Caution is the watchword for neck injuries sustained in contact sports, as the first ever reported case of an atlas fracture in an adult sports player has shown. Keeping to a defined clinical system of examination, x ray investigations, and interpretation is essential for a correct diagnosis, however rare that diagnosis may be. The telling sign in this case— swelling behind the pharynx—could be the only clue to a serious injury.

The 28 year old male 16 stone (102 kg) rugby player sustained the injury meeting a tackle head on during a match. Immediately he felt a dull pain throughout his neck, greatly worsened by trying to run. Later the pain focused in the axial area, and his head felt heavy and loose.

A lateral spine radiograph taken two days later showed pronounced soft tissue swelling behind the pharynx in the upper cervical spine. An open mouth view showed a slight asymmetry in the atlas-axis joints and minor lateral displacement of the C1 vertebra. Reassessment of the radiographs at a regional neurological centre prompted a computed tomographic examination through the C1 ring, which disclosed a rare—probably congenital—anterior arch midline cleft with separation of the anterior cartilaginous joint. The joint would be prone to breakage with axial compression loading if incomplete ossification of the C1 ring persisted into adulthood.

The man had his neck immobilised in an Aspen collar cervical orthosis for about 10 weeks or so. The atlas cleft remained, but the swelling and neck movement were normal. Unsurprisingly, he was advised to avoid contact sports.