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being thrown through a windscreen of a car. They may be associated with fractures of the
jaw, as shown in the following case:
A 19-year-old apprentice electrician, while passenger in a bubble car, was involved
in an accident on 27 December 1968, and was thrown through the windscreen. Apart
from lacerations on skull and chin and a fracture of the right mandible, he sustained a
fracture-dislocation of the odontoid with downward displacement of its processes,
resulting in a complete motor, but incomplete sensory tetraplegia below C3 with areflexia.
He was unconscious for several hours. Following skull traction with 7 Ib weight he was
at first able to move all limbs and pass urine, but deteriorated later, and 2 days after
injury tracheotomy had to be performed and an indwelling catheter inserted into the
paralysed bladder in the hospital of his first admission.
On admission to Stoke Mandeville 7 days later, the first X-ray of the cervical spine
showed a separation and marked vertical over-distraction of the fractured odontoid
from the third cervical vertebra, obviously as a result of the pull of the skull traction
(Fig. 44). The weight was immediately reduced and the two vertebrae joined together,
with the result that the motor paralysis started to improve and a few days later bladder
function also gradually returned. In due course, he made an excellent neurological
recovery and control X-rays in marked retroflexion and ventroflexion showed excellent
stabilization of the fractured odontoid. He was discharged home on 21 May 1969, about
6 months after injury, being able to walk and having good control of bladder and bowels.
Urine remained sterile throughout, following intermittent catheterization (Guttmann,
1949,1963; Guttmann & Frankel, 1966). On the last clinical check-up on 27 November
1970, the muscle power of all muscles in upper and lower limbs was practically normal,
but he still had sensory disturbances of the spino-thalamic tract and upgoing toes to
plantar stimulation. He was quite independent and his sexual function had also returned.
Another example of unstable fracture-dislocation of the odontoid, resulting in an
incomplete tetraplegia which deteriorated temporarily following vertical hyperextension
through excessive skull traction, is shown in Figs. 453 and b. I saw this patient, aged 20,
at the Spinal Injuries Centre of the Robert Jones and Agnes Hunt Orthopaedic Hospital,
Oswestry, and I am indebted to Mr Sweeney and Dr Jones for letting me have the photo
graph of the X-rays of this case. A weight of 40 Ib had been initially used in the hospital
where the patient was first admitted. Following reducing the pull weight of the skull
traction to 4 Ib, the patient made a considerable recovery of his tetraplegia, is able to walk
without any support, but still shows some patches of hypoalgesia on the left side. He
has returned to his job. These are two classical examples of true (iatrogenic) hyper-
extension in cephaled vertical direction.
However, especially in retroflexion injuries of the odontoid combined with rotation,
the fractured processes may be driven into the spinal cord by the acting force, and may
lead to immediate death. An unusual case of fatal dens-fracture of the axis has recently
been reported by Mayer & Peters (1971):
A woman, aged 51, while working in a stooping-forward position, received a kick
on the buttocks. She was thrown forward, hitting a concrete wall with the vertex of her
head, the cervical spine being retro-flexed and the head rotated to the right. Death
occurred immediately. The autopsy revealed a fracture of both upper articulations of the
