What is your diagnosis?

Odontoid fracture, type II. The odontoid process, or dens, is a superior bony projection of C2 that, along with the transverse ligament, is a key stabilizer of C1.

Case courtesy of Dr Talal F M Abdullah, Radiopaedia.org, rID: 58030. Annotations by author, fracture highlighted in red

• Pearl: Odontoid fractures can occur in elderly patients via a low energy mechanism like ground level falls. They may also occur in younger patients during high energy trauma that causes hyperflexion or hyperextension.

How do you further classify this injury? Which injuries are considered stable?

Type I: Alar ligament avulsion fracture of the apex. Stable

Type II: Fracture at the waist of the odontoid process. Unstable

Type III: Fracture of the body of C2 with involvement of the lateral masses. Unstable 

Case courtesy of Dr Mohammad Taghi Niknejad, Radiopaedia.org, rID: 21310. Odontoid fractures type 1, 2, and 3 from left to right

• Pearl: Type II fractures have a high nonunion rate because the waist of the odontoid process has limited blood supply for two reasons [1]:

• Vascular supply arrives from the apex and the base, forming a watershed area at the waist

• The waist lacks cancellous bone, which contains a highly vascularized meshwork of bone and blood vessels that allows for faster healing

What is your management in the ED?

The patient should be placed in a cervical collar and maintained in strict spinal precautions. A spine surgeon should be consulted emergently as guided by institutional protocols. MRI can be obtained if neurologic symptoms are present.

• Pearl: Management typically includes the following
  • Type I   -> hard cervical collar for 6-12wk
  • Type II  -> operative management (screw fixation or C1-2 posterior fusion) [1-2]
  • Type III -> hard cervical collar or halo immobilization [1]