PMC4913000_01
Clinical photograph illustrating severe facial trauma and soft tissue injury.
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He was noted to have severe facial trauma and complex neck lacerations (Figure 1).
Intraoperative photo highlighting extent of facial trauma.
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There were no spontaneous movements of his extremities or withdrawal response from painful stimulus secondary to sedation, but he maintained hemodynamic stability.  Figure 2 illustrates his significant facial trauma.
Midaxial sagittal cervical spine CT showing a slightly distracted Type II dens fracture without additional cervical spine fracture.
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Type 2 dens fracture (Figure 3). There was no evidence of obvious distraction or translation at either the occipital-C1 junction or the C1-C2 joints on either the sagittal or coronal reformats (Figures 4 and 5).
Right and left parasagittal cuts through the occipital-cervical junction demonstrating reduced occipital condyle-C1 and C1-C2 joints bilaterally. There is no evidence of distraction across these joints.
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Type 2 dens fracture (Figure 3). There was no evidence of obvious distraction or translation at either the occipital-C1 junction or the C1-C2 joints on either the sagittal or coronal reformats (Figures 4 and 5).
Coronal reconstruction of the cervical spine again demonstrating the reduced occipital condyle-C1 joints bilaterally. There is an avulsion injury of the left occipital condyle consistent with a Type III fracture. The second coronal reconstruction illustrates reduced C1-C2 joint.
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Type 2 dens fracture (Figure 3). There was no evidence of obvious distraction or translation at either the occipital-C1 junction or the C1-C2 joints on either the sagittal or coronal reformats (Figures 4 and 5).
Midsagittal CT soft tissue window demonstrating prevertebral soft tissue swelling of 16.7 mm which is excessive for a transverse Type 2 dens fracture.
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Given the soft tissue swelling measuring 16.7 mm at C2 on CT scan, the Type III occipital condyle, and the distractive Type II dens fracture, concern for a more substantive injury is raised (Figure 6).
Left and right parasagittal STIR weighted MRI showing displaced occiput-C1 joints.
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Given the above findings, a cervical MRI was obtained several hours later (Figures 7 and 8) to evaluate for craniocervical dislocation.
Coronal T2 weighted MRI showing occiput-C1 displacement, C1-C2 displacement, and soft tissue edema in the pericervical spine region.
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Given the above findings, a cervical MRI was obtained several hours later (Figures 7 and 8) to evaluate for craniocervical dislocation.
Postoperative imaging demonstrating a reduced and secured occiput to C2 posterior fusion.
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The tricortical graft was contoured around the posterior elements between the occiput and C2 and secured with #2 FiberWire wrapped around both rods (Figure 9).