Physical Examination

Neurologic assessment of C2 (axis) fractures (C2 nerve root) includes the following:

Motor - Muscles that have a contribution from the C2 nerve root include the sternocleidomastoid (SCM), trapezius, longus capitis, longus colli, rectus capitis anterior, splenius capitis, splenius cervicis, and semispinalis capitis
Sensory - The C2 nerve root provides sensory innervation to the posterior scalp, anterolateral neck, and anteroinferior and posteroinferior external ear
Reflexes - The SCM reflex, which may be elicited by tapping on the clavicular end of the muscle

Clinical examination includes the following:

Observe and palpate for deformities and step-offs
Test muscle strength and tone of upper and lower extremities
Perform sensory testing on upper and lower extremities
Perform rectal examination
Test trapezius muscles by asking patient to shrug shoulders
Observe for torticollis

Workup

Malik SA, Murphy M, Connolly P, O'Byrne J. Evaluation of morbidity, mortality and outcome following cervical spine injuries in elderly patients. Eur Spine J. 2008 Apr. 17 (4):585-91. [QxMD MEDLINE Link].
Omeis I, Duggal N, Rubano J, Cerabona F, Abrahams J, Fink M, et al. Surgical treatment of C2 fractures in the elderly: a multicenter retrospective analysis. J Spinal Disord Tech. 2009 Apr. 22 (2):91-5. [QxMD MEDLINE Link].
Parker SL, McGirt MJ, Garcés-Ambrossi GL, Mehta VA, Sciubba DM, Witham TF, et al. Translaminar versus pedicle screw fixation of C2: comparison of surgical morbidity and accuracy of 313 consecutive screws. Neurosurgery. 2009 May. 64 (5 Suppl 2):343-8; discussion 348-9. [QxMD MEDLINE Link].
Chen YR, Boakye M, Arrigo RT, Kalanithi PS, Cheng I, Alamin T, et al. Morbidity and mortality of C2 fractures in the elderly: surgery and conservative treatment. Neurosurgery. 2012 May. 70 (5):1055-9; discussion 1059. [QxMD MEDLINE Link].
Nizare el F, Abdelali B, Fahd DH, Yassad OM, Rachid G, Rachid el M, et al. Upper cervical spine injuries: a management of a series of 70 cases. Pan Afr Med J. 2013. 15:57. [QxMD MEDLINE Link]. [Full Text].
Stulík J, Nesnídal P, Kryl J, Vyskočil T, Barna M. [Unstable injuries to the upper cervical spine in children and adolescents]. Acta Chir Orthop Traumatol Cech. 2013. 80 (2):106-13. [QxMD MEDLINE Link].
Pratt H, Davies E, King L. Traumatic injuries of the c1/c2 complex: computed tomographic imaging appearances. Curr Probl Diagn Radiol. 2008 Jan-Feb. 37 (1):26-38. [QxMD MEDLINE Link].
Conneely M, Park J, Demos TC. Radiologic case study. Cervical spine trauma: unstable fractures, C2-C7 injuries, and imaging guidelines. Orthopedics. 2008 Aug. 31 (8):818. [QxMD MEDLINE Link].
Koller H, Acosta F, Tauber M, Komarek E, Fox M, Moursy M, et al. C2-fractures: part I. Quantitative morphology of the C2 vertebra is a prerequisite for the radiographic assessment of posttraumatic C2-alignment and the investigation of clinical outcomes. Eur Spine J. 2009 Jul. 18 (7):978-91. [QxMD MEDLINE Link].
Koller H, Acosta F, Forstner R, Zenner J, Resch H, Tauber M, et al. C2-fractures: part II. A morphometrical analysis of computerized atlantoaxial motion, anatomical alignment and related clinical outcomes. Eur Spine J. 2009 Aug. 18 (8):1135-53. [QxMD MEDLINE Link].
Wang MY. Cervical crossing laminar screws: early clinical results and complications. Neurosurgery. 2007 Nov. 61 (5 Suppl 2):311-5; discussion 315-6. [QxMD MEDLINE Link].
Frangen TM, Zilkens C, Muhr G, Schinkel C. Odontoid fractures in the elderly: dorsal C1/C2 fusion is superior to halo-vest immobilization. J Trauma. 2007 Jul. 63 (1):83-9. [QxMD MEDLINE Link].
Aydinli U, Kara GK, Ozturk C, Serifoglu R. Surgical treatment of odontoid fractures with C1 hook and C2 pedicle screw construct. Acta Orthop Belg. 2008 Apr. 74 (2):276-81. [QxMD MEDLINE Link].
De Iure F, Donthineni R, Boriani S. Outcomes of C1 and C2 posterior screw fixation for upper cervical spine fusion. Eur Spine J. 2009 Jun. 18 Suppl 1:2-6. [QxMD MEDLINE Link].
Ying Z, Wen Y, Xinwei W, Yong T, Hongyu L, Zhu H, et al. Anterior cervical discectomy and fusion for unstable traumatic spondylolisthesis of the axis. Spine (Phila Pa 1976). 2008 Feb 1. 33 (3):255-8. [QxMD MEDLINE Link].
Shilpakar S, McLaughlin MR, Haid RW Jr, Rodts GE Jr, Subach BR. Management of acute odontoid fractures: operative techniques and complication avoidance. Neurosurg Focus. 2000 Jun 15. 8 (6):e3. [QxMD MEDLINE Link].
Vaccaro AR, Kepler CK, Kopjar B, Chapman J, Shaffrey C, Arnold P, et al. Functional and quality-of-life outcomes in geriatric patients with type-II dens fracture. J Bone Joint Surg Am. 2013 Apr 17. 95 (8):729-35. [QxMD MEDLINE Link].
Chapman J, Smith JS, Kopjar B, Vaccaro AR, Arnold P, Shaffrey CI, et al. The AOSpine North America Geriatric Odontoid Fracture Mortality Study: a retrospective review of mortality outcomes for operative versus nonoperative treatment of 322 patients with long-term follow-up. Spine (Phila Pa 1976). 2013 Jun 1. 38 (13):1098-104. [QxMD MEDLINE Link]. [Full Text].
Di Paolo A, Piccirilli M, Pescatori L, Santoro A, D'Elia A. Single institute experience on 108 consecutive cases of type II odontoid fractures: surgery versus conservative treatment. Turk Neurosurg. 2014. 24 (6):891-6. [QxMD MEDLINE Link].
Wang J, Zhou Y, Zhang ZF, Li CQ, Zheng WJ, Liu J. Comparison of percutaneous and open anterior screw fixation in the treatment of type II and rostral type III odontoid fractures. Spine (Phila Pa 1976). 2011 Aug 15. 36 (18):1459-63. [QxMD MEDLINE Link].
Cho DC, Sung JK. Analysis of risk factors associated with fusion failure after anterior odontoid screw fixation. Spine (Phila Pa 1976). 2012 Jan 1. 37 (1):30-4. [QxMD MEDLINE Link].
[Guideline] Trauma Quality Programs Best Practices Guidelines: spine injury. American College of Surgeons. Available at https://www.facs.org/-/media/files/quality-programs/trauma/tqip/spine_injury_guidelines.ashx. March 2022; Accessed: April 7, 2022.
Platzer P, Vécsei V, Thalhammer G, Oberleitner G, Schurz M, Gaebler C. Posterior atlanto-axial arthrodesis for fixation of odontoid nonunions. Spine (Phila Pa 1976). 2008 Mar 15. 33 (6):624-30. [QxMD MEDLINE Link].

Media Gallery

Odontoid type II fracture
Atlantooccipital and atlantoaxial dissociation
Hangman fracture
Three types of C2 odontoid fractures: type I is an oblique fracture through the upper part of the odontoid process; type II is a fracture occurring at the base of the odontoid as it attaches to the body of C2; type III occurs when the fracture line extends through the body of the axis.

of 4

Author

Igor Boyarsky, DO, FACEP, FAAEM Emergency Room Physician, Kaiser Permanente Southern California

Igor Boyarsky, DO, FACEP, FAAEM is a member of the following medical societies: American Academy of Anti-Aging Medicine, American Academy of Emergency Medicine, American College of Emergency Physicians, American Osteopathic Association

Disclosure: Nothing to disclose.

Coauthor(s)

Gary Godorov, MD Staff Physician, Department of Emergency Medicine, Bellflower Medical Center

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

William O Shaffer, MD Former Orthopedic Spine Surgeon, Northwest Iowa Bone, Joint, and Sports Surgeons

William O Shaffer, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Association, International Society for the Study of the Lumbar Spine, Kentucky Medical Association, Kentucky Orthopaedic Society, North American Spine Society, Southern Medical Association, Southern Orthopaedic Association

Disclosure: Nothing to disclose.

Chief Editor

Jeffrey A Goldstein, MD Clinical Professor of Orthopedic Surgery, New York University School of Medicine; Director of Spine Service, Director of Spine Fellowship, Department of Orthopedic Surgery, NYU Hospital for Joint Diseases, NYU Langone Medical Center

Jeffrey A Goldstein, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American College of Surgeons, American Orthopaedic Association, AOSpine, Cervical Spine Research Society, International Society for the Advancement of Spine Surgery, International Society for the Study of the Lumbar Spine, Lumbar Spine Research Society, North American Spine Society, Scoliosis Research Society, Society of Lateral Access Surgery

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Medtronic, Nuvasive, NLT Spine, RTI, Magellan Health<br/>Received consulting fee from Medtronic for consulting; Received consulting fee from NuVasive for consulting; Received royalty from Nuvasive for consulting; Received consulting fee from K2M for consulting; Received ownership interest from NuVasive for none.

Additional Contributors

James F Kellam, MD, FRCSC, FACS, FRCS(Ire) Professor, Department of Orthopedic Surgery, University of Texas Medical School at Houston

James F Kellam, MD, FRCSC, FACS, FRCS(Ire) is a member of the following medical societies: American Academy of Orthopaedic Surgeons, Orthopaedic Trauma Association, Royal College of Physicians and Surgeons of Canada

Disclosure: Nothing to disclose.

C2 (Axis) Fractures Clinical Presentation

Physical Examination

References

Tables

Contributor Information and Disclosures

What would you like to print?