Occipital Condyle Fractures

Associated pages
AOD

FACTS

  • very rare traumatic fractures
  • Anderson and Montesano classifications
  • mechanism: high-energy blunt trauma
  • Classification systems: Anderson and Montesano (1988), Tuli and colleagues (1997), Hanson et al.
    • some will argue these classifications are less relevant than whether there is crani-cervical misalignment and compromise of neural elements [1]
    • The bottom line is Anderson/Montesano classifications are useful descriptors at best, and knowing if a Type 3 fracture is present is useful to raise the suspicion of AOD, but ultimately the Measurement of Pang and neural element compression are more important in your operative algorithm (see below).
 
notion image
Anderson / Montesano
Type 1
Type 2
Type 3
Frequency
3-13%
22-54%
33-75%
description
impacted / comminuted
basilar skull fracture extending to condyle
avulsion fracture
mechanism
axial loading of skull onto atlas
direct blow to lower skull
rotation / contralateral bending
Stability
stable (intact tectorial / contralateral alar)
stable (intact tectorial membrane / alar ligament)
potentially unstable (loading of contralateral alar, tectorial membrane); associated with AOD
Treatment
Aspen C-collar
Aspen C-collar
rigid immobilization +/- fusion

HPI

  • universal ROS

PHYSICAL EXAM

universal neuro exam
  • evaluate for lower cranial nerve palsies (CN 12 most commonly involved)

IMAGING

CT Cervical spine without contrast
  • Calculate the measurements of Pang (condyle-C1 interval)
  • Measure 4 equidistant points on sagittal / coronal image on each side (you should be making a total of 16 measurements)
    • Combined L Pang = mean of 4 sagittal and 4 coronal measurements on L side
    • Combined R Pang = mean of 4 sagittal and 4 coronal measurements on R side
MRI Cervical spine w/o contrast to assess for ligamentous integrity/epidural/subdural hematoma

A/P

Stabilization
Rigid C-collar at all times for at least 6 weeks
Fusion/Halo considered if Condyle-C1 interval > 2mm (Adult measurements of Pang)

Occipital Condyle Fractures: clinical decision rule and surgical management (Okonkwo 2009)

  • Retrospective review of N = 24745 trauma patients admitted to UPMC 3/2022-4/2008
  • 100 patients with 106 occipital condyle fractures (incidence 0.4%)
    • Two patients had cranio-cervical misalignment and underwent occipitocervical fusion
    • All other patients who survived to discharge received rigid cervical collar or counseling
    • No patients developed delayed craniocervical instability or misalignment
  • Conclusion:
    • focus should be on identifying craniocervical misalignment on CT scans
    • Management should be
      • occipitocervical fusion / halo fixation in cases demonstrating misalignment
      • rigid C-collar with delayed clinical and radiographic evaluation in spine trauma clinic if no misalignment
 
Cranio-cervical misalignment is defined as Measurements of Pang (condyle-C1 interval) > 2.0mm. Nearly all patients will be in right lower quadrant and not require any operation.
Cranio-cervical misalignment is defined as Measurements of Pang (condyle-C1 interval) > 2.0mm. Nearly all patients will be in right lower quadrant and not require any operation.

Citations

[1] Maserati MB, Stephens B, Zohny Z, Lee JY, Kanter AS, Spiro RM, Okonkwo DO. Occipital condyle fractures: clinical decision rule and surgical management. J Neurosurg Spine. 2009 Oct;11(4):388-95. doi: 10.3171/2009.5.SPINE08866. PMID: 19929333.