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Jefferson Fracture

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Other Names

  • C1 Burst Fracture
  • C1 Anterior Arch Fracture
  • C1 Posterior Arch Fracture

Background

  • This page describes traumatic C1 burst fracture, known more commonly as a 'Jefferson Fracture'
    • Also covers isolated anterior and posterior arch fractures

History

  • First reported by British Neurosurgery Sir Geoffrey Jefferson in 1920

Epidemiology

  • C1 fractures account for:
    • 25% of the upper cervical spine injuries[1]
    • 2%–13% of all acute cervical spine fractures
    • 1%–2% of all fractures of the human spinal column
  • Males represent 57-69% of cases[2]
  • Bimodal distribution: young men (20s) and elderly females (80s)[3]
  • Mean age at diagnosis is 50,

Pathophysiology

  • Typically seen after an axial load to the upper cervical spine and skull
  • Less commonly seen with rotational forces
  • Considered unstable due to tears to the transverse atlantal ligament
  • By definition, both the anterior and posterior atlas rings are fractured
  • Generally not associated with neuro deficits, fragments tend to spread away from spinal canal

Etiology

  • Most commonly due to diving in a shallow body of water, falling or motor vehicle accident

Pathoanatomy

  • C1 (also known as atlas)
    • No vertebral body, instead has anterior and posterior arches
    • Sits bellow the occiput and above C2, articulating with both
    • Vertebral arteries pass through the transverse foramina
  • Transverse atlantal ligament (TAL)
    • Rupture of ligament compromises atlantodens relationship

Associated Injuries


Risk Factors

  • Unknown

Differential Diagnosis


Clinical Features

  • General: Physical Exam Neck
  • History
    • Often a history of significant trauma with axial load, flexion or extension mechanism
    • Patients will endorse neck pain
    • Neurologic symptoms frequently absent
  • Physical Exam
    • Avoid range of motion
    • Thorough neurovascular exam of extremities

Evaluation

Radiographs

  • Standard cervical radiographs are rarely helpful
  • Difficult to see C1 fractures on plain films
  • May demonstrate
    • Ligamentous instability inferred with lateral mass displacement of 7 mm or greater
    • Increased atlanto-dens interval (ADI)

CT

  • Gold standard for osseus evaluation

MRI

  • Useful to evaluate soft tissue and ligamentous injury

Pediatric Considerations

  • Challenging diagnostically in young children
  • C1 body not radiographically visible until age 1[4]
  • Does not fuse until age 4
  • Congenital abnormalities can also cloud the picture

Classification

  • Type I
    • Axial load and flexion or extension
    • Isolated fracture of the anterior or posterior arch
  • Type II
    • Axial load
    • Bilateral fractures of anterior and posterior arch
  • Type III
    • Axial load and rotation
    • Lateral mass fracture

Management

  • No standardized management guidelines
  • Recommendations based on case reports and case series

Prognosis

  • Needs to be updated

Nonoperative

  • Indications
    • Stable fracture
    • First line in most cases
  • Technique
    • Rigid collar
    • Halo-thoracic brace
    • Sterno-occipitomandibular immobilization
    • Minerva Jacket
  • Immobilize for 8-12 weeks

Operative

  • Indications
    • Complex fracture patterns
    • Co-occuring C2 fracture, atlanto-occipital dislocation
    • Instability
    • Neurologic compromise
  • Technique
    • Occiput-C1 or C1-C2 fusion

Rehab and Return to Play

Rehabilitation

  • Needs to be updated

Return to Play

  • Needs to be updated

Complications

  • Myelopathy
  • Death
  • Nonoperative
    • Neck Pain
    • Discomfort from orthosis
  • Surgical
    • Infection
    • Hardware displacement
  • Cock-robin deformity (atlantoaxial rotatory fixation)

See Also


References


  1. Levine AM, Edwards CC. Fractures of the atlas. J Bone Joint Surg Am. 1991;73:680–91.
  2. Matthiessen C, Yohan R. Epidemiology of atlas fractures—a national registry-based cohort study of 1,537 cases. Spine J. 2015;15(11):2332–7.
  3. Kakarla UK, Chang SW, Theodore N, Sonntag VK. Atlas fractures. Neurosurgery. 2010;66(3 Suppl):60–7.
  4. Lee C, Woodring JH. Unstable Jefferson variant atlas fractures: an unrecognized cervical injury. AJNR Am J Neuroradiol. 1991;12(6):1105–10
Created by:
John Kiel on 4 July 2019 09:26:55
Authors:
Last edited:
17 November 2020 15:40:50
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