First described by Bell in 1817, these are extremely uncommon . The conscious patient may complain of occipito-cervical or neck pain, or may have lower cranial nerve palsies. These injuries are difficult to identify with plain radiographs and require a high index of suspicion. A retropharyngeal hematoma could be the only sign of serious injury. CT with reconstructions provides the definitive diagnosis.
The classification of Anderson and Monte-sano is the most widely used and divides these fractures into three types (Fig. 22.1) . A type I fracture consists of comminution of the occipital condyle, with minimal to no involvement of the foramen magnum. Axial loading into the atlas is the responsible mechanism. Although the ipsilateral alar ligament may be torn, these are stable fractures due to the integrity of the tectorial membrane and the contralateral alar ligament. An occipital condyle fracture associated with a basilar skull fracture is called a type II injury. Axial CT scanning shows a fracture line involving the skull base and the condyle. As with type I fractures, the mechanism and stability are the same. The type III fractures are avulsion fractures of the condyle by the alar ligament. Usually unstable because of disruption of the tectorial membrane and the contralateral alar ligament, they are the result of excessive rotation and/or lateral bending.
Stable type I and II fractures can be treated in a hard cervical collar or cervicothoracic brace for 6-8 weeks. When in type II fractures the condyle is separated from the occiput, treatment with a halo vest for 12 weeks is indicated. In the case of stable type III injuries, a hard cervical collar or a halo vest provides adequate treatment. Injuries that involve total ligamen-tous disruption are best managed with a posterior occipital to C2 arthrodesis. The Bohlman wire technique and the posterior occipital cervical fusion with atlanto-occipital (AO) reconstruction plates can be done .
The Bohlman wire technique involves careful sub-periosteal dissection of the occiput down to C2. Two parallel troughs, 2-3cm from the foramen magnum, separated by about 5 mm of bone, are drilled. A tunnel is created and a 20-gauge wire is looped around the bone; additional wire is looped around the lamina of C1 and through the spinous process of C2. After harvesting bone of 5 cm long and 1 cm thick and decorticating the occiput, the lamina of C1 and C2, wires are passed through the drill holes placed in the grafts. The wires are then tightened. Post-operatively, the patient wears a halo vest for 12 weeks.
The postero-occipital cervical fusion is done by exposing the medial edge of the pedicle of C2, which is then drilled to a depth of 20-22 mm. Screws are inserted 3-5 mm above the center of C2-C3 facet articulation, with the direction being 20-30° cranial and 15-20° medial. C1 can be fixated using sub-laminar wires. After the length and contour of the plate to be used are determined, it is fixed to C2 with a 3.5-mm screw, 20-24 mm in length. The occiput is then drilled and the usual length of the screw
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