C2 Fractures Research Articles

Management of combined atlas-axis fractures: a review of forty one cases.

To outline a management principle for the combined atlas (C1)-axis (C2) fractures and assess its therapeutic effects. Forty-one patients with combined C1-C2 fractures were treated according to their C2 fracture types. Non-operative external immobilization in the form of a cervical collar or halo vest was used in 22 patients. Early posterior pedicle screw fixations were performed in 19 patients whose fractures had a combination of any of the three conditions: an atlantodens interval (ADI) ≥ 5mm, lateral mass displacement (LMD) > 7mm, and/or C2-C3 angulation > 11°. Thirty-nine patients were followed up regularly with an average of 19.3months (range, 12 to 45months). Clinical and radiographic data were then collected and compared. At three months following treatment, patients' visual analog scale (VAS), Neck Disability Index (NDI), American Spinal Injury Association (ASIA) scale, and Frankel grades were all significantly improved when compared to pretreatment. These results indicated that the cervical collar, halo vest, and posterior pedicle screw fixation approaches were all able to effectively treat cases of combined C1-C2 fractures. One patient in the non-surgical group developed nonunion which required late surgical treatment and one patient had pin site infection in the non-surgical group (2/22), while there were three minor complications in the surgical group. We propose a management principle that bases the treatment of a combined C1-C2 fracture on the nature of the C2 fracture. This treatment strategy has yielded promising results as a satisfactory means for the management of combined C1-C2 fractures.

Impact of associated injuries in conjunction with fracture of the axis vertebra on inpatient outcomes and postoperative complications: a Nationwide Inpatient Sample analysis from 2002 to 2011

Background ContextThere are limited data available on the impact of associated spinal (other spinal injuries [OSIs]) and extra-spinal injuries (ESIs) occurring in conjunction with fractures of the axis vertebra (C2) on clinical outcomes. PurposeThis study aimed to compare outcomes in patients with isolated C2 fractures versus patients with associated injuries in conjunction with C2 fractures. Study Design/SettingA retrospective cohort study. Patient SampleA total of 30,472 adult patients with C2 fractures (International Classification of Diseases, Ninth Revision, Clinical Modification code 805.02) registered in the Nationwide Inpatient Sample (NIS) database (2002–2011) comprised the patient sample. Outcome MeasuresInpatient mortality, unfavorable discharge, prolonged length of stay (LOS) and high-end hospital charges in the non-operative and operative cohorts, and postoperative complications (deep venous thrombosis [DVT]; acute renal failure [ARF]; respiratory complications and wound infections) for the operative cohort were the outcome measures. MethodsPatients were stratified into four categories based on injury type: (1) isolated C2 fracture (n=10,135; 33.3%); (2) C2 fracture+OSI (8.7%); (3) C2 fracture+ESI (37.2%); and (4) C2 fracture+OSI+ESI (20.8%). Multivariable logistic regression fitted with generalized estimating equations using the sandwich variance-covariance matrix estimator to account for clustering of similar outcomes within hospitals was used to examine the association of primary endpoints for each of the associated injury categories with reference to isolated C2 fractures. ResultsMean age of the cohort was 66.27±21.67 years and 52% were female. Of the cohort, 52% underwent surgical intervention for C2 fracture. In a pooled regression analysis involving the operative cohort, the risks for inpatient mortality (odds ratio [OR]: 3.77; 95% confidence interval [CI]: 3.02–4.70; p<.001), unfavorable discharge (OR: 1.83; 95% CI: 1.66–2.01; p<.001), prolonged LOS (OR: 1.33; 95% CI: 1.18–1.50; p<.001), high hospital charges (OR: 1.49; 95% CI: 1.31–2.69; p<.001), DVT (OR: 2.08; 95% CI: 1.61–2.68; p<.001), and ARF (OR: 1.46; 95% CI: 1.16–1.83; p=.001) were significantly higher in patients with additional injuries when compared with patients with C2 fractures alone. Likewise, increased chances of inpatient mortality (OR: 1.40; 95% CI: 1.21–1.62; p<.001), unfavorable discharge (OR: 1.24; 95% CI: 1.15–1.34; p<.001) and high hospital charges (OR: 1.31; 95% CI: 1.21–1.43; p<.001) were observed in a pooled analysis of patients with concomitant associated injuries in the non-operative cohort. ConclusionsAssociated injuries occurring concomitantly with C2 fractures adversely influence postoperative outcomes. In comparison to isolated C2 fractures, patients with associated injuries tend to have a greater propensity for higher health-care resource use because of more complicated and longer hospital inpatient stay.

Transoral osteosynthesis for C1 fractures: two cases report

The upper cervical spine fractures are rare and often fatal injuries so immediately with the traumatic event. Due to the amplitude of the spinal canal in the upper cervical region, only 16% of the survivors exhibit neurological compromise, so they can go unnoticed for emergency care. C I injuries are rare. We report two cases in relation to our experience in the management of this injury through transoral.

Burst C2 Fractures Combined with Traumatic Spondylolisthesis: Can Atlantoaxial Motion Be Preserved? Including Some Technical Tips for Reduction and Fixation.

Study Design Retrospective comparative clinical case series.Objective Burst C2 fractures are very rare. Treatment options include conservative treatment or fusion (anterior, posterior, or anterior and posterior). Anterior fusion addresses mainly hangman component. The bursting body usually needs posterior or combined anterior-posterior fusion, but both permanently sacrifice atlantoaxial motion. Can anterior-“first” approach preserve C1–C2 motion and restore function?Methods We report nine cases of burst C2 combined with C2–C3 spondylolisthesis and an odontoid fracture. The surgical group included six patients treated initially with an anterior approach, moving to a posterior one when necessary. All were treated with anterior diskectomy fusion using one session and one incision. The halo group included three patients treated conservatively using halo traction followed by rigid collar. Assessments included self-reported, physiologic, and functional measures. Reduction was assessed using Roy-Camille's criteria and improvement of canal compression ratio. Clinical outcome was graded excellent, very good, good, or poor according to pain, range of motion, and work status.Results Mean follow-up was 44.5 ± 8.3 (range 36.0 to 62.0) weeks. Results in the surgical group were judged to be excellent in four and good in two. One patient developed atlantoaxial osteoarthritis. Results were good in one patient and poor in two patients in the halo group. Two patients developed atlantoaxial osteoarthritis. All three cases had work limitations.Conclusion A single anterior approach achieved union and preserved C1–C2 motion and function in some cases. Conservative treatment achieved union but failed to achieve good reduction or good clinical outcome in grossly instable fractures. However, we believe that the ideal management is yet to evolve.

A retrospective review of fixation of C1 ring fractures—does the transverse atlantal ligament (TAL) really matter?

Background ContextIn contrast to the majority of outcome data, many consider C1 fractures to be benign injuries and so have advocated for conservative management, except in the case of concomitant transverse atlantal ligament (TAL) injury where C1–C2 or occiput–C2 fusions are recommended. PurposeOur goal was to evaluate a series of unstable C1 fractures treated with C1 open reduction and internal fixation (ORIF) to assess clinical and radiographic outcomes by determining the success of reduction and pain relief. Study Design/SettingThis is a retrospective cohort review. Patient SampleThe sample includes adult patients with unstable C1 fractures treated with open reduction and primary internal fixation. Outcome MeasuresPrimary outcome measures included visual analog pain scale (VAS), radiographic reduction (lateral mass displacement), maintenance of reduction, C1–C2 instability, and complications. MethodsA retrospective review of all patients with C1 fractures between September 2002 and September 2013 identified 12 consecutive patients from a level I trauma center who were treated with primary internal fixation without fusion. Electronic medical records and preoperative and postoperative radiographs were reviewed. The surgical technique consisted of a posterior cervical approach to the C1 arch and open reduction using bilateral C1 lateral mass screws connected transversely with a rod. Pre- and postoperative computed tomography scans were used to assess reduction. Long-term follow-up flexion and extension radiographs were used to assess C1–C2 stability. The authors did not receive relevant funding in relation to this research. ResultsTwelve patients underwent C1 ORIF, with a mean age of 43 (9 males and 3 females) and a mean follow-up of 17 months. Transverse atlantal ligament was found to be disrupted with type I or type II injury in 11 of the 12 patients: 5 type I and 6 type II. Preoperative lateral mass displacement averaged 7.1 mm, with postoperative displacement after reduction averaging 2.4 mm (p-value <.001). The VAS score averaged 0.7 at latest follow-up. No patients went on to develop C1–C2 instability on final flexion-extension films. No patients had a complication that resulted in neurologic deficit or vascular injury associated with the procedure. No patients were found to have late sequelae of malunion or loss of reduction. Two surgically related complications occurred, namely one patient with errant screw requiring return to the operating room (OR) and one with arthrosis of the occipital–C1 joint. ConclusionsAlthough a small series, early evidence suggests that patients with unstable C1 ring fractures can be successfully managed with primary ORIF. Open reduction and internal fixation results in a stable construct that maintains reduction, results in excellent pain control, and does not lead to C1–C2 instability. In our series, we have not observed the presence of TAL injury to adversely affect outcomes, and thus do not believe it is a contraindication to ORIF. Comparative studies comparing internal fixation with non-operative, C1–C2, or occiput–C2 fusions would yield more insight into optimal treatment options for these fractures.

Osteosynthesis with long volar locking plates for metaphyseal-diaphyseal fractures of the distal radius

ObjectiveMetaphyseal-diaphyseal fractures of the distal radius are a major treatment dilemma and orthopaedic surgeons have to pay due consideration to restoration of anatomy of distal radius together with rotation of the radial shaft and maintenance of radial bow and interosseous space. We performed this study to evaluate the clinic-radiological outcome of metaphyseal-diaphyseal fractures of the distal radius treated with long volar locking plates. MethodsThis prospective study involved 27 patients (22 males and 5 females) with metaphyseal-diaphyseal fracture of the distal radius. Their mean age was (30.12±11.48) years (range 19-52 years) and the follow-up was 26.8 months (range 22-34 months). All patients underwent open reduction and internal fixation with a long volar locking plate. According to AO/OTA classification, there were 7 type A3, 13 type C2 and 7 type C3 fractures. Subjective assessment was done based on the disabilities of the arm, shoulder and hand (DASH) questionnaire. Functional evaluation was done by measuring grip strength and range of motion around the wrist and the radiological determinants included radial angle, radial length, volar angle and ulnar variance. The final assessment was done according to Gartland and Werley scoring system. ResultsPostoperative radiological parameters were well maintained throughout the trial, and there was significant improvement in the functional parameters from 6 weeks to final follow-up. The average DASH scores improved from 37.5 at 6 weeks to 4.2 at final follow-up. Final assessment using Gartland and Werley scoring system revealed 66.67% (n=18) excellent and 33.33% (n=9) good results. There was one case of superficial infection which responded to antibiotics and another carpel tunnel syndrome which was managed conservatively. ConclusionVolar locking plate fixation for metaphyseal-diaphyseal fractures of distal radius is associated with excellent to good functional outcome, early rehabilitation and minimal complications.

The Unstable Distal Radius Fracture-How Do We Define It? A Systematic Review.

Background Unstable distal radius fractures are a popular research subject. However, to appreciate the findings of studies that enrolled patients with unstable distal radius fractures, it should be clear how the authors defined an unstable distal radius fracture. Questions In what percentage of studies involving patients with unstable distal radius fractures did the authors define unstable distal radius fracture? What are the most common descriptions of an unstable distal radius fracture? And is there one preferred evidence-based definition for future authors? Methods A systematic search of literature was performed to identify any type of study with the term unstable distal radius fracture. We assessed whether a definition was provided and determined the level of evidence for the most common definitions. Results The search yielded 2,489 citations, of which 479 were included. In 149 studies, it was explicitly stated that patients with unstable distal radius fractures were enrolled. In 54% (81/149) of these studies, the authors defined an unstable distal radius fracture. Overall, we found 143 different definitions. The seven most common definitions were: displacement following adequate reduction; Lafontaine's definition; irreducibility; an AO type C2 fracture; a volarly displaced fracture; Poigenfürst's criteria; and Cooney's criteria. Only Lafontaine's definition originated from a clinical study (level IIIb). Conclusion In only half of the studies involving patients with an unstable distal radius fracture did the authors defined what they considered an unstable distal radius fracture. None of the definitions stood out as the preferred choice. A general consensus definition could help to standardize future research.

Upper Cervical Epidural Abscess in a Patient With Parkinson Disease: A Case Report and Review.

To our knowledge, there are no reports in the literature of patients with Parkinson disease (PD) developing upper cervical spine infections. Our objective is to present a case of upper cervical epidural abscess in a patient with PD and to review upper cervical spine infection. We present the patient’s presentation, physical examination, imaging findings, and management as well a review of the literature. A 66-year-old male with PD presented to the emergency department (ED) following referral by a neurologist for a presumed C2 fracture. The preceding history was 1 week of severe neck pain requiring a magnetic resonance imaging (MRI), which was initially interpreted as a C2 fracture. On admission from the ED, further review of the MRI appeared to show anterior prevertebral abscess and an epidural abscess. The patient’s neurological examination was at baseline. In the span of 2 days, the patient developed significant motor weakness. A repeat MRI demonstrated expansion of the epidural collection and spinal cord compression. Surgical management consisting of C1 and C2 laminectomy, irrigation, and debridement from anterior and posterior approaches was performed. Postoperatively, the patient did not recover any motor strength and elected to withdraw care and died. Spinal epidural abscess requires a high index of suspicion and needs prompt recognition to prevent neurological impairment. Upper cervical spine infections are rare but can lead to lethal consequences.

Clinical findings of conservative cases with a coronally oriented vertical fracture of the posterior region of the C2 vertebral body.

This report describes the characteristics of conservative cases with a coronally oriented vertical fracture of the posterior region of the C2 vertebral body. Eight consecutive patients with a coronally oriented vertical fracture of the posterior region of the axis body who received conservative treatment were retrospectively reviewed. All the patients were male. The average patient age at injury was 71.4 years. The medical records of the patients were reviewed, and we identified the fractures associated with the cervical spine, other associated spinal fractures and the details of conservative treatment. Six patients had associated cervical spinal fractures, such as Jefferson fractures in four cases, spinous process fractures of the lower cervical spine in two cases, a teardrop fracture in one case and a unilateral spinous process fracture of C2 in one case. Two patients had associated spinal fractures in the thoracic spine. All the patients acquire solid bony fusion, including fusion of the associated cervical spinal fractures. The patients with a coronally oriented vertical fracture of the posterior region of the C2 vertebral body consisted were all elderly males in our study. Six of the eight patients demonstrated associated cervical spinal fractures; however, all patients acquired solid bony union, including fusion of the associated cervical spinal fractures. We suggest that a Philadelphia collar may be sufficient for conservatively treating coronally oriented vertical C2 body fractures, including associated cervical spinal fractures.

Biomechanical Comparison of Volar Fixed-Angle Locking Plates for AO C3 Distal Radius Fractures: Titanium Versus Stainless Steel With Compression

To determine biomechanical differences between a fixed-angle locking volar titanium plate (VariAx; Stryker, Kalamazoo, MI) and a fixed-angle compression locking volar stainless steel plate (CoverLoc Volar Plate; Tornier, Amsterdam, Netherlands) in the fixation of simulated AO C3 distal radius fractures. Eighteen cadaveric upper extremities (9 matched pairs) with an average age of 54 years were tested. A 4-part AO C3 fracture pattern was created in each specimen. The fractures were reduced under direct vision and fixed with either the fixed-angle locking volar titanium plate or the fixed-angle compression locking volar stainless steel plate. Motion tracking analysis was then performed while the specimens underwent cyclic loading. Changes in displacement, rotation, load to failure, and mode of failure were recorded. The fragments, when secured with the fixed-angle compression locking stainless steel construct, demonstrated less displacement and rotation than the fragments secured with the fixed-angle locking titanium plate under physiological loading conditions. In the fixed-angle compression locking stainless steel group, aggregate displacement and rotation of fracture fragments were 5 mm and 3° less, respectively, than those for the fixed-angle locking titanium group. The differences between axial loads at mechanical failure and stiffness were not statistically significant. The compression locking stainless steel group showed no trend in mode of failure, and the locking titanium plate group failed most often by articular fixation failure (5 of 9 specimens). The fixed-angle compression locking stainless steel volar plate may result in less displacement and rotation of fracture fragments in the fixation of AO C3 distal radius fractures than fixation by the fixed-angle locking volar titanium plate. However, there were no differences between the plates in mechanical load to failure and stiffness. Fixation of distal radius AO C3 fracture patterns with the fixed-angle compression locking stainless steel plate may provide improved stability of fracture fragments.

Extra-articular implant stabilization for locked atlantoaxial fracture-subluxation with intrusion on the vertebral artery: a new option in less-invasive C2 fracture repair

Extra-articular implant stabilization for locked atlantoaxial fracture-subluxation with intrusion on the vertebral artery: a new option in less-invasive C2 fracture repair

Hybrid External Fixation for Arbeitsgemeinschaft für Osteosynthesefragen (AO) 43-C Tibial Plafond Fractures

Arbeitsgemeinschaft für Osteosynthesefragen (AO) type 43-C tibial plafond/pilon fractures represent a challenge for the treating orthopedic surgeon. We assessed the outcomes of using hybrid external fixation for this fracture type. The present prospective cohort study was started in August 2009 and ended by July 2012. Thirty consecutive patients (mean age 37.4 ± 10.7 years) with a type C tibial plafond fracture who had presented to our tertiary care orthopedic hospital were included. Motor vehicle accidents and fall from height were the cause of the fracture in 14 (46.7%) and 13 (43.3%) patients, respectively. A type C3 fracture was present in 25 patients (83.3%), and type C1 and C2 fractures were present in 2 (6.7%) and 3 (10.0%) patients, respectively. Nine fractures (30.0%) were open. Hybrid external fixation was used for all fractures. All fractures were united; clinical healing was achieved by a mean of 18.1 ± 2.2 weeks postoperatively and radiologic healing at a mean of 18.9 ± 1.9 weeks. The fixator was removed at a mean of 20.4 ± 2.0 weeks postoperatively. At a mean follow-up point of 13.4 ± 2.6 months, the mean modified Mazur ankle score was 84.6 ± 10.4. It was not associated with wound classification (p = .256). The most commonly seen complication was ankle osteoarthritis (17 patients; 56.7%); however, it was mild in >50.0% of the affected patients. In conclusion, using hybrid external fixation for type C tibial plafond fractures resulted in good outcomes. However, this should be investigated further in studies with a higher level of evidence.

Tibial pilon fractures treated by interlocking intramedullary nail with distal multi-directional locking

Objective To explore the clinical efficacy of pilon fracture treated by tibial multi-directional interlocking intramedullary nail. Methods From June 2010 to January 2013, data of 23 patients with pilon fracture who were treated by tibial multi-directional interlocking intramedullary nail were retrospectively analyzed. There were 15 males and 8 females, with an average age of 36.9 years (range, 32-61 years). They were all fresh fractures, including 22 cases of closed fractures and 1 case of opened fracture (Tscherne grade 1). According to the AO/OTA classification, there were 10 fractures of type C1, 8 fractures of type C2 and 5 fractures of type C3. According to the injury mechanisms, open reduction and internal fixation' was used. Non-restrictive screws were used to convert type C to type A after pry poking reposition, then intramedullary nail was used to fixate the fracture. Burwell-Charnley radiological evaluation system was used for radiological assessment, and Teeny-Wiss ankle clinical symptoms and functional score system was used for efficacy assessment postoperative. Results The mean followup period was 20.6± 2.3 months (range, 18-24 months). All fractures were healed at an average period of 16.8±4.0 weeks (range, 14-28 weeks). According to the Burwell-Charnley radiological evaluation system, 20 cases had obtained anatomic reduction, 2 cases fair reduction and only 1 case poor reduction. The anatomic reduction rate was 87.0% (20/23). At the latest followup, the mean Teeny-Wiss score was 91.6±9.5 (range, 60-100). There were excellent in 12 cases, good in 8 cases, fair in 2 cases, and poor in 1 case, and the overall excellent and good rate was 87.0%(20/23). None of the complications such as infection, breakage of screw loosening, malunion, nonunion occurred at the time of the latest followup, but 7 cases appeared tension blisters, one case appeared skin necrosis, and 6 cases got chronic pain in the knee postoperation. Conclusion Multi-directional interlocking intramedullary nail is a safe alternative for the treatment of pilon fractures with proper patient selection and surgical indication. Key words: Tibial fractures; Fracture fixation, internal; Bone screws

Pilon Fractures

Pilon fractures are uncommon, representing approximately 5-10 % of all lower limb fractures. Pilon fractures are often associated with serious soft tissue injuries resulting in initial external fixation followed by internal fixation once the condition of the soft tissues has improved. Articular distal fractures of the tibia are classified as B3, C1, C2 and C3 fractures according to the AO Classification. Pilon fractures are usually the result of a high energy trauma. A low energy trauma such as a twisting injury of the ankle can also lead to a pilon fracture. Such low energy mechanisms of injury are rarely associated with significant soft tissue injury and can be immediately fixated internally. Pilon fractures are often associated with an unsatisfactory healing response. This is a result of a combination of factors including the severity of the trauma, the extent of the initial soft tissue injury and the accuracy of the articular surface reconstruction.

Predictors of Vertebral Artery Injury in Isolated C2 Fractures Based on Fracture Morphology Using CT Angiography.

Retrospective database analysis. To determine C2 fracture patterns associated with vertebral artery injury (VAI) as assessed by computed tomography angiography. The incidence of C2 fracture hospitalizations has increased significantly in the last decade. The vertebral arteries are susceptible to injury as each courses through the C2 transverse foramen. Early screening for VAI to institute antithrombotic treatment is critical to prevent ischemic neurological sequelae. Imaging-based fracture classification schemes to determine which patterns are predictors of VAI in isolated C2 fractures using computed tomography angiography have not been described. Cervical spine computed tomographic (CT) scans at a level I trauma center were reviewed for isolated C2 fractures from 2004 to 2014 under institutional board review approval. Exclusion criteria included penetrating injury or additional cervical/occipital fractures. Fractures were classified using multiplanar CT scans into type I/II/IIa/III spondylolisthesis, type I/IIA/IIB/IIC/III dens, transverse foramen (displacement/comminution/intraforaminal fragments), and miscellaneous vertebral body fractures. Corresponding CT angiograms were assessed for VAI on the basis of the Denver grading criteria. Fisher exact test and Student t test were performed to determine predictors of VAI on the basis of fracture type. Sixty-seven patients met inclusion criteria. Fracture pattern analysis revealed that the majority were dens fractures (50.8%) and traumatic spondylolisthesis (41.8%); 29.9% had miscellaneous coronal/sagittal fractures and 22.4% were a combination.VAI was identified in 37.3% of patients with isolated C2 fractures, and 88% of patients had transverse foramen involvement. Fracture patterns significantly associated with VAI were type III dens and transverse foramen fractures with intraforaminal fragments, with or without comminution. The C2 fracture pattern most associated with VAI was comminuted transverse foramen fracture with intraforaminal fragments. Transverse foramen fracture alone was not found to be significant. These results help stratify patients with isolated C2 fractures who are at high VAI risk and should be further evaluated with computed tomography angiography. 3.

One stage atlantoaxial pedicle screw fixation for unstable atlas burst fracture

Objective To assess the clinical results of one stage posterior atlanloaxial pedicle screw fixation and fusion for unstable atlas burst fracture. Methods A retrospective analysis of clinical data including 32 cases, which were admitted according to the inclusion and exclusion criteria between May 2010 and December 2013. There were 11 females and 21 males whose age ranged from 22 to 59 years (mean 41.8 years). X-ray, CT scan reconstruction and MRI were done before operation to evaluate the injury of ligament and fracture. There were 17 cases of unstable atlas burst fracture,including 5 cases Jefferson fracture,8 cases untypical Jefferson fracture, and 4 cases lateral mass fracture combined with anterior arch or posterior arch fracture. There were 15 cases combined with axial fracture, 9 cases combined with dens fracture, 4 cases with axial body fracture, and 2 cases with Hangman fracture. The patients had various degrees of occipital neck pain, limited mobility and neurological dysfunction. Degree C in 1 case and degree D in 5 cases were assessed by the American Spinal Cord Injury Association (ASIA) impairment scale. All patients were treated with one stage posterior atlantoaxial pedicle screw fixation and fusion. All patients were assessed clinically by neurologic recovery, atlantoaxial reduc tion and bone graft fusion. The preoperative and postoperative atlanto-dens interval (ADI), lateral mass distance (LMD) and VAS were measured and statistically analyzed. Complications were observed. Clinical outcome of last follow-up was evaluated by dynamic X-ray and CT scan. Results All patients were followed up. The follow-up time ranged from 10 to 24 months (mean 15.6 months). The healing time of bone fusion ranged from 5 to 10 months with an average follow-up time of 6.9 months. The average preoperative VAS score was 5.0±1.4 while the score of last follow-up was 1.0±0.7, with statistically significant differences. Neurological status improved in all patients but one. Four cases with grade D improved to E, and one cases with grade C improved to D. Postoperative cervical spine X-ray and CT showed that the sagittal cervical spine alignment was restored. The preoperative ADI was 4.6±1.2 mm, which was statistically significant different with last follow-up the ADI of 2.4±1.0 mm. There were statistically significant difference between preoperative LMD of 5.6±2.2 mm and postoperative LMD of 1.2±1.0 mm. Conclusion The posterior atlantoaxial pedicle screw for unstable atlas burst fracture combined with atlantoaxial instability seems to be effective. It is technically demanding to place screw into thelateral mass of the atlas. Key words: Cervical atlas; Spinal fractures; Atlanto-axial joint; Joint instability; Spinal fusion

Unstable C1 Ring Fractures Managed with Primary Internal Fixation without Fusion: A Retrospective Review

Introduction While the majority of C1 fractures are treated nonoperatively with external immobilization, there is a subset of C1 fractures known to be unstable. In addition, current literature-based outcomes of nonoperatively managed C1 ring fractures have not been completely favorable, and therefore, leave room for treatment alternatives. Our goal was to evaluate a series of unstable C1 fractures treated with primary internal fixation without fusion (ORIF) to assess clinical and radiographical outcomes. Patients and Methods A retrospective review of all patients with C1 fractures between September 2002 and November 2012 identified 10 consecutive patients from a level I trauma center (Harborview Medical Center, Seattle, Washington United States) who were treated with primary internal fixation without fusion. EMR charts and radiographs were reviewed. The surgical technique consisted of a posterior cervical approach to C1 arch and open reduction utilizing bilateral C1 lateral mass screws connected transversely with a rod. Primary outcome measures included radiographical reduction, maintenance of reduction, ROM, and complications. Pre- and postoperative CT scans were utilized to assess reduction. Results A total of 10 patients with mean age of 53 years were identified to have undergone primary C1 ORIF. The cohort consisted of eight males and two females of which eight unilateral sagittal split–type fractures and two Jefferson burst–type fractures were identified. Mean follow-up was 13 months. Of the 10 patients, there were 2 associated complications, 1 errant screw requiring return to the operating theater for reposition, and 1 osteonecrosis of the lateral mass though the fracture healed. Preoperative lateral mass displacement averaged 7.3 mm and postoperative displacement had a mean of 2.4 mm with a p value after reduction of &lt; 0.002. No patient had serious complication resulting in neurologic deficit or vascular injury associated with the procedure. No patient went on to develop the previously described “cock-robin” deformity from subluxation of the lateral mass with settling of the occiput onto the C2 lateral mass and no patient had subsequent C1–C2 instability as defined by an ADI greater than 3 mm on flexion and extension films. Conclusion Patients with unstable C1 ring fractures can be successfully managed with primary open reduction and internal fixation with a transversely oriented construct using C1 lateral mass screws. Open reduction and internal fixation offers a viable treatment alternative to conservative management or fusion by restoring cervical alignment with C1 reduction and anatomical realignment. Internal fixation of the atlas without fusion prevents progressive, painful deformity, and the need for complex occipitocervical reconstruction procedures that have been reported with nonoperative management of these injuries.

Posterior C2 Instrumentation in the Management of Trauma: Accuracy and Risks Associated with Four Techniques

Introduction Posterior instrumentation of C2 is important in treating occipitocervical, atlanto-axial, and subaxial spinal injuries. The variable C2 anatomy can make instrumentation challenging and prone to potentially severe and even life-threatening complications. The goal of this study was to (1) evaluate a large series of posterior C2 screws to determine accuracy as assessed by computed tomography (CT) scan, (2) assess dimensions of “safe bony windows” with CT, and (3) assess the perioperative complication rate related to errant screw placement. We hypothesize that the evolution of a greater variety of options for C2 fixation and the ability to tailor these techniques to patients' specific anatomy has resulted in decreased complications and increased accuracy. Material and Methods A retrospective review of a single Level I trauma center spine database was assessed to identify all patients with operative management for traumatic conditions with C2 instrumentation between December 2002 and September 2008. Radiographic analysis included evaluation of pre- and postoperative CT scans to quantify the patients' bony anatomy as well as to classify the accuracy of C2 screw placement. All C2 screws were graded using the following definitions: Type I: Screw threads completely within the bony cortex. Type II: Less than half the diameter of the screw violates the surrounding cortex. Type III: Clear violation of the transverse foramen or spinal canal. Results A total of 169 patients (99 males and 70 females) underwent posterior C2 screw fixation for traumatic conditions of the spine, including 23 atlanto-occipital dissociations, 16 unstable C1 ring injuries, 79 dens fractures, 9 Hangman fractures, 8 other C2 fractures, 3 C2 hyperextension injuries, 4 C2–C3 flexion–distraction injuries, 14 subaxial injuries, and 19 odontoid nonunions. Average CT measurements of pedicle height, axial width, and laminar width were 8.1 mm (standard deviation 2.1 mm), 5.8 mm (1.9 mm), and 5.7 mm (1.5 mm), respectively, with males having larger pedicle height ( p &lt; 0.001), pedicle width ( p &lt; 0.001), and laminar width ( p &lt; 0.022). A total of 324 screws underwent CT analysis and chart review. A total of 169 pedicle, 85 trans-articular, 50 laminar, and 20 short pars screws were placed with 80.6, 84.4, 96, and 94.4% accuracy rates (Grade I vs. II and III), respectively. Overall 85% of the screws were rated as being in the ideal location. There were no cases of known vertebral artery injury at the time of surgery. Two pedicle screws were unacceptably placed (Grade III). Both patients had screws encroaching on the vertebral artery foramen: one patient had a vertebral artery occlusion and the other had a Grade I dissection documented on CT angiogram without clinical signs of stroke or emboli as measured on transcranial Doppler. No neurological injuries resulted from instrumentation. Conclusion Our findings demonstrate a lower than previously reported incidence of complications associated with posterior C2 screw placement. In the management of 169 patients with 324 screws, only 2 patients had vascular injuries, neither of whom had any sequelae. The multiple techniques of posterior C2 fixation that are currently available allow for unprecedented flexibility in determining which technique is best suited for a given patient's anatomy.

The use of a single volar locking plate for AO C3-type distal radius fractures.

A single volar locking plate (VLP) is now frequently used for open reduction and internal fixation (ORIF) of many types of distal radius fractures. Comminuted intra-articular distal radius fractures (AO C3-type) are typically the most challenging to surgically treat. No studies directly address the adequacy of a VLP alone for maintaining reduction of AO C-type fractures. We hypothesized that a single VLP provides an effective method for maintaining reduction for these fractures. We retrospectively evaluated radiographs of a series of AO C-type fractures. Seventy-seven patients with 77 AO C3-type fractures were identified from billing records and were eligible for the study. All patients were treated by fellowship-trained hand surgeons. Radiographs at the time of union were compared to those from immediately postoperatively. Sixty-nine of 77 (89.6%) fractures treated with VLP fixation alone for AO C3-type distal radius fractures united without loss of reduction. Eight of 77 (10.4%) patients treated with VLP for AO C3 fractures lost reduction. The most common fracture fragment to lose reduction was the lunate fossa (5 of 8); loss of reduction of the scaphoid fossa die-punch fragment (2 of 8) and the radial styloid (1 of 8) were also seen. The majority (89.6%) of AO C3-type fractures treated with a single volar locking plate come to union without loss of reduction. Level IV.

Conservative Management for a Traumatic Cervical Spine Cycling Injury

Competitive cycling holds an inherent risk of traumatic injury often resulting in fracture. Questions regarding the probability of return to sport then arise. The purpose of this case report is to describe the treatment approach and likelihood of returning to cycling after traumatic fracture of the cervical spine and clavicle. This case report describes the use of an original combination of interventions for a C1 fracture with an associated open reduction internal fixation of a left clavicle fracture in a 39-year-old male cyclist. The patient lost control of his bike while descending a slippery slope and was propelled over the handlebars landing head first. The resultant cervical spine and clavicle fractures required twelve weeks in a cervical collar. Physical therapy interventions focused on regaining strength and functional mobility of the cervical spine and shoulder. Following treatment a minimal detectable change was seen for range of motion (>6%) of the cervical spine and shoulder, the Numerical Pain Rating Scale (3 point change), and the Disabilities of the Arm, Shoulder and Hand (29.2% change). The patient returned to his prior level of function at home and work. Medical clearance was received to return to training, with a hopeful prognosis of eventually returning to competition.