Fracture through a synchondrosis of the anterior arch of the atlas

Isolated synchondrosis fracture of the atlas presenting as rotatory fixation of the neck: Case report and review of literature

Background:

Exclusive to the pediatric population, cartilaginous fractures of the atlas are singularly rare. Rarer still are those fractures that produce a fixed, rotational deficit of the neck. Here, the authors present the case of a 4-year-old boy with an isolated fracture of the anterior synchondrosis of C1 with a rotational component following a fall, as well as a review of the literature. Management with serial bedside manipulation, which is unique to our report, helped conservatively correct the rotation of the patient's neck, and, coupled with rigid bracing, demonstrated a comprehensive management strategy that resulted in fracture ossification at 3 months.

Case Description:

Our patient is a 4-year-old boy who fell from a bunk bed and complained of severe neck pain. The patient was brought to the emergency room and was found to have an isolated anterior fracture of the right frontal synchondrosis of the atlas. After conservative management with a hard collar and cautious manual reductions at the bedside, rotation of our patient's neck spontaneously resolved on day 3. After 3 months of rigid immobilization, the patient remained at neurological baseline and his fracture was healed. Literature review demonstrated age range between 2 and 6 years, with a subset of patients demonstrating rotational components to their fractures. Complete resolution of nearly all patients treated with rigid immobilization after fracture was documented, yet several patients experienced delayed diagnosis.

Conclusions:

Knowledge of the radiographic appearance of the C1 ossification centers as well as the normal timeline and sequence of ossification is essential in differentiating a true synchondrosis fracture from normal, nonossified cervical cartilage. With early diagnosis, immobilization, pain control, and muscle relaxants, patients can recover well with conservative management, can successfully ossify fracture sites, and can recover without sequelae.

Fracture of the anterior arch of atlas after minor trauma of the immature spine postlaminectomy

Torticollis is a common complaint in the pediatric emergency department. Here, we report what we believe to be the first example in a young child of a fracture of the anterior arch of the atlas associated with an acquired, postsurgical defect of the posterior arch. A brief review of pediatric cervical spine injuries and fractures is presented. Atlas laminectomy may predispose patients to isolated atlas fractures even with minor trauma. Those fractures, however, are stable and treated by hard cervical orthosis.

Fluoroscopically guided, transoral, closed reduction, and halo vest immobilization for an atypical C-1 fracture

Fractures through the ring of the C-1 vertebrae are very rare in the pediatric patient population. In this report, the authors describe the case of a widely displaced fracture of the C-1 anterior arch in a 6-year-old boy. The fracture was initially treated using a fluoroscopy-guided, transoral, closed reduction with subsequent halo vest immobilization. Although conservative management of C-1 fractures is generally adequate and efficacious in the pediatric population, mechanistic and anatomical considerations in this case were concerning for potential instability in extension, and prompted an unusual method of closed reduction followed by treatment in a halo vest.

Atlantal fracture with transverse ligament disruption in a child. Case report

Even though fractures in children with immature spines occur predominantly in the upper cervical spine, isolated C-1 fractures are relatively rare. The fractures in almost all cases reported to date were considered stable due to the presence of the intact transverse ligament. The authors report the case of a young child who sustained a Jefferson fracture and in whom MR imaging revealed disruption of the transverse ligament. Although surgical treatment has been suggested as the treatment of choice for children with unstable atlantoaxial injuries, external immobilization alone allowed a full recovery in the patient with no evidence of instability at follow-up.

Jefferson fractures of the immature spine. Report of 3 cases

Jefferson fractures of the immature spine have received little attention in the study of pediatric spinal trauma. Fractures through synchondroses are a possibility in the immature spine, in addition to fractures through osseous portions of the vertebral ring, and they create opportunities for misinterpretation of diagnostic imaging. The authors describe 3 examples of Jefferson fractures in young children. All 3 cases featured fractures through an anterior synchondrosis in association with persistence of the posterior synchondrosis or a fracture of the posterior arch. The possibility of a Jefferson fracture should be considered for any child presenting with neck pain, cervical muscle spasm, or torticollis following a head injury, despite a seemingly normal cervical spine study. Jefferson fractures in young children are probably much more common than previously recognized.

Pediatric cervical spine instability

Cervical spine instability in children is rare but not exceptional and may be due to many factors. Although it mostly occurs at the upper cervical spine, all vertebrae from the occiput to T1 may be involved. It may be acute or chronic, occurring secondary to trauma or due to congenital anomaly, skeletal or metabolic dystrophy or rheumatoid arthritis. It can be isolated or associated with other musculoskeletal or visceral anomalies. A thorough knowledge of embryology, anatomy, physiology and physiopathology of the cervical spine in children is essential to avoid pitfalls, recognize normal variants and identify children at risk of developing cervical spine instability and undertake the appropriate treatment.

A single fracture in the atlas ring: report of two cases and a review of the literature

Atlas fractures commonly present more than two breaks in its ring structure because of the unique anatomy and the mechanism of injury. The incidence of a single break in the atlas ring is exceedingly rare. However, we encountered two cases of a single fracture of the atlas. One patient was struck by a falling tree on the right side of the head and the other was involved in a motor vehicle accident. Radiographs of the cervical spine failed to show a single fracture or other abnormalities. Computed tomography demonstrated the single fracture. The patients were treated conservatively with a cervical collar, and they both recovered completely. In this article, we present two cases of a single fracture of the atlas with a review of the literature.

Fracture of the atlas through a synchondrosis of the anterior arch complicated by atlantoaxial rotatory fixation in a four-year-old child

Fracture of the atlas is rare in children. We report a case of fracture of the atlas through a synchondrosis of the anterior arch complicated by atlantoaxial rotatory fixation in a four-year-old girl.

Displaced fracture through the anterior atlantal synchondrosis

In the acute setting, accurate radiological interpretation of paediatric cervical spine trauma can be difficult due to a combination of normal variants and presence of multiple synchondroses. We present a rare case of a fracture through the anterior atlantal synchondrosis in a paediatric spine. A five-year-old boy, who fell backwards onto the top of his head while swinging across on a monkey bar frame, presented with neck pain, cervical muscle spasm and decreased right lateral rotation and extension of his neck. Computed tomography showed a displaced diastatic fracture through right anterior atlantal synchondrosis. There are only 12 cases of paediatric C1 fractures reported in the world literature. The importance of considering this diagnosis in the appropriate clinical setting, and the normal variants in the paediatric atlas that can cause diagnostic dilemma to the interpreting radiologist, are discussed in this case report.

Pediatric spine injuries

Pediatric spine injuries are rare, not only due to the plasticity of the pediatric spine, but also due to the difficulty of diagnosis and the usually severe, if not fatal, associated injuries. Mechanisms of injury, transportation, initial management, diagnostic exams, and management of such lesions are different from those of the adult, and an individualized approach to each case, looking for specific injury patterns, avoids misdiagnosis. The goal of this manuscripts is to summarize the specific spinal injury patterns of the pediatric population, as well as the present literature regarding their diagnosis and treatment.

Isolated anterior arch fracture of the atlas: child case report

STUDY DESIGN

The authors report a case of an atlas fracture at the anterior arch.

OBJECTIVE

To discuss the difficulty in diagnosing this type fracture.

SUMMARY OF BACKGROUND DATA

Fractures of the atlas are not uncommon, and actually constitute 10% of all cervical spine injuries in adults. However, in the pediatric population, fractures of atlas are extremely rare, and only a few cases have been described. Only two isolated anterior arcus fractures of the atlas have been reported previously.

METHODS

A 2.5-year-old girl was admitted to the authors' department with neck pain and head tilt 2 days after falling from a wall onto the top of the head. Radiographs of the cervical spine reportedly showed no abnormality. Computed tomography of the upper cervical spine showed a fracture in left anterior arch of the C1 vertebra with a 2-mm separation. She was placed in a firm cervical collar and instructed to reduce her daily physical activities. A repeat scan 3 months later showed fusion at the fracture site.

RESULTS

The patient was treated with a firm cervical collar, and fusion of the fracture site was documented with computed tomography scan at 12 weeks after the injury. Her cervical collar was removed, and she has been fully active with no restrictions.

CONCLUSIONS

On plain radiographs, fractures of the atlas and anterior aspect in particular may remain occult. Accurate diagnosis of atlas fractures depends on further radiologic investigations including computed tomography and magnetic resonance imaging. Experience in treating atlas fractures is insufficient because of a paucity of literature. Immobilization with a firm cervical collar is the treatment of choice in stable atlas fracture.

Pediatric atlas fracture: a case of fracture through a synchondrosis and review of the literature

OBJECTIVE AND IMPORTANCE

Although uncommon, atlas fractures occur in the pediatric population. We present an illustrative case of a patient with a fracture through a synchondrosis of the atlas, and we review previous reports of pediatric first cervical vertebral fractures. The clinical and radiographic findings are described. In addition, we describe the use of magnetic resonance imaging in characterizing a pediatric atlas fracture.

CLINICAL PRESENTATION

A 6-year-old boy who fell from a tree onto his vertex presented with neck pain, cervical muscle spasm, and head tilt. Computed tomographic and magnetic resonance imaging studies demonstrated a fracture through a left anterior synchondrosis with surrounding edema. In the literature, 10 cases of pediatric atlas fracture have been reported.

INTERVENTION

Treatment of pediatric atlas fractures consists of rigid bracing such as a Minerva jacket. All of the cases of isolated C1 fracture in children, except the patient originally described by Sir Geoffrey Jefferson, survived and recovered with full function. Surgery is rarely indicated for isolated atlas fractures.

CONCLUSION

The classic clinical presentation, combined with an appropriate injury scenario, should alert the clinician to the possibility of a pediatric atlas fracture and should prompt rapid evaluation with imaging studies to establish a diagnosis. When the injury is appropriately diagnosed and treated, an excellent outcome can be expected.

Fracture of the anterior arch of the atlas associated with a congenital cleft of the posterior arch. Demonstration by CT

A case of a vertical fracture of the anterior arch of the atlas associated with a congenital cleft of the posterior arch of the same vertebra is reported. Such an association has not previously been described in the literature. X-Ray computed tomography is an excellent exam for visualizing this region and for easily distinguishing between fractures and congenital clefts.