Citation, DOI, disclosures and article data
At the time the article was created Rishi Agrawal had no recorded disclosures.View Rishi Agrawal's current disclosures
At the time the article was last revised Calum Worsley had no recorded disclosures.View Calum Worsley's current disclosures
Jefferson fracture is the eponymous name given to a burst fracture of the atlas. It was originally described as a four-part fracture with double fractures through the anterior and posterior arches, but three-part and two-part fractures have also been described.
- 50% are associated with other C-spine injuries
- 33% are associated with a C2 fracture
- 25-50% of young children have a concurrent head injury
- vertebral artery injury 5 (blunt cerebrovascular injury (BCVI))
- extracranial cranial nerve injury 6
A typical mechanism of injury is diving headfirst into shallow water. Axial loading along the axis of the cervical spine results in the occipital condyles being driven into the lateral masses of C1. The Jefferson fracture is not normally associated with neurological deficit although spinal cord injury may occur if there is a retropulsed fragment affecting the cervical cord.
The Gehweiler classification describes injuries of the atlas with a burst or type 3 injury defining the pattern seen in a Jefferson fracture. Disruption of the transverse atlantal ligament (transverse band of the cruciform ligament) was also described by Dickman and incorporated into classifying these injuries.
Radiographs will show asymmetry in the odontoid view with the displacement of the lateral mass(es) away from the odontoid peg (dens). A distance of greater than 6 mm suggests ligamentous injury.
CT demonstrates the fracture line which usually involves both the anterior and posterior arches. If there is an injury to the transverse atlantal ligament, the atlantodental interval (ADI) increases. The normal ADI in the adult population is less than 3 mm; in pediatric populations, the normal distance is less than 5 mm.
The fracture will not be seen as well as with CT. However, localized soft-tissue injury will be apparent. Pre-vertebral hemorrhage or edema will identify injury at the level of C1/2. A ligamentous injury will also be demonstrated. A fat-sat T2 sequence is useful in the trauma setting to help distinguish abnormal soft-tissue injury from normal fat.
Treatment and prognosis
Jefferson fractures are typically treated conservatively (hard collar immobilization) provided the transverse atlantal ligament is considered intact (no widening of the atlantodental interval or intact ligament visualized on MRI).
In cases where the ligament is thought to be disrupted, the injury is considered unstable and more aggressive management is usually required 7. This includes halo immobilization, posterior C1-C2 lateral mass internal fixation or transoral internal fixation.
History and etymology
Named by Sir Geoffrey Jefferson (1886-1961), a neurosurgeon from the United Kingdom 4.
pseudo-Jefferson fracture, or pseudospread of the atlas on the axis
- refers to the normal overhanging of the lateral edges of the lateral masses of C1 over the lateral edges of the body of C2 seen in children 8,9
- rare congenital anatomic anomaly of fusion defects of both the anterior and posterior arches of C1
- 1. Lustrin E, Karakas S, Ortiz A et al. Pediatric Cervical Spine: Normal Anatomy, Variants, and Trauma. Radiographics. 2003;23(3):539-60. doi:10.1148/rg.233025121 - Pubmed
- 2. Hunter T, Peltier L, Lund P. Radiologic History Exhibit. Musculoskeletal Eponyms: Who Are Those Guys? Radiographics. 2000;20(3):819-36. doi:10.1148/radiographics.20.3.g00ma20819 - Pubmed
- 3. Jefferson G. Fracture of the Atlas Vertebra. Report of Four Cases, and a Review of Those Previously Recorded. British Journal of Surgery. 1919;7(27):407-22. doi:10.1002/bjs.1800072713
- 4. Botterell E. Sir Geoffrey Jefferson 1886–1961. Journal of Neurosurgery. 1961;18(3):407-9. doi:10.3171/jns.1961.18.3.0407
- 5. Muratsu H, Doita M, Yanagi T et al. Cerebellar Infarction Resulting from Vertebral Artery Occlusion Associated with a Jefferson Fracture. J Spinal Disord Tech. 2005;18(3):293-6. - Pubmed
- 6. Connolly B, Turner C, DeVine J, Gerlinger T. Jefferson Fracture Resulting in Collet-Sicard Syndrome. Spine (Phila Pa 1976). 2000;25(3):395-8. doi:10.1097/00007632-200002010-00023 - Pubmed
- 7. Norton J, Barie P, Bollinger R et al. Surgery. (2008) ISBN: 9780387308005 - Google Books
- 8. Suss R, Zimmerman R, Leeds N. Pseudospread of the Atlas: False Sign of Jefferson Fracture in Young Children. AJR Am J Roentgenol. 1983;140(6):1079-82. doi:10.2214/ajr.140.6.1079 - Pubmed
- 9. Lustrin E, Karakas S, Ortiz A et al. Pediatric Cervical Spine: Normal Anatomy, Variants, and Trauma. Radiographics. 2003;23(3):539-60. doi:10.1148/rg.233025121 - Pubmed
- 10. Laubach M, Pishnamaz M, Scholz M et al. Interobserver Reliability of the Gehweiler Classification and Treatment Strategies of Isolated Atlas Fractures: An Internet-Based Multicenter Survey Among Spine Surgeons. Eur J Trauma Emerg Surg. 2020. doi:10.1007/s00068-020-01494-y - Pubmed
- 11. Mead L, Millhouse P, Krystal J, Vaccaro A. C1 Fractures: A Review of Diagnoses, Management Options, and Outcomes. Curr Rev Musculoskelet Med. 2016;9(3):255-62. doi:10.1007/s12178-016-9356-5 - Pubmed