J Neurosurg

J Neurosurg
Pediatrics
Pediatrics
3:000–000,
3:15–19, 2009

Jefferson fractures of the immature spine

Report of 3 cases

Nicholas AuYong, M.S., and Joseph Piatt Jr., M.D.

Section of Neurosurgery, St. Christopher’s Hospital for Children, and Drexel University College of Medicine,
Philadelphia, Pennsylvania

Jefferson fractures of the immature spine have received little attention in the study of pediatric spinal trauma.
Fractures through synchondroses are a possibility in the immature spine, in addition to fractures through osseous
portions of the vertebral ring, and they create opportunities for misinterpretation of diagnostic imaging. The authors
describe 3 examples of Jefferson fractures in young children. All 3 cases featured fractures through an anterior syn-
chondrosis in association with persistence of the posterior synchondrosis or a fracture of the posterior arch. The pos-
sibility of a Jefferson fracture should be considered for any child presenting with neck pain, cervical muscle spasm,
or torticollis following a head injury, despite a seemingly normal cervical spine study. Jefferson fractures in young
children are probably much more common than previously recognized. (DOI: 10.3171/2008.10.PEDS08243)

Key Words      •      atlas      •      Jefferson fracture      •      ossification center      •     

synchondrosis      •      trauma

J
efferson fractures have been described infrequently
in the immature spine.1,2,4,6,8,11–13,15,20–23,25–27,29,31,32 As
cited by Jefferson, priority belongs to Sir Astley Coo-
per, who in 1822 described fractures of both arches of the
atlas in a 3-year-old boy who had suffered a fall.10 The
child died of an unrelated condition, and the diagnosis
was made at autopsy 12 months after the injury. As far as
we can determine, 161 years passed until Marlin et al.20
and Galindo and Francis6 reported the next 2 cases, which
were diagnosed by means of CT. Subsequent universal,
liberal employment of CT scanning in evaluation of pe-
diatric trauma patients has produced mentions or descrip-
tions of only 25 more cases (Table 1). Here we describe
3 more cases encountered over a period of only a few
months in the senior author’s practice. Because the imag-
ing diagnosis is readily obscured by the variable matura-
tion of synchondroses between ossification centers, and
because the symptoms are short-lived and responsive to
nonspecific treatment, we believe that Jefferson fractures
in young children are grossly underrecognized.
Case Reports
Case 1
This 5-year-old child struck the vertex of her head on
a metal bar on a playground structure. She did not interrupt
Abbreviation used in this paper: ROM = range of motion.
her activities, but later that night she was awakened from
sleep by severe neck pain. In the emergency department,
she was noted to have torticollis with rotation of the head
to the left. A CT scan of the cervical spine obtained at
the referring institution was interpreted as showing only
anterior pivoting of the atlas on the left atlantoaxial joint.
The cervical spine was immobilized in a hard cervical or-
thosis, and symptoms were controlled with ketorolac and
lorazepam. Within 36 hours, the torticollis resolved, and
the patient felt well. A follow-up scan showed resolution of
the atlantoaxial rotation. The patient was discharged with
instructions to remove the orthosis only for bathing once
a day. Two weeks after discharge, she was still experienc-
ing intermittent headache and neck pain, but she had full
active ROM. Six weeks after discharge, a CT scan was ob-
tained to confirm persisting reduction of the subluxation. It
showed a slightly diastatic fracture of the anterior arch of
the atlas with a persistent posterior synchondrosis. In ret-
rospect, this fracture had been present on the earlier scan,
but it had been interpreted as a synchondrosis (Fig. 1). The
anterior fragments had separated slightly in the interval.
Immobilization of the cervical spine was continued for an-
other 6 weeks. The patient remained asymptomatic, and
CT scans obtained at 8 and 12 weeks showed progressive
callus formation. Use of the orthosis was discontinued at
12 weeks.
Case 2
This 31-month-old boy fell down a full flight of con-

J. Neurosurg.: Pediatrics / Volume 3 / January 2009 15

 N. AuYong and J. Piatt Jr.
TABLE 1: Atlas fractures in children 7 years of age or younger*

Authors & Year Age Study Deficit Fx Pattern

Cooper, 1822† 3 yrs autopsy no ant & pst arch fxs
Galindo & Francis, 5 yrs tomo, CT no midline ant arch fx; pst spina bifida
  1983
Marlin et al., 1983 2 yrs CT no ant synchondrosis fx (2 pr ant arch synchondroses)
Suss et al., 1983 30 mos CT no ant synchondrosis fx (2 pr ant synchondroses)
3 yrs CT no ant synchondrosis fx
Richards, 1984 7 yrs tomo yes ant arch fx (axis facet fx)
5 yrs tomo yes ant arch fx; compression fx lateral mass
4 yrs CT yes ant arch fx
Mikawa et al., 1987 4 yrs CT no ant synchondrosis fx
Wirth et al., 1987 46 mos CT no ant & pst synchondrosis fxs
Routt & Green, 1989 23 mos CT no pst arch fx
Kesterson et al., 1991 4 yrs CT no —
McGrory et al., 1993 2 yrs — — —
2 yrs — — —
2 yrs — — —
Judd et al., 2000 7 yrs CT, MRI no ant synchondrosis fx w/out any other break
Abuamara et al., 2001 11 mos CT no bilat “pedicle” fxs
22 mos CT no bilat “pedicle” fxs
Bayar et al., 2002 30 mos CT no ant arch fx btwn synchondroses
Mazur et al., 2002 5 yrs CT no ant synchondrosis fx; pst spina bifida (dens fx)
Kapoor et al., 2004 21 mos CT no midline ant arch fx; symmetrical separation of anterolateral synchondroses
Avellino et al., 2005 3 yrs — — —
5 yrs — — —
Reilly & Leung, 2005 6 yrs CT no ant synchondrosis fx/dis (digital transoral reduction)
Thakar et al., 2005 5 yrs CT no ant synchondrosis fx w/out any other break
Hagino et al., 2006 4 yrs CT no ant synchondrosis fx w/out any other break; rotatory atlantoaxial sublux-­
  ation
Korinth et al., 2007 7 yrs CT, MRI no ant arch fx lateral to synchondrosis; pst arch fx
present study 5 yrs CT no ant synchondrosis fx; persistent pst synchondrosis
31 mos CT no ant synchondrosis fx; pst arch fx
30 mos CT no ant synchondrosis fx; persistent pst synchondrosis

*  Ant = anterior; dis = dislocation; fx = fracture; pr = pair(s); pst = posterior; tomo = plain tomography.
†  Cited by Jefferson.10

crete steps to a tile floor. Evaluation in the emergency de-
partment showed a scalp hematoma in the right temporal
region. There was guarding of cervical spine movement.
The patient refused to flex or extend, and rotation was limit-
ed to 30° in each direction. A CT scan of the head showed a
fracture of the floor of the right middle fossa extending into
the parietal region. A CT scan of the cervical spine showed
a fracture of the posterior arch of the atlas just behind the
lateral mass associated with an unusual posterior midline
ossification center and paired posterolateral synchondroses.
There was dislocation of a synchondrosis on the left side of
the anterior arch (Fig. 2). The patient was discharged in a
hard cervical orthosis. At the 4-week follow-up, the patient
was free of pain but anxious about removing the orthosis.
Active ROM of the cervical spine was unrestricted. Six
weeks after the injury the patient was completely asymp-
tomatic, and CT showed minimal callus formation at the
anterior fracture site. At 12 weeks, the patient was perform-
ing cartwheels in his orthosis, and CT showed persisting
lucencies with minimal visible callus at both fracture sites.
Dynamic cervical spine radiographs showed no instability.
Use of the orthosis was discontinued.
Case 3
This 30-month-old girl, who had been born prema-
turely at 32 weeks’ gestational age, pushed out a window
screen and fell 2 stories onto concrete. Evaluation in the
emergency department was notable for a left frontal scalp
laceration with extruded brain tissue. Computed tomogra-
phy showed a comminuted left orbitofrontal fracture and
a frontal lobe contusion. The synchondroses of the ante-
rior arch of the atlas were noted to be unequal in width,
and there was a persistent posterior synchondrosis (Fig. 3).
An urgent craniotomy was performed with the head and

16 J. Neurosurg.: Pediatrics / Volume 3 / January 2009

Jefferson fractures

Fig. 1.  Case 1.  A–C: Axial CT through the atlas obtained at admission showing a fracture of the central segment of the an-
terior arch. The fracture has a stair-step configuration in the coronal plane, so it is difficult to appreciate in the middle image (B).
There is a persistent posterior synchondrosis (white asterisk).  D–F: Axial CT obtained 6 weeks after the injury showing slight
separation of the fracture fragments and possible early callus formation.

neck in a neutral position, and after surgery an attempt
was made to immobilize the cervical spine in a rigid or-
thosis. When normal behavioral responsiveness had been
restored, the patient was exhibiting torticollis. A follow-up
scan confirmed fractures of the atlas. Because of failure to
achieve satisfactory fit in a rigid orthosis, the patient was
discharged on hospital Day 10 in a soft collar. By 3 weeks
after the injury, the torticollis had resolved, but the patient
was resistant to remove the collar for bathing. The patient
was asymptomatic at 6 weeks. She was no longer anxious
about removal of the collar, and she exhibited full active
ROM. Computed tomography showed little callus forma-
tion. There was slight separation of fracture fragments
with settling of the atlas on the axis (Fig. 4). Use of the
soft collar was discontinued. The patient continued to do
well, and CT scanning at 6 months showed healing of the
anterior arch. Dynamic cervical spine radiographs showed
no instability.
Discussion
As in adults, Jefferson fractures in young children
are usually the consequence of axial loading injuries. A
fall on the head is the most common history, but mecha-
nisms particular to the anatomy and behavior of the child
must not be overlooked. Playground slides are sometimes
constructed with overhead bars from which children can
swing to begin their descents; the patient in Case 1 struck
the vertex of her head against such a bar. In the case de-
scribed by Kapoor et al.,12 in the course of a fall on the
buttocks, the inertial mass of the head was a sufficient ax-
ial load to cause a fracture in their 21-month-old patient.
Although the term “Jefferson fracture” is commonly
associated with a 4-part burst pattern, atlas fracture pat-
terns are highly variable.10 Fractures may be confined to
a single arch (Type I), include both arches (Type II), or
involve the lateral masses (Type III).16 Two-part and 3-part
burst variants have been shown to be more common than
the 4-part burst pattern.5,9,10,16 Normal developmental fea-
tures in the immature spine, specifically synchondroses
between ossification centers, make radiological diagnosis
of atlas injury more challenging in young patients.2,14,19 The
posterior midline synchondrosis, formed by extensions

Fig. 2.  Case 2. Axial CT through the atlas showing a dislocation of a synchondrosis on the left side of the anterior arch (white
arrowheads). There is a fracture of the right side of the posterior arch just behind the lateral mass (white arrow). Note the unusual
posterolateral synchondroses on each side of a posterior midline ossification center.

J. Neurosurg.: Pediatrics / Volume 3 / January 2009 17


Fig. 3.  Case 3. Axial CT scans through the atlas, obtained at admis-
sion, showing nonuniform widths of the synchondroses of the anterior
arch of the atlas (A). The central synchondrosis and the left synchon-
drosis (2 and 3) are wider than the right synchondrosis (1). At 6 months
postinjury, the central synchondrosis had healed solid, and the left and
right synchondroses were equal in width and narrower (not shown).
There is a persistent posterior synchondrosis (B, asterisk).
from the lateral mass ossification centers, typically fuses by
the third year.3,24 The neurocentral synchondroses, formed
at the juncture of the anterior arch and lateral mass ossifi-
cation centers, typically fuse by 7 years of age.3,11,24 For the
purposes of this review, we defined “immature” as 7 years
of age or younger. Two or even 3 ossification centers may
contribute to the development of the anterior arch, yielding
3 or 4 synchondroses.3,24 Rarely there is no anterior ossifica-
tion center, and the anterior arch forms from the posterior
ossification centers with a midline synchondrosis.24 There
are large variances in ages of completion of fusion of os-
sification centers, but failure of a synchondrosis to fuse by
adulthood results in an arch defect that is sometimes termed
“spina bifida.” Posterior arch defects are much more preva-
lent than anterior arch defects (1.5–5% and 0.09–0.33%,
respectively, in adults).11,17,28 Clinicians are often cautioned
against misinterpreting synchondroses or preexisting arch
defects as fractures.14,19 However, synchondroses can also
be the site of injury.11,12,23 Atlas injury may involve the dis-
ruption of single or multiple synchondroses. Synchondrosis
fractures or dislocations are difficult to appreciate radio-
graphically and contribute to the high diagnostic error rate
for cervical spine injury (24%) in young children.2 All 3
cases in this report exhibited developmental lucencies in
the posterior ring. We presume that these lucencies were
synchondroses bridged by cartilage, but the actual continu-
ity of ring at these sites cannot be confirmed positively by
CT. Patterns of injury seen in the literature and in Cases 1
and 2 indicate that synchondroses are not necessarily more
susceptible to fracture than other ossified sites around the
ring. Nor is it clear whether an atlas with an arch defect is
more susceptible to fracturing. Computer modeling studies
have demonstrated that the anterior arch in adults is most
vulnerable to tension in the plane of the atlas ring.30 Be-
cause the noncontiguous atlas likely expands under com-
pression, axial loading will widen the anterior arch when
a posterior arch defect is present, especially with the neck
flexed. The higher elastic properties in a developing atlas
may absorb the elevated tensile stresses, protecting it from
injury. Fracture in one arch accompanied by a defect in
the opposite arch should be viewed as a Type II Jefferson
fracture and managed accordingly.
Fractures of the atlas may be accompanied by trans-
verse ligament rupture or avulsion with gross atlantoaxial
instability. An avulsed transverse ligament often takes its
osseous tubercle with it and can therefore be identified by
means of CT.18 Ruptures of the ligament are best visualized
18
N. AuYong and J. Piatt Jr.
Fig. 4.  Case 3. Coronal reformatting of a CT scan through the cran-
iocervical junction on admission (A) and at 6 weeks (B) shows slight
lateral displacement of the right lateral mass of the atlas with respect to
the superior articular facet of the axis (white arrowhead).
with MR imaging, whereas atlantoaxial stability is typi-
cally evaluated with dynamical cervical spine radiographs.
The possibility of atlantoaxial instability must be born in
mind in the setting of a Jefferson fracture in a young child
and must be excluded either by MR imaging in the acute
stage or by dynamic radiographs when the prescribed pe-
riod of immobilization has been completed.
The dawn of the awareness of the possibility of Jeffer-
son fractures in the immature spine is clearly attributable
to the use of CT scanning in the evaluation of the child
trauma victim. Before CT scanning, the diagnosis of Jef-
ferson fractures, both in children and in adults, rested on
plain radiographs and tomography. Our review disclosed
only 3 examples of Jefferson fractures in young children
detected by these techniques.26 The fact that the patients
in these cases were the only ones who exhibited neurologi-
cal deficits suggests that the typical clinical threshold for
suspicion of fracture of the immature atlas was quite high.
Radiographs and tomography had low sensitivity in actual
demonstration of fractures of the ring, so attention was
paid to indirect signs such as separation or “spread” of the
lateral masses. In anteroposterior radiographs and coronal
tomographic images, displacement of the lateral mass of
the atlas by > 2 mm with respect to the superior articular
facet of the axis is held to indicate disruption of the ring in
an adult.7 Displacement to this degree is commonly seen,
however, in young children without any other imaging evi-
dence of atlas fracture.19 So-called “pseudospread” is be-
lieved to reflect accelerated growth and earlier attainment
of adult dimensions for the atlas as compared with the axis.
A curious milestone in the progress of imaging technology
was the 1983 paper by Suss et al.,29 which studied the vari-
ances of several geometric indices that could be derived
from anteroposterior radiographs to define a quantitative
upper bound for pseudospread. To illustrate that several
cases with borderline indices were pseudospread and not
real spread due to a fracture, these authors presented the
corresponding “normal” CT scans. Two of their 3 examples
seem to exhibit fractures through anterior synchondroses.
Jefferson fractures of the immature spine were essen-
tially unknown before the advent of CT. The natural his-
tory of this condition can be approached speculatively by
considering what happened to affected children prior to
the CT era. Rigid cervical orthoses available off-the-shelf
in pediatrics sizes and comfortable enough to be worn for
weeks are a more recent development than CT scans, so
management options for the young child with neck pain
J. Neurosurg.: Pediatrics / Volume 3 / January 2009
Jefferson fractures
and immobility and with “negative” radiographs were
limited: a soft cervical collar, a brief course of halter trac-
tion, or—for longer periods of immobilization—a plaster
Minerva jacket. Subjection of a small child without any
recognized radiographic abnormality to a long course of
treatment in a Minerva jacket cannot have been a popular
practice, so before CT scans, young children with Jeffer-
son fractures must have been managed symptomatically.
They probably recovered quickly and completely without
much treatment. Whether the associated spread of the lat-
eral masses and the settling of the craniocervical junction
have any adverse long-term consequences is a matter for
speculation as well; no such late complications have been
described.
In the cases we encountered, we recommended 6–12
weeks of immobilization in a properly fitted, rigid cervi-
cal orthosis. This measure seemed to provide some com-
fort in the first few weeks. Beyond the early symptomatic
period, the purpose of the orthosis was to moderate the
excesses of the child’s behavior and thereby discourage
early reinjury. As a behavior modification tool, the ortho-
sis was not successful. For the management of Jefferson
fractures of the immature spine, in the absence of imag-
ing evidence of atlantoaxial instability, there seems to be
no reason to use a cervical orthosis for any purpose other
than relief of symptoms.
Disclaimer
The authors report no conflict of interest concerning the mate-
rials or methods used in this study or the findings specified in this
paper.
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Manuscript submitted August 14, 2008.
Accepted October 21, 2008.
Address correspondence to: Joseph Piatt Jr., M.D., Section of
Neurosurgery, St. Christopher’s Hospital for Children, Erie Avenue
at Front Street, Philadelphia, Pennsylvania 19134-1095. email:
joseph.piatt@drexelmed.edu.
19