1. A Jefferson fracture is a burst fracture of the C1 vertebra (atlas) that results in a break of both the anterior and posterior arches of the ring. 2. It is caused by axial compression, often from a fall on the head, and may not be evident on lateral x-rays but displacement of the lateral masses on open-mouth views suggests a Jefferson fracture. 3. Treatment involves halo traction followed by a halo vest or posterior fusion to stabilize and fuse the fracture, with the goals of maintaining spinal alignment and preventing neurological injury.

1. C1 Fracture
(Jefferson Fracture)
Dr. Dibyendunarayan Bid

2. • Definition
A Jefferson # is a burst #
of C1 (atlas), resulting in
combined #s of the
anterior and posterior
arches of the ring of C1
(Figure 35-1).

3. • Mechanism of Injury
• This # is caused by axial compression,
commonly from a fall on the head, such as
from diving into shallow water.

4. Radiographic Evaluation
• The standard trauma series for this cervical spine #
consists of anteroposterior, lateral, and open-mouth
(dens) views.
• Oblique radiographs help rule out associated #s in
the subaxial spine.
• The patient's head should not be passively moved.

5. • On the dens or odontoid view, lateral displacement
of the lateral articular masses of C1 relative to C2
suggests a Jefferson #.
• The # may not be evident on the lateral view, but soft
tissue swelling may be visualized anterior to the ring
of C1.

6. • The ring of the atlas fails in tension through both the
anterior and posterior arches.
• At least one # line is present through each arch.
• If the sum of displacement of the lateral masses, on
the odontoid view, is greater than 7 mm, this
strongly suggests a rupture of the transverse atlantal
ligament.

7. • Typically, the ligament fails by avulsion at its bony
insertion rather than as a mid-substance tear.
• A thin section computed tomography scan parallel to
the ring of the atlas best defines the # anatomy of a
C1 ring disruption as well as bony avulsion #s
associated with the transverse ligament.

8. Treatment Goals
• Orthopaedic Objectives
1. Obtain and maintain spinal alignment and
reduction of the #.
2. Provide spinal stability.
3. Prevent new neurologic deficits and attempt to
improve and prevent the exacerbation of existing
neurologic deficits.
4. Prevent future spinal deformity.

10. • Muscle Strength
– Restore and maintain the strength of paracervical
and cervical muscles, including the trapezius and the
upper extremity muscles.
– Restore the strength of the muscles of the lower
extremities that may atrophy from bed rest or
neurologic injury.
• Functional Goals
Develop cervical spinal flexibility for functional
independence.

11. • Expected Time of Bone Healing
Eight to 16 weeks before fusion is solid or # healing is
complete.
• Expected Duration of Rehabilitation
Three to 6 months.

12. Methods of Treatment
• Orthosis
– Hard collar (e.g., Philadelphia collar),
– Sternal-occiput-mandibular immobilization (SOMI) brace,
– cervicothoracic orthosis,
– four-poster brace, or halo vest (see Figures 8-7, 8-8, 8-9, 8-10, and 8-
11).
• Biomechanics: Stress-sharing device.
• Mode of bone healing: Secondary.

13. • Indication:
– A nondisplaced or minimally displaced # (less than 2
mm of combined displacement of the lateral masses
on the dens view) may be treated with a hard collar,
such as a Philadelphia collar, or one of the other rigid
nonhalo braces.
– A displaced # (2 to 7 mm of combined displacement
on the dens view) should first be reduced with halo
skeletal traction and then treated with a halo vest
once cervical muscle spasm has resolved.

14. – A # with a transverse ligament injury (greater than
7 mm of combined displacement of the lateral
masses on the dens view) should be treated with
4 weeks or more of halo skeletal traction followed
by halo vest.
– The length of skeletal traction before application
of the halo vest is still under debate.

15. Open Reduction and Posterior Spinal Fusion
• Biomechanics: Stress-sharing device until solid
arthrodesis occurs.
• Mode of bone healing: Secondary.

16. • Indications:
– Surgery is rarely necessary for isolated #s of the
ring of C1.
– Indications include failure to achieve or maintain
reduction in a halo vest, instability of the C1-2
motion segment, and failure of the # to reduce,
despite an adequate trial of skeletal traction.
– Operative treatment is also indicated if the
reduction is not maintained with halo vest
immobilization.

17. • Treatment generally consists of a posterior arthrodesis from
the occiput to C2 using various wiring techniques and
autogenous bone graft.
• Screw-plate fixations from the occiput to C2 may also be
used.
• An alternative technique that limits the fusion to the C1-2
joint complex and perhaps obviates the need for
postoperative halo immobilization is Magerl's C1-2
transarticular screw fixation.

18. Special Considerations of the Fracture
• Most Jefferson #s do not result in neurologic impairment
because the spinal canal is generally widened as a result of
the #, and there is sufficient space to accommodate the spinal
cord and associated swelling at the C1-2 level.
• The initial evaluation must include a thorough neurologic
examination and search for associated injuries.
• Halo traction should be used with the patient awake so that
the patient's neurologic status can be closely observed (see
page 557).

19. • Unstable injuries, in which greater than 7mm of
combined lateral mass widening has occurred, may
require a period of halo traction followed by halo
vest immobilization.
• The length of skeletal traction before application of
the halo vest is still under debate.

20. Associated Injuries
• Patients with Jefferson #s should be carefully
evaluated for head injuries as well as other
cervical spine #s, particularly #s of the upper
three cervical segments.
• In addition, injuries to the brachial plexus, thorax
and abdomen, and extremities may occur and
must be addressed in a timely fashion.

21. TREATMENT

31. LONG-TERM CONSIDERATIONS
• Residual pain may require temporary bracing and
anti-inflammatory medications.
• Residual neurologic deficits must be addressed and
may require extremity bracing, therapy, or surgery
for contracture releases and tendon transfers.

32. • If progressive cervical spine deformity occurs,
surgery may be necessary.
• There may be permanent loss of range of motion.
• The degree depends on the number of segments
arthrodesed and the level and extent of the fracture.

33. • Removal of the instrumentation may be necessary if
it is painful.
• If pseudoarthrosis occurs, reinstrumentation and
fusion may be necessary.
• Reflex sympathetic dystrophy may be a long-term
problem requiring cervical stellate ganglion blocks
and long-term physical therapy.

34. Reference