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Case report: nonoperative treatment of an unstable Jefferson fracture using a cervical collar.

ABSTRACT: The treatment of unstable burst fractures of the atlas (Jefferson fractures) is controversial. Unstable Jefferson fractures have been managed successfully with either immobilization, typically halo traction or halo vest, or surgery. We report a patient with an unstable Jefferson fracture treated nonoperatively with a cervical collar, frequent clinical examinations, and flexion-extension radiographs. Twelve months after treatment, the patient achieved painless union of his fracture. The successful treatment confirms prior studies reporting unstable Jefferson fractures have been treated nonoperatively. The outcome challenges the clinical relevance of treatment algorithms that rely on the "rules of Spence" to guide treatment of unstable Jefferson fractures and illustrates instability may not necessarily be present in patients with considerable lateral mass widening. Additionally, it emphasizes a more reliable way of assessing C1-C2 stability in unstable Jefferson fractures is by measuring the presence and extent of anterior subluxation on lateral flexion and extension views.

SUBMITTER: Haus BM

PROVIDER: S-EPMC2311473 | biostudies-other | 2008 May

REPOSITORIES: biostudies-other

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Project description:ImportanceUnstable chest wall injuries have high rates of mortality and morbidity. In the last decade, multiple studies have reported improved outcomes with operative compared with nonoperative treatment. However, to date, an adequately powered, randomized clinical trial to support operative treatment has been lacking.ObjectiveTo compare outcomes of surgical treatment of acute unstable chest wall injuries with nonsurgical management.Design, setting, and participantsThis was a multicenter, prospective, randomized clinical trial conducted from October 10, 2011, to October 2, 2019, across 15 sites in Canada and the US. Inclusion criteria were patients between the ages of 16 to 85 years with displaced rib fractures with a flail chest or non-flail chest injuries with severe chest wall deformity. Exclusion criteria included patients with significant other injuries that would otherwise require prolonged mechanical ventilation, those medically unfit for surgery, or those who were randomly assigned to study groups after 72 hours of injury. Data were analyzed from March 20, 2019, to March 5, 2021.InterventionsPatients were randomized 1:1 to receive operative treatment with plate and screws or nonoperative treatment.Main outcomes and measuresThe primary outcome was ventilator-free days (VFDs) in the first 28 days after injury. Secondary outcomes included mortality, length of hospital stay, intensive care unit stay, and rates of complications (pneumonia, ventilator-associated pneumonia, sepsis, tracheostomy).ResultsA total of 207 patients were included in the analysis (operative group: 108 patients [52.2%]; mean [SD] age, 52.9 [13.5] years; 81 male [75%]; nonoperative group: 99 patients [47.8%]; mean [SD] age, 53.2 [14.3] years; 75 male [76%]). Mean (SD) VFDs were 22.7 (7.5) days for the operative group and 20.6 (9.7) days for the nonoperative group (mean difference, 2.1 days; 95% CI, -0.3 to 4.5 days; P = .09). Mortality was significantly higher in the nonoperative group (6 [6%]) than in the operative group (0%; P = .01). Rates of complications and length of stay were similar between groups. Subgroup analysis of patients who were mechanically ventilated at the time of randomization demonstrated a mean difference of 2.8 (95% CI, 0.1-5.5) VFDs in favor of operative treatment.Conclusions and relevanceThe findings of this randomized clinical trial suggest that operative treatment of patients with unstable chest wall injuries has modest benefit compared with nonoperative treatment. However, the potential advantage was primarily noted in the subgroup of patients who were ventilated at the time of randomization. No benefit to operative treatment was found in patients who were not ventilated.Trial registrationClinicalTrials.gov Identifier: NCT01367951.

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Case report: nonoperative treatment of an unstable Jefferson fracture using a cervical collar.

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