In one centre, the treatment was pos terior c1c2 stabilization with screws and plate. Reliability of the stir sequence for acute type ii odontoid. Fractures of the dens and risk of pseudarthrosis springerlink. These results confirm the lack of consensus in the literature on the management of odontoid fractures since mixter and osgood described the first surgical management of odontoid fractures in 1910. The odontoid process is a portion of the axis which arises from the upper surface of the c2 vertebrae. Fractures of the dens can be seen at any time of life, but especially in young adolescents and also in those after 60. Pseudarthrosis was found to be present in seven cases. Type ii dens fracture mortality 156 patients average age 82 3 years post injury 39 % mortality operative 21 % mortality at one year nonoperative 36 % mortality at one year surgery protective in patients 65 74 years type ii odontoid fractures of the cervical spine. Approximately 50% of axial rotation of the cervical spine occurs at the c1c2 articulation. As a result, we concluded that odontoid process was not broken. Functional and qualityoflife outcomes in geriatric patients with typeii dens fracture. Treatment modality in type ii odontoid fractures defines. Young adult posttrauma with a type iii dens fracture.
Axis fractures, hangman fractures, odontoid fractures neurosurgery 72. A casecontrol study of patients with isolated type ii dens fractures treated with halo vest immobilization. Displaced odontoid fractures in the elderly are treated non surgically with a cervical collar or. Conservative treatment in patients with type 2 odontoid.
Dens fractures are known to have high rates of pseudarthrosis. Sep 12, 2010 considerable controversy exists regarding the optimal management of elderly patients with type ii odontoid fractures. Conservative nonoperative treatment is appropriate for stable undislocated displaced odontoid fractures. The commonest type of the axis injury is an odontoid fracture at the junction of the dens. Age also should be considered when determining the. Anderson and dalonzo classification of odontoid process.
Fractures of the dens represent almost 15% of all cervical spine injuries and represent the most common axial fracture type. Type ii odontoid fractures have been associated with limited healing potential, and both nonoperative and operative management are associated with high mortality rates. The management of these fractures is controversial. The treatment of specific c1c2 fracture combinations has been the subject of numerous reports. A fracture of the odontoid bone also called the dens, is an upward extension of c2 cervical vertebrae i. Axis fractures, hangman fractures, odontoid fractures. Odontoid process fracture an overview sciencedirect topics. Management options are discussed in terms of fracture anatomy, radiographic evidence of fusion, and patient comfort and compliance.
Although many investigators have examined patient age as a risk factor for nonfusion using halo immobilization, all studies have been supported only by class iii data. An atlantooccipital displacement with a concomitant c1 fracture may be diagnosed on ct scans, which show a basiondens interval bdi, the distance between the basion and the tip of the dens, exceeding 1012 mm. The first image is an odontoid view, which shows the fracture line extending beyond the base of the dens. Fractures of the dens can be seen at any time of life, but. Evaluation and treatment of odontoid and hangmans fractures. Doctors have used this term since 1965, when some doctors used it to describe traumatic spondylolisthesis involving the pars interarticularis of c2 on both sides. The demographic group varies as these fractures occur in both in young patients due to a highenergy trauma e.
Lifethreatening fractures can occur as a result of forces acting on this anatomical structure due to its proximity to the spinal cord and brainstem. Off all the cases of cervical trauma, about one out of five involves the axis1. Possible treatment options are either conservative or surgical. Considerable controversy exists regarding the optimal management of elderly patients with type ii odontoid fractures. Dens fractures comprise the majority of all cervical fractures in patients older than 80 years and remain the most common cervical fracture pattern in all geriatric patients. What are the types of odontoid process fractures of the. Dens fracture or odontoid bone 15 continuity of the periosteum of these two parts. This study deals with 49 fractures of the dens treated at the orthopedic department of athens university during the past 17 years. Traumatic fracture can be transverse, oblique, spiral, displaced. The uppsala study on odontoid fracture treatment usoft is a multicentre, openlabel, randomised. Pdf the management of odontoid fractures remains controversial.
Catastrophic failure of conservatively treated odontoid. The risk of nonunion is highly variable, likely reflecting the variable population demographics in the various studies. On admission, each patient was assessed assigning asa score, modified rankin scale mrspre and charlson comorbidity index cci. The person is unresponsive, isnt breathing or isnt moving. Management of isolated fractures of the axis in adults key words. Musculoskeletal s tructures and f unction the s keletal s tructures modern orthopaedics is concerned with the diagnosis and management of disorders of the musculoskeletal system, that is the skeleton and. There are three types of dens fractures with type ii being the most common. Fracture of c2 dens bimodal age distribution young injury secondary to blunt trauma to head or flexionextension injury.
Chronic hypertrophic nonunion of the type ii odontoid. A patient with this type of fracture comes in after a whiplash type injury complaining of worsening neck pain. Request pdf management of type ii dens fractures study design, a casecontrol study of patients with isolated type ii dens fractures treated with halo vest immobilization. Odontoid process fracture, also known as a peg or dens fracture, occurs where there is a fracture through the odontoid process of c2 pathology. The best treatment remains unclear because of the morbidity associated with prolonged cervical immobilisation versus the risks of surgical intervention. If the broken bone is the result of major trauma or injury, call 911 or your local emergency number. B type ii odontoid fracture is a fracture at the base of the dens. A total of 50 geriatric patients with type ii odontoid fractures were treated with aspenvista collars. Open fractures are often the result of highenergy trauma and can lead to significant longterm morbidity and disability. Odontoid fractures can be classified into three different categories 1. Odontoid fractures account for approximately 20% of all fractures of the cervical spine. Oct 01, 2000 orthopedics a fracture of the odontoid process is the most common injury to the second cervical vertebrae. Atlantooccipital dissociation injuries may also be diagnosed when the occipital condylec1 interval cci exceeds 4 mm 8, 15. The currently available data on the distribution of c2 fracture subtypes is sparse.
Type ii fractures, which occur at the base of the dens, are by far the most common odontoid fractures seen in clinical practice. As a general concept, the management of dens fractures is based on three principles. Odontoid fractures are the most common fracture of the axis and are the most common type of cervical spine fracture in patients over 65. There is uncertainty regarding the consequences of nonunion. Anderson and dalonzo classification of odontoid process fracture. Imaging of the cervical spine fractures dens fracture type ii. Type i fracture fracture through tip of dens 1% of odontoid fractures. Mar 28, 20 download fulltext pdf nonoperative management of odontoid fractures. Classification type i rare fracture of the upper part of the odontoid peg above the level of the transverse band of. When considering the optimal treatment for a type ii of in the elderly, several factors need to be taken into consideration including associated injuries, medical comorbidities american society of anaesthesiologists asa grade, healing potential of fracture, anticipated tolerance of the halo vest hv or surgery and patients wishes 3, 6, 34, 37, 46, 63, 70. Ct images revealed a typical odontoid bone with anteriorly displaced atlas on the axis.
In treating a fracture, the objectives of the treatment are as follows. 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 bone healing. It constitutes 10%15% of all cervical spine fractures. The aim of this study was to analyze the rate of successful osseous consolidation of c2 fractures with conservative treatment by wearing a semirigid collar or halo thoracic vest without further surgical. Conservative management of dens fractures in the elderly is still a subject of great controversy despite numerous studies on this topic. 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. Similar to the literature on isolated type ii odontoid fracture.
The incidence of odontoid fractures has a bimodal distribution with increased incidence in younger patients with high energy injuries and older. Treatment of odontoid fractures national journal of clinical. Odontoid fractures are the most common fracture of the axis and the most common cervical spine fracture in patients over 65. Contemporary management of adult cervical odontoid fractures. Historically, there has been some debate in the literature with regards to optimal management strategies to maximize outcomes in geriatric patients. The anderson and dalonzo classification is the most commonly used classification of fractures of the odontoid process of c2. Management of acute combination fractures of the atlas and. In anatomy, the second cervical vertebra c2 of the spine is named the axis from latin axis, axle or epistropheus by the atlantoaxial joint, it forms the pivot upon which the first cervical vertebra the atlas, which carries the head, rotates the most distinctive characteristic of this bone is the strong odontoid process known as the dens, which rises perpendicularly from the upper. The mechanism of injury is variable, and can occur both during flexion or extension, and with or without compression 5. Treatment modality in type ii odontoid fractures defines the. Elderly injury secondary to fall, higher morbiditymortality than young patients.
C2 fracture hangmans fracture is the colloquial name for a traumatic spinal cord injury that affects the axis vertebrae. Complications may arise during diagnosis, nonoperative management, decisionmaking regarding operative management technique, or by execution of the chosen surgical method. Routinely, type i is considered as an avulsion at the isthmus of the dens, type iii is the fracture of the body. Sasso care of the patient with an odontoid fracture continues to be fraught with difficulty. Hangmans fracture c2 vertebrae fracture causes and treament. T2weighted mri of cervical spine demonstrates severe stenosis at c23 level with cord compression and intrinsic cord signal abnormality. Controversies in the management of geriatric odontoid. The objective of this study is to analyze the biomechanics of dens fractures of the second cervical vertebra in the adult population due to motor vehicle crashes. Odontoid fractures usually displace anteriorly with posterior angulation of the dens. C with type iii odontoid fracture, the fracture line extends into the body.
The best surgical treatment for type ii fractures of the dens. Pdf evidencebased analysis of odontoid fracture management. 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. Orthopedics a fracture of the odontoid process is the most common injury to the second cervical vertebrae. Odontoid process fractures are the most common fracture of the 2nd cervical vertebrae pratt et al. Spine, odontoid injuries, anterior posterior fixation.
The aim of this study was to define clinical and radiographic longterm outcomes, specifically in relation to osseous union, cervical spine movement, neurological sequelae, and quality of life, in a geriatric cohort sixtyfive years of age or older treated operatively or nonoperatively for a dens fracture. Type ii odontoid fracture in elderly patients treated. Search criteria a national library of medicine pubmed computerized literature search from 1966 to 2011 was undertaken using medical subject headings in combination with vertebral fracture. Complications related to the management of odontoid fractures. A type i fracture involves only the proximal tip of the odontoid process, while a type ii fracture, like our patients, passes through the base of the odontoid process. Vaccaro ar, kepler ck, kopjar b, chapman j, shaffrey c, arnold p, et al. Current concepts in the management of type ii odontoid fractures. Odontoid fractures account for 920% of cervical spine fractures. This type iia fracture was highly unstable and was. A dataset of all patients treated between 2002 and 2014 for c2 fractures was extracted from the regional hospital information system.
Patients and methods between february 1976 and february 1994, 62 patients with fractures of the odontoid process were managed nonsurgically at the university of virginia health sciences center, charlottesville, va. Management and outcome of dens fracture nonunions in. Management of acute combination fractures of the atlas and axis. Latin american spine centers experience find, read and cite all the research you. The nonunion rate in the present study 29% is comparable to other series, where the range was between 32 and 41 percent2,3. Since then there has been no clear consensus on the management of odontoid fracture. However, due to the high level of potentially fatal neurological injury associated with these fractures, the exact incidence is not well known. The odontoid process, also called the dens, is a protuberance of the axis. Fractures of the odontoid process and of the body of the axis are common injuries, occurring in 8% to 18% of patients with a cervical spine fracture. Spine injury dens fracture odontoid fracture bone talks.
In centre two, odontoid fracture line was fixed by anterior screws. Lennarson pj1, mostafavi h, traynelis vc, walters bc. Analysis of functional outcome of elderly patients with type ii odontoid fractures treated conservatively in relation to their radiological outcome. The c2 vertebra, also known as the axis, is one of three atypical vertebrae. These studies, consequently, carry little or no statistical significance. Management of isolated fractures of the axis in adults. Morbiditymortality surgery operative and nonoperative treatment in geriatric population have high risk of poor outcome meta analysis one year mortality after surgery for odontoid fracture 65 74 21 % 75 84 29 % 85 45 % higher complication rate with anterior vs. The base of the dens represents a watershed region between 2 arcades1 supplying the body of c2 and another supplying the tip of the dens. This study was designed to identify the proportions of the second cervical vertebra c2 fracture subtypes and to present age and gender specific incidences of subgroups.
We assessed the quality of the available literature for management of type ii odontoid fractures and surgeryrelated parameters, including surgical indications, clinical failure rate, and survivorship, postoperative rom and function, neurologic deficits, complication and death rates, and radiographic healing rates related to either anterior dens screw or posterior c1c2. 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. Request pdf on oct 1, 2016, asdrubal falavigna and others published management of type ii odontoid fractures. C2 fracture subtypes, incidence, and treatment allocation. Patient was informed and conservative treatment was recommended. Fractures of the odontoid process are common and make up almost one fifth of all cervical fractures 2. The optimum treatment of type ii odontoid fractures in the elderly remains controversial. Nonoperative management of types ii and iii odontoid. A type 2 fracture is a break at the base of the dens, and a type 3 fracture is when the break goes into the main portion of the second vertebre.