This case report describes successful conservative management of a comminuted fracture of the atlas. To the authors knowledge, fracture of the atlas in the horse and intrathecal corticosteroid injection in the standing sedated patient has not been previously reported. Clinical signs included acute onset ataxia, proprioceptive deficits and neck stiffness; which developed immediately post trauma during assisted recovery from general anaesthesia. Radiographic examination was not diagnostic immediately post trauma and computed tomographic (CT) imaging subsequently identified a fracture of the atlas. Treatment included ultrasound guided intrathecal medication of the cerebrospinal fluid and intra-articular medication of the atlantooccipital joint under standing sedation. Medication resulted in a marked improvement in clinical signs (grade 4 ataxia to grade 1 ataxia).