Odontoid Fracture

Traumatic Spondylolisthesis
of Axis (Hangman's Fracture)
SUMMARY
Odontoid Fractures are relatively common fractures of the C2
(axis) dens that can be seen in low energy falls in elderly
patients and high energy traumatic injuries in younger
patients.
Diagnosis can be made with standard lateral and open-mouth
odontoid radiographs. Some fractures may be difficult to
visualize on Xrays and require a CT scan to diagnose. MRI is
rarely indicated as these fractures are usually not associated
with neurologic symptoms. 
Treatment may be nonoperative or operative depending on the
Anderson and D'Alonzo type and risk factors for nonunion.
Patient older than 80 have a high morbidity and mortality
regardless of nonoperative or operative treatment. 
• Incidence
most common fracture of the axis
account for 10-15% of all cervical fractures
most common cervical spine fractures in the elderly 
Demographics
occur in bimodal fashion in elderly and young patients
elderly
common, often 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
children
rare and almost occur at site of  basilar synchondrosis
• 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 
etiology
- 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
- imaging
appears like a type II odontoid fx on xray
- treatment
observation
• Osteology
axis has odontoid process (dens) and body
contains a transverse foramen which vertebral artery
travels through
embryology
develops from five ossification centers 
subdental (basilar) synchondrosis
is an initial cartilaginous junction between the dens
and vertebral body that does not fuse until ~6 years of
age
secondary ossification center   
appears at ~ age 3 and fuses to the dens at ~ age 12
•Arthrology
C1-Dens
anterior dens articulates with anterior
arch of C1
CI-C2 articulation
is a diarthrodial joint 
C2-3 joint
participates in subaxial (C2-C7) cervical
motion 
• Ligaments
occipital-C1-C2 ligamentous stability
provided by the odontoid process and its
supporting ligaments
transverse ligament 
primary stabilizer of atlantoaxial joint
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
supplied by branches of internal carotid
artery
base
supplied from branches of vertebral artery
the limited blood supply in this watershed
area is thought to affect healing of type II
odontoid fractures.
• Blood Supply
a vascular watershed exists between the
apex and the base of the odontoid   
apex
supplied by branches of internal carotid
artery
base
supplied from branches of vertebral artery
the limited blood supply in this watershed
area is thought to affect healing of type II
odontoid fractures.
 •Kinematics

• Normal Cervical Kinematics

• Flexion/Extension • Rotation • Lateral Bend

•Occipitocervical • 50 •4 •8
joint (OC)
•Atlantoaxial • 10 • 50 •0
joint (C1-2)
•Subaxial Spine (C3- • 50 • 50 • 60
7)
•Total • 110 • 100 • 68
Motion (degrees)
 CLASSIFICATION
• Anderson and D'Alonzo Classification

•Oblique avulsion fx of tip of odontoid. Due to avulsion of alar

•Type I ligament. Although rare,atlantooccipital instability should be ruled
out with flexion and extension films .  
•Fracture through waist (high nonunion rate due to interruption of
•Type II blood supply).
•Fx extends into cancellous body of C2 and involves a variable portion
•Type III of the C1-C2 joint.

• Grauer Classification of Type II Odontoid fractures

•Type IIA •Nondisplaced/minimally displaced with no comminution.

Treatment is external immobilization
•Displaced fracture with fracture line from anterosuperior
•Type IIB to posteroinferior. Treatment is with anterior odontoid
screw (if adequate bone density).
•Fracture from anteroinferior to posterosuperior, or with
•Type IIC significant comminution. Treatment is with posterior
stabilization.
PRESENTATION
Symptoms
neck pain
worse with motion, especially rotation
dysphagia
may be present when associated with a large
retropharyngeal hematoma
Physical exam
neurologic deficits
very rare due to large cross-section area of
spinal canal at this level
IMAGING findings
Radiographs fx pattern best seen on open-
required views mouth odontoid 
AP, lateral, open-mouth odontoid CT
view of cervical spine study of choice for fracture
optional views delineation and to assess
flexion-extension radiographs stability of fracture pattern
are important to diagnose CT angiogram
occipitocervical instability in required to determine location of
Type I fractures and Os vertebral artery prior to posterior
odontoideum instrumentation procedures 
instability defined as MRI
atlanto-dens-interval (ADI) indicated if neurologic
> 10mm symptoms present 
space available for cord (SAC)
< 13mm 
• Nonoperative indications
observation alone Type II fractures with risk factors for nonunion 
indications indicated in patient 50-80   
Os odontoideum Type II/III fracture nonunions 
assuming no neurologic symptoms or instability Os odontoideum with neurologic deficits or
hard cervical orthosis instability
indications anterior odontoid screw 
Type I indications
Type II in elderly who are not surgical candidates   Type II fractures with risk factors for nonunion
union is unlikely, however a fibrous union should AND
provide sufficient stability except in the case of acceptable alignment and minimal displacement
major trauma (reduction obtained)  
Type III   anterior oblique fracture pattern    
no evidence to support Halo over hard collar    fracture line is perpendicular to screw trajectory
technique patient body habitus must allow proper screw
typically worn for 6-12 weeks trajectory
halo immobilization outcomes
indications associated with higher failure rates than posterior
Type II young patient with no risk factors for C1-2 fusion
nonunion  transoral odontoidectomy
contraindications indications
elderly patients severe posterior displacement of dens with spinal
do not tolerate halo (may lead to aspiration, cord compression and neurologic deficits
pneumonia, and death) rarely performed due to high complication rate
technique C1 laminectomy typically provides sufficient
typically work for 6-12 weeks decompression of the spinal canal and is
Operative preferred
posterior C1-C2 fusion
 TREATMENT
• Treatment Overview Table
•Type I •Collar
•Type II (age < 40) •Halo Vest
•Type II (40-80) •Surgery
•Type II (> 80 years) •Collar
•Type III •Collar
Traumatic Spondylolisthesis
of Axis (Hangman's Fracture)
SUMMARY
Traumatic Spondylolisthesis of Axis, also
known as a Hangman's Fracture, is a
traumatic fracture of the bilateral pars
interarticularis of C2.
Diagnosis is made with CT of the cervical
spine.
Treatment may be C-collar immobilization,
halo immobilization, or surgical stabilization
depending on displacement, angulation, and
fracture stability. 
•ETIOLOGY
Mechanism 
hyperextension
leads to fracture of pars
secondary flexion
tears PLL and disc allowing
subluxation
Associated injuries
30% have concomitant c-spine fx
• PRESENTATION flexion and extension
Symptoms radiographs show
neck pain subluxation 
Physical exam CT
patients are usually study of choice to
neurologically intact delineate fracture
IMAGING pattern
MRA
consider if suspicious of
a vascular injury to the
vertebral artery
Radiographs
 • Levine and Edwards Classification
• (based on mechanism of injury)
• Mechanism • Characteristics • Treatment
•< 3mm horizontal displacement
•Axial C2/3
• Type I  compression and • No angulation •Rigid collar x 4-6 weeks
hyperextension • C2/3 disc remains intact
•Stable fx pattern

•> 3mm of horizontal

•If < 5 mm displacement, reduction
•Hyperextension displacement with traction then halo immobilization x 6-12 weeks
and axial load • Significant angulation
• Type II  followed by • If > 5mm displacement,  displacement, surgery or prolonged
• Vertical fracture line traction
rebound flexion • C2/3 disc and PLL are disrupted
•Unstable fracture pattern • Usually heal despite displacement (autofuse C2 on C3)

•No horizontal displacement •Avoid traction in Type IIA.

•Flexion-
• Type IIA  distraction • Horizontal fracture line • Reduction with gentle axial load + hyperextension,
• Significant angulation then compression halo immobilization for 6-12 weeks.

•Flexion- •Type I fracture with associated

distraction •Surgical reduction of facet dislocation followed by stabilization
• Type III  followed by bilateral C2-3 facet dislocation
required.
hyperextension •Rare injury pattern
• TREATMENT Operative
Nonoperative reduction with surgical
rigid cervical collar x 4-6 weeks   stabilization
indications indications
Type I fractures (< 3mm horizontal Type II with > 5 mm displacement
displacement) and severe angulation
closed reduction followed by halo Type III (facet dislocations)
immobilization for 8-12 weeks technique
indications anterior C2-3 interbody fusion
Type II with 3-5 mm displacement posterior C1-3 fusion
Type IIA bilateral C2 pars screw
reduction technique osteosynthesis
Type II use axial traction combined
+ extension
Type IIA use hyperextension (avoid
axial traction in Type IIA)
Subaxial Cervical Vertebral
Body Fractures
• SUMMARY radiographs of the
Subaxial Cervical cervical spine. CT scan
Vertebral Body Fractures can be helpful for
are a subset of cervical fracture characterization
spine injuries that and surgical planning. 
consist of compression Treatment can be
fractures, burst nonoperative or surgical
fractures, flexion stabilization depending
teardrop fractures, and on fracture pattern,
extension teardrop mechanical stability, and
avulsion fractures. the presence of
Diagnosis is made with neurological deficits. 
• ETIOLOGY posterior portion of vertebra retropulsed
Types posteriorly
compression fracture posterior column failure in tension
characterized by larger anterior lip fragments may be called
compressive failure of anterior vertebral body 'quadrangular fractures'  
without disruption of posterior body cortex and prognosis
without retropulsion into canal associated with SCI
often associated with posterior ligamentous treatment
injury unstable and usually requires surgery
burst fracture  extension teardrop avulsion fracture 
characterized by characterized by
fracture extension through posterior cortex with small fleck of bone is avulsed of anterior endplate
retropulsion into the spinal canal usually occur at C2
often associated with posterior ligamentous must differentiate from a true teardrop fracture
injury mechanism
prognosis extension
often associated with complete and incompete prognosis
spinal cord injury stable injury pattern and not associated with SCI
treatment treatment
unstable and usually requires surgery cervical collar
flexion teardrop fracture 
characterized by
anterior column failure in flexion/compression
• SUBAXIAL SPINE INJURY extension-compression
CLASSIFICATION extension-distraction
Allen and Ferguson lateral flexion
classification(of subaxial spine Radiographic description
injuries) classification (of subaxial
typically used for research and spine injuries)
not in clinical setting more commonly used in
based solely on static clinical setting
radiographs appearance and includes
mechanisms of injury compression fracture
six groups represent a burst fraction
spectrum of anatomic flexion-distraction injury
disruption and includeflexion- facet dislocation (unilateral or
compression bilateral)
vertical compression facet fracture
flexion-distraction
PRESENTATION
Symtoms
incomplete vs. complete cord injury
IMAGING
Must determine if there is a posterior ligamentous
injury so MRI often important
• TREATMENT height
Nonoperative unstable burst fracture with cord
collar immobilization for 6 to 12 weeks compression
indications unstable tear-drop fracture with cord
stable mild compression fractures (intact compression   
posterior ligaments & no significant minimal injury to posterior elements
kyphosis) early decompression (< 24 hours) has
anterior teardrop avulsion fracture been shown to improve neurologic
external halo immobilization outcomes compared with delayed (>/ 24
indications hours) decompression  
only if stable fracture pattern (intact posterior decompression, & fusion with
posterior ligaments & no significant instrumentation
kyphosis) indications
Operative significant injury to posterior elements
anterior decompression, corpectomy, anterior decompression not required
strut graft, & fusion with instrumentation
indications
compression fracture with 11 degrees of
angulation or 25% loss of vertebral body
Thoracolumbar Burst
Fractures
SUMMARY
Thoracolumbar Burst Fractures are a common high-energy
traumatic vertebral fractures caused by flexion of the spine
that leads to a compression force through the anterior and
middle column of the vertebrae leading to retropulsion of
bone into the spinal canal and compression of the neural
elements.
Diagnosis is made with radiographs of the thoracolumbar
spine. CT scan is useful for fracture characterization and
surgical planning. 
Treatment is bracing or surgical decompression and
stabilization depending on whether the patient has
neurologic deficits and whether the facture is unstable with
a risk of drifting into kyphosis.
•Demographics
often seen from falls
from height or motor
cycle accidents
• Pathophysiology spinal cord injury
mechanism conus medullaris syndrome
axial loading with flexion   neurogenic claudication due to stenosis distal
pathoanatomy to conus
at thoracolumbar junction there is fulcrum of Associated injuries
increased motion that makes spine more concomitant spine fractures
vulnerable to traumatic injury occurs in 20%
burst fractures typically occur between T10-L2 traumatic durotomy
(thoracolumbar junction)  associated with 
neurologic deficits lamina fractures
canal compromise often caused by split spinous process
retropulsion of bone chest and intra-abdominal injuries
maximum canal occlusion and neural common
compression at moment of impact thoracic spine fractures with neurologic deficit
tissue recoiling post-injury can minimize the 1/3 associated with hemopneumothorax,
extent of displacement major vessel injury, and diaphragmatic rupture
retropulsed fragments resorb over time and flexion-distration and fracture-dislocations
usually do not cause progressive neurologic bowel rupture, major vessel injury, upper
deterioration urinary tract injury, hepatic, splenic, and
deficit type pancreatic lacerations
location of stenosis relative to conus long bone fractures
determines can make rehabilitation difficult
• ANATOMY instability defined by
Thoracic osteology injury to middle column
T1-10 are rigidly fixed to ribs that join each other anteriorly via as evidenced by widening of interpedicular distance on AP
the sternum radiograph
least mobile portion of the entire spine loss of height of posterior cortex of vertebral body
T10-L2 is considered the thoracolumbar junction disruption of posterior ligament complex combined with anterior
T10-12 have free floating ribs and are more mobile than the and middle column involvement
upper thoracic spine Posterior Ligamentous Complex 
transition from rigid thoracic spine to mobile lumbar spine acts considered to be a critical predictor of spinal fracture stability
as a stress riser and predisposes to injury consists of
Lumbar osteology supraspinous ligament
increasingly more mobile as progresses caudal interspinous ligament
increasingly prone to degenerative changes ligamentum flavum
Denis three column system facet capsule
clinical relevance evaluation
only moderately reliable in determining clinical degree of determining the integrity of the PLC can be challenging
stability conditions where PLC is clearly ruptured
definitions bony chance fracture
anterior column  widening of interspinous distance
anterior longitudinal ligament (ALL) progressive kyphosis with nonoperative treatment
anterior 2/3 of vertebral body and annulus facet diastasis
middle column  conditions where integrity of PLC is indeterminant
posterior longitudinal ligament (PLL) MRI shows signal intensity between spinous process
posterior 1/3 of vertebral body and annulus Spinal cord
posterior column  spinal cord ends at L1-2
pedicles conus medullaris
lamina houses upper motor neurons on the sacral motor nerves
facets fractures involving L1 and result in conus medullaris syndrome
ligamentum flavum paralysis of the bowel and bladder with sparring of the motor
spinous process nerve roots of the lower extremity
posterior ligament complex (PLC)
• Dennis classification neurologic status
Type A intact (0 point)
fracture of both end-plates. The bone is retropulsed into nerve root (+2 points)
the canal. incomplete Spinal cord or conus medullaris injury (+3
Type B points)
fracture of the superior end-plate. It is common and complete Spinal cord or conus medullaris injury (+2
occurs due to a combination of axial load with flexion. points)
Type C cauda equina syndrome (+3 points)
fracture of the inferior end-plate. posterior ligamentous complex integrity  
Type D intact (0 point)
Burst rotation. This fracture could be misdiagnosed as a no interspinous ligament widening seen with flexion
fracture-dislocation. The mechanism of this injury is a views. MRI shows no edema in interspinous ligament
combination of axial load and rotation. region
Type E suspected/indeterminate (+2 points)
Burst lateral flexion. This type of fracture differs from the MRI shows some signal in region of interspinous
lateral compression fracture in that it presents an ligaments
increase of the interpediculate distance on disrupted (+3 points)
anteroposterior roentgenogram widening of interspinous distance seen
Thoracolumbar Injury Classification and Severity Score    TLICS treatment implications 
injury characteristic qualifier points score < 4 points
injury morphology nonsurgical management
compression (+1 point) score = 4 points
burst (+2 points) nonsurgical or surgical managment
rotation/translation (+3 points) score > 4 points
distraction (+4 points) surgical management indicated
• PRESENTATION inspection
History log roll patient during initial assessment to avoid
high-energy mechanism iatrogenic spinal cord injury in the setting of an
axial-loading and flexion mechanisms unstable fracture pattern
fall from height (e.g. fall from deer hunting stand, skin abraisons and ecchymosis
fall from ladder, etc.) open spinal fractures are uncommon
high-speed motor vehicle collision palpation of spinous processes
Symptoms fluid collection
severe back pain crepitus
radicular pain increased interspinous distance
parasthesias suggests injury to the posterior elements
Physical exam localized tenderness
vital signs neurologic examination
hypotension is common motor
neurogenic shock sensory
hypotension with associated bradycardia reflexes 
suggests spinal cord injury leading to loss of absence of bulbocavernous reflex is considered
autonomic regulation spinal shock
hypovolemic shock can persist for up to 72 hours
hypotension with compensatory tachycardia hyperactive bulbocavernous reflex suggests
suggests massive hemorrhage from major vessel disinhibition and a complete spinal cord injury
injury
Radiographs better assessment vertebral body comminution
recommended views CT myelography
AP/lateral cervical, thoracic, lumbar spine indications
often CT chest, abdomen, and pelvis done by trauma team and alternative for patients with pacemaker and other implants that
instead of radiographs are MRI incompatible
imaging of entire spine must be performed due to concomitant cannot assess the cord status
spine fractures in 20% consider traumatic durotomy
flexion and extension lateral radiographs MRI
useful once patient is stabilized to get understanding of integrity indications
of PLC whenever neurological deficits
findings assess the presence of a posterior ligamentous injury
AP shows should be performed in nearly every case, unless radiographs
widening of pedicles and CT clearly suggest injury
coronal deformity useful to evaluate for
lateral shows level of conus relative to retropulsed bone
retropulsion of bone into canal spinal cord or thecal sac compression by disk or osseous
extent of retropulsion can be underestimated with plain material
radiographs alone cord edema or hematoma
kyphotic deformity cord edema
chance-like spinous process fx fusiform cord enlargement
flexion/extension increased signal intensity on T2-weighted images
diastasis of spinous process with flexion indicates soft tissue cord hematoma
injury to PLC decreased singal intensity on T2-weighted images
CT scan halo of T2 enhancement for surrounding edema
indications presence of cord edema more than 2 vertebral levels and
fracture on plain film hematoma are poor prognostic signs for functional motor
neurologic deficit in lower extremity recovery
inadequate plain films injury posterior ligament complex
higher sensitivity at detecting acute spine fractures than plain increased signal intensity on T2 weighted images in PLC is
films concerning for instability and may warrant surgical intervention
most accurately assesses the extent of fragment retropulsion best visualized on the sagittal images
• TREATMENT neurologic decompression & spinal stabilization  
Nonoperative indications
activity as tolerated +/- thoracolumbosacral orthosis   neurologic deficits with radiographic evidence of cord/thecal sac compression
indications both complete and incomplete spinal cord injuries require decompression and
patients that are neurologically intact and mechanically stable stabilization to facilitate rehabilitation
posterior ligament complex preserved TLICS score = 5 or higher  
no focal kyphosis on flexion and extension lateral radiographs techniques
kyphosis < 30° (controversial) while classic teaching was anterior approach is required to eliminate anterior
vertebral body has lost < 50% of body height (controversial) pathology, with modern techniques decompression can be performed with
TLICS score = 3 or lower  posterior approach 
modality favored when
thoracolumbar orthosis  below conus so possible to medialize thecal sac to perform decompression of canal /
recent evidence shows no clear advantage of TLSO on outcomes posterior corpectomy and expandable cage
if it provides symptomatic relief, may be beneficial for patient injury to posterior ligamentous complex so posterior tension-band stabilization
bracing may not be suitable for those with associated abdominal or chest injuries required
outcomes fracture dislocations
retropulsed fragments resorb over time and usually do not cause neurologic anterior/direct lateral approach 
deterioration favored when
decreased complication rates in neurologically intact patients treated nonsurgically   neurologic deficits caused by anterior compression (bony retropulsion) , especially
equivalent outcomes in neurologically intact patients  above the conus medullaris (above L2)  
prolonged bedrest associated with increased deconditioning and recumbency allow for thorough decompression of the thecal sac
complications (pneumonia, DVT, etc.) substantial vertebral body comminution in order to reconstitute the anterior column
Operative kyphotic deformity >30°
posterior instrumented fusion/stabilization without decompression chronic injuries
indications greater than 4-5 days from the injury
unstable fracture pattern as defined by cons
injury to the Posterior Ligament Complex (PLC)   must consider level of diaphragm
progressive kyphosis outcomes
lamina fractures (controversial) studies have suggested posterior distraction instrumentation with ligamentotaxis
polytrauma have similar clinical and radiographic outcomes as anterior decompression and 360°
surgical stabilization can assist with recovery and rehabilitation of other injuries stabilization
technique over distraction of the anterior column can lead to pseudoarthrosis, chronic pain, and
may be performed with percutanous pedicle screws using fluoroscopy or navigation recurrent deformity
may extend instrumentation further than level of arthrodesis (fuse short, instrument
long)
outcomes
unstable injuries are more likely to benefit from surgical stabilization compared to
nonsurgical treatment