Stable fractures of the atlas and axis in children.

Abstract

SUMMARY Three cases of stable fractures of the atlas and axis in children are presented. All patients presented with pain, spasm of neck musculature and head tilt along with a neurological deficit. All fractures were apparently stable; with conservative treatment all symptoms and signs resolved.Fractures of the atlas and axis without dislocation are rare, being particularly rare in children. Three cases are presented here along with discussion of their diagnosis and management. Case reportsCase I A 7-year-old girl was knocked down by a motorcycle in October 1981. She was unconscious for five minutes and suffered a simple, undisplaced fracture of the left ulna and a compound fracture of the left tibia. On recovering consciousness she complained of pain in the neck which was associated with spasm of the cervical muscles giving head tilt to the right. There was a grade 4 (MRC Scale) global weakness of the left arm with absent biceps and supinator reflexes, but no sensory loss. Standard antero-posterior and lateral cervical radiographs were reported as showing no abnormality. The symptoms and signs persisted for six weeks which led to investigation. Radiographs were repeated along with A-P and lateral tomography. These revealeil an abnormally high odontoid peg with tilting to the left, separation of the lateral masses of the atlas and a possible crush fracture of the right lateral mass of the axis (Fig). It was concluded that she had suffered a forced flexion injury on the right side, fracturing the anterior arch of the atlas and the right lateral mass of the axis. These injuries were thought to be associated with a mild traction injury of the left brachial plexus. She had been wearing a soft cervical collar from the time of injury which was replaced by a firm collar. She began to show signs of recovery of neck movements 8 weeks after injury. After supporting her neck in the firm collar for a further 3 weeks she was pain free with full neck mobility. During this period her arm weakness recovered completely. Examination revealed tendemess of the left upper cervical region with spasm of the cervical muscles and head tilt to the right. There was a grade 4+ (MRC Scale) right hemiparesis with normal reflexes and sensation. Cervical spine radiographs showed a compression fracture of the left lateral mass of the atlas with separation of the lateral masses. The odontoid was tilted to the right. As in case 1 it was felt that he had fractured the lateral mass and the anterior arch of the atlas. The hemiparesis was thought to be due to a mild cord contusion. He was placed in a firm cervical collar which was changed several days later to a plaster-of-Paris Minerva jacket. His hemiparesis rapidly recovered. The Minerva jacket was removed 6 weeks after injury and he was found to be pain free with no limitation of neck movement and no neurological signs.Case 3 A 4-year-old girl was knocked down by a car in May 1983. She was unconscious for a few minutes after impact but on admission to hospital was found to be fully alert with a l...

Jefferson Fracture in a Child – Illustrative Case Report

“…Such factors include the disproportionately large head mass and underdeveloped neck musculature in the pediatric population, which contribute to greater bending of the cervical spine with flexion/extension forces (higher fulcrum of cervical movement, higher inertia and torque forces associated with a larger head/body mass ratio), greater elasticity of the interspinous and posterior joint capsules, which allow hypermobility, horizontally angulated articulating facets, especially at the C 1 –C 2 level, wedge-shaped vertebral bodies that allow for anterior sliding and less mature bone ossification [18]. However, isolated burst fractures of the atlas, as described and illustrated in this paper, are extremely rare in children, and less than 10 comparable cases have been published since the first description by Sir Geoffrey Jefferson in 1920 [5,6,7,8,9,10,11, 15]. …”

“…They currently constitute 26% of all injuries to the atlantoaxial complex and 5.5–10% of all injuries to the cervical spine [1,2,3,4]. However, in the pediatric population, isolated atlas burst fractures, also known as Jefferson fractures, are extremely rare [5, 6], and only few cases have been reported so far [7,8,9,10,11]. They have to be distinguished from synchondrosis fractures in children [12, 13] and from normal variants as well as congenital arch malformations [2, 13, 14].…”

“…Generally, atlas fractures in the pediatric population are treated conservatively with external immobilization and show recovery with full function without any surgical intervention [7, 8, 10, 11, 17]. …”

Jefferson fractures of the immature spine

“…Our review disclosed only 3 examples of Jefferson fractures in young children detected by these techniques. 26 The fact that the patients in these cases were the only ones who exhibited neurological deficits suggests that the typical clinical threshold for suspicion of fracture of the immature atlas was quite high. Radiographs and tomography had low sensitivity in actual demonstration of fractures of the ring, so attention was paid to indirect signs such as separation or "spread" of the lateral masses.…”

“…1,2,4,6,8,[11][12][13]15,[20][21][22][23][25][26][27]29,31,32 As cited by Jefferson, priority belongs to Sir Astley Cooper, who in 1822 described fractures of both arches of the atlas in a 3-year-old boy who had suffered a fall. 10 The child died of an unrelated condition, and the diagnosis was made at autopsy 12 months after the injury.…”