A 23 y.o. male is the driver of a car that crashed into a curb at 70 mph, he complains of neck pain
What injuries could be associated with this tiny chip fracture? He is neuro intact
Our pt had an occipital condyle fracture. Occipital condyle fractures are typically associated with high speed motor vehicle collisions. They are important to diagnose because of the possibility of delayed sequellae and cranial nerve injuries. They can be associated with vertigo, diplopia or even limb weakness. 3-4% of patients with traumatic brain injuries have an occipital condyle fractures.
The occipital condyle fracture was first described by Charles Bell in 1817. In the first case a young patient with trauma bent down to pick something up and died suddenly from a bone fragment compressing the medulla. The paper was written after autopsy evaluation. The occipital condyle is stabilized by the atlantooccipital joint capsule and the alar ligaments which connect the dens to the occipital condyle.
alar ligaments connect the dens to the occipital condyle
An injury to the the occipital condyle can occur in three ways:
Type I – is caused by axial compression and is stable.
Type II- is caused by extension from a basilar skull fracture often caused by a blow to the back of the head. This fracture is also stable.
Type III- This is the most common condyle fracture and is unstable. It results from bending or rotation at the condyle and usually is the result of high speed injury. This is the type of fracture our patient sustained.
The tectorial membrane can be injured at the same time as the occipital condyle. This membrane is an extension of the posterior longitudinal ligament on to the back of the clivus. Since its posterior surface is in contact with the dura; when it is torn subarachnoid blood can be seen in the brain and spinal cord. In the case of our patient the tectorial membrane was ruptured and a spinal epidural hematoma was noted as well as intraventricular hemorrhage in the 4th ventricle.
In our patient there was a cervical epidural hematoma caused by the tectorial membrane tear
Our patient also had a femur fracture, and a L hemothorax with a chest tube placed into the mediastinum causing a pneumomediastinum and multiple rib fractures . He was managed conservatively for his occipital condyle fracture and discharged with a cervical collar.
A second injury which is closely related to the occipital condyle fracture is craniocervical dissociation. This is often a fatal injury. In this case the head is literally torn from the neck. This can be obvious or relatively occult.
craniocervical dissociation
how the diagnosis of craniocervical dissociation is made.
The difference in treatment of craniocervical dissociation is that a cervical collar can cause further dissociation and it is recommended the collar be removed and side bolsters are applied. Tongs followed by a fusion of C2 to the base of the skull is recommended.
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