They represent the most common cervical spine injury for patients older than 70 years, the majority being type ii fractures 6574%, which are considered to be relatively unstable. Demographic data, mechanism of injury, associated injuries, neurology, imaging studies and. This subclass, accounting for 5% of type 2 fractures, also involves additional chip fracture fragments at the base of the dens, making it more unstable and definitely necessitating surgical stabilisation to prevent nonunion fig. In 3 cases, the type ii odontoid fracture was accompanied by a c1 vertebral fracture. Ap openmouth view shows a fracture line at the base of the odontoid process a. Sasso care of the patient with an odontoid fracture continues to be fraught with difficulty. Nonunion is common in type ii dens fracture and ranges from 11% to 63% of all cases3. Whereas in the younger patients highenergy trauma accounted for the majority of the fractures, lowenergy falls were the underlying cause in 90% of the odontoid fractures in the elderly.
The results of this study show that both type ii and iii odontoid fractures can be effectively treated nonoperatively. Surgical management of odontoid fractures at level one trauma. Conditions such as cervical conditions such as cervical evaluation and acute management of cervical spine injuries in children and adolescents view in chinese. We therefore designed a study to analyze geriatric patients with type ii odontoid fractures treated with either rigid cervical collar or surgery.
For stable type iii odontoid fracture without significant\. Aug 22, 2018 displaced odontoid fractures in the elderly are treated nonsurgically with a cervical collar or surgically with c1c2 fusion. The first image is an odontoid view, which shows the fracture line extending beyond the base of the dens. This type iia fracture was highly unstable and was characterized by a comminuted fracture of the base of the odontoid with associated free fracture fragments. Evaluation and treatment of odontoid and hangmans fractures. Type i fracture fracture through tip of dens 1% of odontoid fractures. Thus, new classification systems have been devised to identify patients who might benefit from early surgical treatment. Conservative management of type ii and iii odontoid fractures in the elderly at a regional spine center. Odontoid fractures are frequent in patients over 70 years of age, and in patients over 80 years of age they form the majority of spinal fractures. A fracture of the odontoid bone also called the dens, is an upward extension of c2 cervical vertebrae i. Management of type ii odontoid fractures in the geriatric.
In conclusion, type iii odontoid fractures were more comminuted, had a larger odontoid fragment, had a larger fracture surface, but were less posteriorly displaced when compared to type ii. Complications related to the management of odontoid fractures paul kraemer rick c. The odontoid process is a portion of the axis which arises from the upper surface of the c2 vertebrae. The goal of management with these fractures is to achieve clinical or radiological union. What are the types of odontoid process fractures of the. This study of 54 patients who were followed after undergoing the nonsurgical management of types ii and iii odontoid fractures is the first attempt at the statistical comparison of equivalent numbers of patients externally mobilized in the halo vest and the philadelphia collar. C with type iii odontoid fracture, the fracture line extends into the body. The second image is a ct that confirms the fracture in the. Treatment depends on the location of the fracture within the c2 vertebrae defined by the anderson and dalonzo classification system and the patients risk factors for nonunion failed. What is the role of an odontoid view in the radiologic. Surgical outcome of type ii odontoid fracture, harms technique. The positive outcome of conservative treatment in terms of higher union rate is related to the higher stability of the type i and iii fractures in comparison to type ii fractures.
Conservative management of type ii and iii odontoid fractures in the elderly at a regional spine centre. The problem lies in the management of type ii odontoid fractures, which are the most common. Type ii fractures, which occur at the base of the dens, are by far the most common odontoid fractures seen in clinical practice. C with type iii odontoid fracture, the fracture line. A typical indication for direct screw fixation of the odontoid process are type il fractures neck fractures according to anderson and dalonzo2 a,b.
This fracture is considered mechanically unstable, as it allows the atlas and the occiput to now move together as once unit and independent of the rest of the cervical column. Pdf conservative management of type ii and iii odontoid. A 77yearold woman was injured in a car accident and sustained a type il odontoid fracture. In a retrospective analysis of 23 geriatric 70 years patients with a fracture of the odontoid, we compared some of the clinical features to a contemporary series of patients younger than 70 years. Sep 12, 2010 considerable controversy exists regarding the optimal management of elderly patients with type ii odontoid fractures. Reliability of the stir sequence for acute type ii odontoid.
There are three types of dens fractures with type ii being the most common. Reliability of the stir sequence for acute type ii. In the adult population, odontoid fractures account for 9% to 15% of cervical spine fractures. Complications may arise during diagnosis, nonoperative management, decisionmaking regarding operative management technique, or by execution of the chosen surgical method. Diagnosis type 3 odontoid fracture discussion type iii odontoid fractures are actually fractures of the c2 vertebral body rather than the odontoid.
There is uncertainty regarding the consequences of nonunion. A type iii odontoid fracture is characterized by a horizontal fracture through the odontoid with extension into the lateral masses of c2. The uppsala study on odontoid fracture treatment usoft is a multicentre, openlabel, randomised controlled superiority trial. In a retrospective analysis of 23 geriatric 70 years patients with a fracture of the odontoid, we compared some of the clinical features to a contemporary series of patients younger than 70 years of age. The fracture was through the base of the odontoid process type 2 in 49 patients and was into the body of c2 type 3 in 2 patients. Treatment modality in type ii odontoid fractures defines the. Nonoperative management of type ii odontoid fractures in the elderly article pdf available in spine 3326. Management of isolated fractures of the axis in adults. Management of odontoid fractures neurosurgery oxford. Type iii odontoid fractures are managed quite efficiently with closed immobilization in a hard collar and heal without incidence. Type iii fracture extension through vertebral body of axis. As a result, we concluded that odontoid process was not broken.
Type ii fractures figure 281 are the most common type of dens fracture and are more often subject to nonunion, especially in patients older than 50 years of age when displacement is greater than 5 mm. Displacement of the odontoid fracture plays a key role in determining union. The anderson and d alonzo classification system, most commonly applied to these fractures, identify type ii odontoid fractures at the junction of the odontoid process with the body of the second cervical vertebra. Odontoid process fracture an overview sciencedirect topics. Cervical spine imaging revealed a posterior displaced type ii odontoid fracture with sclerotic margins, severe stenosis at the level of c2 3 with cord. Type i fractures occur very rarely and type ii is the most common. Instability at this level occurs most commonly as a result of fractures of the odontoid or bursting injuries of the atlas with disruption of. Displaced odontoid fractures in the elderly are treated nonsurgically with a cervical collar or surgically with c1c2 fusion. Nonoperative treatment of displaced type ii odontoid peg. Good fracture union rates were achieved at 6 and 9 months from the injury. Nonoperative management of types ii and iii odontoid.
In this article the authors describe the management of type ii odontoid fractures with special attention to operative technique and avoidance of complication. In contrast to the younger age group, in elderly patients predominantly type ii fractures 95% were identified. When choosing treatment strategies for type ii odontoid fractures, the surgeon must consider the integrity of the transverse ligament, age and orientation of the fracture. Instability at this level occurs most commonly as a result of fractures of the odontoid or bursting injuries of the atlas with disruption of the transverse ligament. Fractures of the odontoid process are common and make up almost one fifth of all cervical fractures 2. Ct images revealed a typical odontoid bone with anteriorly displaced atlas on the axis. The management of these fractures is controversial. The most commonly used classification system for odontoid fractures is that of anderson and dalonzo figure 2. Type ii fracture fracture through base of dens most common odontoid fracture. Type ii fractures occur at the base of the odontoid, between the level of the transverse ligament and the c2 vertebral body, and are the most common type of odontoid fracture and considered relatively unstable. This is called the anderson and dalonzo classification. Conservative management of type ii and iii odontoid fractures.
Odontoid fractures comprise 920% of all cervical spine fractures. The best treatment remains unclear because of the morbidity associated with prolonged cervical immobilisation versus the risks of surgical intervention. Treatment modality in type ii odontoid fractures defines. B type ii odontoid fracture is a fracture at the base of the dens. Recognition of the incidence of odontoid fractures as well as the associated morbidity and unexpectedly high mortality rates has prompted significant changes in the management of these fractures in the past decade. Approximately 50% of axial rotation of the cervical spine occurs at the c1c2 articulation. This unique fracture was associated with severe instability in their series and represented 3 of the 62 type ii odontoid.
Odontoid fractures are relatively common fractures of the c2 vertebral body axis that can be seen in low energy falls in eldery patients and high energy traumatic injuries in younger patients. Type i fractures can be managed conservatively with a hard collar for 68 weeks in duration. Pdf nonoperative management of type ii odontoid fractures. Based on our assessment of existing literature and experience, we attempt to provide an evidencebased treatment algorithm for the management of odontoid fractures in the elderly figure 4.
Odontoid fractures can be classified into three different categories 1. Pdf management of odontoid fractures in the elderly. Odontoid fractures are typically categorized by the andersondalonzo classification as type iiii 1, 6. In most cases, type i and type iii odontoid fractures are best managed in a cervical collar. The mechanism of injury is poorly understood but likely related to. Whereas type i fractures are very rare, type ii and iii fractures are frequently experienced in clinical practice. Spine fractures in older patients following groundlevel falls are common, with type ii odontoid fractures occurring most frequently. Only the 2 patients with type 3 fractures healed in minerva casts. Due to the paucity of evidence, the treatment decision is often left to the discretion of the expert surgeon. Management of odontoid fractures neurosurgery oxford academic. Dens fracture or odontoid bone 15 continuity of the periosteum of these two parts. The objective of the study was to evaluate the published. Odontoid fractures account for approximately 20% of all fractures of the cervical spine. There are three different types of odontoid process fracture characterised by the anatomic location of the fracture line.
Type ii odontoid fractures are among the most common cervical spine fractures in older adults. Type 3 odontoid fracture joseph junewick, md facr 10182009 history 17 year old female involved in a motor vehicle accident. Surgical management of odontoid fractures at level one. These fractures account for approximately 9% of all cervical spine fractures. Nonsurgical management of type ii odontoid fracture has historically been associated with a high nonunion rate. What is the role of an odontoid view in the radiologic workup. Nonoperative treatment of odontoid fractures should be considered when possible, especially in elderly patients. Complications related to the management of odontoid fractures. Patient was informed and conservative treatment was recommended. Possible treatment options are either conservative or surgical. Anterior odontoid screw fixation is a procedure the authors have performed over the last 8 years in cases with acute type ii and rostral type iii odontoid fractures. Conservative treatment in patients with type 2 odontoid. The uppsala study on odontoid fracture treatment usoft is a multicentre, openlabel, randomised controlled superiority trial evaluating the clinical.
Thirtyfour patients underwent early posterior cervical fusion, whereas the others were treated initially with external immobilization. Odontoid fractures comprise 915% of all cervical spine fractures. Incidence of dysphagia after odontoid screw fixation of. Catastrophic failure of conservatively treated odontoid. In this paper, our aim is to report our experience in management of patients with odontoid fracture type ii. Considerable controversy exists regarding the optimal management of elderly patients with type ii odontoid fractures. The 3 types of odontoid process fractures are classified based on the anatomic level at which the fracture occurs see the image below. Descriptive statistics mean, sd, median, minimum, maxi. Conservative management of type ii and iii odontoid. Fractures of the axis are the most common cervical spine fracture in the elderly population. The type iia fracture is the only widely accepted modification to the andersondalonzo nomenclature and includes comminution associated with a type ii fracture.
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