Jefferson Fracture
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Definition
A Jefferson fracture is a fracture of the C1 vertebra. The vertebra C1 is a bony ring with two wedge-shaped lateral masses connected by relatively thin anterior and posterior arches and a transverse ligament. The lateral mass on vertebra C1, which is taller, is directed laterally. Therefore, vertical forces compressing the lateral masses between the occipital condyles and the axis drive them apart, fracturing one or both anterior or posterior arches. The impact forces cause an outward spread of the lateral masses of C1.
A Jefferson fracture does not always result in a spinal cord injury, because the dimensions of the bony ring increase. Spinal cord injury is more expected if the transverse ligament has also been ruptured. [1]
Clinically Relevant Anatomy
The first vertebra of the cervical spine is also called the atlas. The atlas has in contrast to the other vertebra no body. The upper surface of the atlas bears a superior articular facet on a thick lateral mass on each side. The lateral masses articulate with the occipital condyles.
Epidemiology /Etiology
3% to 13% of injuries to the cervical spine are fractures of the atlas and in 1.3% to 2% of all spinal injuries.[2]
The Jefferson fracture occurs most likely because of a motor vehicle accident or sport related mishaps like shallow diving or hard tackles. The mechanism of injury are either a hyperextension or axial compression injury of the C1 vertebra.[3]
A fracture may be complicated by atlantoaxial rotatory fixation or caused by a forceful head rotation, though such cases have only been reported once in an adult.
Clinical symptoms
- Pain in the upper cervical spine
- Muscle tenderness
- Muscle spasm
- Decreased ROM
- Rare occasions patient can present with:
- Torticollis
- Cock-robin deformity
- Neurological deficits[4]
Classification
There are a number of classification system used for atlas fractures but none is accepted everywhere. According to the Jefferson classification a Jefferson fracture is a Type 3 fracture and according to Gehweiler it is classified as a Type III a and b.
- Jefferson Classification[2]
- Type 1: Fracture of the Posterior Arch
- Type 2: Fracture of the Anterior Arch
- Type 3: Fracture of both the anterior and posterior arches( Jefferson fracture)
- Type 4: Fracture of the Lateral Mass.
- Gehweiler Classification[3]
- Type I: Isolated anterior arch fracture
- Type II: Isolated bilateral fracture of the posterior atlas ring
- Type III: Fracture of both arches (Jefferson fracture)
- Type IIIa: Intact transverse atlantal ligament (TAL)
- Type IIIb: Ruptured TAL Type IV: Lateral mass involvement
- Type V: Isolated fractures of the C1 transverse process
Management
Patient with a Jefferson fracture must be diagnosed with a CT scan. Jefferson fractures can be either stable or unstable. Unstable fractures is usually accompanied by a TAL (transverse atlantal ligament). For stable fracture most of the time they are treated conservatively by immobilisation by means of a hard collar.[6]
The goal of treatment is to:
- Reduce the fracture
- Correctly dislocate fracture
- Stabilise the atlantoaxial joint
- Preserve the maximum ROM of the upper cervical spine
For unstable fractures surgical strategies have become the standard of care however the strategies are still controversial. Below is a list of possible surgeries:
- Occiput-C2 wiring and fusion[2]
- C1-ring plate osteosynthesis[2]
- Anterior or posterior screw fixation
- Posterior Osteosynthesis with lateral mass screw rof
- Posterior C1 to C2 fusion
- C0 to C2 fusion[2]
Physiotherapy Management
Physiotherapy management is going to vary of according to the surgeons protocol but generally begins 6 weeks post operatively.
Below is a general post operative rehabilitation plan for the cervical spine:[7]
- Neck and shoulder muscle strengthening: Start with non resistance exercises and progress to isometric and resistance exercises.
- Neural mobilisations
- Balance exercises
- Try incorporating Virtual Reality.
References
- ↑ Ellis H, Mahadevan V. Clinical Anatomy. John Wiley & Sons; 2013.
- ↑ 2.0 2.1 2.2 2.3 2.4 Guo W, Lin Y, Huang J, Hu F, Ding Z, Xiao Z. Treatment strategy of unstable atlas fracture. Medicine [Internet]. 2020 May 1 [cited 2024 Nov 19];99(18):e20153–3.
- ↑ 3.0 3.1 Gurjar HK, Rai HIS, Mishra S, Garg K. Technical Considerations in Surgical Fixation of Jefferson Fracture. Indian Journal of Neurotrauma. 2022 Dec 27;
- ↑ Miguel Angel Martinez-Romo, Christopher Eric McCoy. Jefferson Fracture and the Classification System for Atlas Fractures, A Case Report. PubMed [Internet]. 2021 Apr 1;6(2):V16–9.
- ↑ Radiology ChannelJefferson fracture - radiology video tutorial (x-ray, CT) Available from https://www.youtube.com/watch?time_continue=1&v=xlv6Vo218Ps&feature=emb_logo
- ↑ Tu Q, Chen H, Li Z, Chen Y, Xu A, Zhu C, et al. Anterior reduction and C1-ring osteosynthesis with Jefferson-fracture reduction plate (JeRP) via transoral approach for unstable atlas fractures. BMC Musculoskeletal Disorders. 2021 Aug 30;22(1).
- ↑ Sakaguchi T, Heyder A, Tanaka M, Koji Uotani, Omori T, Kodama Y, et al. Rehabilitation to Improve Outcomes after Cervical Spine Surgery: Narrative Review. Journal of Clinical Medicine. 2024 Sep 10;13(18):5363–3.