayed C-
spine clearance so it is important to clear expeditiously
Pseudoarthrosis
C2 ODANTOID FRACTURE
Hangman's Fracture, C2 Fracture
• https://www.orthobullets.com/video/view?id=103756