Tuli classification of occipital condyle fractures

Last revised by Francis Deng on 17 Jan 2022

The Tuli classification of occipital condyle fractures is a clinically-oriented system for describing these injuries based on fracture displacement and ligamentous injury. It is newer than the more well-known Anderson and Montesano classification of occipital condyle fractures and allows the incorporation of MRI findings.

The classification is based upon fracture displacement and instability of the occipitoatlantoaxial (O-C1-C2) joint 1.

  • type 1: undisplaced occipital condyle fracture
  • type 2: displaced occipital condyle fracture
    • type 2A: with stability of the O-C1-C2 joint
    • type 2B: with instability of the O-C1-C2 joint based on any criteria from radiographic, CT, and/or MRI findings

The following criteria for O-C1-C2 instability were proposed:

  • CT/radiographic criteria:
    • >8 degrees of axial rotation of O-C1 to one side
    • >1 mm of O-C1 translation
    • >7 mm of overhang of C1 lateral masses on C2
    • >45 degrees of axial rotation of C1-C2 to one side
    • >4 mm of C1-C2 translation
    • <13 mm distance between the posterior body of C2 to the posterior ring of C1
    • avulsed transverse ligament
  • MR evidence of ligamentous disruption

The incidence distribution of the Tuli classification types amongst occipital condyle fractures has been reported 2,3:

  • type 1: 56-58%
  • type 2A: 23-34%
  • type 2B: 11-19%

Tuli et al. suggested management according to the fracture type 1:

  • type 1: no immobilization required
  • type 2A: hard collar
  • type 2B: halo vest or surgical fixation

The classification was proposed by Canadian neurosurgeon Sagun Tuli and colleagues in 1997 accompanying a case series of 3 patients diagnosed by CT and a literature review of 96 previously reported cases 1.

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