Type ii odontoid fracture is the most common cervical spine fracture in the elderly, and the incidence of this injury is increasing. Due to the paucity of evidence, the treatment decision is often left to the discretion of the expert surgeon. Conservative treatment in patients with type 2 odontoid fracture. This is the least common type of odontoid fracture. Two thirds of all odontoid process fractures are type ii. Despite their frequency, there is considerable ambiguity regarding optimal management strategies for these fractures in the elderly. Chapter 315 evaluation and treatment of odontoid and hangmans fractures. If the mri determines that there is associated ligament injury it is likely that the fracture is unstable and we would suggest operative management. The alar ligaments, together with the apical ligaments, are attached from the sloping upper edge of the odontoid peg. High energy trauma accounts for the first peak, especially road traffic accidents. A relative contraindication to arthrodesis is an ununited fracture which has been immobilized for less than 20 weeks without neurologic deficit. However, in atraumatic odontoid fractures, mainly reported by orthopedic surgeons, bone status has not been described yet 1.
Fracture of the odontoid process is the most common type of cervical spine fracture in elderly patients i. However, good radiological outcome union does not necessarily provide good functional outcome. Lifethreatening fractures can occur as a result of forces acting on this anatomical structure due to its proximity to the spinal cord and brainstem. Fractures of the axis are the most common cervical spine fracture in the elderly population. Type ii occurs at the base of the odontoid process and represents the most common fracture type. This fracture is therefore described as an oblique avulsion fracture of the tip of odontoid resulting from avulsion of the alar ligament. This is the least common type of odontoid fracture and is generally stable. Its treatment remains quite challenging because of the associated risk owing to the complex anatomy of the craniocervical junction. Recognition of the incidence of odontoid fractures as well as the associated morbidity and unexpectedly high mortality rates has prompted significant changes in. Be aware of potential pitfalls and how to avoid them when imaging the odontoid peg. Odontoid process fractures represent an uncommon injury in small children, with their optimal management remaining unclear. Morphometric analysis of the c2 body and the odontoid process.
The odontoid process lies anterior to the spinal cord and is used as the pivot for the rotation of the head. The uppsala study on odontoid fracture treatment usoft is a multicentre, openlabel, randomised controlled superiority trial evaluating the clinical. 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. Displaced type 2 odontoid peg fracture with atlantoaxial subluxation.
Management of type ii odontoid fractures in adults. Treatment modality in type ii odontoid fractures defines. The cement augmentation of a conventional anterior screw fixation in type ii odontoid process fractures for elderly patients significantly increased stiffness and load to failure under anteriorposterior load in comparison with nonaugmented fixation. Orthopedics although a consensus exists on the nonoperative management of types i and iii odontoid peg fractures, treatment of type ii fractures remains controversial.
In our population group, there is a bimodal distribution of odontoid peg fractures with the first peak among young adults and the second as expected in the elderly. The uppsala study on odontoid fracture treatment usoft is a multicentre, openlabel, randomised controlled superiority trial. Type i consisting of an avulsion of the superior portion of the odontoid peg, which is extremely uncommon. Here, for patients 65 years of age with type ii odontoid fractures treated with screw fixation, the authors documented the incidence of postoperative dysphagia, its complications, and costs. Table 1 lists some of the recent published studies on the management of type ii odontoid fractures in elderly. A 19 yearold boy presented with type ii odontoid fracture and subsequently underwent anterior odontoid screw fixation. Odontoid fractures to fuse or not to fuse orthopaedicsone. Complications may arise during diagnosis, nonoperative management, decisionmaking regarding operative management technique, or by execution of the chosen surgical method. Dysphagia and deformity afterundetected odontoid fracture. Their clinical signs included reluctance to move the neck and head, dullness, and abnormalities of gait. Anterior odontoid screw fixation for type ii odontoid. Optimal treatment for odontoid fractures in the elderly. Management comprises of conservative measures with external immobilization using a hard cervical collar.
Fracture from anteroinferior to posterosuperior, or with significant comminution. Odontoid process fractures account for 10%15% of all cervical fractures. Current who definition of osteoporosis excludes cervical fractures. Treatment is with anterior odontoid screw if adequate bone density. Odontoid type ii fractures in the elderly complications. Management of odontoid fractures in the elderly springerlink. We present a case of conservatively managed displaced type 2 odontoid process fracture in a small child. Incidence of dysphagia after odontoid screw fixation of. Fracture along the attachment of the odontoid process to the body of c2 is known as a type ii fracture, and. This mechanism of injury gives rise to odontoid fractures that are of. Treatment protocol for fractures of the odontoid process. Odontoid, geriatric, dens, type ii odontoid fracture, c1c2 fusion. Introduction fracture of the odontoid of the axis is a common injury in the cervical spine. Fracture of the odontoid superior to its attachment to the body of c2 is known as a type i fracture.
Odontoid fractures anterior odontoid screw fixation. Displaced fracture with fracture line from anterosuperior to posteroinferior. Demographic data, mechanism of injury, associated injuries, neurology, imaging studies and. Patients who were treated with the halo vest had a higher fusion rate than those managed with the philadelphia collar. Incidence of dysphagia after odontoid screw fixation of type. Any information contained in this pdf file is automatically generated from digital material. General description odontoid projects superiorly from body of axis c2 odontoid attaches to articular facet on anterior arch of atlas odontoid allows enormous mobility rotation for the atlas and occiput ligaments.
Odontoid fractures are the most common fracture of the axis and the most common cervical spine fracture in patients over 65. The majority of these injuries are type ii injuries. In this study, we wanted to clarify the role of bone. 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. Odontoid peg fracture, axis, nonoperative, anderson dalonzo. The management of these fractures is controversial. These structures may be difficult to visualize effectively. Complications related to the management of odontoid fractures paul kraemer rick c. Treatment modality in type ii odontoid fractures defines the. The c1 vertebra, carrying the cranium, rotates on this.
Patient selection in odontoid fracture care is critical. C12 fusion through the anterior approach for failed. 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. Odontoid process definition of odontoid process by the.
Surgical treatment of type ii fractures in the elderly does not negatively impact survival 14. Pdf odontoid fractures are frequent in patients over 70 years of age, and in patients over 80 years. The peg has an articular facet at its front and forms part of a joint with the anterior arch of the atlas. 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. Fractures of the dens of the axis are of considerable.
Management of odontoid fractures with percutaneous. Sasso care of the patient with an odontoid fracture continues to be fraught with difficulty. Background odontoid peg fractures account for 15% of cervical spine fractures following a motor. Displaced odontoid fractures in the elderly are treated nonsurgically with a cervical collar or surgically with c1c2 fusion. 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. Pdf management of odontoid fractures in the elderly researchgate. C12 fusion through the anterior approach for failed odontoid screw fixation introduction odontoid fractures occur commonly in a. The alar ligaments, together with the apical ligaments, are attached from the sloping upper edge of the odontoid peg to the margins of the foramen magnum. The conservative treatment includes cervical orthoses, halo vests, and jackets, which may allow for the fracture to fuse without the. Noninvasive management of an odontoid process fracture in. The mechanism of injury is variable, and can occur both during flexion or extension, and with or without compression 5 classification. What are the types of odontoid process fractures of the. Evaluation and treatment of odontoid and hangmans fractures. The amount and quality of bone cement are usually taken ad hoc in clinical practise.
Ct of the cervical spine a, b showed that old type ii dens fracture. 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. Radiography was essential for the diagnosis, and the method of treatment varied depending on the severity of the neurological. Management of odontoid fractures in the elderly article pdf available in european spine journal 85. The most commonly used classification scheme to categorize odontoid fractures was described by anderson and dalonzo and is based on the anatomic location of the fracture. Complications related to the management of odontoid fractures. Identify the anatomy and imaging features of different types of odontoid peg fractures. The odontoid process, also called the dens, is a protuberance of the axis. These are commonly sustained in the elderly following low energy trauma and concommitant neurological injury is uncommon. Odontoid type ii fractures in the elderly complications and. It is also more costeffective than conservative treatment in. Dysphagia and deformity afterundetected odontoid fracture in. Asf is the treatment of choice for most type ii and unstable iii fractures including. Sagittal t2 mri demonstrating distracted type 23 odontoid peg fracture with.
Possible treatment options are either conservative or surgical. 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. The merits of operative vs nonoperative management, fibrous union, and. Despite controversy over the optimal management of type ii odontoid fractures, there has been an increase in the operative management reported. We conducted a prospective study from january 2016 to january 2017 in patients. Halo devices provided successful results in stable type iii fractures. Nonoperative treatment of displaced type ii odontoid peg. Aug 22, 2018 displaced odontoid fractures in the elderly are treated nonsurgically with a cervical collar or surgically with c1c2 fusion. Journalof accidentand emergency medicine1995 12, 293295 case report dysphagiaanddeformityafterundetectedodontoid fracture in elderlypatients m. Evaluation and acute management of cervical spinal column injuries in adults view in chinese scenarios, including trauma involving elder patients, who are more likely to sustain type ii odontoid fractures. Osteoporosis is the most important risk factor for. The axis shows a peg like odontoid process that projects itself superiorly from the body.
Fractures of the cervical vertebral odontoid in four. The uppsala study on odontoid fracture treatment usoft is a multicentre. Odontoid fractures are the most common spinal fracture in the elderly, with rising incidence and costs. Nonoperative management of types ii and iii odontoid. Odontoid peg, fracture, elderly, mortality, complications, epidemiology background odontoid peg fractures comprise up to 15% of all spine injuries. 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. Pdf management of odontoid fractures in the elderly. The mechanism of injury is variable, and can occur both during flexion or extension, and with or without compression 5. Odontoid fractures account for approximately 20% of all fractures of the cervical spine. The 3 types of odontoid process fractures are classified based on the anatomic level at which the fracture occurs see the image below.
Displaced odontoid fractures in the elderly are treated non surgically with a. Pdf evidencebased analysis of odontoid fracture management. Current concepts in the management of type ii odontoid fractures. Odontoid process fracture, also known as a peg or dens fracture, occurs where there is a fracture through the odontoid process of c2 pathology.
Case report type ii old odontoid fractures in the ankylosing. The problem lies in the management of type ii odontoid fractures, which are the most. Four horses and one pony, ranging in age from one to 11 years, were diagnosed with two different types of odontoid peg fractures. Noninvasive management of an odontoid process fracture in a. Although a consensus exists on the nonoperative management of types i and iii odontoid peg fractures, treatment of type ii fractures remains controversial. Odontoid process fracture an overview sciencedirect topics. Fractures of the odontoid account for approximately 20% of all cervical fractures, with approximately 70% being type ii fractures ie, fracture crossing the base of the odontoid process at the junction with the axis body. Conservative treatment in patients with type 2 odontoid. Definitions, mechanisms, and radiographs view in chinese unstable atlantooccipital or atlantoaxial joint dislocation, with or without an associated odontoid fracture several measurements are used to determine the presence of atlanto.
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. Management of odontoid fractures in the elderly practiceupdate. To investigate bone status in elderly patients sustaining a low energy odontoid fracture. Odontoid process definition of odontoid process by the free. Sep 12, 2010 the best treatment remains unclear because of the morbidity associated with prolonged cervical immobilisation versus the risks of surgical intervention. Good fracture union rates were achieved at 6 and 9 months from the injury. The majority of the data is class iii evidence, and unfortunately due to the heterogeneous nature of these studies with regard to patient selection, comorbidities, lack of clear definition of fracture subtype with age as well as. Issues relating to fracture configuration, the size of the remaining peg in achieving distal fixation, the need for and ease of fracture reduction, and bone density are all variables to consider in the ability to properly place screws with sufficient fixation to encourage fracture healing figures 1 and 2. There is a lack of consensus on optimal management strategies. Discussion the results of this study show that both type ii and iii odontoid fractures can be effectively treated nonoperatively. In a retrospective analysis of 23 geriatric 70 years patients with a fracture of the odontoid. A fracture of the odontoid bone also called the dens, is an upward extension of c2 cervical vertebrae i.
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