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Fracture of the Occipital Condyle: the Forgotten Part of the Neck

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Fracture of the Occipital Condyle: the Forgotten Part of the Neck 220 J Accid Emerg Med 2000;17:220–228 CASE REPORTS J Accid Emerg Med: first published as 10.1136/emj.17.3.225 on 1 May 2000. Downloaded from Fracture of the occipital condyle: the forgotten part of the neck Andrew Kelly, Richard Parrish Abstract A case of occipital condylar fracture in a multiply injured and unconscious motor- cyclist is reported. This injury was clini- cally unsuspected but found on the lowest cuts of head computed tomography. It is shown that this site is often inadequately imaged when scanning the head and neck in victims of trauma. The Anderson and Montesano classification of occipital con- dylar fracture is described. It is noted that types 1 and 2 are stable injuries but type 3 is potentially unstable. A retrospective analysis of 30 head computed tomography scans in trauma cases revealed that in only 16 were the occipital condyles adequately imaged. It is emphasised that vigilance is required to detect fractures of the occipi- tal condyle and that it should be standard Figure 1 Computed tomography showing fractured right practice to include this area when per- occipital condyle. forming computed tomography of the head in trauma victims. ists and the neurosurgical team. Intracranial (J Accid Emerg Med 2000;17:220–221) pressure was monitored and remained normal. Halo traction was applied before his extubation http://emj.bmj.com/ Keywords: occipital condyle; fracture; trauma on day four. He required three months rigid fixation in a halo vest. Follow up computed Case report tomography showed healing at the fracture site A 16 year old male road traYc accident victim without evidence of subluxation. Residual cog- was found lying beside his motorcycle with the nitive impairment at two weeks necessitated helmet some distance away. The exact speed referral to the head injury rehabilitation unit and circumstances of the incident were un- and at the time of writing cognitive function on October 1, 2021 by guest. Protected copyright. clear. Paramedic roadside opinion was that the and speech are now normal and a residual victim had suVered a tumbling fall with conse- swallowing problem is improving constantly. quent potential for twisting head injury. In the prehospital phase a semirigid cervical collar Discussion was applied and fluid resuscitation given. Occipital condylar fracture was originally On arrival at hospital the patient was described by Charles Bell in 1817.1 This was a haemodynamically stable with a Glasgow postmortem diagnosis of a hospital patient Coma Scale score of 9 and other than bleeding who sustained a fall at the time of discharge! from an occipital scalp wound no external His demise was attributed to medullary Department of injury was seen. He was electively intubated compression by the condylar fragment. Before Accident and Emergency, Derriford and ventilated. Cervical spine control was the wide availability of computed tomography Hospital, Derriford maintained at all times. Fluid resuscitation was diagnosis in life was rare but by 1996 61 cases Road, Plymouth continued and initial radiographs revealed had been reported in the literature. In addition PL6 8DH bilateral pulmonary contusions. Cervical spine other occipital condylar fractures found at A Kelly plain films were normal. postmortem examination have been described. R Parrish Immediate computed tomography of the Often patients with this diagnosis have loss Correspondence to: head chest and abdomen was performed and a of consciousness because of associated head Mr Kelly, StaV Grade frontal lobe haematoma with mild cerebral injury and indeed most early neurological defi- (e-mail: doctorandykelly@ oedema was seen. The lowermost head cuts cits in patients with occipital condylar fracture hotmail.com) revealed a displaced fracture of the right are attributable to such related injury. In those Accepted for publication occipital condyle (fig 1). Ventilation was patients who are conscious on presentation 8 December 1999 continued and ongoing care given by intensiv- neck pain is usual and indeed may be the only Fracture of the occipital condyle 221 injury mechanism and computed tomography fracture morphology.4 Class I fractures are J Accid Emerg Med: first published as 10.1136/emj.17.3.225 on 1 May 2000. Downloaded from impacted condylar fractures consequent upon axial loading injuries. Type II fractures are extensions of a basilar skull fracture. Both these types are functionally stable consequent Tectorial membrane upon integrity of the tectorial membrane and contralateral alar ligament. Type III fractures, sustained during extreme rotation and/or lateral bending are avulsion fractures of the Apical ligament of dens condyle by the alar ligament. This type of frac- ture is potentially unstable because of loading of the tectorial membrane and contralateral Alar ligament alar ligament. Tuli et al2 recommend an alternative classification. They propose that instability is determined more by ligamentous injury as detected by computed tomography alignment criteria and magnetic resonance imaging findings than on fracture morphology. Optimal treatments are not fully agreed upon but most sources propose semirigid Figure 2 The atlantooccipital joint viewed from behind. collar provision for stable injury and rigid immobilisation of varying design for the poten- symptom although neurological deficit includ- tially unstable injury. ing hemiparesis (attributable to contusion of To monitor the adequacy of our computed ipsilateral adjacent spinal cord) is recognised. tomography head scans in imaging the crani- Lower cranial nerve deficits (that is, IX–XII) ocervical junction we retrospectively assessed a are a “classic” sign. However they occur in only series of 30 computed tomography scans of a third of cases and within this group a third of head injured patients examined before the case such deficits present late.2 under discussion. The hard copies were exam- Cervical spine radiographs are usually ined for inclusion of the occipital condyles. In normal2 although prevertebral soft tissue swell- only 16 of 30 patients was there satisfactory ing and asymmetry of the odontoid peg as seen demonstration of these structures. It is already on the anteroposterior view are recognised our policy to print “bone window” images in signs. In addition computed tomography of the addition to standard “brain windows” in head often neglects fully to image the cranio- acutely head injured patients and we now cervical junction and the recognition of this ensure that computed tomography in patients injury therefore presents a diagnostic chal- with head injury starts at the C1 ring. lenge. Because neurological deficit can be late In conclusion, vigilance is required to in onset it is however necessary to make the diagnose occipital condylar fracture and in http://emj.bmj.com/ diagnosis at the time of presentation. It is particular we advise that all unconscious therefore important to retain the same index of trauma victims undergoing computed tomog- suspicion for skull base injury as is widespread raphy head imaging need careful examination for the cervicodorsal junction. of the craniocervical base. This should include It is best to consider the paired occipital 3 or 5 mm axial sections to cover the occipital condyles and the first two cervical vertebrae as condyles, with inspection of the resulting a functional unit. The stability of the atlanto- images on “bone windows” in addition to the occipital junction within this unit is maintained conventional “brain” settings. on October 1, 2021 by guest. Protected copyright. by several structures.3 Firstly, the tectorial membrane is a continuation of the posterior Contributors Andrew Kelly initiated the case report, searched the literature longitudinal ligament and attaches to the and wrote the report. Richard Parrish conceived the idea of a foramen magnum. This limits flexion and retrospective analysis of our CT scans, performed this review and contributed materially to the discussion. extension. Secondly, the paired alar ligaments Guarantor run directly from the odontoid peg to each Andrew Kelly is the guarantor for this paper. occipital condyle; their function is to check lat- Thanks to Sallie Waring for medical illustration. eral flexion and rotation. It is these above structures that primarily stabilise this part of Funding: none. the neck. Finally, the anterior and posterior atlanto-occipital membranes interconnect the Conflicts of interest: none. margins of the foramen magnum and the ring 1 Bell C. Surgical observations. Middlesex Hospital Journal of the atlas while in addition the apical 1817;4:469–70. 2 Tuli S, Tator CH, Fehlings MG, Mackay M. Occipital con- ligament extends from the odontoid peg to the dyle fractures. Neurosurgery 1997;41:368–76. anterior margin of the foramen magnum. 3 Werne. Studies in spontaneous atlas dislocation. Acta Scand Orthopaedika (Suppl) 1957;23:1–50. Anderson and Montesano described a com- 4 Anderson PA, Montesano PX. Morphology and treatment monly used classification system based on of occipital condyle fractures. Spine 1988;13:731–6. 222 Holloway, Harris Spontaneous pneumothorax: Is it under tension? J Accid Emerg Med: first published as 10.1136/emj.17.3.225 on 1 May 2000. Downloaded from V J Holloway, J K Harris Abstract and a portable chest radiograph ordered. The A diagnosis of tension pneumothorax is radiograph showed a left tension pneumotho- usually only considered within the context rax with marked mediastinal shift. On re- of trauma, incorrect chest drain insertion examination the apex beat was found to be or positive pressure ventilation. Four heard maximally over the sternum and on per- patients are presented who developed cussion, the mediastinum was shown to be dis- spontaneous tension pneumothorax with placed to the right. He remained well until he no precipitating factors. In three of these lay flat for a chest drain insertion, upon which instances, the diagnosis was only made he became breathless and tachycardic. His radiologically and in every case the treat- symptoms settled when he sat up and the chest ing physician was unaware that a sponta- drain was inserted without diYculty. He was neous tension pneumothorax could occur.
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