Odontoid fracture

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Odontoid fractures most often result from traumatic flexion injury. In young patients they require a good deal of force, as in motor vehicle collision, skiing accident or fall from a height. In the elderly, even a trivial fall may lead to an odontoid fracture. Immediate death from medullary injury may occur. Other presenting signs include high posterior neck pain/ point tenderness with or without occipital neuralgia, reduced range of motion, upper extremity parathesias, and a tendency to hold one’s head in the process of laying down.


Classification and Treatment

Type I: fracture through tip of dens above transverse ligament; rare; considered stable but may be associated with atlanto-occipital dislocation. In this case, surgical fusion is indicated.

Type II: fracture through base of the dens neck; most common type; usually unstable. Whether fusion will occur with immolization alone depends on both patient age and degree of displacement. Treatment remains controversial, but in general patients younger than seven years or with less than 4mm of displacement tend to fuse with 10-12 weeks of halo immobilization. Fractures displaced beyond 6mm in patients older than seven, or that are unstable even in a halo, require surgery. Nonunion is manifested by continued neck pain, myelopapthy, or radiographic findings (vascular or atrophic pseudarthrosis, loss of cortical continuity, movement of fragments on flex-ex series) Type IIA: large bone fragments at fracture site. Treat with early surgery.

Type III: fracture through body of C2; usually stable. Immobilize, preferably with halo.

References

1. Crockard HA, Heilman AE, Stevens JM. Progressive myelopathy secondary to odontoid fractures: clinical, radiological, and surgical features. J Neurosurg. 1993 Apr;78(4):579-86.'

2. Greene KA, Dickman CA, Marciano FF, Drabier JB, Hadley MN, Sonntag VK. Acute axis fractures. Analysis of management and outcome in 340 consecutive cases. Spine. 1997 Aug 15;22(16):1843-52.

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