Dens Fracture

A fracture of the dens (otherwise known as the odontoid), which is the proximal
process arising from C2 (the axis). Based on their location as well as patient
characteristics, these can be treated non-operatively or surgically.

History

• Do you have other sites of pain along your spine?

• Do you have any weakness, numbness, or tingling?

Physical Exam

• Trauma evaluation (Appendix A)

• Complete neurologic exam (Appendix A)

Diagnosis

Imaging

• C-spine XRs—AP, lateral, open mouth (odontoid) views

• C-spine CT—consider for all dens fractures due to higher inter-rater reliability
than XRs
• C-spine MRI—obtain if neurologic deficit, or suspected ligamentous instability

© Springer International Publishing Switzerland 2017 53

M.C. Makhni et al. (eds.), Orthopedic Emergencies,
DOI 10.1007/978-3-319-31524-9_16
54 M.C. Makhni et al.

Fig. 1 Dens fracture diagram

• Sagittal fracture displacement: distance between anterior borders of proximal

and distal fragments
• Fracture angulation: angle between posterior aspects of proximal and distal
fragments

Classification

Anderson and D'Alonzo (Fig. 1)

• Type 1: tip of dens
– Avulsion
– Be suspicious for occipito-cervical dissociation
• Type 2: base of dens (Fig. 2)
– High nonunion risk due to limited trabecular bony surface; distractive forces
from apical ligament
• Type 3: body of axis (Fig. 3)
– High healing rate due to large cancellous surface
Grauer classification
• Detailed classification of type 2 and type 3 fractures that helps predict manage-
ment options (see References below)
Dens Fracture 55

Fig. 2 Type 2 dens fracture

Fig. 3 Type 3 dens fracture

Treatment Plan

Non-operative

• C-collar, halo vest, cervico-thoracic orthosis

• Nearly all type 1 fractures heal with non-operative management
• Higher healing rates for type 3 compared to type 2
– Type 2: C-collar 51 %, halo vest 65 % healing
– Type 3: 90 + % healing with immobilization
56 M.C. Makhni et al.

• High morbidity/mortality of halo vests, especially in patients >70 years old (2×
mortality than c-collar)
– Aspiration, cardiac arrest, pin site infection, pin loosening
• Closed reduction with axial traction
– If posterior displacement, cord impingement and neurologic symptoms
– Secure airway prior to reduction to prevent respiratory compromise
– Stabilize neck during intubation to avoid fracture displacement
– Beware of over-distraction! *IMPORTANT*

Surgical

• Fixation (odontoid screw, trans-articular screw) vs. atlanto-axial arthrodesis

• 90 + % healing
• Indications:
– Cord compression
– Neurologic deficit
– Instability
– >2 mm secondary displacement compared to initial
– High nonunion risk (relative)—if stable, can operate initially, or attempt non-
operative management first. This will decrease chance of success of primary
fixation, but still allow option for fusion if fails to improve. Risk factors:
° ≥5 mm posterior displacement
° Comminution
° Fracture gap >1 mm
° Fracture angulation >11 °
° 4+ day delay in initiating treatment
° Age >40 years old

References

Grauer JN, Shafi B, Hilibrand AS, Harrop JS, Kwon BK, Beiner JM, et al. Proposal of a modified,
treatment-oriented classification of odontoid fractures. Spine J. 2005;5(2):123–9.
Hsu WK, Anderson PA. Odontoid fractures: update on management. J Am Acad Orthop Surg.
2010;18:383–94.