C2 fracture

Case contributed by Dr Dayu Gai


This 65 year old female crashed her vehicle into a building at 80 kilometers per hour. The airbag was deployed, however the patient described significant chest and abdominal pain. A CT trauma series was performed.

Patient Data

Age: 65
Gender: Female
  1. C2 fracture through the lateral masses and body in obliquely coronal plane.
  2. Right C6 transverse process fracture.
  3. T2 superior endplate compression fracture.
  1. Right L4 transverse process fracture.
  2. Possible liver laceration without hemoperitoneum.
  3. Prominent hematoma involving the abdominal wall with a more focal part lateral to the right iliac crest containing contrast blush in keeping with ongoing bleeding.

Case Discussion

This patient has multiple injuries including multiple cervical vertebral fractures. 

Cervical fractures can be divided into two main categories2:

  • upper cervical fractures (C1 (atlas) and C2 (axis))
  • lower cervical fractures (C3 - C7)

In this case, the patient has an upper cervical axial fracture of C2 as well as a lower cervical C6 fracture. The C2 fracture can be best appreciated in the sagittal view, where there is clear separation of the C2 body with the C2 spine. The C6 fracture can be best visualized on the coronal image, where the inferior articular process has a breach in cortex, with mild angulation.
C2 or axial fractures can be divided into four main types1:

  • Type I: fracture without an angular deviation and translational deviation of less than 3.5 mm that occurs due to hyperextension and axial compression;
  • Type II: fracture with a significant translational or angular deviation that occurs due to hyperextension and axial compression combined with a mechanism of flexion-compression;
  • Type IIa: fracture with a small translational deviation and wide angulation, with an increase in posterior disc space between C2-C3 upon application of traction that occurs due to a flexion-distraction; and
  • Type III: fracture with a large translational and angular deviation, which is associated with unilateral or bilateral dislocation of the C2-C3 joint facets and occurs due to a flexion-compression mechanism.

Due to the minimal amount of angular or translational deviation, our patient has a type I C2 fracture. These fractures can be managed non-operatively with immobilization for a period of 12 weeks.

Subaxial fractures (C3 - C7 fractures) can be assessed using the Subaxial Injury Classification score3,4. It is a 3 part scoring system, which gives a total possible score out of 10. The 3 parts to be considered include:

  • Morphology of the vertebral injury
    • No abnormality - 0
    • Compression - 1
    • Burst Compression - 2
    • Distraction - 3
    • Rotation/translation - 4
  • Disc-ligamentous complex
    • Intact - 0
    • Indeterminate - 1
    • Disrupted - 2
  • Neurological status
    • Intact - 0
    • Root injury - 1
    • Complete spinal cord injury - 2
    • Incomplete spinal cor injury - 3 
    • Continuous cord compression in setting of neurological deficit - Add 1

A score of 4 or more warrants surgical intervention.

Case contributed by A/Prof. Pramit Phal.

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