Jefferson fracture

Last revised by Calum Worsley on 9 Nov 2021

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.

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.

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
  • split atlas
    • rare congenital anatomic anomaly of fusion defects of both the anterior and posterior arches of C1

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Cases and figures

  • Figure 1: illustration
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  • Case 1: CT - 4-part fracture
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  • Figure 2a: type 3a
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  • Case 2: odontoid view
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  • Figure 2b: type 3b (Dickman 1)
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  • Case 3: odontoid view
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  • Figure 2c: type 3b (Dickman 2)
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  • Case 4
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  • Case 5: in ankylosing spondylitis
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  • Case 6
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  • Case 7
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  • Case 8
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  • Case 9
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