Fig. 18

Transverse ligament and alar ligament rupture in a middle-aged male driver of a car involved in a collision with a bus; the victim was quadriparetic and respiratory-compromised at the scene: a axial image of 3D T2 SPACE MRI sequence demonstrates marrow oedema and fracture of the left anterior arch of the atlas extending to and involving the medial tubercle attachment of the transverse ligament on this side associated with rupture and detachment of the the transverse ligament at this site (arrow). Cord oedema is evident (black arrow); b coronal image of the same MRI study demonstrates traumatic signal abnormality and tear of the left alar ligament (thick black arrow) as well as the loss of integrity of the left side of the transverse ligament (thick white arrow). Some intrasubstance high-signal strain injury is noted affecting the right alar ligament at its condylar attachment (thin black arrow). Traumatic effusions are present in the atlanto-occipital and atlanto-axial joints bilaterally but are more marked on the left indication associated with capsular ligament strain injury (thin white arrows); c sagittal image of the same MRI study demonstrates haemorrhagic cord injury at the C1-C2 level (thin black arrow), abnormal haemorrhagic signal and fullness in the supra-odontoid space (“apical cave”) related to the apical ligament (thick black arrow), an intact tectorial membrane but abnormal traumatic signal change in the anterior atlanto-occipital membrane (thin white arrow) associated with a large haematoma in the prevertebral space (thick white arrow)