Introduction Epidemiology make up ~7% of cervical spine fractures risk of neurologic injury is low commonly missed due to inadequate imaging of occipitocervical junction Pathophysiology mechanism includes hyperextension, lateral compression, and axial compression Associated conditions spine fracture 50% have an associated spine injury 40% associated with axis fx Prognosis stability dependent on degree of injury and healing potential of transverse ligament Anatomy 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 Ligamentous anatomy occipital-cervical junction and atlantoaxial junction are coupled intrinsic ligaments are located within the spinal canal, provide most of the ligamentous stability. They include transverse ligament primary stabilizer of atlantoaxial junction connects the posterior odontoid to the anterior atlas arch, inserting laterally on bony tubercles. paired alar ligaments connect the odontoid to the occipital condyles relatively strong and contributes to occipitalcervical stability apical ligament 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 atlas (C1) is a ring containing two articular lateral masses it lacks a vertebral body or a spinous process anatomic variation incomplete formation of the posterior arch is a relatively common anatomic variant and does not represent a traumatic injury Ligamentous anatomy intrinsic ligaments are located within the spinal canal, provide most of the ligamentous stability. They include tectorial membrane (most dorsal layer) connects the posterior body of the axis to the anterior foramen magnum and is the cephalad continuation of the PLL transverse ligament is the strongest component connects the posterior odontoid to the anterior atlas arch, inserting laterally on bony tubercles. paired alar ligaments connect the odontoid to the occipital condyles relatively strong apical ligament Classification Landells Atlas Fractures Classification Type I Isolated anterior or posterior arch fracture. A "plough fracture is an isolated anterior arch fracture caused by a force driving the odontoid through the anterior arch. Stable. Treat with hard collar. Type II Jefferson burst fracture with bilateral fractures of anterior and posterior arch resulting from axial load. Stability determined by integrity of transverse ligament. If intact, hard collar. If disrupted, halo vest (for bony avulsion) or C1-2 fusion (for intrasubstance tear)(see Dickman classification below). Type III Unilateral lateral mass fx. Stability determined by integrity of transverse ligament. If stable, treat with hard collar. If unstable, halo vest. Dickman Transverse Ligament Injuries Classification Type I Intrasubstance tear. Treat with C1-2 fusion. Type II Bony avulsion at tubercle on C1 lateral mass. Treat with halo vest (successful in 75%) Imaging Radiographs lateral radiographs atlantodens interval (ADI) < 3 mm = normal in adult (< 5mm normal in child) 3-5 mm = injury to transverse ligament with intact alar and apical ligaments > 5 mm = injury to transverse, alar ligament, and tectorial membrane open-mouth odontoid open-mouth odontoid view important to identify atlas fractures sum of lateral mass displacement if sum of lateral mass displacement is > 7 mm (8.1mm with radiographic magnification) then a transverse ligament rupture is assured and the injury pattern is considered unstable CT study of choice to delineate fracture pattern and identify associated injuries in the cervical spine MRI more sensitive at detecting injury to transverse ligament Treatment Nonoperative hard collar vs. halo immobilization for 6-12 weeks indications stable Type I fx (intact transverse ligament) stable Jefferson fx (Type II) (intact transverse ligament) stable Type III (intact transverse ligament) technique controversy exists around optimal form of immobilization Operative posterior C1-C2 fusion vs. occipitocervical fusion indications unstable Type II (controversial) unstable Type III (controversial) technique may consider preoperative traction to reduce displaced lateral masses Techniques Posterior C1-C2 fusion preserves motion compared to occipitocervical fusion fixation C1 lateral mass / C2 pedicle screw construct may be sufficient if adequate purchase with C1 lateral mass screws C1-2 transarticular screw placement Occipitocervical fusion (C0-C2) uses when unable to obtain adequate purchase of C1 (comminuted C1 fracture) leads to significant loss of motion Complications Delayed C-spine clearance higher rate of complications in patients with delayed C-spine clearance so it is important to clear expeditiously
QUESTIONS 1 of 7 1 2 3 4 5 6 7 Previous Next (SBQ18SP.74) A 17-year-old male jumped headfirst into a shallow lake and sustained a comminuted C1 fracture. On exam, he is alert and oriented with normal motor and sensation in the upper and lower extremities. Which of the following radiographic parameters measurements suggests transverse ligament rupture? Tested Concept QID: 211916 Type & Select Correct Answer 1 Space available for cord 15 mm 3% (36/1370) 2 Atlanto-dens interval 2 mm 9% (128/1370) 3 Basion-dens interval 11 mm 12% (158/1370) 4 Combined lateral mass displacement 9 mm 74% (1016/1370) 5 5 mm of prevertebral soft tissue swelling at C2 1% (20/1370) L 3 Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review tested concept (OBQ13.55) A 28-year-old male patient dives head first into a shallow pool. He presents to the emergency room and radiographs and a CT are performed and shown in Figures A-D. Which of the following statements are true regarding these radiographic findings. Tested Concept QID: 4690 FIGURES: A B C D Type & Select Correct Answer 1 The transverse ligament is disrupted, the fracture is unstable and should be treated with either a rigid orthosis, halo immobilization, or surgical stabilization 68% (3376/4942) 2 The transverse ligament is intact, the fracture is stable and can be treated in a soft cervical collar 16% (815/4942) 3 It is classified as Anderson and D'Alonzo Type II because the fracture extends into the C1/C2 facet 4% (173/4942) 4 It is classified as Anderson and D'Alonzo Type III because the fracture extends into the C1/C2 facet 4% (218/4942) 5 The imaging findings are relatively common and represent a congenital incomplete formation of the posterior arch and not a traumatic injury 6% (318/4942) L 4 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 1 Review tested concept (OBQ12.255) A 35-year-old patient sustains a bilateral anterior and posterior arch (C1) injury with an intact transverse ligament. Which of the following treatment options is most appropriate? Tested Concept QID: 4615 Type & Select Correct Answer 1 Observation alone 1% (45/4098) 2 Soft collar orthosis for 4-6 weeks 4% (156/4098) 3 Occipitocervical fusion 7% (301/4098) 4 Rigid collar orthosis for 6-12 weeks 80% (3288/4098) 5 Posterior C1-C2 fusion 7% (294/4098) L 2 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review tested concept (OBQ10.71) Figure A shows the coronal and axial CT images of a 27-year-old male that suffered a fall from a significant height. Which of the following radiographic measurements would best indicate disruption of the transverse ligament? Tested Concept QID: 3159 FIGURES: A Type & Select Correct Answer 1 Atlantodental interval (ADI) of 2mm 6% (237/4062) 2 Posterior atlanto-dens interval (PADI) of 16mm 10% (395/4062) 3 C2 pars horizontal displacement of 3 mm 3% (126/4062) 4 Combined lateral mass displacement of 8.2mm 78% (3152/4062) 5 A Power's ratio of 1.2 3% (128/4062) L 2 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review tested concept Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (OBQ05.67) A Gallie C1-2 fusion with sublaminar wiring of C1 to the spinous process of C2 is a valid treatment option for which of the following injury patterns? Tested Concept QID: 953 Type & Select Correct Answer 1 occipital-cervical dissociation 4% (71/1627) 2 comminuted C1 burst fracture 8% (129/1627) 3 type I odontoid fracture 4% (66/1627) 4 type III odontoid fracture 13% (216/1627) 5 transverse ligament disruption 70% (1138/1627) L 2 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review tested concept (OBQ04.176) Biomechanical studies have shown that an atlanto-dens interval of >7mm is likely associated with? Tested Concept QID: 1281 Type & Select Correct Answer 1 an intact transverse ligament, with ruptured alar and apical ligaments 6% (218/3665) 2 a ruptured transverse ligament, with intact alar and apical ligaments 21% (756/3665) 3 a ruptured transverse and apical ligament, with an intact alar ligaments 9% (317/3665) 4 a ruptured transverse and alar ligament, with an intact apical ligaments 19% (689/3665) 5 a ruptured transverse and alar ligament, and a ruptured tectorial membrane 45% (1663/3665) L 4 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review tested concept
All Videos (2) Podcasts (2) Login to View Community Videos Login to View Community Videos Tips in upper cervical injuries Ahmed Attar Spine - Atlas Fractures & Transverse Ligament Injuries 5/19/2020 101 views 0.0 (0) Login to View Community Videos Login to View Community Videos Atlas (C1) Fractures & Transverse Ligament Injuries - Review Lecture - Dr. Derek Moore Derek W. Moore Spine - Atlas Fractures & Transverse Ligament Injuries D 5/18/2013 2044 views 4.8 (21) Question Session⎜Atlas Fractures & Transverse Ligament Injuries, Coronoid Fractures & Cardiac Conditions in Sports Orthobullets Team Spine - Atlas Fractures & Transverse Ligament Injuries Listen Now 30:17 min 11/11/2019 38 plays 5.0 (1) Spine⎪Atlas Fracture & Transverse Ligament Injuries Team Orthobullets 4 Spine - Atlas Fractures & Transverse Ligament Injuries Listen Now 15:46 min 10/15/2019 336 plays 4.0 (2)
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