Unilateral C-1 lateral mass sagittal split fracture: an unstable Jefferson fracture variant

Clinical article

Richard Bransford M.D. 1 , Alexis Falicov M.D., Ph.D. 2 , Quynh Nguyen P.A.-C., M.P.S. 3 and Jens Chapman M.D. 1
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  • 1 Departments of Orthopaedics and Sports Medicine and
  • 3 Radiology, Harborview Medical Center, University of Washington; and
  • 2 Seattle Orthopaedic and Fracture Clinic, Seattle, Washington
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The object of this study was to describe an unusual fracture subtype within C-1 injuries with a propensity to result in late deformity and pain. Most patients with C-1 injuries are nonsurgically treated using external immobilization unless there is an injury of the transverse atlantal ligament. The authors describe an unusual variant involving a unilateral sagittal split with a high tendency to late deformity and pain. They also review the literature and treatment of C-1 fractures.


A retrospective review of 12,671 CT scans from a Level I trauma center over a 6-year period yielded 54 patients with C-1 fractures. Among these patients, 6 had an unusual unilateral lateral mass sagittal split, which resulted in a late cock-robin deformity in all survivors and thus a surgical deformity correction with occipital-cervical instrumented fusions. Patient charts and radiographs were reviewed, this fracture subtype is described, and its treatment discussed.


Radiographic studies in 6 patients with C-1 fractures demonstrated a unilateral sagittal split of the lateral mass but an intact transverse atlantal ligament. In the 3 surviving patients, a late cock-robin deformity, significant loss of neck rotation, and severe neck pain developed. Vertebral artery occlusion, as revealed on CT angiography, occurred in 1 patient. All patients were placed in traction and underwent successful occipital-cervical fusion and deformity correction. At the final follow-up, all patients had satisfactory pain relief and improved head alignment.


Patients with a unilateral sagittal split of the C-1 lateral mass have unstable injuries and must be carefully monitored, with a low threshold for surgical reconstruction or prolonged traction. Patients with late deformity can be successfully treated with occipital-cervical instrumented fusions.

Abbreviations used in this paper: ASIA = American Spinal Injury Association; HVI = halo-vest immobilization; TAL = transverse atlantal ligament; VA = vertebral artery.

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Contributor Notes

Address correspondence to: Richard Bransford, M.D., Harborview Medical Center, Box 359798, 325 Ninth Avenue, Seattle, Washington 98104. email: rbransfo@u.washington.edu.
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