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Fracture of the Atlas or Developmental Abnormality?

1937; Radiological Society of North America; Volume: 29; Issue: 2 Linguagem: Inglês

10.1148/29.2.227

1527-1315

H. F. Plaut,

Facial Trauma and Fracture Management

THE following is the report of a patient seen after an automobile accident, July 17, 1936. A colored girl, student, 18 years of age, was admitted to the St. Philip's Hospital, Medical College of Virginia, Richmond, Va. (Neurosurgical Department, service of Dr. C. C. Coleman), about fifteen minutes after she had jumped from the rumble seat of a moving automobile. She had projectile vomiting about ten minutes after admission. She was unconscious, showed a soft swelling of lemon-size over the left parietal region, and there was oozing of blood from the left ear without demonstrable abrasion in the auditory canal. The pupils reacted to light and were equal in size. No rigidity of the neck was found. Immediate x-ray examination revealed a definite fracture line through the parietal bone on either side (see Fig. 3). The fracture line followed the lambdoid suture rather closely on the right side and was situated more anteriorly on the left with another fracture line extending through the region of the sella on the left side. This fracture line apparently did not separate the sphenoid but the bone overlapping the sphenoid. The head was seen to be lower than usual, as if the lower part of the occiput was pressed against the arch of the axis, mashing that part of the atlas-ring in between. In the further course no neurological changes or deafness were observed. Three days later another roentgen examination was made. In the lateral view there was a large bilateral gap in the posterior arch about 8 mm. wide (see Fig. 4). The axis was in normal position. On July 27 the patient was discharged, on her request, with a Thomas collar. Discussion A case reported by Lawrence and Anderson (13) has many similar features. Their female patient was sitting in an automobile when a street car bumped into it. Her head jerked backward with some violence. On account of the x-ray findings, a diagnosis of fracture of the posterior arch of the atlas was made by the attending surgeon. This was also the first impression of the authors. When re-examined for medicolegal purposes ten days after the accident, the patient still complained about stiffness in the neck. A space about one-half inch wide, separating the undisplaced portion of the posterior arch from the anterior portions of the vertebræ, was noted. No fragments were seen in the gap. The diagnosis then was altered to one of rare developmental abnormality. Objective neurologic changes were not mentioned. It is interesting to study the facts concerning these two cases in order to discuss the differential diagnosis of injuries and anomalies of the atlas. Strassmann describes a transverse rupture of the trachea, and Romanese (14) a fracture of the third cervical vertebra, both fatal lesions without any signs of direct force to the neck, alone due to a backward jerk of the head when the individual was hit from behind by an automobile.