C2 Dens Fracture

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FACTS

Recall C2 Axis fracture Types
  1. Odontoid/Dens (15% of all C-spine fractures)
  1. Hangman's (traumatic spondylolisthesis)
  1. Miscellaneous Fx
 
Type
Description
Stability
Typical Management
Type I
Avulsion fracture of the tip of the dens at the attachment of the alar ligament
Stable
Usually managed conservatively with rigid cervical collar or halo vest for 6–8 weeks
Type II
Fracture at the base of the dens, at the junction with the C2 body (most common type)
Unstable (high risk of nonunion due to poor vascularity)
Surgical fixation often recommended — either anterior odontoid screw (for acute, reducible fractures) or posterior C1–C2 fusion (if chronic, displaced, or comminuted)
Type III
Fracture line extends into the body of C2 (below base of dens, involving cancellous bone)
Potentially stable (good healing potential)
Non-operative management typically sufficient — rigid collar or halo immobilization for 8–12 weeks; surgery if displacement or nonunion

HPI

universal ROS
  • attention to history of radiculopathy/myelopathy

PHYSICAL EXAM

universal physical exam
  • if Type 2 dens fx, do they have any of the following:
    • obesity
    • barrell chest
    • severe cervical evident kyphosis

IMAGING

MRI C-spine with STIR sequences in coronal and axial planes
  • evaluate integrity of transverse ligament. If transverse ligament violated, C1/C2 translation can happen hence cannot do odontoid screw fixation (need C1-C2 fusion)

A/P

  • Hard C-collar at all times for all types
  • Generally need to operate on Type 2 dens fractures
  • Elderly patients with Type II fractures have higher morbidity with halo fixation; surgical stabilization is often preferred.
Surgical options for Type 2 dens fractures:
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C1-2 PSF
Anterior odontoid screws
Contraindications
none
- TAL violation
- simultaneous atlanto-axial joint injuries
- fx line parallel to screw trajectory
- cervical kyphosis
- barrel chest habitus (chest gets in way of anchoring screw)
- obesity
- non-union fractures
Other Notes
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- only reapproximates fractured odontoid peg C2 (does not restore ligamentous stability)
 

Factors predicting non-union

  1. comminution of dens
  1. displacement ≥ 5 mm
  1. > 40 years old
  1. posteriorly displaced fx
  1. neuro deficits
 
  • Factors necessitating surgical stabilization
  1. displacement ≥ 5mm
  1. prior nonuinion
  1. instability of fracture in rigid immobilization