EXTERN CONFERENCE

ARUN YACHARAD
RAMATHIBODI HOSPITAL
04-08-60
PATIENT PROFILE
:

CHIEF COMPLAINT
:
?
PRESENT ILLNESS

:
PRESENT ILLNESS
AT ER MNRH
AT ER MNRH
MANAGEMENT AT ER
On Philadelphia collar

Film C-spine AP, lateral cross table swimming view, open mouth
Film C-spine AP, lateral cross table
swimming view, open mouth
Film C-spine AP, lateral cross table
swimming view, open mouth
Normal vs Abnormal
Normal vs Abnormal
 DIAGNOSIS IN THIS CASE

Odontoid fracture Type II without neurodeficit

 MANAGEMENT IN THIS CASE
CT C- spine

On skull traction 5 Kg.

Pain control

Bed rest
MANAGEMENT IN THIS CASE
CT C- spine
 REVIEW : ODONTOID FRACTURE
A fracture of the dens of the axis (C2)
Epidemiology incidence
• most common fracture of the axis
• account for 10-15% of all cervical fractures

• Demographics occur in bimodal fashion in elderly and young patients

• elderly
• common, often missed, and caused by simple falls
• associated with increased morbidity and mortality compared to younger patients with this injury
• young patients
• result from blunt trauma to head leading to cervical hyperflexion or hyperextension
 REVIEW : ODONTOID FRACTURE
Pathophysiology mechanism
• displacement may be anterior (hyperflexion) or posterior (hyperextension)
• anterior displacement
• is associated with transverse ligament failure and atlanto-axial instability
• posterior displacement
• caused by direct impact from the anterior arch of atlas during hyperextension

• biomechanics
• a fracture through the base of the odontoid Type II process severely compromises the
stability of the upper cervical spine
 REVIEW : ODONTOID FRACTURE
Associated conditions
• Os odontoideum
• appears like a type II odontoid fx on xray
• previously thought to be due to failure of fusion at the base of the odontoid
• evidence now suggests it may represent the residuals of an old traumatic process
• treatment is observation
 REVIEW : ODONTOID FRACTURE

Anderson and D'Alonzo Classification

Type I Oblique avulsion fx of tip of odontoid. Due to avulsion of alar
ligament. Although rare, atlantooccipital instability should be
ruled out with flexion and extension films.

Type II Fx through waist (high nonunion rate due to interruption of

blood supply).

Type III Fx extends into cancellous body of C2 and involves a variable

portion of the C1-C2 joint.
 REVIEW : ODONTOID FRACTURE
Grauer Classification of Type II Odontoid fractures
Type IIA Nondisplaced/minimally displaced with no
comminution. Treatment is external
immobilization
Type IIB Displaced fracture with fracture line from
anterosuperior to posteroinferior. Treatment is
with anterior odontoid screw (if adequate bone
density).
Type IIC Fracture from anteroinferior to posterosuperior,
or with significant comminution. Treatment is
with posterior stabilization.
 REVIEW : ODONTOID FRACTURE
Type II :

•
•

•
 REVIEW : ODONTOID FRACTURE
Type III
• Healing
• Halo-vest 8-12 wk.
 REVIEW : ODONTOID FRACTURE
Symptoms
• neck pain worse with motion
• dysphagia may be present when associated with a large retropharyngeal hematoma

Physical exam
• myelopathy
• very rare due to large cross section area of spinal canal at this level
 REVIEW : ODONTOID FRACTURE
Radiographs required views
• AP, lateral, open-mouth odontoid view of cervical spine

optional views
• flexion-extension radiographs are important to diagnose occipitocervical instability
in Type I fractures and Os odontoideum
• instability defined as
• atlanto-dens-interval (ADI) > 10mm
• < 13mm space available for cord (SAC)

findings
• fx pattern best seen on open-mouth odontoid
 REVIEW : ODONTOID FRACTURE

CT
• study of choice for fracture delineation and to assess stability of fracture pattern

CT angiogram
• required to determine location of vertebral artery prior to posterior instrumentation
procedures

MRI indicated if neurologic symptoms present

REVIEW : ODONTOID FRACTURE

Treatment
Os Odontoideum Observation
Type I Cervical Orthosis

Type II Young Halo if no risk factors for nonunion

Surgery if risk factors for nonunion
Type II Elderly Cervical Orthosis if not surgical
candidates
Surgery if surgical candidates
Type III Cervical Orthosis
 REVIEW : ODONTOID FRACTURE
Non operative
• observation alone
• indications
• Os odontoideum
• assuming no neurologic symptoms or instability

• Hard cervical orthosis for 6-12 weeks

• indications
• Type I
• Type II in elderly who are not surgical candidates
• union is unlikely, however a fibrous union should provide sufficient stability except in the case of major trauma

• Type III fractures : no evidence to support Halo over hard collar

• Halo vest immobilization for 6-12 weeks

• Indications : Type II young patient with no risk factors for nonunion
• Contraindications : elderly patients do not tolerate halo (may lead to aspiration, pneumonia, and death)
 REVIEW : ODONTOID FRACTURE
Operative
• posterior C1-C2 fusion
• indications
• Type II fractures with risk factors for nonunion
• Type II/III fracture nonunions
• Os odontoideum with neurologic deficits or instability

• anterior odontoid osteosynthesis

• indications
• Type II fractures with risk factors for nonunion AND
• acceptable alignment and minimal displacement
• oblique fracture pattern perpendicular to screw trajectory
• patient body habitus must allow proper screw trajectory
• outcomes
• associated with higher failure rates than posterior C1-2 fusion

• transoral odontoidectomy
• indications
• severe posterior displacement of dens with spinal cord compression and neurologic deficits
REVIEW : ODONTOID FRACTURE
Complication
• Nonunion
• increased risk in Type II fractures due to poor blood supply
• average nonunion rate 33% (up to as high as 88%)
• risk factors for nonunion include
• ≥ 6 mm displacement (>50% nonunion rate)
• strongest reason to opt for surgery
• age > 50 years
• fx comminution
• angulations > 10°
• delay in treatment
• smoker
REFFERENCES
THANK YOU…