There are three types of dens fractures with type ii being the most common. There are three different types of odontoid process fracture characterised by the anatomic location of the fracture line. Complications related to the management of odontoid fractures. The uppsala study on odontoid fracture treatment usoft is a multicentre, openlabel, randomised controlled superiority trial. 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. Nonoperative treatment of displaced type ii odontoid peg. Treatment modality in type ii odontoid fractures defines the. In most cases, type i and type iii odontoid fractures are best managed in a cervical collar.
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. 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. Management of isolated fractures of the axis in adults. In the adult population, odontoid fractures account for 9% to 15% of cervical spine fractures. The most commonly used classification system for odontoid fractures is that of anderson and dalonzo figure 2. Management of odontoid fractures neurosurgery oxford. In contrast to the younger age group, in elderly patients predominantly type ii fractures 95% were identified. In this article the authors describe the management of type ii odontoid fractures with special attention to operative technique and avoidance of complication. Conservative management of type ii and iii odontoid. Sep 12, 2010 considerable controversy exists regarding the optimal management of elderly patients with type ii odontoid fractures. Pdf management of odontoid fractures in the elderly. Treatment modality in type ii odontoid fractures defines.
B type ii odontoid fracture is a fracture at the base of the dens. Dens fracture or odontoid bone 15 continuity of the periosteum of these two parts. The second image is a ct that confirms the fracture in the. 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. Type iii odontoid fractures are managed quite efficiently with closed immobilization in a hard collar and heal without incidence. 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. Reliability of the stir sequence for acute type ii odontoid. 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.
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. Odontoid fractures, especially type ii peg fractures, pose a treatment dilemma due to lack of consensus on the ideal treatment of these injuries. Conservative management of type ii and iii odontoid fractures in the elderly at a regional spine center. C with type iii odontoid fracture, the fracture line extends into the body. Management of odontoid fractures neurosurgery oxford academic. 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. Pdf conservative management of type ii and iii odontoid. There is uncertainty regarding the consequences of nonunion. Due to the paucity of evidence, the treatment decision is often left to the discretion of the expert surgeon. What are the types of odontoid process fractures of the. Approximately 50% of axial rotation of the cervical spine occurs at the c1c2 articulation.
For stable type iii odontoid fracture without significant\. Catastrophic failure of conservatively treated odontoid. A fracture of the odontoid bone also called the dens, is an upward extension of c2 cervical vertebrae i. A 77yearold woman was injured in a car accident and sustained a type il odontoid fracture. Good fracture union rates were achieved at 6 and 9 months from the injury. Descriptive statistics mean, sd, median, minimum, maxi.
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. This is called the anderson and dalonzo classification. 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. Nonoperative management of type ii odontoid fractures in the elderly article pdf available in spine 3326. Odontoid fractures account for approximately 20% of all fractures of the cervical spine. The objective of the study was to evaluate the published. Aug 22, 2018 displaced odontoid fractures in the elderly are treated nonsurgically with a cervical collar or surgically with c1c2 fusion. Incidence of dysphagia after odontoid screw fixation of. Type ii fracture fracture through base of dens most common odontoid fracture. A typical indication for direct screw fixation of the odontoid process are type il fractures neck fractures according to anderson and dalonzo2 a,b. Reliability of the stir sequence for acute type ii. The odontoid process is a portion of the axis which arises from the upper surface of the c2 vertebrae.
The results of this study show that both type ii and iii odontoid fractures can be effectively treated nonoperatively. Odontoid fractures can be classified into three different categories 1. Conservative treatment in patients with type 2 odontoid. 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. The uppsala study on odontoid fracture treatment usoft is a multicentre, openlabel, randomised controlled superiority trial evaluating the clinical. Only the 2 patients with type 3 fractures healed in minerva casts. Demographic data, mechanism of injury, associated injuries, neurology, imaging studies and. Conservative management of type ii and iii odontoid fractures in the elderly at a regional spine centre. 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. Type i fracture fracture through tip of dens 1% of odontoid fractures. 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. Displaced odontoid fractures in the elderly are treated nonsurgically with a cervical collar or surgically with c1c2 fusion.
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. Nonoperative management of types ii and iii odontoid. What is the role of an odontoid view in the radiologic workup. Instability at this level occurs most commonly as a result of fractures of the odontoid or bursting injuries of the atlas with disruption of. Whereas type i fractures are very rare, type ii and iii fractures are frequently experienced in clinical practice. As a result, we concluded that odontoid process was not broken. The best treatment remains unclear because of the morbidity associated with prolonged cervical immobilisation versus the risks of surgical intervention. 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. Conservative management of type ii and iii odontoid fractures.
Spine fractures in older patients following groundlevel falls are common, with type ii odontoid fractures occurring most frequently. Type ii odontoid fractures are among the most common cervical spine fractures in older adults. Type i fractures can be managed conservatively with a hard collar for 68 weeks in duration. Thus, new classification systems have been devised to identify patients who might benefit from early surgical treatment. Ct images revealed a typical odontoid bone with anteriorly displaced atlas on the axis. What is the role of an odontoid view in the radiologic. In this paper, our aim is to report our experience in management of patients with odontoid fracture type ii. Nonoperative treatment of odontoid fractures should be considered when possible, especially in elderly patients. 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. Management of odontoid fractures in the elderly springerlink.
Complications may arise during diagnosis, nonoperative management, decisionmaking regarding operative management technique, or by execution of the chosen surgical method. These fractures account for approximately 9% of all cervical spine fractures. A type iii odontoid fracture is characterized by a horizontal fracture through the odontoid with extension into the lateral masses of c2. Type ii fractures, which occur at the base of the dens, are by far the most common odontoid fractures seen in clinical practice. Displacement of the odontoid fracture plays a key role in determining union. Fractures of the axis are the most common cervical spine fracture in the elderly population. 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. 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.
Surgical management of odontoid fractures at level one. 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. 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. The management of these fractures is controversial. Complications related to the management of odontoid fractures paul kraemer rick c. Possible treatment options are either conservative or surgical. Evaluation and treatment of odontoid and hangmans fractures. Odontoid process fracture an overview sciencedirect topics.
C with type iii odontoid fracture, the fracture line. Type iii fracture extension through vertebral body of axis. 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. Type 3 odontoid fracture joseph junewick, md facr 10182009 history 17 year old female involved in a motor vehicle accident. Considerable controversy exists regarding the optimal management of elderly patients with type ii odontoid fractures. Cervical spine imaging revealed a posterior displaced type ii odontoid fracture with sclerotic margins, severe stenosis at the level of c2 3 with cord. 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. Type i fractures occur very rarely and type ii is the most common. Thirtyfour patients underwent early posterior cervical fusion, whereas the others were treated initially with external immobilization. Ap openmouth view shows a fracture line at the base of the odontoid process a. Conditions such as cervical conditions such as cervical evaluation and acute management of cervical spine injuries in children and adolescents view in chinese. This unique fracture was associated with severe instability in their series and represented 3 of the 62 type ii odontoid. Surgical management of odontoid fractures at level one trauma.
The goal of management with these fractures is to achieve clinical or radiological union. Surgical outcome of type ii odontoid fracture, harms technique. The mechanism of injury is poorly understood but likely related to. Pdf nonoperative management of type ii odontoid fractures. Nonsurgical management of type ii odontoid fracture has historically been associated with a high nonunion rate. The problem lies in the management of type ii odontoid fractures, which are the most common. The decisionmaking process is particularly difficult when treating elderly patients. Odontoid fractures are typically categorized by the andersondalonzo classification as type iiii 1, 6. Diagnosis type 3 odontoid fracture discussion type iii odontoid fractures are actually fractures of the c2 vertebral body rather than the odontoid. The 3 types of odontoid process fractures are classified based on the anatomic level at which the fracture occurs see the image below. Odontoid fractures comprise 915% of all cervical spine fractures. The first image is an odontoid view, which shows the fracture line extending beyond the base of the dens. We therefore designed a study to analyze geriatric patients with type ii odontoid fractures treated with either rigid cervical collar or surgery.
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