Fractures of the first cervical vertebra (C1) represent approximately 7% of all acute cervical spine fractures. Frequently, the atlas will be fractured in combination with the axis (44% of cases). Treatment of isolated C1 fractures should be governed by the rules of Spence. The treatment of combination C1-C2 fractures is dictated by the type and severity of the C2 fracture. Experience with 57 cases of acute traumatic atlas fractures are reviewed. The long-term outcome from an atlas fracture is good (median follow-up, 40 months).