In addition, the authors noted the difficulty in differentiating a low type ii fracture from a high type iii fracture. Conservative management of type ii and iii fractures. The aim of this study was to compare conservative and surgical management in patients with type ii c2 fractures regarding outcomes, complications, and the mortality rate. Fracture at base of odontoid where it meets c2 body unstable fracture. The treatment of specific c1c2 fracture combinations has been the subject of numerous reports. 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. Treatment is with anterior odontoid screw if adequate bone density. Nonunion occurs in 30% to 50% in the elderly and those with significant displacement angulation of more than. This was a retrospective study enrolled 34 patients underwent posterior cabledragged reductioncantileverbeam internal fixation surgery. Displaced odontoid fractures in the elderly are treated nonsurgically with a cervical collar or surgically with c1c2 fusion. Surgical outcome of type ii odontoid fracture, harms technique.
Surgical methods for type ii odontoid fracture can be classified into 2 main groups. Hangmans fractures, a traumatic spondylolisthesis through the pars interarticularis. Original article treatment of odontoid type ii fractures in. Sep 12, 2010 the objective of the study was to evaluate the published literature and determine the current evidence for the management of type ii odontoid fractures in elderly. 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. Type iii odontoid fractures are managed quite efficiently with closed immobilization in a hard collar and heal without incidence. This is a very important case of providing spine surgeons with a treatment plan for treating patients with old type ii odontoid fractures complicated. Pdf evidencebased analysis of odontoid fracture management. Evaluation and treatment of odontoid and hangmans fractures. Pdf nonoperative management of type ii odontoid fractures. Type iii fractures occur through the body of the axis with frequent extension into the atlantoaxial facet joints 9. Cervical trauma is a common cause of disability following spinal cord injury especially in athletic populations. Lennarson pj1, mostafavi h, traynelis vc, walters bc. The best treatment remains unclear because of the morbidity associated with prolonged cervical immobilisation versus the risks of surgical intervention.
High risk of nonunion 30% due to interruption of blood supply. Nonunion is common in type ii dens fracture and ranges from 11% to 63% of all cases3. Nonoperative treatment of odontoid fractures should be considered when possible, especially in elderly patients. Treatment of type ii odontoid fracture with a novel techniqu. The sensitivity of stir to detect fracture in the age group 57 years and older was significantly worse than that in the age group younger than 57 years 54% and 82%, respectively. Treatment modality in type ii odontoid fractures defines. Type ii fractures are the most common odontoid frac. Odontoid fractures are typically categorized by the andersondalonzo classification as type iiii 1, 6. We sought to compare the outcomes of patients managed with these devices in terms of risk factors for non. It has the highest incidence of nonunion and is considered unstable. Sometimes, type ii fracture is associated with a comminuted fragment at the base of the dens called the type ii a variety. Functional and qualityoflife outcomes in geriatric patients with typeii dens fracture. Fractures of the dens can be seen at any time of life, but especially in young adolescents and also in those after 60. The fracture occurs at the base of the odontoid between the level of the transverse ligament and the base of the odontoid process.
Seventyfive patients with type ii odontoid fracture and 75 healthy controls mean and median age of 57 years were identified. The goal of management with these fractures is to achieve clinical or radiological union. Pdf retrospective case series of elderly patients with type ii odontoid fractures, with prospective functional followup. Nov 18, 2011 to evaluate fracture healing, functional outcomes, complications, and mortality associated with rigid cervical collars. Jan 23, 2019 cervical trauma is a common cause of disability following spinal cord injury especially in athletic populations. Approximately 50% of axial rotation of the cervical spine occurs at the c1c2 articulation. Vast majority of type ii fractures treated with cervical collar anterior odontoid screw fixation in selected patients with fracture pattern and body habitus amenable to procedure c1 c2 psf for markedly displaced fractures cant remember the last time i put a halo on an elderly patient. Management of isolated fractures of the axis in adults.
This type is unstable and has a high rate of nonunion. Treatment of type ii odontoid fracture with a novel. Therefore, the aim of our study was to describe and evaluate a novel technique, cabledragged reduction cantilever beam internal fixation for the treatment of type ii odontoid fracture. Type iii odontoid fractures may occur without major trauma 10. Apr 12, 2020 initial management of a type i dens fracture is use of a cervical orthosis. Nondisplacedminimally displaced with no comminution. In cases of type ii fracture, analysis of the class iii evidence suggests that both operative and nonoperative management remain treatment options. For patients with type ii fractures, treatment remains controversial, as discussed by anderson and dalonzo, due to the rising morbidity and mortality rates for any treatment. Type i fractures occur very rarely and type ii is the most common type i. Factors that affect fracture healing include the anderson and dalonzo classification of fracture line anatomy, the magnitude of distraction andor angulation 4, 12, and the age of the patient 2, 4, 6, 7, 18. The optimum treatment of type ii odontoid fractures in the elderly remains controversial.
Management of acute combination fractures of the atlas and axis. Nonunion occurs in 30% to 50% in the elderly and those with significant displacement angulation of more than 10 degrees or translation of more than 5 mm. Odontoid screw fixation is the preferred method for stabilization of acute, unstable type ii odontoid fractures. There is uncertainty regarding the consequences of nonunion. Still, due to the paucity of evidence the published treatment guidelines are far from equivocal. Rigid cervical collar treatment for geriatric type ii. 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. Nonsurgical measures include immobilization, prevent or restrict movement, in a. To evaluate fracture healing, functional outcomes, complications, and mortality associated with rigid cervical collars. Surgical management of odontoid fractures at level one. Cochrane form ii for rcts 9, cochrane table 1 the medline search strategy odontoid fractures or odontoid fracture or os odontoideum or c2 fracture or c2 fractures or c2.
Considerable controversy exists regarding the optimal management of elderly patients with type ii odontoid fractures. Other potential variables include the presence of more pressing sequelae of trauma and the. Fractures at the dens base, classified by the anderson and dalonzo system as type ii injuries, are the most common pattern of all odontoid fractures and are also the most common cervical injuries in patients older than 70. Case report type ii old odontoid fractures in the ankylosing. Direct transoral reduction of anteriorly displaced type ii. Despite the publication of numerous studies, there remains controversy regarding the non. The mechanism of injury is variable, and can occur both during flexion or extension, and with or without compression 5. Anterior osteosynthesis with 1 or 2 screws leads to good results in the classical unstable type ii odontoid fracture in patients with good bone. May 15, 2000 therefore, a casecontrol study based on class ii data was designed to evaluate age as a risk factor for failure of halo vest immobilization in patients with type ii dens fractures. Odontoid process fracture an overview sciencedirect topics. How are odontoid process fractures of the cervical spine. Aug 22, 2018 displaced odontoid fractures in the elderly are treated nonsurgically with a cervical collar or surgically with c1c2 fusion. Nonoperative management of types ii and iii odontoid.
Original article treatment of odontoid type ii fractures. Current concepts in the management of type ii odontoid fractures. Pdf nonoperative management of type ii odontoid fractures in. Displaced fracture with fracture line from anterosuperior to posteroinferior. The biomechanics in the atlantoaxial joint carry more than 50% of the rotational movement which can be affected in transverse ligament tear associated with odontoid fracture type ii. B type ii odontoid fracture is a fracture at the base of the dens. Management of type ii odontoid process fractures in geriatric patients.
Nonoperative treatment is usually the treatment of choice for odontoid fracture types i and iii. Treatment options for type ii odontoid fractures can be nonsurgical or surgical. Type i is a rarely occurring fracture of the apical portion of the odontoid process. Imaging of the cervical spine fractures dens fracture type ii. Similar to the literature on isolated type ii odontoid fracture. How are odontoid process fractures of the cervical spine treated. Type iii odontoid fractures of the axis are the second most common injuries of the cervical spine. Patients who were treated with the halo vest had a higher fusion rate than those managed with the philadelphia collar. Lateral subluxation of the atlas c1 and axis c2 associated with type ii odontoid fracture of the dens is very rare. The objective of the study was to evaluate the published. Treatment modality in type ii odontoid fractures defines the. N2 external immobilization with a halo vest is the traditional treatment of choice for type iii fracture of the odontoid process of c2 dens. Odontoid fracture type ii is considered an unstable fracture with a high rate of nonunion in. Thirtythree patients with isolated type ii dens fractures treated with halo vest immobilization at the university of iowa hospitals and clinics between 1983 and 1997 were included.
It is associated with excellent clinical results and a high rate of fusion. Grauer classification of type ii odontoid fractures. Every patient with an odontoid fracture presents a unique clinical challenge. Initial management of a type i dens fracture is use of a cervical orthosis. The optimal treatment of odontoid fractures in elderly. Approximately 9% to 20% of all cervical fractures are dens fractures, 2, 6 10 with most 65% to 74% being type ii fractures. Odontoid fractures comprise 920% of all cervical spine fractures. Type ii odontoid fracture the spine hospital at the neurological. The fracture line involves the junction of the body of the dens with the body of the axis.
The nonoperative management of type ii odontoid fractures in elderly patients results in fracture stability, by either osseous union or fibrous union in almost all patients. Fractures at the dens base, classified by the anderson and dalonzo system as type ii injuries, are the most common pattern of all odontoid fractures and are also the most common cervical injuries in patients older than 70 years of age. These injuries may be missed clinically because of the lack of clinical signs except for neck pain. Medical records, rates of reduction, the location of the instrumentation and fracture healing during followup were analyzed. Odontoid process fracture, also known as a peg or dens fracture, occurs where there is a fracture through the odontoid process of c2 pathology. Traumatic atlantoaxial lateral subluxation with chronic type. A search of the english language literature from january 1970 to date was performed using medline and the following keywords.
Type ii fractures with any additonal risk factors for nonunion displacement, comminution, etc should be considered for surgical management. Therefore, a casecontrol study based on class ii data was designed to evaluate age as a risk factor for failure of halo vest immobilization in patients with type ii dens fractures. Type ii is the most common dens fracture and occurs at the base of the dens. Reliability of the stir sequence for acute type ii odontoid.
Vaccaro ar, kepler ck, kopjar b, chapman j, shaffrey c, arnold p, et al. Whereas type i fractures are very rare, type ii and iii fractures are frequently experienced in clinical practice. Thirtyfour patients with surgical management by fusion. C with type iii odontoid fracture, the fracture line extends into the body. Management of type iii dens fracture taipei medical. 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. Ii, is the commonest injury in the upper cervical spine. Although a consensus exists on the nonoperative management of types i and iii odontoid peg fractures, treatment of type ii fractures remains controversial. Reliability of the stir sequence for acute type ii. 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 the only spinal fixation technique for fractures that restores spinal stability yet completely preserves normal spinal motion. Outcome scores were compared with a group of 40 agematched control subjects average age 79. Contemporary management of adult cervical odontoid fractures. 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. The management of these fractures is controversial. Extension of the fracture through upper portion of body of c2 unstable fracture. First is the difficulty in precise differentiation between a low type ii and a high type iii fractures. Fractures of the odontoid process comprise 18% to 20% of cervical injuries, of which 65% to 74% are type ii fractures. Unstable injuries to the upper cervical spine are a hazard to every elderly person, since associated dysphagia and respiratory restrictions are potential deadly complications.
The odontoid fracture is the most common type of injury to the cervical spine in people over. Odontoid fractures comprise as many as 20% of all cervical spine fractures. Type ii fracture extends through the base of the dens. 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. What are the types of odontoid process fractures of the.
Odontoid fractures type ii according to anderson and dalonzo are not uncommon in the elderly patients. Fractures of the dens can be seen at any time of life, but. Due to the paucity of evidence, the treatment decision is often left to the discretion of the expert surgeon. The commonest type of the axis injury is an odontoid fracture at the junction of the dens and the body type ii odontoid fracture2. Odontoid process fracture, also known as a peg or dens fracture, occurs where there is a fracture through the odontoid process of c2. Surgical methods for type ii odontoid fracture can be classified into 2 main. This is the only spinal fixation technique for fractures that restores spinal stability yet. Recommendations for diagnosis and treatment of odontoid. Type i fracture extends through the tip of the dens. The most common fracture types according to the anderson and dalonso classification are type ii fractures 6574%, which are considered to be relatively unstable 4, 5. Type ii fractures were defined with plain radiography as per the andersondalonzo classification. Nonoperative treatment of displaced type ii odontoid peg.
It is the most commonly encountered fracture for this region of the axis. The optimal treatment of type ii and iii odontoid fractures. A more effective way to achieve bone fusion with the lowest possible surgical risk is needed. This type iia fracture was highly unstable and was. Roycamille classification of odontoid process fracture. Odontoid fractures account for 9%15% of cervical spine fractures. A casecontrol study of patients with isolated type ii dens fractures treated with halo vest immobilization.
Thirtythree patients with isolated type ii dens fractures treated with halo vest immobilization at the university of iowa hospitals and clinics between. This classification scheme aids 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. Odontoid fractures account for approximately 20% of all fractures of the cervical spine. The most common upper cervical fracture in elderly people aged. Manage types ii and iii fractures by applying traction with cervical tongs. Conservative treatment in patients with type 2 odontoid. The roycamille classification of fractures of the odontoid process of c2 depends on the direction of the fracture line 1 the level of fracture line as described by the anderson and dalonzo classification is not predictive of the degree of instability or the risk of nonunion. Possible treatment options are either conservative or surgical. The uppsala study on odontoid fracture treatment usoft is a multicentre, openlabel, randomised controlled superiority trial evaluating the clinical.
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