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Odontoid Fracture (Adult and Pediatric)

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Topic updated on 04/21/14 2:31pm
Introduction
  • 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
          • commonoften 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
  • 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 process severely compromises the stability of the upper cervical spine.
  • 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
Anatomy
  • Axis Osteology
    • axis has odontoid process (dens) and body
    • embryology
      • develops from five ossification centers  
      • subdental (basilar) synchondrosis is an initial cartilagenous junction between the dens and vertebral body that does not fuse until ~6 years of age  
      • the secondary ossification center appears at ~ age 3 and fuses to the dens at ~ age 12 
  • Axis Kinetmatics
    • CI-C2 (atlantoaxial) articulation
      • is a diarthrodal joint that provides 
        • 50 (of 100) degrees of cervical rotation 
        • 10 (of 110) degrees of flexion/extension 
        • 0 (of 68) degrees of lateral bend 
    • C2-3 joint
      • participates is subaxial (C2-C7) cervical motion which provides
        • 50 (of 100) degress of rotation
        • 50 (of110) degrees of flexion/extension
        • 60 (of 68) degrees of lateral bend
  • Occipital-C1-C2 ligamentous stability 
    • provided by the odontoid process and its supporting ligaments
      • transverse ligament  
        • limits anterior translation of the atlas
      • apical ligaments
        •  limit rotation of the upper cervical spine
      • alar ligaments
        • limit rotation of the upper cervical spine
  • Blood Supply
    • a vascular watershed exists between the apex and the base of the odontoid   
      • apex is supplied by branches of internal carorid artery
      • base is supplied from branches of vertebral artery
      • the limited blood supply in this watershed area is thought to affect healing of type II odontoid fractures.
Classification
  •  Anderson and D'Alonzo Classification  
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.
  
 
Presentation
  • 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
Imaging
  • 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  
  • 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  
Treatment

Treatment Overview
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
  • Nonoperative
    • 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)
  • 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
        • Type I with atlantooccipital instability (extremely rare)
    • 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
Surgical Techniques
  • Halo immobilization 
    • in children and adults 
  • C1-C2 posterior fusion techniques
    • approach
      • posterior midline cervical approach
    • stabilization technique
      • sublaminar wiring techniques (Gallie or Brooks)
        • require postoperative halo immobilization and rarely used
      • posterior C1-C2 transarticular screws construct  
        • contraindicated in patients with an aberrant vertebral artery 
      • posterior C1 lateral mass screw and C2 pedicle screw construct  
        • modern screw constructs do not require postoperative halo immobilization
    • outcomes
      • C1-C2 fusion will lead to 50% loss of neck motion
  • Anterior odontoid screw osteosynthesis  
    • approach
      • anterior approach to cervical spine 
    • technique
      • single screw adequate
    • pros & cons
      • associated with higher failure rate than posterior C1-2 fusion
      • advantage is preservation of atlantoaxial motion
  • Transoral odontoidectomy post
    • technique
      • usually combined with posterior stabilization procedure
Complications
  • Nonunion
    • increased risk in Type II fractures due to poor blood supply
    • risk factors for nonunion include 
      • > 5 mm displacement (>50% nonunion rate)
      • fx comminution
      • angulations > 10 degrees
      • age > 50 years
      • delay in treatment

 

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Qbank (8 Questions)

TAG
(OBQ12.65) A 45-year old male is involved in a motor vehicle accident and presents to the emergency room with complaints of neck pain. Physical exam shows he is an ASIA E. An open-mouth cervical radiograph is shown in Figure A. A sagittal CT scan is shown in Figure B. A CT axial angiogram is shown in Figure C. Which of the following treatment options is contraindicated in this patient. Topic Review Topic
FIGURES: A   B   C      

1. Anterior screw osteosynthesis with single cannulated screw
2. Halo immobilization
3. Anterior screw osteosynthesis with two cannulated screws
4. C1-C2 transarticular screws
5. Posterior C1-C2 wiring with autograft

PREFERRED RESPONSE ▶
TAG
(OBQ12.103) A young boy is involved in a motor vehicle accident and presents with neck pain. A CT scan is performed and is negative for fractures. Based on the presence of the ossification center shown in Figure A, what is the most likely age bracket of this patient. Topic Review Topic
FIGURES: A          

1. < 1 years of age
2. 1-3 years of age
3. 3-6 years of age
4. 8-10 years of age
5. > 12 years of age

PREFERRED RESPONSE ▶
TAG
(OBQ12.116) A 67-year-old male smoker was involved in a motor vehicle accident and presents with neck pain. On initial presentation his neurologic exam was intact. Injury films are shown in Figure A and B. The patient was evaluated and surgical treatment was recommended. The patient left the hospital against medical advice. Seven months later he returns with continued neck pain. His current neurologic exam shows no deficits. A current CT scan and MRI is performed and shown in Figure C and D. What is the most appropriate treatment at this time? Topic Review Topic
FIGURES: A   B   C   D    

1. Physical therapy and NSAIDS
2. Hard Cervical Orthosis
3. Halo Immobilization
4. Anterior screw osteosynthesis
5. Posterior C1-C2 fusion

PREFERRED RESPONSE ▶
TAG
(OBQ11.263) In Figures A-E, which of the following fracture patterns is at greatest risk for nonunion with nonoperative treatment? Topic Review Topic
FIGURES: A   B   C   D   E  

1. Figure A
2. Figure B
3. Figure C
4. Figure D
5. Figure E

PREFERRED RESPONSE ▶
TAG
(OBQ10.130) In patients who are neurologically intact, all of the following cervical spine injuries can be appropriately managed with external immobilization in a rigid cervical orthosis EXCEPT Topic Review Topic
FIGURES: A   B   C   D   E  

1. Figure A
2. Figure B
3. Figure C
4. Figure D
5. Figure E

PREFERRED RESPONSE ▶
TAG
(OBQ10.185) In elderly patients with type II odontoid fractures, which of the following treatment modalities has the highest morbidity and mortality? Topic Review Topic

1. Hard cervical collar
2. Anterior screw osteosynthesis
3. Halo vest immobilzation
4. Posterior cervical stabilization
5. Soft cervical orthosis

PREFERRED RESPONSE ▶
TAG
(OBQ08.78) A 37-year-old male was involved in a motorcycle accident. He is neurologically intact. A coronal and sagittal CT scan is shown in Figure A. What is the most appropriate management? Topic Review Topic
FIGURES: A          

1. Posterior C1-C2 fusion
2. Anterior odontoid screw fixation
3. Transoral anterior odontoid resection
4. Cervical immobilization for 6-8 week in an external orthosis
5. Treatment in a soft cervical orthosis for two weeks followed by range of motion exercises

PREFERRED RESPONSE ▶
TAG
(OBQ06.263) A 36-year-old male falls while intoxicated two weeks ago and has had persistent neck pain ever since. For unclear reasons he did not seek medical attention. He now reports persistent neck pain, but denies symptoms in his upper and lower extremities. On physical exam he has Grade 5 motor strength in his upper and lower extremities, normal reflexes, and his sensory exam is normal. A CT scan is shown in Figure A. All of the following place this patient at an increased risk of nonunion EXCEPT: Topic Review Topic
FIGURES: A          

1. Fracture gap of 2 mm
2. Posterior displacement of > 5mm
3. Delay in treatment of 2 weeks
4. Age < 40 years
5. Posterior angulation

PREFERRED RESPONSE ▶
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http://upload.orthobullets.com/cases/1072/6 mos post lat.jpg http://upload.orthobullets.com/cases/1072/6 mos post open mouth odontoid.jpg http://upload.orthobullets.com/cases/1072/preop xray lat.jpg
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