A 27-year-old male presents with neck pain after diving headfirst into the shallow water of his pool. He has midline cervical spine tenderness and a normal neurological exam. CT of the cervical spine is shown below (Figure 1).
CT cervical spine of a Jefferson fracture

Figure 1. Case courtesy of Dr Andrew Dixon, Radiopaedia.org, rID: 9601

 

The patient has a C1 burst fracture, otherwise known as a Jefferson burst fracture, defined as fractures of the anterior and posterior arches of the C1 vertebra (Figure 2). It is caused by an axial load that forces the occipital condyles into the lateral masses of C1.

CT cervical spine of a Jefferson fracture

Figure 2. Jefferson burst fracture. Note the fracture of the anterior arch (green arrow ) and the posterior arch (blue arrow). Case courtesy of Dr. Andrew Dixon, Radiopaedia.org, rID: 9601

  • PEARL: This can be a highly unstable fracture that may be associated with neurologic deficits and vertebral artery injury [1].
  • PEARL: Bone fragments usually spread radially but can occasionally be retropulsed into the spinal canal, causing neurologic deficits [1].

Stability is determined by the transverse ligament, which maintains positioning of the C2 dens. Many different imaging modalities can help assess for injury. However, MRI is the gold standard to assess for transverse ligament injury.

  1. Lateral cervical radiographs (Figure 3).

Atlantodens Interval (ADI): Distance from posterior aspect of the anterior arch to the anterior aspect of the dens.

    • Possible transverse ligament injury if ADI > 3mm
Lateral cervical spine x-ray

Figure 3. Lateral cervical radiographs. Case courtesy of Dr. Andrew Dixon, Radiopaedia.org, rID: 9601. Annotations by author

2. Open mouth odontoid radiographs (Figure 4).

If sum of lateral mass displacement is > 7mm, suspect Jefferson fracture and transverse ligament injury.

Odontoid view cervical spine x-ray

Figure 4. Case courtesy of Dr. Andrew Dixon, Radiopaedia.org, rID: 9601. Annotations by author.

3. CT: Gold standard to delineate the fracture pattern (Figure 5).

    • If ADI is > 2mm, suspect transverse ligament injury.
CT cervical spine of a Jefferson fracture

Figure 5. Case courtesy of Dr. Andrew Dixon, Radiopaedia.org, rID: 9601. Annotations by author.

4. MRI: Gold standard to assess for transverse ligament injury.

The patient should be placed in a cervical collar and maintained in strict spinal precautions. MRI should be obtained in the ED if neurologic deficits are present. A spine surgeon should be consulted emergently as guided by institutional protocols. Additional trauma imaging and workup should also be obtained and the patient admitted for further management.

  • PEARL: A CT angiography of the neck should also be ordered to assess for vertebral artery injury, which, if present, may require anticoagulation in discussion with your consultants.

Treatment depends on the integrity of the transverse ligament [2].

  1. If intact -> hard collar.
  2. If torn -> C1-2 fusion or occipitocervical fusion (C0-2).
  3. If bony avulsion on the insertion point of the transverse ligament -> halo vest.

 

References and Resources

Check out ALiEM’s Paucis Verbis cards to brush up on other can’t miss adult neck and cervical spine injuries.

  1. Muratsu H, Doita M, Yanagi T, Sekiguchi K, Nishida K, Tomioka M, Kurosaka M. Cerebellar infarction resulting from vertebral artery occlusion associated with a Jefferson fracture. J Spinal Disord Tech. 2005 Jun;18(3):293-6. PMID: 15905778.
  2. Lee TT, Green BA, Petrin DR. Treatment of stable burst fracture of the atlas (Jefferson fracture) with rigid cervical collar. Spine (Phila Pa 1976). 1998 Sep 15;23(18):1963-7. doi: 10.1097/00007632-199809150-00008. PMID: 9779528
BuMin Kong, MD

BuMin Kong, MD

Resident
Department of Emergency Medicine
Loma Linda University Medical Center
BuMin Kong, MD

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Mark Hopkins, MD

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Loma Linda University Health
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Alexander J. Tomesch, MD

Alexander J. Tomesch, MD

Primary Care Sports Medicine Fellow
Department of Orthopedic and Sports Medicine
University of Arizona - Tucson
Alexander J. Tomesch, MD

@DocTomesch

Emergency Medicine physician, Primary Care Sports Medicine Fellow, Father, Husband, Sports Enthusiast, Craft Beer Lover!
Alexander J. Tomesch, MD

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