====== Atlas fracture nonoperative management ======
Nonoperative [[management]] remains the mainstay of [[atlas fracture treatment]]. Isolated [[fracture]]s of the [[atlas]] can be effectively managed with 8 to 12 weeks of external [[cervical immobilization]] of the [[craniocervical junction]] 
((Kakarla UK, Chang SW, Theodore N, Sonntag VK. [[Atlas fracture]]s. Neurosurgery. 2010 Mar;66(3 Suppl):60-7. doi: 10.1227/01.NEU.0000366108.02499.8F. PMID: 20173529.)).
[[Collar]] [[immobilization]] or [[cervical traction]] for this period of time is usually sufficient to allow for proper healing; however, the type of orthosis required varies 
((Kakarla UK, Chang SW, Theodore N, Sonntag VK. [[Atlas fracture]]s. Neurosurgery. 2010 Mar;66(3 Suppl):60-7. doi: 10.1227/01.NEU.0000366108.02499.8F. PMID: 20173529.)).
((Lee TT, Green BA, Petrin DR. Treatment of stable burst fracture of the [[atlas]] ([[Jefferson fracture]]) with [[rigid cervical collar]]. Spine (Phila Pa 1976). 1998 Sep 15;23(18):1963-7. doi: 10.1097/00007632-199809150-00008. PMID: 9779528.)).
Nonoperative treatment typically consists of external immobilization through use of a [[rigid cervical collar]], [[halo-vest]], or [[Minerva jacket]] 
((Lee TT, Green BA, Petrin DR. Treatment of stable burst fracture of the [[atlas]] ([[Jefferson fracture]]) with [[rigid cervical collar]]. Spine (Phila Pa 1976). 1998 Sep 15;23(18):1963-7. doi: 10.1097/00007632-199809150-00008. PMID: 9779528.)).

[[Soft cervical collar]]s are inadequate for immobilization and often result in worsening pain to the patient with neck motion as well as further fracture displacement. Following immobilization, dynamic imaging studies such as flexion-extension films should be ordered to rule out late instability 
((Kakarla UK, Chang SW, Theodore N, Sonntag VK. [[Atlas fracture]]s. Neurosurgery. 2010 Mar;66(3 Suppl):60-7. doi: 10.1227/01.NEU.0000366108.02499.8F. PMID: 20173529.)).

In the absence of significant [[displacement]], [[C1 fracture]]s can often be treated with a period of [[rigid cervical collar]] immobilization. In cases with more significant fracture displacement, more rigid [[immobilization]] with the [[halo-vest]] or [[Minerva jacket]] may be required. The halo vest is more rigid than the Minerva jacket, providing greater restriction of the C1–2 joint. Flexion and extension of the [[upper cervical spine]] is diminished by as much as 75 % when a halo vest is employed. The greater rigidity of the halo orthosis also restricts more lateral movement of the atlantoaxial joint when compared with the Minerva jacket 
((Lauweryns P. Role of conservative treatment of cervical spine injuries. Eur Spine J. 2010 Mar;19 Suppl 1(Suppl 1):S23-6. doi: 10.1007/s00586-009-1116-4. Epub 2009 Aug 8. PMID: 19669171; PMCID: PMC2899724.)).
For this reason, the [[halo-vest]] is the preferred option for upper cervical injuries 
((Benzel EC, Hadden TA, Saulsbery CM. A comparison of the Minerva and halo jackets for stabilization of the cervical spine. J Neurosurg. 1989 Mar;70(3):411-4. doi: 10.3171/jns.1989.70.3.0411. PMID: 2915248.)).
With injuries extending to the mid and lower cervical spine, thermoplastic Minerva jackets offer greater comfort to patients, fewer complications, and can provide effective stabilization
((Benzel EC, Hadden TA, Saulsbery CM. A comparison of the Minerva and halo jackets for stabilization of the cervical spine. J Neurosurg. 1989 Mar;70(3):411-4. doi: 10.3171/jns.1989.70.3.0411. PMID: 2915248.)).
Despite its superiority over the [[Minerva jacket]], the [[halo]] [[orthosis]] has significant potential complications. Halo ring slippage, loosening, infection, and irritation and discomfort are common
((Garrett M, Consiglieri G, Kakarla UK, Chang SW, Dickman CA. [[Occipitoatlantal dislocation]]. Neurosurgery. 2010 Mar;66(3 Suppl):48-55. doi: 10.1227/01.NEU.0000365802.02410.C5. PMID: 20173527.))
((Lee TT, Green BA, Petrin DR. Treatment of stable burst fracture of the [[atlas]] ([[Jefferson fracture]]) with [[rigid cervical collar]]. Spine (Phila Pa 1976). 1998 Sep 15;23(18):1963-7. doi: 10.1097/00007632-199809150-00008. PMID: 9779528.)).
[[Halo-vest]] immobilization (HVI) failure rates reported in the literature reach as high as 85 %
((Shin JJ, Kim SJ, Kim TH, Shin HS, Hwang YS, Park SK. Optimal use of the halo-vest orthosis for upper cervical spine injuries. Yonsei Med J. 2010 Sep;51(5):648-52. doi: 10.3349/ymj.2010.51.5.648. PMID: 20635437; PMCID: PMC2908866.)).
[[Pediatric patient]]s in particular are subject to complications with use of [[halo-vest]]s
((Garrett M, Consiglieri G, Kakarla UK, Chang SW, Dickman CA. [[Occipitoatlantal dislocation]]. Neurosurgery. 2010 Mar;66(3 Suppl):48-55. doi: 10.1227/01.NEU.0000365802.02410.C5. PMID: 20173527.)).

Such orthoses may not be appropriate for patients who are morbidly obese, or who lack the necessary neurological function to avoid the formation of [[decubitus ulcer]]s 
((Garrett M, Consiglieri G, Kakarla UK, Chang SW, Dickman CA. [[Occipitoatlantal dislocation]]. Neurosurgery. 2010 Mar;66(3 Suppl):48-55. doi: 10.1227/01.NEU.0000365802.02410.C5. PMID: 20173527.)).
Instead, [[cranial traction]] or [[rigid cervical collar]]s should be supplemented in these cases with vigilant [[nursing care]]
((Benzel EC, Larson SJ, Kerk JJ, Millington PJ, Novak SM, Falkner RH, Wenninger WJ. The thermoplastic Minerva body jacket: a clinical comparison with other cervical spine splinting techniques. J Spinal Disord. 1992 Sep;5(3):311-9. PMID: 1520990.)).

[[Rigid cervical collar]]s avoid many of the potential complications of more restrictive orthoses at the cost of stability. Thus, patients must be simultaneously assessed for their ability to comply with various [[immobilization]] methods as well as their required degree of [[stabilization]]. Occasionally, orthotic stabilization will result in nonunion or continued [[instability]], in which case surgical intervention is necessary. Stability is assessed after an appropriate course of immobilization, with flexion-extension radiographs. Greater than a 5 mm increase in the [[atlantodental interval]] is often considered unstable and may require surgical intervention
((Mead LB 2nd, Millhouse PW, Krystal J, Vaccaro AR. C1 fractures: a review of diagnoses, management options, and outcomes. Curr Rev Musculoskelet Med. 2016 Sep;9(3):255-62. doi: 10.1007/s12178-016-9356-5. PMID: 27357228; PMCID: PMC4958388.)).

===== References =====