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Year : 2005  |  Volume : 15  |  Issue : 4  |  Page : 473-476
Fracture of the occipital : Case reports and review of the literature a series of 3 cases


Government Medical College, Nagpur, India

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   Abstract 

Fracture of the occipital condyle is a rare injury. We report three patients with occipital condyle fracture who presented with neck pain, restricted neck movements; no neurological deficit and unremarkable plain radiographs following fall. Diagnosis was established with high-resolution computed tomography. Hence we recommend high resolution computed tomography evaluation of base of skull in patients of cervical trauma with painful restricted neck movements for detection of subtle base of skull fracture which are not detected by plain radiography.

Keywords: Fracture; Occipital condyle; High resolution Computed Tomography

How to cite this article:
Taori K B, Disawal A, Mahajan S M, Ingle V. Fracture of the occipital : Case reports and review of the literature a series of 3 cases. Indian J Radiol Imaging 2005;15:473-6

How to cite this URL:
Taori K B, Disawal A, Mahajan S M, Ingle V. Fracture of the occipital : Case reports and review of the literature a series of 3 cases. Indian J Radiol Imaging [serial online] 2005 [cited 2014 Jul 28];15:473-6. Available from: http://www.ijri.org/text.asp?2005/15/4/473/28777

   Case reports Top


Fracture of the occipital condyle is a rare injury that can be easily overlooked. Review of literature revealed only few cases since Bell first described this injury in 1817 in a patient of trauma in a cadaver. Plain radiographs are usually normal and high resolution computed tomography is the best diagnostic method to evaluate the patients of suspected occipital condyle fracture.

All the three patients were from the third and fourth decade of life and had clinical history of fall from height while at work. All these patients had loss of consciousness following the fall. But, none of these patients had developed neurological deficit following the fall.

Radiological protocol was plain radiographs anteroposterior and lateral views and 2-mm axial slices high resolution computed tomography sections from base of skull to C-2 vertebra with sagittal and coronal multiplanner reconstruction for craniovertebral junction evaluation.

CASE REPORT ( I ):

Plain radiographs of cervical spine showed only fracture of the spinous process of C-7 vertebra. High resolution computed tomography demonstrated left occipital condyle fracture. Patient was managed conservatively with Minerva collar and strict immobilization, as there was no neurological deficit.

CASE REPORT ( II ):

Point of clinical relevance in the case was fall from negligible height. Plain radiographs of cervical spine showed capitalization of  Atlas More Details, subluxation of C-1 over C-2 and angular kyphosis.There was high suspicion of odontoid process fracture. High resolution computed tomography revealed not only the fracture of base of dens but also fracture in the occipital condyle on left side with caudal displacement of avulsed fragment to atlantoaxial level adjacent to dens. The patient was managed conservatively with good recovery.

CASE REPORT (III ):

Plain radiographs of cervical spine showed fracture of the spinous process of C-6 vertebra. High resolution computed tomography showed fracture of the occipital condyle with caudal displacement of the fracture fragment into the spinal canal. Patient was treated conservatively with a Minerva collar and strict immobilization.


   Discussion Top


Occipital condyle fracture is a rare injury. Some authors emphasize the rate of occurrence of occipital condyle fracture, which may be detected in as many as 16% of patients with craniovertebral injury [1]. In our 3-cases, the mode of injury was fall from height. Other modes of injury are vehicular accidents, high impaction blunt trauma like dive into shallow swimming pool [1],[2],[3],[5]. Plain radiographs of cervical spine are not diagnostic for the detection of occipital condyle fracture. In these reported cases, because of persistent neck pain following trauma, high resolution computed tomography was performed with sagittal and coronal reconstruction, which detected fractures of occipital condyle. Usually condylar fractures are associated with head injury, maxillofacial injury, fracture of cervical spine including dens and cranial nerve palsies in multitrauma patients [1],[3],[4].In addition to diagnosis of fracture , high resolution computed tomography classifies the injury which modifies the management according to the type of injury which makes high resolution computed tomography evaluation mandatory in these cases.

The occipital condyle fractures are classified as Type-I, II, III according to Anderson and Montesano [5].

Type-I: Impacted occipital condyle fracture.

Type-II: Occipital condyle fracture associated with basilar skull fracture.

Type-III: Avulsion fracture of occipital condyle with displacement of the fracture fragment either cranially or caudally into spinal canal with partial spinal cord obstruction. It is an unstable injury and requires surgical intervntion. But all our cases were treated conservatively as there was no neurological deficit.

The mechanism of injury (MOI) is based on rationale of theoretical analysis. Mechanism of injury suggested for Type-I and II is vertical (Y-axis) compression and is considered as stable injury. For Type-III, combination of antero-posterior (Z-axis) translation and axial (Y-axis) rotation with the associated force and movement is the cause of injury. It appears that it is an avulsion of that portion of the occipital condyle to which the alar ligament is attached and hence the possibility of instability in association with Type-III occipital condyle fracture should be kept in mind [6].

Following effective treatment and management-associated complications like cranial nerve palsies can be averted thereby reducing significant morbidity.

We strongly believe, together with several other authors [1],[2],[3],[7] that fracture of occipital condyle should be suspected in a case of trauma and normal cervical spine radiographs. High resolution computed tomography with sagittal and coronal reconstruction is very sensitive and specific in diagnosing and typing the condyle fractures.

Other observation as in case-2 is patients with craniovertebral junction anomalies have increased probability of occipital condyle fracture even following fall from trivial height.

High resolution computed tomography also provide significant relevant information to the treating surgeons in opting conservative or surgical management. Even in Type-III injuries as in case-3 a combined high resolution computed tomography and clinical evaluation of patient pointed towards conservative management in spite of Type-III injury as there was no neurological deficit.

 
   References Top

1.Jan Stroobants MD et al : Occipital condyle fracture must be considered in the peditive population : case report. J. Trauma Vol. 36 No. 3 (440-441), 1994.  Back to cited text no. 1    
2.Bridge SA, Mc. Mad-W, Traumatic occipital condyle fracture multiple cranial hence palsies and torticollis- a case report and review of literature J. Surg. Neurol 1992 Aug 38 (2); 152-6  Back to cited text no. 2    
3.Desai SS Coumos JM et al : fracture of occipital condyle case report and review of literature J. Trauma 2 (1990) 240.  Back to cited text no. 3    
4.R. Olsson and R. Kunz : fracture of occipital condyle as an incidental finding during CT evaluation of a maxillary fracture. J. Acta Radiologica 35 (1994) P. 90-91  Back to cited text no. 4    
5.Anderson P.A. & Monstesano P.X. morphology and treatment of occipital condyle fracture Spine 7 (1988) 731.  Back to cited text no. 5    
6.White and Punjabi, Clinical biomechanics of spine 1990 p. 192-193.  Back to cited text no. 6    
7.Bloom - Al, Neeman-Z, Slasky-BS, Floman-Y, Milgrom -M, Rivicind -A,-Fracture of the occipital condyles and associated cranio cervical ligament injury incidance. CT imaging and implication, J. Clinical Radiology 1997 Mar.52 (3) 198-202.  Back to cited text no. 7    

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Correspondence Address:
K B Taori
Dept. of Radio-Diagnosis, Govt. Medical College, Nagpur
India
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DOI: 10.4103/0971-3026.28777

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    Figures

[Figure - 1], [Figure - 2], [Figure - 3]

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