Anderson type iii odontoid fractures have traditionally been considered stable and treated conservatively. The most commonly used classification system for odontoid fractures is. We therefore designed a study to analyze geriatric patients with type ii odontoid fractures treated with either rigid cervical collar or surgery. In our patient, this displaced type iii odontoid process fracture was anatomically reduced and then immobilized with a halo vest. Nonunion is not a major problem with these injuries because of a good blood supply and the greater amount of cancellous bone.
Odontoid fractures comprise 920% of all cervical spine fractures. Further studies are required to confirm these results. Conservative management of type ii and iii odontoid. Type i fractures occur very rarely and type ii is the most common type i. A surgical procedure for typeii fractures in the elderly population is associated with a higher union rate and potentially less mortality. There is a very low incidence of nonunion, and surgery is seldom indicated for these fractures. Pdf purpose odontoid fractures are the most common cervical spine fractures in the elderly. Certain typeii fractures can be treated nonoperatively, depending on fracture morphology and. 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. Grauer classification of type ii odontoid fractures.
The amount of cancellous bone contact is greater compared to type ii fractures. Type iii odontoid fractures j craniovert jun spine. Type ii fractures are the most common and involve the base of the odontoid process. Odontoid fractures have been divided into 3 major types according to the classification of anderson and dalonzo. High rates of bony union and stable fibrous nonunion with a good functional outcome can be achieved in the elderly population sustaining type ii or iii odontoid.
Odontoid fractures are divided into type i through the tip of the odontoid, type ii at the base of the odontoid, and type iii extending from the base of the odontoid into the vertebral body. For stable type iii odontoid fracture without significant\. It can be the only radiological sign of a type iii low odontoid fracture in an elderly patient. There are three different types of odontoid process fracture characterised by the anatomic location of the fracture line. A type i fracture is an avulsion fracture of the apex of the odontoid, a type ii fracture occurs at the junction between the base of the odontoid and body of the c2 the most frequently seen type, comprising 6574% of all cases, and a type iii fracture line extends through the body of c2. Approximately 50% of axial rotation of the cervical spine occurs at the c1c2 articulation. There was agreement in 70% of the cases by at least 5 of 7 raters. The optimum treatment of type ii odontoid fractures in the elderly remains controversial. 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. In cases of type ii fracture, analysis of the class iii evidence suggests that both operative and nonoperative management remain treatment options.
Presented by michele johnson, md, of the university of texas houston. This is in contrast to type ii fractures which can be managed conservatively. Type i fractures at the tip of the odontoid are rare and usually stable, type ii fractures at the base of the odontoid process are the most common and are inherently unstable, and type iii. 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. Oct 01, 2000 this type is the most common and potentially the most unstable. Catastrophic failure of conservatively treated odontoid. Whereas type i fractures are very rare, type ii and iii fractures are frequently experienced in clinical practice. 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. Treatment of type ii odontoid fracture with a novel techniqu.
Odontoid fracture that is not listed in the existing classifications a. While most authors agree that cervical immobilisation yields satisfactory results for type i and iii fractures in the elderly, the optimal management for type ii fractures remain unsolved. The results of this study show that both type ii and iii odontoid fractures can be effectively treated nonoperatively. Contemporary management of adult cervical odontoid fractures. The mechanism of injury is variable, and can occur both during flexion or extension, and with or without compression 5 classification. As these are unstable fractures, their detection is important, even before a spiral ct is performed. This study is a retrospective evaluation of surgically treated type ii odontoid fracture cases. A regression model was constructed and identified fracture type as the only independent predictor of time to union, with type iii fractures healing faster than type ii. A type iii odontoid fracture is characterized by a horizontal. The management of these fractures is controversial. Good fracture union rates were achieved at 6 and 9 months from the injury. Conservative management of type ii and iii odontoid fractures. 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.
These injuries are classified into type 1, ii or iii according to the location of fracture of the odontoid process. Odontoid fractures of the elderly related to osteoporosis often have intact c1c2 joint capsules, anterior longitudinal ligament, and accessory ligaments, which stabilise the osteoporotic type ii odontoid fracture produced in a lowenergy mechanism. Nondisplacedminimally displaced with no comminution. Orthopedics although a consensus exists on the nonoperative management of types i and iii odontoid peg fractures, treatment of type ii fractures remains controversial. Surgical management of odontoid fractures at level one. For complex type iii fractures, we recommend initial conservative treatment, while maintaining close monitoring throughout patient recovery and fracture union. In this article the authors describe the management of type ii odontoid fractures with special attention to operative technique and avoidance of complication.
The most prevalent type of odontoid fracture was type ii 55% followed by type iii 40%. Type iii odontoid fracture occurs when the fracture line extends into the body of the axis. Conservative management of type ii and iii odontoid fractures in the elderly at a regional spine center. Pdf the optimal treatment of type ii and iii odontoid fractures in the. Odontoid fractures account for 918 % of all cervical spine fractures. Fracture from anteroinferior to posterosuperior, or with significant comminution. The optimal treatment of type ii and iii odontoid fractures. N2 external immobilization with a halo vest is the traditional treatment of choice for type iii fracture of the odontoid process of c2 dens. In 1988, a new subtype of odontoid fracture type iia was described that involves comminution at the base of the dens.
Type i fractures can be managed conservatively with a hard collar for 68 weeks in duration. Surgical outcome of type ii odontoid fracture, harms technique. Management of acute combination fractures of the atlas and axis. This was a retrospective study enrolled 34 patients underwent posterior cabledragged reductioncantileverbeam internal fixation surgery. Fracture at base of odontoid where it meets c2 body unstable fracture. Type iii is a fracture extending into the body of the axis 24. The cervical spine research society had used the anderson and. 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. The most prevalent type of treatment used for type ii and iii fractures. Type i fractures involve avulsion off the tip of the odontoid solid green line. 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. The commonest type of the axis injury is an odontoid fracture at.
Nonoperative management of types ii and iii odontoid. Treatment is with anterior odontoid screw if adequate bone density. As the population ages, their incidence is expected to. The problem lies in the management of type ii odontoid fractures, which are the most common. The type iia fracture is the only widely accepted modification to the andersondalonzo nomenclature and includes comminution associated with a type ii fracture. Treatment modality in type ii odontoid fractures defines the. They occur through the tip of the dens type i, the base of the dens type ii, or through the body of c2 type iii. They applied their revised scheme to a series of 52 patients with odontoid fractures. There is insufficient evidence to establish a standard or guideline for odontoid fracture management in elderly. Odontoid process fracture, also known as a peg or dens fracture, occurs where there is a fracture through the odontoid process of c2 pathology.
Type ii fractures occur at the odontoid base dotted yellow line, while type iii fractures extend into the c2 body dashed blue line and typically involve the superior c2 facet joint arrows. A treatment algorithm is presented based on the available literature. Off all the cases of cervical trauma, about one out of five involves the axis1. Reliability of the stir sequence for acute type ii odontoid. C1type ii odontoid fractures and 1 c1type iii odontoid combination fracture injury.
This type is the most common and potentially the most unstable. Psf for type ii odontoid fx 26 patients average age 79 years 19 % mortality at months 66 % fracture nonunion rate all stable nonunions no difference in disability neck pain to age matched cohort functional outcomes, morbidity, mortality, and fracture healing in 26 consecutive geriatric odontoid fracture patients treated with. Possible treatment options are either conservative or surgical. Treatment modality in type ii odontoid fractures defines. 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. Nonoperative treatment of displaced type ii odontoid peg. Odontoid fracture type ii is found to have high inci. Odontoid process fracture an overview sciencedirect topics.
Geriatric patients can develop odontoid fractures after minor trauma with hyperextension injuries. However, unstable cases with unfavorable results following conservative treatment have been reported. In this paper, our aim is to report our experience in management of patients with odontoid fracture type ii. In this system, type i describes an oblique fracture of the tip of the dens, type ii is a fracture at the junction of the dens and the central body of the axis, and type iii is a fracture in which the fracture line extends downward into the cancellous portion of the body of the axis. Odontoid fractures account for approximately 20% of all fractures of the cervical spine. About 15% of these patients will have neurological injury. Management of odontoid fractures in the elderly springerlink. Surgical management of odontoid fractures at level one trauma.
Type ii fracture fracture through base of dens most common odontoid fracture. Odontoid, geriatric, dens, type ii odontoid fracture, c1c2 fusion. Nonsurgical management of type ii odontoid fracture has historically been associated with a high nonunion rate. The parameters studied were age, gender, and characteristics of the fracture, such as degree of odontoid displacement, displacement of the odontoid relative to the body of the c2, anatomy of the fracture line, and the distance between fragments. 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. Analysis of predisposing factors in elderly people with type ii. Although who osteoporosis definition excludes cervical fractures, odontoid fracture may be considered as an osteoporotic fracture. Seven raters were asked to characterize the odontoid fracture injuries. Management of type iii dens fracture taipei medical university. Type ii fractures usually have the most difficulty reestablishing bony union at the. The determination of operative versus nonoperative treatment for type ii fractures was made on the basis of fracture anatomy, patient age, other associated injuries,and patient preference. Type 2 odontoid fracture, halo vest, union rate, function and neck pain introduction odontoid fractures continue to pose clinical challenges.
Extension of the fracture through upper portion of body of c2 unstable fracture. What are the types of odontoid process fractures of the. N2 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. Conservative treatment in patients with type 2 odontoid. High risk of nonunion 30% due to interruption of blood supply. Seventyfive patients with type ii odontoid fracture and 75 healthy controls mean and median age of 57 years were identified. Sep 12, 2010 there is insufficient evidence to establish a standard or guideline for odontoid fracture management in elderly. Displaced fracture with fracture line from anterosuperior to posteroinferior. Therefore type ii odontoid fractures in the young and in the elderly are two different injuries, and different treatment protocols may be necessary. Typeii odontoid fractures are associated with higher nonunion rates compared with type i and type iii. Pdf conservative management of type ii and iii odontoid.
The merits of operative vs nonoperative management, fibrous union, and the choice of operative approach in elderly patients are discussed. We believe that type i and type iii odontoid fractures can be managed in a collar in most cases. Evaluation and treatment of odontoid and hangmans fractures. Type iii fracture extension through vertebral body of axis. The 3 types of odontoid process fractures are classified based on the anatomic level at which the fracture occurs see the image below. This is the least common type of odontoid fracture and is generally stable. Fracture along the attachment of the odontoid process to the body of c2 is known as a type ii fracture, and fracture of the odontoid inferior to its attachment to the body of c2 that includes part of the body of c2 is known as a type iii odontoid fracture. Medical records, rates of reduction, the location of the instrumentation and fracture healing during followup were analyzed. Reliability of the stir sequence for acute type ii.
Odontoid fractures are the most common type of axis injury and account for 7 to 14% of cervical. Displacement of the odontoid fracture plays a key role in determining union. Management of type ii odontoid fractures in the geriatric. Management of isolated fractures of the axis in adults. Tracheal tube placement in patients with type iii odontoid fractures should be performed very carefully to prevent. For complex type iii fractures, we recommend initial conservative treatment, while maintaining close monitoring throughout patient recovery and. Pdf evidencebased analysis of odontoid fracture management. In general, nonsurgical management of type iii odontoid fractures was recommended, accompanied by use of a cervical orthosis. This is called the anderson and dalonzo classification. 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.
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