Advanced Trauma Life Support ATLS Student Course Manual 2018

SPECIFIC TYPES OF SPINAL INJURIES 137
n FIGURE 7-4 Jefferson Fracture. Open-mouth view radiograph
showing a Jefferson fracture. This fracture involves disruption
of both the anterior and posterior rings of C1, with lateral
displacement of the lateral masses.
n FIGURE 7-5 Odontoid Fracture. CT view of a Type II odontoid
fracture, which occurs through the base of the dens.
a persistent rotation of the head (torticollis). With
this injury, the odontoid is not equidistant from the
two lateral masses of C1. Do not force the patient to
overcome the rotation, but restrict motion with him
or her in the rotated position and refer for further
specialized treatment.
Axis (C2) Fractures
The axis is the largest cervical vertebra and the most
unusual in shape. Thus it is susceptible to various
fractures, depending on the force and direction of the
impact. Acute fractures of C2 represent approximately
18% of all cervical spine injuries. Axis fractures of note
to trauma care providers include odontoid fractures
and posterior element fractures.
Odontoid Fractures
Approximately 60% of C2 fractures involve the
odontoid process, a peg-shaped bony protuberance
that projects upward and is normally positioned in
contact with the anterior arch of C1. The odontoid
process is held in place primarily by the transverse
ligament. Type I odontoid fractures typically involve
the tip of the odontoid and are relatively uncommon.
Type II odontoid fractures occur through the base of
the dens and are the most common odontoid fracture
(n FIGURE 7-5). In children younger than 6 years of age,
the epiphysis may be prominent and resemble a fracture
at this level. Type III odontoid fractures occur at the
base of the dens and extend obliquely into the body
of the axis.
Posterior Element Fractures
A posterior element fracture, or hangman’s fracture,
involves the posterior elements of C2—the pars interarticularis
(n FIGURE 7-6). This type of fracture is usually
caused by an extension-type injury. Ensure that patients
with this fracture are maintained in properly sized
rigid cervical collar until specialized care is available.
Fractures and Dislocations (C3 through C7)
The area of greatest flexion and extension of the cervical
spine occurs at C5–C6 and is thus most vulnerable to
injury. In adults, the most common level of cervical
vertebral fracture is C5, and the most common level
of subluxation is C5 on C6. Other injuries include
subluxation of the articular processes (including
unilateral or bilateral locked facets) and fractures of
the laminae, spinous processes, pedicles, or lateral
masses. Rarely, ligamentous disruption occurs without
fractures or facet dislocations.
The incidence of neurological injury increases
significantly with facet dislocations and is much more
severe with bilateral locked facets.
Thoracic Spine Fractures
Thoracic spine fractures may be classified into four broad
categories: anterior wedge compression injuries, burst
injuries, Chance fractures, and fracture-dislocations.
Axial loading with flexion produces an anterior wedge
compression injury. The amount of wedging usually is
quite minor, and the anterior portion of the vertebral
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