Category Archive Fracture of Bone A-Z

Treatment of Knee Dislocation/Knee Dislocation is a potentially devastating injury and is often a surgical emergency. This injury requires prompt identification, evaluation with appropriate imaging, and consultation with surgery for definitive treatment. Vascular injury and compartment syndrome are dreaded complications that the clinician should not miss in the workup of a knee dislocation. Note that this is in distinct contrast to patellar dislocations, which generally do not require immediate surgical or vascular intervention.[rx][rx]

A knee dislocation is a knee injury in which there is a complete disruption of the joint between the tibia and the femur. Symptoms include knee pain and instability of the knee. Complications may include injury to an artery around the knee, most commonly the artery behind the knee, or compartment syndrome.^[rx][rx][rx]

Types /Classification of Knee Dislocation

They may be divided into five types: anterior, posterior, lateral, medial, and rotatory. This classification is based on the movement of the tibia with respect to the femur. Anterior dislocations are the most common, followed by posterior dislocations. They may also be classified based on what ligaments are damaged.^[rx]

Kennedy classification based on the direction of displacement of the tibia

Anterior (30-50%)

• most common
• due to hyperextension injury
• usually involves tear of PCL
• an arterial injury is generally an intimal tear due to traction
• the highest rate of peroneal nerve injury

Posterior (30-40%)

• 2nd most common
• due to axial load to the flexed knee (dashboard injury)

The highest rate of vascular injury (25%) based on Kennedy classification

• has highest incidence of a complete tear of the popliteal artery

Lateral (13%)

• due to a varus or valgus force
• usually involves tears of both ACL and PCL

Medial (3%)

• varus or valgus force
• usually disrupted PLC and PCL

Rotational (4%)

• posterolateral is most common rotational dislocation
• usually irreducible
• buttonholing of femoral condyle through the capsule

Anatomic Classification System

The letters C and N can be added to denote arterial and neurologic injury, respectively.

Schenck Classification

• based on a pattern of multi ligamentous injury of knee dislocation (KD)

• Car accidents – If you bang your knee against a hard surface like your dashboard, the force of the blow may be strong enough to dislocate your knee.
• Sports injuries – This is less common than car accidents, but it’s possible to dislocate your knee if you collide with great force with another player or with the ground when your knee is bent, or if you over-extend your knee (bend it back farther than it’s supposed to go).
• Hard falls – It may happen to skiers or runners who lose control and fall on a bent or overextended knee. You may even dislocate your knee if you fall after stepping into a hole in the ground by mistake.
• Result of major trauma – and about half occur as a result of minor trauma.^[rx] Major trauma may include mechanisms like falls from a significant height, motor vehicle collisions, or a pedestrian being hit by a motor vehicle.
• Major trauma – often have other injuries.^[rx] Minor trauma may include tripping while walking or while playing sports. Risk factors include obesity.^[rx] The condition may also occur in a number of genetic disorders such as Ellis–van Creveld syndrome, Larsen syndrome, and Ehlers–Danlos syndrome.^[rx]
• Sudden forceful  fall down
• Road traffic accident
• Falls – Falling onto an outstretched hand is one of the most common causes of the broken or dislocation knee.
• Sports injuries – Many cervical spine fractures occur during contact sports or sports in which you might fall onto an outstretched hand — such as in-line skating or snowboarding.
• Motor vehicle crashes – Motor vehicle crashes can cause the knee dislocation to break, sometimes into many pieces, and often require surgical repair.
• Have osteoporosis –  a disease that weakens your bones
• Eave low muscle mass or poor muscle strength – or lack agility and have poor balance (these conditions make you more likely to fall)
• Walk or do other activities in the snow or on the ice – or do activities that require a lot of forwarding momenta, such as in-line skating and skiing.
• Previous fractures record.
• Wave an inadequate intake of calcium or vitamin D.
• Football or soccer, especially on artificial turf
• Athletic injury with a sports injury.

The ligamentum patellae. Attached above to the lower border of the patella and below to the tuberosity of the tibia. A continuation of the central portion of the common tendon of the quadriceps femoris muscle. The oblique popliteal ligament. A tendinous expansion derived from the semimembranosus muscle. It strengthens the posterior aspect of the capsule.

Symptoms of Knee Dislocation

• Symptoms include knee pain. The joint may also be obviously out of place. A joint effusion is not always present.^[rx]
• Hearing a “popping” sound at the time of injury
• Severe pain in the area of the knee
• A visible deformity at the knee joint
• Instability of the knee joint, or feeling like your knee joint is “giving way”
• Limitations in the range of movement of your knee
• Inability to continue with activities, whether they involve day-to-day tasks or sports
• Feeling the kneecap shift or slide out of the groove
• Feeling the knee buckle or give way
• Hearing a popping sound when the patella dislocates
• Swelling
• A change in the knee’s appearance — the knee may appear misshapen or deformed
• Apprehension or fear when running or changing direction.

Diagnosis of Knee Dislocation

Vascular exam (especially popliteal artery distribution)

Perfusion Assessment

• Dorsalis pedis pulse
• Posterior tibial pulse
• Capillary Refill
• Ankle-Brachial Index (ABI) – Normal ABI (as well as pulses, Capillary Refill) may not exclude popliteal artery disruption

Hard signs of vascular injury

• Distal pulse loss or ischemia (e.g. pallor, coolness)
• Active bleeding
• Expanding hematoma
• Palpable thrill or bruit over the popliteal artery

Neurologic Exam (especially peroneal nerve)

• First web space and dorsal foot sensation
• Ankle dorsiflexion

Multidirectional instability

• Multidirectional instability may be only finding if knee spontaneously reduced prior to presentation
• Three of four ligaments are likely injured (ACL Tear, PCL Tear, LCL tear, MCL tear)

Skin changes

• Dimple Sign – Anteromedial skinfold at medial joint line. Seen in posterolateral dislocation (not reducible without surgery)
• Skin necrosis – Entrapped skin at femoral condyle
• Overlying Laceration – Suggests open Knee Dislocation (accompanies 20-30% of Knee Dislocations)

Others exam may include

• Checking the pulse in several places on your leg and knee – This is called checking posterior tibial and dorsal pedal pulses, which are located in the region of the knee and foot. Lower pulses in your injured leg could indicate an injury to a blood vessel in your leg.
• Checking the blood pressure in your leg – Called the ankle-brachial index (ABI), this test compares the blood pressure measured in your arm to the blood pressure measured in your ankle. A low ABI measurement can indicate poor blood flow to your lower extremities.
• Checking your sense of touch or sensation – Your doctor will assess the feeling in the injured leg versus the unaffected leg.
• Checking nerve conduction – Tests like electromyography (EMG) or nerve conduction velocity (NCV) will measure the function of the nerves in your leg and knee.
• Checking your skin color and temperature – If your leg is cold or changing colors, there may be blood vessel problems.
• X-rays – These tests create clear pictures of bone. Your doctor may order x-rays to look for skeletal abnormalities in the knee, such as a shallow groove in the femur.
• Magnetic resonance imaging (MRI) scans – These scans create better pictures of the soft structures surrounding the knee, like ligaments. An MRI is seldom necessary because the doctor can usually diagnose a dislocated patella through an examination and x-rays. However, if your doctor needs additional, more detailed images, he or she may order an MRI.

^{Treatment of Knee Dislocation}

Nonoperative

• Immobilization – Your doctor may recommend that your child wear a brace for 3 to 4 weeks. This stabilizes the knee while it heals.
• Weightbearing –  Because putting weight on the knee may cause pain and slow the healing process, your doctor may recommend using crutches for the first week or two after the injury.
• Physical therapy – Once the knee has started to heal, your child’s doctor will recommend physical therapy to help your child regain normal motion. Specific exercises will strengthen the thigh muscles holding the knee joint in place. Your child’s commitment to the exercise program is important for a successful recovery. Typically, children return to activity 3 to 6 weeks after the injury.
• Emergent closed reduction followed by vascular assessment/consult – indications to considered an orthopedic emergency, vascular consult indicated if pulses are absent or diminished following reduction if arterial injury confirmed by arterial duplex ultrasound or CT angiography
• Immobilization as definitive management – successful closed reduction without vascular compromise, most cases require some form of surgical stabilization following reduction, outcomes of worse outcomes are seen with nonoperative management/prolonged immobilization will lead to loss of ROM with persistent instability.
• Rest Your Leg – Once you’re discharged from the hospital in a legislating, your top priority is to rest your and not further inflame the injury. Of course, the arm sling not only provides support, but it also restricts movement, which is why you should keep it on even during sleep. Avoiding the temptation to move your will help the bone mend quicker and the pain fades away sooner.

Medication

• Antibiotic – Cefuroxime or Azithromycin, or  Flucloxacillin or any others cephalosporin/quinolone antibiotic must be used to prevent infection or clotted blood remove to prevent furthers swelling and edema
• NSAIDs – Prescription-strength drugs that reduce both pain and inflammation. Pain medicines and anti-inflammatory drugs help to relieve pain and stiffness, allowing for increased mobility and exercise. There are many common over-the-counter medicines called non-steroidal anti-inflammatory drugs (NSAIDs). They include and Ketorolac, Aceclofenac, Naproxen, Etoricoxib.
• Corticosteroids – Also known as oral steroids, these medications reduce inflammation.
• Muscle Relaxants –  These medications provide relief from associated muscle spasms.
• Neuropathic Agents – Drugs(pregabalin & gabapentin) that address neuropathic—or nerve-related—pain. This includes burning, numbness, and tingling.
• Opioids – Also known as narcotics, these medications are intense pain relievers that should only be used under a doctor’s careful supervision.
• Topical Medications – These prescription-strength creams, gels, ointments, patches, and sprays help relieve pain and inflammation through the skin.
• Calcium & vitamin D3 – to improve bone health and healing fracture. As a general rule, men and women age 50 and older should consume 1,200 milligrams of calcium a day, and 600 international units of vitamin D a day.
• Glucosamine & Diacerein, Chondroitin sulfate – can be used to tightening the loose tension, cartilage, ligament, and cartilage, ligament regenerate cartilage or inhabit the further degeneration of cartilage, ligament
• Dietary supplement-to remove general weakness & improved health.
• Antidepressants – A drug that blocks pain messages from your brain and boosts the effects of endorphins (your body’s natural painkillers).

Surgical Treatment

Open reduction

• irreducible knee
• posterolateral dislocation
• open fracture-dislocation
• obesity (may be difficult to obtain closed)
• vascular injury

External fixation

• vascular repair (takes precedence)
• open fracture-dislocation
• compartment syndrome
• obese (if difficult to maintain reduction)
• polytrauma patient

Delayed ligamentous reconstruction/repair

• instability will require some kind of ligamentous repair or fixation
• patients can be placed in a knee immobilizer until treated operatively
• improved outcomes with early treatment (within 3 weeks)

Arthroscopy +/- open debridement

• Arthroscopic or open debridement with removal of any loose bodies may be necessary for displaced osteochondral fractures or loose bodies.

MPFL re-attachment or reconstruction (proximal realignment)

• Proximal realignment constitutes the reconstruction of the MPFL. In brief, to repair the ligament, a longitudinal incision is made at the border of the VMO, just anterior to the medial epicondyle. The ligament is usually re-attached to the femur using bone anchors. If the patient has had recurrent dislocations, then reconstruction may be necessary by harvesting gracilis or semitendinosus which are then attached to the patella and femur.
• Isolated repair/reconstruction of the MPFL is not a recommendation in those with bony abnormalities including TT-TG distance greater than 20mm, convex trochlear dysplasia, severe patella alta, advanced cartilage degeneration or severe femoral anteversion.[rx]

Lateral release (distal realignment)

• A lateral release cuts the retinaculum on the lateral aspect of the knee joint. The aim is to improve the alignment of the patella by reducing the lateral pull.

Osteotomy (distal realignment)

• Where there is abnormal anatomy contributing to poor patella tracking and a high TT-TG distance, the alignment correction can be through an osteotomy. The most common procedure of this type is known as the Fulkerson-type osteotomy and involves an osteotomy as well as removing the small portion of bone to which the tendon attaches and repositioning it in a more anteromedial position on the tibia.

Trochleoplasty

• Trochleoplasty is indicated in recurrent dislocators with a convex or flat trochlea. The trochlear groove is deepened to create a groove for the patella to glide through; this may take place alongside an MPFL reconstruction. Studies suggest it is not advisable in those with open growth plates or severely degenerative joints. This procedure is uncommon except in refractory cases.

Complications of Knee Dislocation

Vascular compromise

• incidence of – 5-15% in all dislocations. 40-50% in anterior or posterior dislocations
• risk factors – KD IV injuries have the highest rate of vascular injuries
• treatment-emergent vascular repair and prophylactic fasciotomies

Stiffness (arthrofibrosis)

• incidence – most common complication (38%)
• risk factors – more common with delayed mobilization
• avoid stiffness with early reconstruction and motion
• arthroscopic lysis of adhesion
• manipulation under anesthesia

Laxity and instability 

• incidence – 37% of some instability, however, redislocation is uncommon
• treatment – arthroscopic lysis of adhesion, manipulation under anesthesia

Peroneal nerve injury 

• incidence- 25% occurrence of a peroneal nerve injury, 50% recover partially
• posterolateral dislocations

Treatment

• A to prevent equinus contracture
• neurolysis or exploration at the time of reconstruction
• nerve repair or reconstruction or tendon transfers if chronic nerve palsy persists
• a dynamic tendon transfer involves transferring the posterior tibial tendon (PTT) to the foot

References

Test Diagnosis of Knee Dislocation/Knee Dislocation is a potentially devastating injury and is often a surgical emergency. This injury requires prompt identification, evaluation with appropriate imaging, and consultation with surgery for definitive treatment. Vascular injury and compartment syndrome are dreaded complications that the clinician should not miss in the workup of a knee dislocation. Note that this is in distinct contrast to patellar dislocations, which generally do not require immediate surgical or vascular intervention.[rx][rx]

A knee dislocation is a knee injury in which there is a complete disruption of the joint between the tibia and the femur. Symptoms include knee pain and instability of the knee. Complications may include injury to an artery around the knee, most commonly the artery behind the knee, or compartment syndrome.^[rx][rx][rx]

Types /Classification of Knee Dislocation

They may be divided into five types: anterior, posterior, lateral, medial, and rotatory. This classification is based on the movement of the tibia with respect to the femur. Anterior dislocations are the most common, followed by posterior dislocations. They may also be classified based on what ligaments are damaged.^[rx]

Kennedy classification based on the direction of displacement of the tibia

Anterior (30-50%)

• most common
• due to hyperextension injury
• usually involves tear of PCL
• an arterial injury is generally an intimal tear due to traction
• the highest rate of peroneal nerve injury

Posterior (30-40%)

• 2nd most common
• due to axial load to the flexed knee (dashboard injury)

The highest rate of vascular injury (25%) based on Kennedy classification

• has highest incidence of a complete tear of the popliteal artery

Lateral (13%)

• due to a varus or valgus force
• usually involves tears of both ACL and PCL

Medial (3%)

• varus or valgus force
• usually disrupted PLC and PCL

Rotational (4%)

• posterolateral is most common rotational dislocation
• usually irreducible
• buttonholing of femoral condyle through the capsule

Anatomic Classification System

The letters C and N can be added to denote arterial and neurologic injury, respectively.

Schenck Classification

• based on a pattern of multi ligamentous injury of knee dislocation (KD)

• Car accidents – If you bang your knee against a hard surface like your dashboard, the force of the blow may be strong enough to dislocate your knee.
• Sports injuries – This is less common than car accidents, but it’s possible to dislocate your knee if you collide with great force with another player or with the ground when your knee is bent, or if you over-extend your knee (bend it back farther than it’s supposed to go).
• Hard falls – It may happen to skiers or runners who lose control and fall on a bent or overextended knee. You may even dislocate your knee if you fall after stepping into a hole in the ground by mistake.
• Result of major trauma – and about half occur as a result of minor trauma.^[rx] Major trauma may include mechanisms like falls from a significant height, motor vehicle collisions, or a pedestrian being hit by a motor vehicle.
• Major trauma – often have other injuries.^[rx] Minor trauma may include tripping while walking or while playing sports. Risk factors include obesity.^[rx] The condition may also occur in a number of genetic disorders such as Ellis–van Creveld syndrome, Larsen syndrome, and Ehlers–Danlos syndrome.^[rx]
• Sudden forceful  fall down
• Road traffic accident
• Falls – Falling onto an outstretched hand is one of the most common causes of the broken or dislocation knee.
• Sports injuries – Many cervical spine fractures occur during contact sports or sports in which you might fall onto an outstretched hand — such as in-line skating or snowboarding.
• Motor vehicle crashes – Motor vehicle crashes can cause the knee dislocation to break, sometimes into many pieces, and often require surgical repair.
• Have osteoporosis –  a disease that weakens your bones
• Eave low muscle mass or poor muscle strength – or lack agility and have poor balance (these conditions make you more likely to fall)
• Walk or do other activities in the snow or on the ice – or do activities that require a lot of forwarding momenta, such as in-line skating and skiing.
• Previous fractures record.
• Wave an inadequate intake of calcium or vitamin D.
• Football or soccer, especially on artificial turf
• Athletic injury with a sports injury.

The ligamentum patellae. Attached above to the lower border of the patella and below to the tuberosity of the tibia. A continuation of the central portion of the common tendon of the quadriceps femoris muscle. The oblique popliteal ligament. A tendinous expansion derived from the semimembranosus muscle. It strengthens the posterior aspect of the capsule.

Symptoms of Knee Dislocation

• Symptoms include knee pain. The joint may also be obviously out of place. A joint effusion is not always present.^[rx]
• Hearing a “popping” sound at the time of injury
• Severe pain in the area of the knee
• A visible deformity at the knee joint
• Instability of the knee joint, or feeling like your knee joint is “giving way”
• Limitations in the range of movement of your knee
• Inability to continue with activities, whether they involve day-to-day tasks or sports
• Feeling the kneecap shift or slide out of the groove
• Feeling the knee buckle or give way
• Hearing a popping sound when the patella dislocates
• Swelling
• A change in the knee’s appearance — the knee may appear misshapen or deformed
• Apprehension or fear when running or changing direction.

Diagnosis of Knee Dislocation

Vascular exam (especially popliteal artery distribution)

Perfusion Assessment

• Dorsalis pedis pulse
• Posterior tibial pulse
• Capillary Refill
• Ankle-Brachial Index (ABI) – Normal ABI (as well as pulses, Capillary Refill) may not exclude popliteal artery disruption

Hard signs of vascular injury

• Distal pulse loss or ischemia (e.g. pallor, coolness)
• Active bleeding
• Expanding hematoma
• Palpable thrill or bruit over the popliteal artery

Neurologic Exam (especially peroneal nerve)

• First web space and dorsal foot sensation
• Ankle dorsiflexion

Multidirectional instability

• Multidirectional instability may be only finding if knee spontaneously reduced prior to presentation
• Three of four ligaments are likely injured (ACL Tear, PCL Tear, LCL tear, MCL tear)

Skin changes

• Dimple Sign – Anteromedial skinfold at medial joint line. Seen in posterolateral dislocation (not reducible without surgery)
• Skin necrosis – Entrapped skin at femoral condyle
• Overlying Laceration – Suggests open Knee Dislocation (accompanies 20-30% of Knee Dislocations)

Others exam may include

• Checking the pulse in several places on your leg and knee – This is called checking posterior tibial and dorsal pedal pulses, which are located in the region of the knee and foot. Lower pulses in your injured leg could indicate an injury to a blood vessel in your leg.
• Checking the blood pressure in your leg – Called the ankle-brachial index (ABI), this test compares the blood pressure measured in your arm to the blood pressure measured in your ankle. A low ABI measurement can indicate poor blood flow to your lower extremities.
• Checking your sense of touch or sensation – Your doctor will assess the feeling in the injured leg versus the unaffected leg.
• Checking nerve conduction – Tests like electromyography (EMG) or nerve conduction velocity (NCV) will measure the function of the nerves in your leg and knee.
• Checking your skin color and temperature – If your leg is cold or changing colors, there may be blood vessel problems.
• X-rays – These tests create clear pictures of bone. Your doctor may order x-rays to look for skeletal abnormalities in the knee, such as a shallow groove in the femur.
• Magnetic resonance imaging (MRI) scans – These scans create better pictures of the soft structures surrounding the knee, like ligaments. An MRI is seldom necessary because the doctor can usually diagnose a dislocated patella through an examination and x-rays. However, if your doctor needs additional, more detailed images, he or she may order an MRI.

^{Treatment of Knee Dislocation}

Nonoperative

• Immobilization – Your doctor may recommend that your child wear a brace for 3 to 4 weeks. This stabilizes the knee while it heals.
• Weightbearing –  Because putting weight on the knee may cause pain and slow the healing process, your doctor may recommend using crutches for the first week or two after the injury.
• Physical therapy – Once the knee has started to heal, your child’s doctor will recommend physical therapy to help your child regain normal motion. Specific exercises will strengthen the thigh muscles holding the knee joint in place. Your child’s commitment to the exercise program is important for a successful recovery. Typically, children return to activity 3 to 6 weeks after the injury.
• Emergent closed reduction followed by vascular assessment/consult – indications to considered an orthopedic emergency, vascular consult indicated if pulses are absent or diminished following reduction if arterial injury confirmed by arterial duplex ultrasound or CT angiography
• Immobilization as definitive management – successful closed reduction without vascular compromise, most cases require some form of surgical stabilization following reduction, outcomes of worse outcomes are seen with nonoperative management/prolonged immobilization will lead to loss of ROM with persistent instability.
• Rest Your Leg – Once you’re discharged from the hospital in a legislating, your top priority is to rest your and not further inflame the injury. Of course, the arm sling not only provides support, but it also restricts movement, which is why you should keep it on even during sleep. Avoiding the temptation to move your will help the bone mend quicker and the pain fades away sooner.

Medication

• Antibiotic – Cefuroxime or Azithromycin, or  Flucloxacillin or any others cephalosporin/quinolone antibiotic must be used to prevent infection or clotted blood remove to prevent furthers swelling and edema
• NSAIDs – Prescription-strength drugs that reduce both pain and inflammation. Pain medicines and anti-inflammatory drugs help to relieve pain and stiffness, allowing for increased mobility and exercise. There are many common over-the-counter medicines called non-steroidal anti-inflammatory drugs (NSAIDs). They include and Ketorolac, Aceclofenac, Naproxen, Etoricoxib.
• Corticosteroids – Also known as oral steroids, these medications reduce inflammation.
• Muscle Relaxants –  These medications provide relief from associated muscle spasms.
• Neuropathic Agents – Drugs(pregabalin & gabapentin) that address neuropathic—or nerve-related—pain. This includes burning, numbness, and tingling.
• Opioids – Also known as narcotics, these medications are intense pain relievers that should only be used under a doctor’s careful supervision.
• Topical Medications – These prescription-strength creams, gels, ointments, patches, and sprays help relieve pain and inflammation through the skin.
• Calcium & vitamin D3 – to improve bone health and healing fracture. As a general rule, men and women age 50 and older should consume 1,200 milligrams of calcium a day, and 600 international units of vitamin D a day.
• Glucosamine & Diacerein, Chondroitin sulfate – can be used to tightening the loose tension, cartilage, ligament, and cartilage, ligament regenerate cartilage or inhabit the further degeneration of cartilage, ligament
• Dietary supplement-to remove general weakness & improved health.
• Antidepressants – A drug that blocks pain messages from your brain and boosts the effects of endorphins (your body’s natural painkillers).

Surgical Treatment

Open reduction

• irreducible knee
• posterolateral dislocation
• open fracture-dislocation
• obesity (may be difficult to obtain closed)
• vascular injury

External fixation

• vascular repair (takes precedence)
• open fracture-dislocation
• compartment syndrome
• obese (if difficult to maintain reduction)
• polytrauma patient

Delayed ligamentous reconstruction/repair

• instability will require some kind of ligamentous repair or fixation
• patients can be placed in a knee immobilizer until treated operatively
• improved outcomes with early treatment (within 3 weeks)

Arthroscopy +/- open debridement

• Arthroscopic or open debridement with removal of any loose bodies may be necessary for displaced osteochondral fractures or loose bodies.

MPFL re-attachment or reconstruction (proximal realignment)

• Proximal realignment constitutes the reconstruction of the MPFL. In brief, to repair the ligament, a longitudinal incision is made at the border of the VMO, just anterior to the medial epicondyle. The ligament is usually re-attached to the femur using bone anchors. If the patient has had recurrent dislocations, then reconstruction may be necessary by harvesting gracilis or semitendinosus which are then attached to the patella and femur.
• Isolated repair/reconstruction of the MPFL is not a recommendation in those with bony abnormalities including TT-TG distance greater than 20mm, convex trochlear dysplasia, severe patella alta, advanced cartilage degeneration or severe femoral anteversion.[rx]

Lateral release (distal realignment)

• A lateral release cuts the retinaculum on the lateral aspect of the knee joint. The aim is to improve the alignment of the patella by reducing the lateral pull.

Osteotomy (distal realignment)

• Where there is abnormal anatomy contributing to poor patella tracking and a high TT-TG distance, the alignment correction can be through an osteotomy. The most common procedure of this type is known as the Fulkerson-type osteotomy and involves an osteotomy as well as removing the small portion of bone to which the tendon attaches and repositioning it in a more anteromedial position on the tibia.

Trochleoplasty

• Trochleoplasty is indicated in recurrent dislocators with a convex or flat trochlea. The trochlear groove is deepened to create a groove for the patella to glide through; this may take place alongside an MPFL reconstruction. Studies suggest it is not advisable in those with open growth plates or severely degenerative joints. This procedure is uncommon except in refractory cases.

Complications of Knee Dislocation

Vascular compromise

• incidence of – 5-15% in all dislocations. 40-50% in anterior or posterior dislocations
• risk factors – KD IV injuries have the highest rate of vascular injuries
• treatment-emergent vascular repair and prophylactic fasciotomies

Stiffness (arthrofibrosis)

• incidence – most common complication (38%)
• risk factors – more common with delayed mobilization
• avoid stiffness with early reconstruction and motion
• arthroscopic lysis of adhesion
• manipulation under anesthesia

Laxity and instability 

• incidence – 37% of some instability, however, redislocation is uncommon
• treatment – arthroscopic lysis of adhesion, manipulation under anesthesia

Peroneal nerve injury 

• incidence- 25% occurrence of a peroneal nerve injury, 50% recover partially
• posterolateral dislocations

Treatment

• A to prevent equinus contracture
• neurolysis or exploration at the time of reconstruction
• nerve repair or reconstruction or tendon transfers if chronic nerve palsy persists
• a dynamic tendon transfer involves transferring the posterior tibial tendon (PTT) to the foot

References

First Symptoms of Knee Dislocation /Knee Dislocation is a potentially devastating injury and is often a surgical emergency. This injury requires prompt identification, evaluation with appropriate imaging, and consultation with surgery for definitive treatment. Vascular injury and compartment syndrome are dreaded complications that the clinician should not miss in the workup of a knee dislocation. Note that this is in distinct contrast to patellar dislocations, which generally do not require immediate surgical or vascular intervention.[rx][rx]

A knee dislocation is a knee injury in which there is a complete disruption of the joint between the tibia and the femur. Symptoms include knee pain and instability of the knee. Complications may include injury to an artery around the knee, most commonly the artery behind the knee, or compartment syndrome.^[rx][rx][rx]

Types /Classification of Knee Dislocation

They may be divided into five types: anterior, posterior, lateral, medial, and rotatory. This classification is based on the movement of the tibia with respect to the femur. Anterior dislocations are the most common, followed by posterior dislocations. They may also be classified based on what ligaments are damaged.^[rx]

Kennedy classification based on the direction of displacement of the tibia

Anterior (30-50%)

• most common
• due to hyperextension injury
• usually involves tear of PCL
• an arterial injury is generally an intimal tear due to traction
• the highest rate of peroneal nerve injury

Posterior (30-40%)

• 2nd most common
• due to axial load to the flexed knee (dashboard injury)

The highest rate of vascular injury (25%) based on Kennedy classification

• has highest incidence of a complete tear of the popliteal artery

Lateral (13%)

• due to a varus or valgus force
• usually involves tears of both ACL and PCL

Medial (3%)

• varus or valgus force
• usually disrupted PLC and PCL

Rotational (4%)

• posterolateral is most common rotational dislocation
• usually irreducible
• buttonholing of femoral condyle through the capsule

Anatomic Classification System

The letters C and N can be added to denote arterial and neurologic injury, respectively.

Schenck Classification

• based on a pattern of multi ligamentous injury of knee dislocation (KD)

• Car accidents – If you bang your knee against a hard surface like your dashboard, the force of the blow may be strong enough to dislocate your knee.
• Sports injuries – This is less common than car accidents, but it’s possible to dislocate your knee if you collide with great force with another player or with the ground when your knee is bent, or if you over-extend your knee (bend it back farther than it’s supposed to go).
• Hard falls – It may happen to skiers or runners who lose control and fall on a bent or overextended knee. You may even dislocate your knee if you fall after stepping into a hole in the ground by mistake.
• Result of major trauma – and about half occur as a result of minor trauma.^[rx] Major trauma may include mechanisms like falls from a significant height, motor vehicle collisions, or a pedestrian being hit by a motor vehicle.
• Major trauma – often have other injuries.^[rx] Minor trauma may include tripping while walking or while playing sports. Risk factors include obesity.^[rx] The condition may also occur in a number of genetic disorders such as Ellis–van Creveld syndrome, Larsen syndrome, and Ehlers–Danlos syndrome.^[rx]
• Sudden forceful  fall down
• Road traffic accident
• Falls – Falling onto an outstretched hand is one of the most common causes of the broken or dislocation knee.
• Sports injuries – Many cervical spine fractures occur during contact sports or sports in which you might fall onto an outstretched hand — such as in-line skating or snowboarding.
• Motor vehicle crashes – Motor vehicle crashes can cause the knee dislocation to break, sometimes into many pieces, and often require surgical repair.
• Have osteoporosis –  a disease that weakens your bones
• Eave low muscle mass or poor muscle strength – or lack agility and have poor balance (these conditions make you more likely to fall)
• Walk or do other activities in the snow or on the ice – or do activities that require a lot of forwarding momenta, such as in-line skating and skiing.
• Previous fractures record.
• Wave an inadequate intake of calcium or vitamin D.
• Football or soccer, especially on artificial turf
• Athletic injury with a sports injury.

The ligamentum patellae. Attached above to the lower border of the patella and below to the tuberosity of the tibia. A continuation of the central portion of the common tendon of the quadriceps femoris muscle. The oblique popliteal ligament. A tendinous expansion derived from the semimembranosus muscle. It strengthens the posterior aspect of the capsule.

Symptoms of Knee Dislocation

• Symptoms include knee pain. The joint may also be obviously out of place. A joint effusion is not always present.^[rx]
• Hearing a “popping” sound at the time of injury
• Severe pain in the area of the knee
• A visible deformity at the knee joint
• Instability of the knee joint, or feeling like your knee joint is “giving way”
• Limitations in the range of movement of your knee
• Inability to continue with activities, whether they involve day-to-day tasks or sports
• Feeling the kneecap shift or slide out of the groove
• Feeling the knee buckle or give way
• Hearing a popping sound when the patella dislocates
• Swelling
• A change in the knee’s appearance — the knee may appear misshapen or deformed
• Apprehension or fear when running or changing direction.

Diagnosis of Knee Dislocation

Vascular exam (especially popliteal artery distribution)

Perfusion Assessment

• Dorsalis pedis pulse
• Posterior tibial pulse
• Capillary Refill
• Ankle-Brachial Index (ABI) – Normal ABI (as well as pulses, Capillary Refill) may not exclude popliteal artery disruption

Hard signs of vascular injury

• Distal pulse loss or ischemia (e.g. pallor, coolness)
• Active bleeding
• Expanding hematoma
• Palpable thrill or bruit over the popliteal artery

Neurologic Exam (especially peroneal nerve)

• First web space and dorsal foot sensation
• Ankle dorsiflexion

Multidirectional instability

• Multidirectional instability may be only finding if knee spontaneously reduced prior to presentation
• Three of four ligaments are likely injured (ACL Tear, PCL Tear, LCL tear, MCL tear)

Skin changes

• Dimple Sign – Anteromedial skinfold at medial joint line. Seen in posterolateral dislocation (not reducible without surgery)
• Skin necrosis – Entrapped skin at femoral condyle
• Overlying Laceration – Suggests open Knee Dislocation (accompanies 20-30% of Knee Dislocations)

Others exam may include

• Checking the pulse in several places on your leg and knee – This is called checking posterior tibial and dorsal pedal pulses, which are located in the region of the knee and foot. Lower pulses in your injured leg could indicate an injury to a blood vessel in your leg.
• Checking the blood pressure in your leg – Called the ankle-brachial index (ABI), this test compares the blood pressure measured in your arm to the blood pressure measured in your ankle. A low ABI measurement can indicate poor blood flow to your lower extremities.
• Checking your sense of touch or sensation – Your doctor will assess the feeling in the injured leg versus the unaffected leg.
• Checking nerve conduction – Tests like electromyography (EMG) or nerve conduction velocity (NCV) will measure the function of the nerves in your leg and knee.
• Checking your skin color and temperature – If your leg is cold or changing colors, there may be blood vessel problems.
• X-rays – These tests create clear pictures of bone. Your doctor may order x-rays to look for skeletal abnormalities in the knee, such as a shallow groove in the femur.
• Magnetic resonance imaging (MRI) scans – These scans create better pictures of the soft structures surrounding the knee, like ligaments. An MRI is seldom necessary because the doctor can usually diagnose a dislocated patella through an examination and x-rays. However, if your doctor needs additional, more detailed images, he or she may order an MRI.

^{Treatment of Knee Dislocation}

Nonoperative

• Immobilization – Your doctor may recommend that your child wear a brace for 3 to 4 weeks. This stabilizes the knee while it heals.
• Weightbearing –  Because putting weight on the knee may cause pain and slow the healing process, your doctor may recommend using crutches for the first week or two after the injury.
• Physical therapy – Once the knee has started to heal, your child’s doctor will recommend physical therapy to help your child regain normal motion. Specific exercises will strengthen the thigh muscles holding the knee joint in place. Your child’s commitment to the exercise program is important for a successful recovery. Typically, children return to activity 3 to 6 weeks after the injury.
• Emergent closed reduction followed by vascular assessment/consult – indications to considered an orthopedic emergency, vascular consult indicated if pulses are absent or diminished following reduction if arterial injury confirmed by arterial duplex ultrasound or CT angiography
• Immobilization as definitive management – successful closed reduction without vascular compromise, most cases require some form of surgical stabilization following reduction, outcomes of worse outcomes are seen with nonoperative management/prolonged immobilization will lead to loss of ROM with persistent instability.
• Rest Your Leg – Once you’re discharged from the hospital in a legislating, your top priority is to rest your and not further inflame the injury. Of course, the arm sling not only provides support, but it also restricts movement, which is why you should keep it on even during sleep. Avoiding the temptation to move your will help the bone mend quicker and the pain fades away sooner.

Medication

• Antibiotic – Cefuroxime or Azithromycin, or  Flucloxacillin or any others cephalosporin/quinolone antibiotic must be used to prevent infection or clotted blood remove to prevent furthers swelling and edema
• NSAIDs – Prescription-strength drugs that reduce both pain and inflammation. Pain medicines and anti-inflammatory drugs help to relieve pain and stiffness, allowing for increased mobility and exercise. There are many common over-the-counter medicines called non-steroidal anti-inflammatory drugs (NSAIDs). They include and Ketorolac, Aceclofenac, Naproxen, Etoricoxib.
• Corticosteroids – Also known as oral steroids, these medications reduce inflammation.
• Muscle Relaxants –  These medications provide relief from associated muscle spasms.
• Neuropathic Agents – Drugs(pregabalin & gabapentin) that address neuropathic—or nerve-related—pain. This includes burning, numbness, and tingling.
• Opioids – Also known as narcotics, these medications are intense pain relievers that should only be used under a doctor’s careful supervision.
• Topical Medications – These prescription-strength creams, gels, ointments, patches, and sprays help relieve pain and inflammation through the skin.
• Calcium & vitamin D3 – to improve bone health and healing fracture. As a general rule, men and women age 50 and older should consume 1,200 milligrams of calcium a day, and 600 international units of vitamin D a day.
• Glucosamine & Diacerein, Chondroitin sulfate – can be used to tightening the loose tension, cartilage, ligament, and cartilage, ligament regenerate cartilage or inhabit the further degeneration of cartilage, ligament
• Dietary supplement-to remove general weakness & improved health.
• Antidepressants – A drug that blocks pain messages from your brain and boosts the effects of endorphins (your body’s natural painkillers).

Surgical Treatment

Open reduction

• irreducible knee
• posterolateral dislocation
• open fracture-dislocation
• obesity (may be difficult to obtain closed)
• vascular injury

External fixation

• vascular repair (takes precedence)
• open fracture-dislocation
• compartment syndrome
• obese (if difficult to maintain reduction)
• polytrauma patient

Delayed ligamentous reconstruction/repair

• instability will require some kind of ligamentous repair or fixation
• patients can be placed in a knee immobilizer until treated operatively
• improved outcomes with early treatment (within 3 weeks)

Arthroscopy +/- open debridement

• Arthroscopic or open debridement with removal of any loose bodies may be necessary for displaced osteochondral fractures or loose bodies.

MPFL re-attachment or reconstruction (proximal realignment)

• Proximal realignment constitutes the reconstruction of the MPFL. In brief, to repair the ligament, a longitudinal incision is made at the border of the VMO, just anterior to the medial epicondyle. The ligament is usually re-attached to the femur using bone anchors. If the patient has had recurrent dislocations, then reconstruction may be necessary by harvesting gracilis or semitendinosus which are then attached to the patella and femur.
• Isolated repair/reconstruction of the MPFL is not a recommendation in those with bony abnormalities including TT-TG distance greater than 20mm, convex trochlear dysplasia, severe patella alta, advanced cartilage degeneration or severe femoral anteversion.[rx]

Lateral release (distal realignment)

• A lateral release cuts the retinaculum on the lateral aspect of the knee joint. The aim is to improve the alignment of the patella by reducing the lateral pull.

Osteotomy (distal realignment)

• Where there is abnormal anatomy contributing to poor patella tracking and a high TT-TG distance, the alignment correction can be through an osteotomy. The most common procedure of this type is known as the Fulkerson-type osteotomy and involves an osteotomy as well as removing the small portion of bone to which the tendon attaches and repositioning it in a more anteromedial position on the tibia.

Trochleoplasty

• Trochleoplasty is indicated in recurrent dislocators with a convex or flat trochlea. The trochlear groove is deepened to create a groove for the patella to glide through; this may take place alongside an MPFL reconstruction. Studies suggest it is not advisable in those with open growth plates or severely degenerative joints. This procedure is uncommon except in refractory cases.

Complications of Knee Dislocation

Vascular compromise

• incidence of – 5-15% in all dislocations. 40-50% in anterior or posterior dislocations
• risk factors – KD IV injuries have the highest rate of vascular injuries
• treatment-emergent vascular repair and prophylactic fasciotomies

Stiffness (arthrofibrosis)

• incidence – most common complication (38%)
• risk factors – more common with delayed mobilization
• avoid stiffness with early reconstruction and motion
• arthroscopic lysis of adhesion
• manipulation under anesthesia

Laxity and instability 

• incidence – 37% of some instability, however, redislocation is uncommon
• treatment – arthroscopic lysis of adhesion, manipulation under anesthesia

Peroneal nerve injury 

• incidence- 25% occurrence of a peroneal nerve injury, 50% recover partially
• posterolateral dislocations

Treatment

• A to prevent equinus contracture
• neurolysis or exploration at the time of reconstruction
• nerve repair or reconstruction or tendon transfers if chronic nerve palsy persists
• a dynamic tendon transfer involves transferring the posterior tibial tendon (PTT) to the foot

References

Foot Muscle/The foot is an intricate structure of 26 bones, 33 joints, multiple muscles, tendons, ligaments, blood vessels, nerves, and lymphatics. The bones form two crossing arches of the foot. The muscles acting on the foot can be divided into two distinct groups; extrinsic and intrinsic muscles. The extrinsic muscles arise from the anterior, posterior, and lateral compartments of the leg. They are mainly responsible for actions such as eversion, inversion, plantarflexion, and dorsiflexion of the foot.

The longitudinal arch runs the length of the foot, and the transverse arch runs the width. The ankle joint is formed by the interaction of the foot and the lower leg, and the toes are on the far side of the foot. The bones of the foot are primarily held together by their fit with each other forming joints surrounded by joint capsules and connected by fibrous tissues known as ligaments. The muscles of the foot, along with a tough, sinewy tissue known as the plantar fascia, provide secondary support to the foot and the longitudinal arch. The foot has internal muscles that originate and insert in the foot and external muscles that begin in the lower leg and attach in various places on the bones of the foot. There are also fat pads in the foot to help with weight-bearing and absorbing impact.

To simplify the organization of the muscles, the following will break them up into those that act upon the foot and ankle and those classified as intrinsic.[rx][rx][rx]

Foot Muscle – Origin, Insertion, Nerve Supply, Functions

BICEPS FEMORIS LONG HEAD

• Origin: Common (conjoint) tendon from the superior medial quadrant of the posterior ischial tuberosity (with semitendinosus)
• Insertion: Majority onto the fibular head; also the lateral collateral ligament of the knee and lateral tibial condyle
• Action: Flexion of the knee, and lateral rotation of the tibia; extension of the hip joint
• Innervation: Tibial nerve (a portion of the sciatic nerve)
• Arterial Supply: Perforating (muscular) branches of profunda femoris artery, inferior gluteal artery, and the superior muscular branches of the popliteal artery

BICEPS FEMORIS SHORT HEAD

• Origin: Lateral lip of linea aspera, the lateral intermuscular septum of the thigh, and lateral supracondylar ridge of femur
• Insertion: Majority on the fibular head; and lateral collateral ligament of the knee, and lateral tibial condyle
• Action: Flexion of the knee, and lateral rotation of the tibia
• Innervation: Common peroneal nerve (a portion of the sciatic nerve)
• Arterial Supply: Perforating (muscular) branches of profunda femoris artery, inferior gluteal artery, and the superior muscular branches of the popliteal artery

SEMIMEMBRANOSUS

• Origin: Superior lateral aspect of the ischial tuberosity
• Insertion: The posterior surface of the medial tibial condyle
• Action: Extension of the hip, flexion of the knee, and medial rotation of the tibia (specifically with knee flexion)
• Innervation: Tibial nerve (a portion of the sciatic nerve)
• Arterial Supply: Perforating (muscular) branches of profunda femoris artery, inferior gluteal artery, and the superior muscular branches of the popliteal artery

SEMITENDINOSUS

• Origin: The common (conjoint) tendon from the superior medial quadrant of the posterior ischial tuberosity (with biceps femoris long head)
• Insertion: Superior aspect of the medial tibial shaft (into the distal portion of the pes anserinus along with the gracilus and sartorius muscles)
• Action: Extension of the hip and flexion of the knee, medial rotation of the tibia (specifically with knee flexion)
• Innervation: Tibial nerve (a portion of the sciatic nerve)
• Arterial Supply: Perforating (muscular) branches of profunda femoris artery, inferior gluteal artery, and the superior muscular branches of the popliteal artery

Biceps Femoris: Short Head

• Origin: Lateral lip of the linea aspera
• Insertion: The fibular head and lateral condyle of the tibia
• Function: Knee flexion and lateral rotation of the tibia
• Innervation: Fibular (common peroneal) nerve
• Vascular supply: Perforating branches of the deep femoral artery

Biceps Femoris: Long Head

• Origin: Ischial tuberosity
• Insertion: The fibular head and lateral condyle of the tibia
• Function: Knee flexion, lateral rotation of the tibia, and hip extension
• Innervation: Tibial nerve
• Vascular supply: Perforating branches of the deep femoral artery

Semitendinosus

• Origin: Lower, medial surface of the ischial tuberosity
• Insertion: Medial tibia (pes anserinus)
• Function: Knee flexion, hip extension and medial rotation of the tibia (with knee flexion)
• Innervation: Tibial nerve
• Vascular supply: Perforating branches of the deep femoral artery

Semimembranosus

• Origin: Ischial tuberosity
• Insertion: Medial tibial condyle
• Function: Knee flexion, hip extension and medial rotation of the tibia (with knee flexion)
• Innervation: Tibial nerve
• Vascular supply: Perforating branches of the deep femoral artery

Foot and Ankle

Peroneus Longus

• The peroneus longus is one of the three muscles that span the lateral leg – peroneus may also be interchanged with fibular, referring to the lateral bone of the lower leg running deep to the peroneal muscles
• Origin: The peroneus longus muscle originates on the head of the fibula and the upper half of the fibular shaft – this muscle crosses the ankle joint and courses deep into the foot and passes into a groove of the cuboid bone.
• Insertion: the posterolateral aspect of the medial cuneiform bone and the lateral portion of the base of the first metatarsal
• Action: The peroneus longus acts to evert the foot, plantarflex the ankle and adds support to the transverse arch of the foot
• Blood Supply: Anterior tibial artery
• Innervation: Superficial peroneal nerve

Peroneus Brevis

• The peroneus brevis is another of the three muscles spanning the lateral leg and may also be called fibularis brevis, referring to the fibula
• Origin: The peroneus brevis originates on the inferior two-thirds of the lateral fibula and courses posteriorly to the lateral malleolus of the fibula ultimately
• Insertion: The styloid process of the fifth metatarsal
• Action: The primary action of the peroneus brevis is to evert the foot and plantar flex the ankle
• Blood Supply: Peroneal artery
• Innervation: The superficial peroneal nerve innervates the peroneus brevis muscle

Peroneus Tertius

• The peroneus tertius is the third and final muscle of the lateral peroneus or fibular muscles
• Origin: The peroneus tertius originates from the middle fibular shaft
• Insertion: The dorsal surface of the fifth metatarsal
• Action: Dorsiflex, evert, and abduct the foot
• Blood Supply: The peroneus tertius primarily receives its blood supply from the anterior tibial artery
• Innervation: Peroneus tertius innervation comes from the deep peroneal nerve, an innervation different than its similarly named peroneal counterparts

Anterior Tibialis

• The anterior tibialis is the most prominent muscle in the anterior leg and is often visible during dorsiflexion of the foot
• Origin: The lateral condyle of the tibia and the proximal half to two-thirds of the tibial shaft.
• Insertion: Occurs after passing under the extensor retinaculum and is on the medial and plantar surfaces of the medial cuneiform and base of the 1st metatarsal.
• Action: Dorsiflex the ankle and invert the hindfoot
• Blood Supply: Anterior tibial artery
• Innervation: Comes from the deep peroneal nerve

Posterior Tibialis

• Origin: The superior two-thirds of the medial posterior surface of the tibia
• Insertion: The tendon courses distally, splitting into two at the calcaneonavicular ligament, to insert on the tuberosity of the navicular bone (superficial slip) and the plantar surfaces of the metatarsals two to four (deep slip)
• Action: The posterior tibialis is the primary inverter of the foot but also adducts, plantar flexes, and aides in supination of the foot
• Blood Supply: Sural, peroneal, and posterior tibial arteries
• Innervation: Tibial nerve

Extensor Digitorum Longus

• Origin: Lateral tibial condyle and continues distally to split into four tendons after the level of the extensor retinaculum
• Insertion: Dorsum of the middle and distal phalanges
• Action: Extend the second through fifth digits and dorsiflex the ankle
• Blood Supply: anterior tibial artery
• Innervation: deep peroneal nerve

Flexor Digitorum Longus

• Origin: Posterior surface of the tibia distal to the popliteal line
• Insertion: Continues distally to split into four individual tendons which insert on the plantar surfaces of the bases of the second through fifth distal phalanges
• Action: Flex the digits two through five and may aid in plantar flexion of the ankle
• Blood Supply: Posterior tibial artery
• Innervation: Tibial nerve

Flexor Hallucis Longus

• Origin: inferior two-thirds of the posterior fibula
• Insertion: The plantar surface of the base of the distal phalanx of the great toe
• Action: Flex the great toe but may minimally supinate and plantar flex the ankle
• Blood Supply: Peroneal and posterior tibial artery
• Innervation: Tibial nerve

Gastrocnemius

• The gastrocnemius is the most superficial calf muscle
• Origin: femoral condyles
• Insertion: thick Achilles tendon inserting on the calcaneus.
• Action: Plantarflex the ankle.
• Blood Supply: Sural branch of the popliteal artery
• Innervation: Tibial nerve

Soleus

• The soleus is the deep muscle of the posterior leg and makes up most of the bulk of the calf
• Origin: Upper quarter of the posterior fibula and the middle third of the posterior tibial shaft
• Insertion: The soleus eventually joins the gastrocnemius to for the Achilles tendon to insert on the calcaneus
• Action: The action is to plantarflex the ankle
• Blood Supply: Posterior tibial, peroneal, and sural arteries
• Innervation: Tibial nerve

Intrinsic

Extensor Digitorum Brevis

• Origin: Dorsal surface of the calcaneus
• Insertion: The base of the proximal phalanx of digits two through four
• Action: Extend the toes
• Blood Supply: Dorsalis pedis
• Innervation: Deep peroneal nerve

Dorsal Interosseus

• The dorsal interossei muscles (3) exist between digits two through five – the two adjacent muscles form a central tendon and act to abduct the metatarsal-phalangeal joints and innervation comes from the lateral plantar nerve

Extensor Hallucis Brevis

• Origin: Dorsal surface of the calcaneus
• Insertion: The base of the proximal phalanx of the great toe
• Action: Extend the great toe
• Blood Supply: Dorsalis pedis.
• Innervation: Deep peroneal nerve

Plantar/1st layer

Abductor Hallucis

• Origin: Calcaneal tuberosity
• Insertion: Base of the great toe and the proximal phalanx.
• Action: Abduct the great toe
• Blood Supply: Medial plantar artery
• Innervation: Medial plantar nerve

Flexor Digitorum Brevis

• Origin: Calcaneal tuberosity
• Insertion: The middle phalanx of digits two thorugh five
• Action: Flex the digits two through five
• Blood Supply: Medial plantar artery
• Innervation: Medial plantar nerve

Abductor Digiti Minimi

• Origin: Calcaneal tuberosity
• Insertion: Base of the fifth metatarsal
• Action: Abduct the 5th digit
• Blood Supply: Lateral plantar artery
• Innervation: Lateral plantar nerve lateral plantar artery

2nd Layer

Quadratus Plantae

• Origin: Plantar surface of the calcaneus
• Insertion: Flexor digitorum longus tendon
• Action: Help flex the distal phalanges
• Blood Supply: Lateral plantar artery
• Innervation: Llateral plantar nerve

Lumbricals

• There are four muscles referred to as lumbricals in the foot
• Origin: Flexor digitorum longus tendon
• Insertion: Extensor digitorum longus tendon
• Action: Flex the metatarsophalangeal joints and extend the interphalangeal joints
• Blood Supply: Medial and lateral plantar arteries
• Innervation: Medial and lateral plantar nerve

3rd layer

Flexor Hallucis Brevis

• Origin: The cuboid and the lateral cuneiform
• Insertion: Proximal phalanx of the great toe
• Action: Flex the great toe
• Blood Supply: Medial plantar artery
• Innervation: Medial plantar nerve

Oblique and Transverse Head of Adductor Hallucis

• The adductor hallucis has two heads, an oblique head, and a transverse head
• Origin: The oblique head originates at the proximal ends of the metatarsals two thourgh four, and the transverse head originates via MTP ligaments of digits three through five
• Insertion: inserts at the proximal phalanx of the great toe
• Action: The primary action is to adduct the great toe
• Blood Supply: First plantar metatarsal artery
• Innervation: Deep branch of lateral plantar

Flexor Digiti Minimi Brevis

• Origin: Base of the fifth metatarsal
• Insertion: Proximal phalanx of the fifth metatarsal
• Action: The primary action is to flex the fifth digit
• Blood Supply: Lateral Plantar artery
• Innervation: Lateral plantar nerve

4th layer

Plantar Interosseous

• The plantar interossei (3)
• Origin: medial aspect of the individual metatarsals of digits three through five
• Insertion: The proximal phalanges
• Action: Adduct the digits
• Blood Supply: Plantar metatarsal artery
• Innervation: Lateral plantar nerve

Blood Supply and Lymphatics of Lower Leg Muscle

The main arterial supply to the lower extremity is provided by the femoral artery.  A continuation of the external iliac artery, the common femoral artery enters the thigh passing deep to the inguinal ligament.  Once in the thigh, the femoral artery gives off the following branches:[rx]

• The medial femoral circumflex artery
• The lateral femoral circumflex artery
• Femoral profunda (deep artery of the thigh) artery

  • Medial and Lateral femoral circumflex branches

    • The medial femoral circumflex artery is the predominant blood supply to the head (via the lateral epiphyseal artery)

  • First, second, and third perforating branches

    • Supply the medial thigh muscles
• Superficial femoral artery

References

Calcaneus fractures are rare but potentially debilitating injuries. The calcaneus is one of seven tarsal bones and is part of the hind-foot which includes the calcaneus and the talus. The hindfoot articulates with the tibia and fibula creating the ankle joint. The subtalar or calcaneotalar joint accounts for at least some foot and ankle dorsal/plantar flexion. Calcaneal anatomy is demonstrated in Figure 1. Historically a burst fracture of the calcaneus was coined a “Lovers Fracture” as the injury would occur as a suitor would jump off a lover’s balcony to avoid detection. [rx][rx][rx]

Causes of Calcaneus Fractures

Calcaneal fractures are often attributed to shearing stress adjoined with compressive forces combined with a rotary direction (Soeur, 1975^[rx]). These forces are typically linked to injuries in which an individual falls from a height, involvement in an automobile accident, or muscular stress where the resulting forces can lead to the trauma of fracture. Overlooked aspects of what can lead to a calcaneal fracture are the roles of osteoporosis and diabetes.

Unfortunately, the prevention of falls and automobile accidents is limited and applies to unique circumstances that should be avoided. The risk of muscular stress fractures can be reduced through stretching and weight-bearing exercise, such as strength training. In addition, footwear can influence forces that may cause a calcaneal fracture and can prevent them as well. A 2012 study conducted by Salzler^[rx] showed that the increasing trend toward minimalist footwear or running barefoot can lead to a variety of stress fractures including that of the calcaneus.

Symptoms of Calcaneus Fractures

The most common symptom is pain over the heel area, especially when the heel is palpated or squeezed. Patients usually have a history of recent trauma to the area or fall from a height. Other symptoms include: inability to bear weight over the involved foot, limited mobility of the foot, and limping. Upon inspection, the examiner may notice swelling, redness, and hematomas. A hematoma extending to the sole of the foot is called “Mondor Sign”, and is pathognomonic for calcaneal fracture.^[rx][rx] The heel may also become widened with associated edema due to the displacement of lateral calcaneal border. Soft tissue involvement should be evaluated because of the association with serious complications (see below).^[rx][rxrx]

Diagnosis ofCalcaneus Fractures

C2 C3 Vertebrae Fracture/Odontoid Fracture, the odontoid process, or dens, is a superior projecting bony element from the second cervical vertebrae (C2, or the axis). The first cervical vertebrae (atlas) rotates around the odontoid process to provide the largest single component of lateral rotation of the cervical spine. Fracture of the odontoid process is classified into one of three types, which are type I, type II, or type III fractures, depending on the location and morphology of the fracture.[rx]

A hangman’s fracture is better described as bilateral fracture traversing the pars inter articularis of C2 with an associated traumatic subluxation of C2 on C3. It is the second most common fracture of the C2 vertebrae following a fracture of the odontoid process and is almost always stable without the need for surgical intervention. Steele’s rule of thirds states that the cross-sectional area at the level of the atlas may be divided into three equally represented parts: the dens, space, and the spinal cord. This increased area for the spinal cord at this level is what allows for the relative lack of neurologic injury associated with a hangman’s fracture. [rx]

Mechanisms of C2 C3 Vertebrae Fracture

Apart from hangings, the mechanism of injury—a sudden forceful hyperextension centered just under the chin—occurs mainly with deceleration injuries in which the victim’s face or chin strike an unyielding object with the neck in extension. The most common scenario is a frontal motor vehicle accident with an unrestrained passenger or driver, with the person striking the dashboard or windshield with their face or chin. Other scenarios include falls, diving injuries, and collisions between players in contact sports.

Although a hangman’s fracture is unstable, survival from this fracture is relatively common, as the fracture itself tends to expand the spinal canal at the C2 level. It is not unusual for patients to walk in for treatment and have such a fracture discovered on X-rays. Only if the force of the injury is severe enough that the vertebral body of C2 is severely subluxated from C3 does the spinal cord become crushed, usually between the vertebral body of C3 and the posterior elements of C1 and C2.

Types of C2 C3 Vertebrae Fracture

Type I Odontoid Fracture 

A type I odontoid fracture occurs when the rostral tip of the odontoid process is avulsed (broken or torn off). This injury commonly occurs due to pulling forces from the apical ligament attachment to the odontoid process. The apical ligament attaches the tip of the odontoid process to the foramen magnum (skull base).

Type II Odontoid Fracture

A type II odontoid fracture is a fracture through the base of the odontoid process. This injury occurs most typically when there is an excessive extension of the cervical spine, and the anterior arch of C1 pushes dorsally (backward) with sufficient force on the odontoid process (dens) to fracture the odontoid process at its base. Type II odontoid fractures can also occur with hyperflexion of the neck and the transverse ligament, pushing the odontoid process forward to the point of fracture.

Type III Odontoid Fracture

A type III odontoid fracture is a fracture through the body of the C2 vertebrae and may involve a variable portion of the C1 and C2 facets.  Type III odontoid fractures occur secondary to hyperextension or hyperflexion of the cervical spine in a similar manner to type II odontoid fractures. The difference is where the fracture line occurs.

C2 fractures can be divided into 2 kinds: Odontoid and Hangmen

Odontoid Fractures

Location

• Fracture through the dens, flexion or extension injury

Nomenclature

Anderson and D’Alonzo classification is the most ubiquitous.

• Type-1 fractures: Upper portion of the odontoid peg, above the transverse portion of the cruciform ligament, these are generally stable
• Type-2 fractures: These are the most common, the fracture through the based of the odontoid below the transverse portion of the cruciform ligament, they have a high risk of non-union
• Type-3 fractures: These fracture through the odontoid peg and into the body of C2, generally well tolerated

The Roy-Camille classification of odontoid fractures is another but less frequently used nomenclature format focusing on the direction of the fracture line.

Hangman’s Fractures

Location

• Fracture through the bilateral pars, generally from hyperextension and axial loading generally
• Stable 90% heal with immobilization alone

Nomenclature

Levine and Edwards Classification

• Type 1: Less than 3 mm subluxation of C2 on C3, due to axial loading, stable, rigid cervical collar treatment
• Type 2: disruption of the C2 to C3 disc, posterior longitudinal ligament, greater than 4 mm subluxation, greater than 11 degrees angulation, less than 5 mm requires a reduction in axial traction and halo fixation for 6 to 12 weeks while those greater than 5 mms can require surgery
• Type 2a: Less displacement more angular deformity, flexion injury, unstable, not suitable for axial traction, treatment in halo
• Type 3: C2 to C3 facet capsule disrupted, anterior longitudinal ligament disruption, unstable, may have deficit, surgical candidates.

Levine and Edwards Classification[rx]

Specifics

• Angulation in this system is measured as the angle between the inferior endplate of C2 and C3. Anterior subluxation of C2 on C3 greater than 3 mm serves as a marker for C2 to C3 intervertebral disc disruption. It is important to recognize that this grading system is not applicaple in the pediatric population.

Grading

• Type 1: Less than 3 mm subluxation of C2 on C3, due to axial loading, stable, rigid cervical collar treatment
• Type 2: Disruption of the C2 to C3 disc, posterior longitudinal ligament, greater than 4 mm subluxation, greater than 11 degrees angulation, less than 5 mm requires a reduction in axial traction and halo fixation for 6 to 12 weeks while those greater than 5 mm can require surgery
• Type 2a: Less displacement more angular deformity, flexion injury, unstable, not suitable for axial traction, treatment in halo
• Type 3: C2 to C3 facet capsule disrupted, anterior longitudinal ligament disruption, unstable, may have deficit, surgical candidates

Francis Grading System[rx]

Specifics

• Two factors are taken into consideration for the Francis Grading system: angulation and displacement. Angulation is measured by the degree of anterior angulation off of the posterior vertebral line drawn straight up from the C3 vertebral body. Displacement is measured by the amount of anterolisthesis, either greater than or less than 3.5 mm.

Grading

• Type 1: Less than 11 degrees of angulation and less than 3.5 mm of displacement
• Type 2: Greater than 11 degrees of angulation and less than 3.5 mm of displacement
• Type 3: Less than 11 degrees of angulation and greater than 3.5 mm displacement
• Type 4: Greater than 11 degrees of angulation and greater than 3.5 mm of displacement
• Type 5: Complete disc disruption

Typical versus Atypical Fractures

• It is important to recognize that not all C2, hangman’s type fractures can be described using these classification systems. A typical hangman’s fracture allows for separation of the anterior elements from the posterior elements of the C2 vertebrae, therefore increase the available space for the spinal cord.
• However, in the case of an atypical hangman’s fracture the posterior aspect of the C2 vertebral body, not the bilateral pars, is involved. This leads to a higher risk of neurologic injury as the space remaining for the spinal cord does not increase secondary to the fracture.

Causes of C2 C3 Vertebrae Fracture

• Odontoid fractures occur as a result of trauma to the cervical spine.
• high-energy trauma, which occurs as a result of a motor vehicle or diving accidents.
• trauma can occur after lower energy impacts such as falls from a standing position.
• hyperextension of the cervical spine, pushing the head and C1 vertebrae backward.
• forceful thrust are high enough (or the patient’s bone density is compromised secondary to osteopenia/osteoporosis),
• The odontoid fracture can also occur with hyperflexion of the cervical spine.
• The transverse ligament runs dorsal to (behind) the odontoid process and attaches to the lateral mass of C1 on either side.
• If the cervical spine is excessively flexed, then the transverse ligament can transmit the excessive anterior forces to the odontoid process and cause an odontoid fracture.[rx]
• Sudden forceful  fall down
• Road traffic accident
• Falls – Falling onto an outstretched hand is one of the most common causes of the broken cervical spine.
• Sports injuries – Many cervical spine fractures occur during contact sports or sports in which you might fall onto an outstretched hand — such as in-line skating or snowboarding.
• Motor vehicle crashes – Motor vehicle crashes can cause cervical spine to break, sometimes into many pieces, and often require surgical repair.
• Have osteoporosis –  a disease that weakens your bones
• Eave low muscle mass or poor muscle strength – or lack agility and have poor balance (these conditions make you more likely to fall)
• Walk or do other activities in the snow or on the ice – or do activities that require a lot of forwarding momenta, such as in-line skating and skiing.
• Previous pelvic fractures record.
• Wave an inadequate intake of calcium or vitamin D.
• Football or soccer, especially on artificial turf
• Athletic injury with a sports injury.
• Horseback riding
• Hockey
• Skiing
• Snowboarding
• Clumsiness in hands
• Gait imbalance
• Degenerative cervical spondylosis (CSM) 
  
• Compression usually caused by anterior degenerative changes (osteophytes, disc osteophyte complex)
• Degenerative spondylolisthesis and hypertrophy of ligamentum flavum may contribute
• The most common cause of cervical myelopathy.

Symptoms of C2 C3 Vertebrae Fracture

Symptoms of cervical spondylosis include:

• Neck stiffness and pain
• Numbness and weakness in the upper limbs
• Difficulty in walking, losing balance, or weakness in limbs
• Difficulty in turning the head fully or bending the neck, which may hinder drive
• Muscle spasms in neck and shoulders
• Headaches
• Grinding and popping feeling in the neck when rotating the head
• Loss of bladder and bowel control.
• neck pain and stiffness
• axial neck pain (oftentimes absent)
• occipital headache common
• extremity paresthesias
• diffuse nondermatomal numbness and tingling
• weakness and clumsiness
• weakness and decreased manual dexterity (dropping object, difficulty manipulating fine objects)
• Gait instability patient feels “unstable” on feet
• weakness walking up and downstairs
• gait changes are the most important clinical predictor
• urinary retention rare and only appear late in disease progression, not very useful in diagnosis due to the high prevalence of urinary conditions in this patient population
• Cervical pain aggravated by movement
• Referred pain (occiput, between the shoulder blades, upper limbs)
• Retro-orbital or temporal pain (from C1 to C2)
• Cervical stiffness—reversible or irreversible
• Vague numbness, tingling, or weakness in upper limbs
• Dizziness or vertigo
• Poor balance
• Rarely, syncope triggers a migraine, “pseudo-angina”

Diagnosis of C2 C3 Vertebrae Fracture

Laboratory tests should be ordered as an adjunct in overall medical status.

• Normalized hemoglobin,
• hematocrit,
• coagulation profile with prothrombin time (PT),
• partial thromboplastin time (PTT), and
• platelet counts will be needed for operative intervention.

In hospitals and countries without readily available advanced imaging capabilities, radiographs are critical to evaluate and assist in ruling out potential odontoid fractures.  Recommended views include:[rx]

• AP C-spine
• Lateral C-spine
• Open-mouth odontoid view

Although radiographs yield lower sensitivity and specificity rates when compared to computed tomogram (CT) scans, experienced clinicians and practitioners can still appreciate suspected injury without CT utilization.  In addition, in the setting of suspected occipito cervical instability (useful in type I odontoid fractures or the setting of os odontoideum), flexion-extension radiographs should be obtained.

X-ray

Evaluation of x-rays will provide limited but important information. Care must be taken to ensure proper radiographic imaging creates a picture from the occiput to the C7 through T1 disc space. This is essential in reviewing cervical spine trauma. Lateral, anteroposterior (AP) and open mouth odontoid views are necessary. Approximately, 93% of cervical spine injuries are apparent with combined, lateral, AP, and odontoid view radiographs. X-rays are an excellent modality for determining alignment during the immediate injury, post-operative period, as well as long-term, follow up.

Computed tomogram (CT) scan

CT scan is the most important modality for determining fracture etiology and ruling out an injury with regards to a C2 fracture. Even if plain films are negative and clinical suspicion is high a CT scan is warranted. CT scan does not directly evaluate the spinal cord, soft tissue, or ligamentous construct. It is important to recognize the importance that complete imaging will require dedicated thin-cut CT reconstructions. Non-contrast CT scan is adequate for evaluation of the bony anatomy for fracture. This can be coupled with a CT angiogram for evaluation of the vascular anatomy.

Magnetic resonance imaging (MRI) scan

Evaluation with MRI is important for the analysis of the ligamentous construct, disc space, spinal cord, nerve roots, and other soft tissue injuries. MRI is also useful for determining the acute nature of the fracture when this is otherwise unknown. This is done via non-contrasted imaging. T2 signal hyperintensities and STIR changes within the dens, ligaments, or soft tissue can illustrate an acute component.

Vascular Imaging

Vascular imaging may be indicated. The vertebral artery’s second segment (V2) runs through the transverse foramen of C2 to C6 while V3 runs extramurally exiting the C2 foramen across the sulcus arteriosus.  This can place it at risk for injury. Indeed, in one series 15% of patients with C1 to C2 fractures had a vertebral artery injury. Of which, type-III odontoid fractures posed the greatest risk. It is important to note that an untreated vertebral artery injury has a 24% stroke rate.

Advanced Imaging modalities

The imaging modality of choice is a CT of the cervical spine. The CT provides the best resolution of the bony elements allowing for identification and characterization of an odontoid fracture. If there is neurologic injury (paresthesia, weakness), then magnetic resonance imaging (MRI) without the contrast of the cervical spine should be obtained to assess the cervical cord for injuries.

Nuclear bone scan – a diagnostic procedure in which a radioactive substance is injected into the body to measure activity in the bones.  (The amount of radiation is small–less than the radiation in half of one CT scan.) This scan helps identify damaged bones.

Treatment of C2 C3 Vertebrae Fracture

The treatment of an odontoid fracture depends on the type of fracture and age of the patient.[rx][rx][rx][rx]

Non-Surgical Treatment

Treatment available can be broadly

• Skeletal traction – Available evidence suggests that treatment depends on the part of the pelvic fracture that is fractured. Traction may be useful for odontoid fracture because it counteracts the force of the muscle pulling the two separated parts together, and thus may decrease bleeding and pain.^[rx] Traction should not be used in the femoral neck and odontoid fracture or when there is any other trauma to the leg or pelvis.^[rx][rx] It is typically only a temporary measure used before surgery. It only considered the definitive treatment for patients with significant comorbidities that contraindicate surgical management.^[rx]
• Get medical help immediately – If you fall on an outstretched arm, get into a car accident or are hit while playing a sport and feel intense pain in your hip area, then get medical care immediately. You’ll innately know that something is seriously wrong because you won’t be able to lift your leg up. Other symptoms include immediate swelling and/or bruising near the fracture, grinding sounds with arm movements and potential numbness, and tingling in the leg.
• Apply ice – After you get home from the hospital odontoid fracture (regardless if you had surgery or not), you should apply a bag of crushed ice (or something cold) to your injured in order to reduce the swelling and numb the pain. Ice therapy is effective for acute (recent) injuries that involve swelling because it reduces blood flow by constricting local blood vessels. Apply the crushed ice to your odontoid fracture  for 15 minutes three to five times daily until the soreness and inflammation eventually fades away
• Lightly exercise after the pain fades – After a couple of weeks when the swelling has subsided and the pain has faded away, remove your arm sling for short periods and carefully move your hip joints in all different directions. Don’t aggravate the odontoid fracture so that it hurts, but gently reintroduce movements to the involved joints and muscles. Start cautiously, maybe starting with light, and then progress to holding light weights (five-pound weights to start).
• Practice stretching and strengthening exercises – of the fingers, leg if your doctor recommends them.
• A splint – which you might use for a few days to a week while the swelling goes down; if a splint is used initially, a cast is usually put on about a week later.
• A cast – which you might need for six to eight weeks or longer, depending on how bad the break is (you might need a second cast if the first one gets too loose after the swelling goes away.)
• Get a supportive arm sling – Due to their anatomical position, necks of odontoid fracture can’t be cast like a broken spine. Instead, a supportive arm sling or “figure-eight” splint is typically used for support and comfort, either immediately after the injury if it’s just a hairline fracture or following surgery, if it’s a complicated fracture.
• Get a referral to physical therapy – Once you’ve recovered and able to remove your arm sling splint for good, you’ll likely notice that the muscles surrounding your neck and lower chest look smaller and feel weaker. That’s because muscle tissue atrophies without movement. If this occurs, then you’ll need to get a referral for some physical rehabilitation. Rehab can start once you are cleared by your orthopedist, are pain-free, and can perform all the basic arm and necks movements. A physiotherapist or athletic trainer can show you specific rehabilitation exercises and stretches to restore your muscle strength, joint movements, and flexibility
• Rigid fixation – osteosynthesis with locking plate, hook plate fixation, fixation with a locking plate, coracoclavicular screws, Knowles pin fixation.
• Flexible fixation – simple k wire fixation, tension band wiring, suture anchors, vinyl tape, dacron arterial graft for ligament reconstruction.
• A splint – which you might use for a few days to a week while the swelling goes down; if a splint is used initially, a cast is usually put on about a week later.
• A cast – which you might need for six to eight weeks or longer, depending on how bad the break is (you might need a second cast if the first one gets too loose after the swelling goes away.)

Rest Your Leg – Once you’re discharged from the hospital in an arm sling, your top priority is to rest your and not further inflame the injury. Of course, the arm sling not only provides support, but it also restricts movement, which is why you should keep it on even during sleep. Avoiding the temptation to move your shoulder and arm will help the bone mend quicker and the pain fades away sooner.

Type I Odontoid Fracture

• Most consider a type I odontoid fracture a stable fracture and treatment for six to 12 weeks in a rigid cervical orthosis (hard cervical collar). Some have suggested that rarely a type I odontoid fracture may be unstable secondary to more extensive and unrecognized ligamentous injury, and flexion/extension x-rays should be obtained at the time of removal of the cervical collar after six to 12 weeks to ensure cervical stability.

Type II Odontoid Fracture[rx]

• Type II odontoid fractures are inherently unstable and have a lower union rate than type III odontoid fractures due to the lower surface area of a fractured bone in type II versus type III odontoid fractures.
• The configuration of type II odontoid fracture and age of patient also play important roles in treatment decisions. The current treatment options for a type II odontoid fracture include rigid cervical orthosis, halo vest immobilization, odontoid screw, transoral adenoidectomy, and posterior instrumentation.

Rigid Cervical Orthosis 

• A type II odontoid fracture is inherently unstable, and a rigid cervical orthosis is not the ideal treatment for such an injury. In the elderly population, many are not surgical candidates (due to comorbidities or poor bone quality), and the elderly typically poorly tolerate a halo vest immobilization. In such situations, a practitioner may attempt a rigid cervical orthosis, although union rates are low.

Halo Vest Immobilization

• If a patient is relatively young and healthy, and there is low risk for nonunion, then halo vest immobilization may be the best treatment for a type II odontoid fracture. Risk factors for nonunion include a fractured space greater than a few millimeters between the odontoid process and vertebral body, poor alignment of the odontoid process with respect to the vertebral body, and poor bone quality and/or health status of the patient.

Medication

• Antibiotic – Cefuroxime or Azithromycin, or  Flucloxacillin or any others cephalosporin/quinolone antibiotic must be used to prevent infection or clotted blood remove to prevent furthers swelling and edema
• NSAIDs – Prescription-strength drugs that reduce both pain and inflammation. Pain medicines and anti-inflammatory drugs help to relieve pain and stiffness, allowing for increased mobility and exercise. There are many common over-the-counter medicines called non-steroidal anti-inflammatory drugs (NSAIDs). They include and Ketorolac, Aceclofenac, Naproxen, Etoricoxib.
• Corticosteroids – Also known as oral steroids, these medications reduce inflammation.
• Muscle Relaxants –  These medications provide relief from associated muscle spasms.
• Neuropathic Agents – Drugs(pregabalin & gabapentin) that address neuropathic—or nerve-related—pain. This includes burning, numbness, and tingling.
• Opioids – Also known as narcotics, these medications are intense pain relievers that should only be used under a doctor’s careful supervision.
• Topical Medications – These prescription-strength creams, gels, ointments, patches, and sprays help relieve pain and inflammation through the skin.
• Calcium & vitamin D3 – to improve bone health and healing fracture. As a general rule, men and women age 50 and older should consume 1,200 milligrams of calcium a day, and 600 international units of vitamin D a day.
• Glucosamine & Diacerein, Chondroitin sulfate – can be used to tightening the loose tension, cartilage, ligament, and cartilage, ligament regenerate cartilage or inhabit the further degeneration of cartilage, ligament
• Dietary supplement-to remove general weakness & improved health.
• Antidepressants – A drug that blocks pain messages from your brain and boosts the effects of endorphins (your body’s natural painkillers).

Odontoid Screw

• An anterior odontoid osteosynthesis (odontoid screw) is a screw placed from the inferior anterior aspect of the C2 vertebral body, in a superior trajectory, and capturing the odontoid process and affixing it in place to allow bony fusion to occur.  The odontoid screw has an advantage of relative preservation of motion of the upper cervical spine while treating a type II odontoid fracture.
• A surgeon can only place the odontoid screw if there are acceptable alignment and minimal displacement of the odontoid process, the fracture line is oblique or perpendicular to the screw trajectory, the injury is relatively recent, and the patient has acceptable body habitus to place the odontoid screw.

Transoral Odontoidectomy

• In some situations, the odontoid process (dens) may be severely posteriorly displaced and compressing the spinal cord causing neurologic deficits. It is difficult and dangerous to reduce the odontoid process in a closed manner, so surgical removal of the odontoid process is required to relieve the compression of the spinal cord.
• This relief is commonly achieved through a transoral adenoidectomy, as the odontoid process commonly is located posterior to the oropharynx. If the odontoid process is removed, the cervical spine remains unstable, and the patient requires instrumented fusion, commonly from a posterior or combined anterior-posterior approach.

Posterior Instrumentation

If the patient has certain risk factors for nonunion, then posterior instrumentation may provide the best treatment option for a type II odontoid fracture. The risk factors include:

• More than a few millimeters gap between the odontoid process and the vertebral body
• Poor odontoid process alignment
• Poor bone quality, older fractures
• Older patients
• Failure of other treatment modalities
• Smoking

Posterior instrumented fusion techniques vary widely and include fusion limited to C1 and C2 as well as more extensive fusions. The fusion of only C1 and C2 will lead to approximately 50% reduction of the lateral rotation of the cervical spine.

Surgical Treatment

Treatment options include conservative management, cervical orthosis, halo-vest orthosis, and surgical procedures.[rx][rx][rx][rx]

External Fixation

• Rigid cervical collar represents the immediate first treatment. For type-I and type-III odontoid fractures this is generally adequate. This is also true for 90% of Hangman’s fractures. Halo-vest orthosis can be used as well for external fixation in certain cases of type-II odontoid fractures or angulated/displaced Hangman’s fractures but is not very well tolerated in the elderly population.

Internal Fixation

• Internal fixation can be achieved via anterior fixation or by a variety of posterior constructs.

Anterior

• An odontoid screw can be placed for type-II odontoid fractures in good alignment with an intact transverse ligament in the acute setting.  There is concern about the placement of the odontoid screw in the elderly population and instances of delayed non-union.

Posterior

• C1 to C2 transarticular screws
• C1 lateral mass and C2 pedicle screws
• C1 lateral mass and C2 pars interarticularis screws
• C1 to C2 wiring (also as an adjunct technique)

Posterior fixation technique selection requires significant review by neurosurgeon or orthopedic spine surgeon. It takes into consideration a variety of factors including surgeon experience, fracture location, vertebral artery location, biomechanical suitability, and anatomical variations. Vascular imaging is mandatory to illustrate the location of the vertebral artery in the V2 and V3 segments.

Collars and Halo Fixators

• The use of collars and halo fixators remains controversial. Soft collars have no stabilizing function, thus we do not recommend them in the early phase. However, they may be used for nonoperative treatment in stable fractures after an initial phase with a hard collar.
• Hard collars (Philadelphia, for example) may be used in the first phase for unstable fractures until a decision for further treatment is made. It may be used for 6 to 8 weeks in cases where nonoperative treatment is indicated. ^[rx–rx]

Anterior Odontoid Screw Fixation

• Initially described by Böhler,^rx] osteosyntheses with 1 or 2 screws by an anterior approach is a standard operative treatment in younger patients with good bone quality if adverse modifiers are absent.
• Patients are operated on in the supine position. With a minimal open incision, the preparation follows the anatomical structures for the standard anterior approach to the cervical spine.

Hangman’s Fracture/Odontoid Fracture, the odontoid process, or dens, is a superior projecting bony element from the second cervical vertebrae (C2, or the axis). The first cervical vertebrae (atlas) rotates around the odontoid process to provide the largest single component of lateral rotation of the cervical spine. Fracture of the odontoid process is classified into one of three types, which are type I, type II, or type III fractures, depending on the location and morphology of the fracture.[rx]

A hangman’s fracture is better described as bilateral fracture traversing the pars inter articularis of C2 with an associated traumatic subluxation of C2 on C3. It is the second most common fracture of the C2 vertebrae following a fracture of the odontoid process and is almost always stable without the need for surgical intervention. Steele’s rule of thirds states that the cross-sectional area at the level of the atlas may be divided into three equally represented parts: the dens, space, and the spinal cord. This increased area for the spinal cord at this level is what allows for the relative lack of neurologic injury associated with a hangman’s fracture. [rx]

Mechanisms of Hangman’s Fracture

Apart from hangings, the mechanism of injury—a sudden forceful hyperextension centered just under the chin—occurs mainly with deceleration injuries in which the victim’s face or chin strike an unyielding object with the neck in extension. The most common scenario is a frontal motor vehicle accident with an unrestrained passenger or driver, with the person striking the dashboard or windshield with their face or chin. Other scenarios include falls, diving injuries, and collisions between players in contact sports.

Although a hangman’s fracture is unstable, survival from this fracture is relatively common, as the fracture itself tends to expand the spinal canal at the C2 level. It is not unusual for patients to walk in for treatment and have such a fracture discovered on X-rays. Only if the force of the injury is severe enough that the vertebral body of C2 is severely subluxated from C3 does the spinal cord become crushed, usually between the vertebral body of C3 and the posterior elements of C1 and C2.

Types of Hangman’s Fracture

Type I Odontoid Fracture 

A type I odontoid fracture occurs when the rostral tip of the odontoid process is avulsed (broken or torn off). This injury commonly occurs due to pulling forces from the apical ligament attachment to the odontoid process. The apical ligament attaches the tip of the odontoid process to the foramen magnum (skull base).

Type II Odontoid Fracture

A type II odontoid fracture is a fracture through the base of the odontoid process. This injury occurs most typically when there is an excessive extension of the cervical spine, and the anterior arch of C1 pushes dorsally (backward) with sufficient force on the odontoid process (dens) to fracture the odontoid process at its base. Type II odontoid fractures can also occur with hyperflexion of the neck and the transverse ligament, pushing the odontoid process forward to the point of fracture.

Type III Odontoid Fracture

A type III odontoid fracture is a fracture through the body of the C2 vertebrae and may involve a variable portion of the C1 and C2 facets.  Type III odontoid fractures occur secondary to hyperextension or hyperflexion of the cervical spine in a similar manner to type II odontoid fractures. The difference is where the fracture line occurs.

C2 fractures can be divided into 2 kinds: Odontoid and Hangmen

Odontoid Fractures

Location

• Fracture through the dens, flexion or extension injury

Nomenclature

Anderson and D’Alonzo classification is the most ubiquitous.

• Type-1 fractures: Upper portion of the odontoid peg, above the transverse portion of the cruciform ligament, these are generally stable
• Type-2 fractures: These are the most common, the fracture through the based of the odontoid below the transverse portion of the cruciform ligament, they have a high risk of non-union
• Type-3 fractures: These fracture through the odontoid peg and into the body of C2, generally well tolerated

The Roy-Camille classification of odontoid fractures is another but less frequently used nomenclature format focusing on the direction of the fracture line.

Hangman’s Fractures

Location

• Fracture through the bilateral pars, generally from hyperextension and axial loading generally
• Stable 90% heal with immobilization alone

Nomenclature

Levine and Edwards Classification

• Type 1: Less than 3 mm subluxation of C2 on C3, due to axial loading, stable, rigid cervical collar treatment
• Type 2: disruption of the C2 to C3 disc, posterior longitudinal ligament, greater than 4 mm subluxation, greater than 11 degrees angulation, less than 5 mm requires a reduction in axial traction and halo fixation for 6 to 12 weeks while those greater than 5 mms can require surgery
• Type 2a: Less displacement more angular deformity, flexion injury, unstable, not suitable for axial traction, treatment in halo
• Type 3: C2 to C3 facet capsule disrupted, anterior longitudinal ligament disruption, unstable, may have deficit, surgical candidates.

Levine and Edwards Classification[rx]

Specifics

• Angulation in this system is measured as the angle between the inferior endplate of C2 and C3. Anterior subluxation of C2 on C3 greater than 3 mm serves as a marker for C2 to C3 intervertebral disc disruption. It is important to recognize that this grading system is not applicaple in the pediatric population.

Grading

• Type 1: Less than 3 mm subluxation of C2 on C3, due to axial loading, stable, rigid cervical collar treatment
• Type 2: Disruption of the C2 to C3 disc, posterior longitudinal ligament, greater than 4 mm subluxation, greater than 11 degrees angulation, less than 5 mm requires a reduction in axial traction and halo fixation for 6 to 12 weeks while those greater than 5 mm can require surgery
• Type 2a: Less displacement more angular deformity, flexion injury, unstable, not suitable for axial traction, treatment in halo
• Type 3: C2 to C3 facet capsule disrupted, anterior longitudinal ligament disruption, unstable, may have deficit, surgical candidates

Francis Grading System[rx]

Specifics

• Two factors are taken into consideration for the Francis Grading system: angulation and displacement. Angulation is measured by the degree of anterior angulation off of the posterior vertebral line drawn straight up from the C3 vertebral body. Displacement is measured by the amount of anterolisthesis, either greater than or less than 3.5 mm.

Grading

• Type 1: Less than 11 degrees of angulation and less than 3.5 mm of displacement
• Type 2: Greater than 11 degrees of angulation and less than 3.5 mm of displacement
• Type 3: Less than 11 degrees of angulation and greater than 3.5 mm displacement
• Type 4: Greater than 11 degrees of angulation and greater than 3.5 mm of displacement
• Type 5: Complete disc disruption

Typical versus Atypical Fractures

• It is important to recognize that not all C2, hangman’s type fractures can be described using these classification systems. A typical hangman’s fracture allows for separation of the anterior elements from the posterior elements of the C2 vertebrae, therefore increase the available space for the spinal cord.
• However, in the case of an atypical hangman’s fracture the posterior aspect of the C2 vertebral body, not the bilateral pars, is involved. This leads to a higher risk of neurologic injury as the space remaining for the spinal cord does not increase secondary to the fracture.

Causes of Hangman’s Fracture

• Odontoid fractures occur as a result of trauma to the cervical spine.
• high-energy trauma, which occurs as a result of a motor vehicle or diving accidents.
• trauma can occur after lower energy impacts such as falls from a standing position.
• hyperextension of the cervical spine, pushing the head and C1 vertebrae backward.
• forceful thrust are high enough (or the patient’s bone density is compromised secondary to osteopenia/osteoporosis),
• The odontoid fracture can also occur with hyperflexion of the cervical spine.
• The transverse ligament runs dorsal to (behind) the odontoid process and attaches to the lateral mass of C1 on either side.
• If the cervical spine is excessively flexed, then the transverse ligament can transmit the excessive anterior forces to the odontoid process and cause an odontoid fracture.[rx]
• Sudden forceful  fall down
• Road traffic accident
• Falls – Falling onto an outstretched hand is one of the most common causes of the broken cervical spine.
• Sports injuries – Many cervical spine fractures occur during contact sports or sports in which you might fall onto an outstretched hand — such as in-line skating or snowboarding.
• Motor vehicle crashes – Motor vehicle crashes can cause cervical spine to break, sometimes into many pieces, and often require surgical repair.
• Have osteoporosis –  a disease that weakens your bones
• Eave low muscle mass or poor muscle strength – or lack agility and have poor balance (these conditions make you more likely to fall)
• Walk or do other activities in the snow or on the ice – or do activities that require a lot of forwarding momenta, such as in-line skating and skiing.
• Previous pelvic fractures record.
• Wave an inadequate intake of calcium or vitamin D.
• Football or soccer, especially on artificial turf
• Athletic injury with a sports injury.
• Horseback riding
• Hockey
• Skiing
• Snowboarding
• Clumsiness in hands
• Gait imbalance
• Degenerative cervical spondylosis (CSM) 
  
• Compression usually caused by anterior degenerative changes (osteophytes, disc osteophyte complex)
• Degenerative spondylolisthesis and hypertrophy of ligamentum flavum may contribute
• The most common cause of cervical myelopathy.

Symptoms of Hangman’s Fracture

Symptoms of cervical spondylosis include:

• Neck stiffness and pain
• Numbness and weakness in the upper limbs
• Difficulty in walking, losing balance, or weakness in limbs
• Difficulty in turning the head fully or bending the neck, which may hinder drive
• Muscle spasms in neck and shoulders
• Headaches
• Grinding and popping feeling in the neck when rotating the head
• Loss of bladder and bowel control.
• neck pain and stiffness
• axial neck pain (oftentimes absent)
• occipital headache common
• extremity paresthesias
• diffuse nondermatomal numbness and tingling
• weakness and clumsiness
• weakness and decreased manual dexterity (dropping object, difficulty manipulating fine objects)
• Gait instability patient feels “unstable” on feet
• weakness walking up and downstairs
• gait changes are the most important clinical predictor
• urinary retention rare and only appear late in disease progression, not very useful in diagnosis due to the high prevalence of urinary conditions in this patient population
• Cervical pain aggravated by movement
• Referred pain (occiput, between the shoulder blades, upper limbs)
• Retro-orbital or temporal pain (from C1 to C2)
• Cervical stiffness—reversible or irreversible
• Vague numbness, tingling, or weakness in upper limbs
• Dizziness or vertigo
• Poor balance
• Rarely, syncope triggers a migraine, “pseudo-angina”

Diagnosis of Hangman’s Fracture

Laboratory tests should be ordered as an adjunct in overall medical status.

• Normalized hemoglobin,
• hematocrit,
• coagulation profile with prothrombin time (PT),
• partial thromboplastin time (PTT), and
• platelet counts will be needed for operative intervention.

In hospitals and countries without readily available advanced imaging capabilities, radiographs are critical to evaluate and assist in ruling out potential odontoid fractures.  Recommended views include:[rx]

• AP C-spine
• Lateral C-spine
• Open-mouth odontoid view

Although radiographs yield lower sensitivity and specificity rates when compared to computed tomogram (CT) scans, experienced clinicians and practitioners can still appreciate suspected injury without CT utilization.  In addition, in the setting of suspected occipito cervical instability (useful in type I odontoid fractures or the setting of os odontoideum), flexion-extension radiographs should be obtained.

X-ray

Evaluation of x-rays will provide limited but important information. Care must be taken to ensure proper radiographic imaging creates a picture from the occiput to the C7 through T1 disc space. This is essential in reviewing cervical spine trauma. Lateral, anteroposterior (AP) and open mouth odontoid views are necessary. Approximately, 93% of cervical spine injuries are apparent with combined, lateral, AP, and odontoid view radiographs. X-rays are an excellent modality for determining alignment during the immediate injury, post-operative period, as well as long-term, follow up.

Computed tomogram (CT) scan

CT scan is the most important modality for determining fracture etiology and ruling out an injury with regards to a C2 fracture. Even if plain films are negative and clinical suspicion is high a CT scan is warranted. CT scan does not directly evaluate the spinal cord, soft tissue, or ligamentous construct. It is important to recognize the importance that complete imaging will require dedicated thin-cut CT reconstructions. Non-contrast CT scan is adequate for evaluation of the bony anatomy for fracture. This can be coupled with a CT angiogram for evaluation of the vascular anatomy.

Magnetic resonance imaging (MRI) scan

Evaluation with MRI is important for the analysis of the ligamentous construct, disc space, spinal cord, nerve roots, and other soft tissue injuries. MRI is also useful for determining the acute nature of the fracture when this is otherwise unknown. This is done via non-contrasted imaging. T2 signal hyperintensities and STIR changes within the dens, ligaments, or soft tissue can illustrate an acute component.

Vascular Imaging

Vascular imaging may be indicated. The vertebral artery’s second segment (V2) runs through the transverse foramen of C2 to C6 while V3 runs extramurally exiting the C2 foramen across the sulcus arteriosus.  This can place it at risk for injury. Indeed, in one series 15% of patients with C1 to C2 fractures had a vertebral artery injury. Of which, type-III odontoid fractures posed the greatest risk. It is important to note that an untreated vertebral artery injury has a 24% stroke rate.

Advanced Imaging modalities

The imaging modality of choice is a CT of the cervical spine. The CT provides the best resolution of the bony elements allowing for identification and characterization of an odontoid fracture. If there is neurologic injury (paresthesia, weakness), then magnetic resonance imaging (MRI) without the contrast of the cervical spine should be obtained to assess the cervical cord for injuries.

Nuclear bone scan – a diagnostic procedure in which a radioactive substance is injected into the body to measure activity in the bones.  (The amount of radiation is small–less than the radiation in half of one CT scan.) This scan helps identify damaged bones.

Treatment of Hangman’s Fracture

The treatment of an odontoid fracture depends on the type of fracture and age of the patient.[rx][rx][rx][rx]

Non-Surgical Treatment

Treatment available can be broadly

• Skeletal traction – Available evidence suggests that treatment depends on the part of the pelvic fracture that is fractured. Traction may be useful for odontoid fracture because it counteracts the force of the muscle pulling the two separated parts together, and thus may decrease bleeding and pain.^[rx] Traction should not be used in the femoral neck and odontoid fracture or when there is any other trauma to the leg or pelvis.^[rx][rx] It is typically only a temporary measure used before surgery. It only considered the definitive treatment for patients with significant comorbidities that contraindicate surgical management.^[rx]
• Get medical help immediately – If you fall on an outstretched arm, get into a car accident or are hit while playing a sport and feel intense pain in your hip area, then get medical care immediately. You’ll innately know that something is seriously wrong because you won’t be able to lift your leg up. Other symptoms include immediate swelling and/or bruising near the fracture, grinding sounds with arm movements and potential numbness, and tingling in the leg.
• Apply ice – After you get home from the hospital odontoid fracture (regardless if you had surgery or not), you should apply a bag of crushed ice (or something cold) to your injured in order to reduce the swelling and numb the pain. Ice therapy is effective for acute (recent) injuries that involve swelling because it reduces blood flow by constricting local blood vessels. Apply the crushed ice to your odontoid fracture  for 15 minutes three to five times daily until the soreness and inflammation eventually fades away
• Lightly exercise after the pain fades – After a couple of weeks when the swelling has subsided and the pain has faded away, remove your arm sling for short periods and carefully move your hip joints in all different directions. Don’t aggravate the odontoid fracture so that it hurts, but gently reintroduce movements to the involved joints and muscles. Start cautiously, maybe starting with light, and then progress to holding light weights (five-pound weights to start).
• Practice stretching and strengthening exercises – of the fingers, leg if your doctor recommends them.
• A splint – which you might use for a few days to a week while the swelling goes down; if a splint is used initially, a cast is usually put on about a week later.
• A cast – which you might need for six to eight weeks or longer, depending on how bad the break is (you might need a second cast if the first one gets too loose after the swelling goes away.)
• Get a supportive arm sling – Due to their anatomical position, necks of odontoid fracture can’t be cast like a broken spine. Instead, a supportive arm sling or “figure-eight” splint is typically used for support and comfort, either immediately after the injury if it’s just a hairline fracture or following surgery, if it’s a complicated fracture.
• Get a referral to physical therapy – Once you’ve recovered and able to remove your arm sling splint for good, you’ll likely notice that the muscles surrounding your neck and lower chest look smaller and feel weaker. That’s because muscle tissue atrophies without movement. If this occurs, then you’ll need to get a referral for some physical rehabilitation. Rehab can start once you are cleared by your orthopedist, are pain-free, and can perform all the basic arm and necks movements. A physiotherapist or athletic trainer can show you specific rehabilitation exercises and stretches to restore your muscle strength, joint movements, and flexibility
• Rigid fixation – osteosynthesis with locking plate, hook plate fixation, fixation with a locking plate, coracoclavicular screws, Knowles pin fixation.
• Flexible fixation – simple k wire fixation, tension band wiring, suture anchors, vinyl tape, dacron arterial graft for ligament reconstruction.
• A splint – which you might use for a few days to a week while the swelling goes down; if a splint is used initially, a cast is usually put on about a week later.
• A cast – which you might need for six to eight weeks or longer, depending on how bad the break is (you might need a second cast if the first one gets too loose after the swelling goes away.)

Rest Your Leg – Once you’re discharged from the hospital in an arm sling, your top priority is to rest your and not further inflame the injury. Of course, the arm sling not only provides support, but it also restricts movement, which is why you should keep it on even during sleep. Avoiding the temptation to move your shoulder and arm will help the bone mend quicker and the pain fades away sooner.

Type I Odontoid Fracture

• Most consider a type I odontoid fracture a stable fracture and treatment for six to 12 weeks in a rigid cervical orthosis (hard cervical collar). Some have suggested that rarely a type I odontoid fracture may be unstable secondary to more extensive and unrecognized ligamentous injury, and flexion/extension x-rays should be obtained at the time of removal of the cervical collar after six to 12 weeks to ensure cervical stability.

Type II Odontoid Fracture[rx]

• Type II odontoid fractures are inherently unstable and have a lower union rate than type III odontoid fractures due to the lower surface area of a fractured bone in type II versus type III odontoid fractures.
• The configuration of type II odontoid fracture and age of patient also play important roles in treatment decisions. The current treatment options for a type II odontoid fracture include rigid cervical orthosis, halo vest immobilization, odontoid screw, transoral adenoidectomy, and posterior instrumentation.

Rigid Cervical Orthosis 

• A type II odontoid fracture is inherently unstable, and a rigid cervical orthosis is not the ideal treatment for such an injury. In the elderly population, many are not surgical candidates (due to comorbidities or poor bone quality), and the elderly typically poorly tolerate a halo vest immobilization. In such situations, a practitioner may attempt a rigid cervical orthosis, although union rates are low.

Halo Vest Immobilization

• If a patient is relatively young and healthy, and there is low risk for nonunion, then halo vest immobilization may be the best treatment for a type II odontoid fracture. Risk factors for nonunion include a fractured space greater than a few millimeters between the odontoid process and vertebral body, poor alignment of the odontoid process with respect to the vertebral body, and poor bone quality and/or health status of the patient.

Medication

• Antibiotic – Cefuroxime or Azithromycin, or  Flucloxacillin or any others cephalosporin/quinolone antibiotic must be used to prevent infection or clotted blood remove to prevent furthers swelling and edema
• NSAIDs – Prescription-strength drugs that reduce both pain and inflammation. Pain medicines and anti-inflammatory drugs help to relieve pain and stiffness, allowing for increased mobility and exercise. There are many common over-the-counter medicines called non-steroidal anti-inflammatory drugs (NSAIDs). They include and Ketorolac, Aceclofenac, Naproxen, Etoricoxib.
• Corticosteroids – Also known as oral steroids, these medications reduce inflammation.
• Muscle Relaxants –  These medications provide relief from associated muscle spasms.
• Neuropathic Agents – Drugs(pregabalin & gabapentin) that address neuropathic—or nerve-related—pain. This includes burning, numbness, and tingling.
• Opioids – Also known as narcotics, these medications are intense pain relievers that should only be used under a doctor’s careful supervision.
• Topical Medications – These prescription-strength creams, gels, ointments, patches, and sprays help relieve pain and inflammation through the skin.
• Calcium & vitamin D3 – to improve bone health and healing fracture. As a general rule, men and women age 50 and older should consume 1,200 milligrams of calcium a day, and 600 international units of vitamin D a day.
• Glucosamine & Diacerein, Chondroitin sulfate – can be used to tightening the loose tension, cartilage, ligament, and cartilage, ligament regenerate cartilage or inhabit the further degeneration of cartilage, ligament
• Dietary supplement-to remove general weakness & improved health.
• Antidepressants – A drug that blocks pain messages from your brain and boosts the effects of endorphins (your body’s natural painkillers).

Odontoid Screw

• An anterior odontoid osteosynthesis (odontoid screw) is a screw placed from the inferior anterior aspect of the C2 vertebral body, in a superior trajectory, and capturing the odontoid process and affixing it in place to allow bony fusion to occur.  The odontoid screw has an advantage of relative preservation of motion of the upper cervical spine while treating a type II odontoid fracture.
• A surgeon can only place the odontoid screw if there are acceptable alignment and minimal displacement of the odontoid process, the fracture line is oblique or perpendicular to the screw trajectory, the injury is relatively recent, and the patient has acceptable body habitus to place the odontoid screw.

Transoral Odontoidectomy

• In some situations, the odontoid process (dens) may be severely posteriorly displaced and compressing the spinal cord causing neurologic deficits. It is difficult and dangerous to reduce the odontoid process in a closed manner, so surgical removal of the odontoid process is required to relieve the compression of the spinal cord.
• This relief is commonly achieved through a transoral adenoidectomy, as the odontoid process commonly is located posterior to the oropharynx. If the odontoid process is removed, the cervical spine remains unstable, and the patient requires instrumented fusion, commonly from a posterior or combined anterior-posterior approach.

Posterior Instrumentation

If the patient has certain risk factors for nonunion, then posterior instrumentation may provide the best treatment option for a type II odontoid fracture. The risk factors include:

• More than a few millimeters gap between the odontoid process and the vertebral body
• Poor odontoid process alignment
• Poor bone quality, older fractures
• Older patients
• Failure of other treatment modalities
• Smoking

Posterior instrumented fusion techniques vary widely and include fusion limited to C1 and C2 as well as more extensive fusions. The fusion of only C1 and C2 will lead to approximately 50% reduction of the lateral rotation of the cervical spine.

Surgical Treatment

Treatment options include conservative management, cervical orthosis, halo-vest orthosis, and surgical procedures.[rx][rx][rx][rx]

External Fixation

• Rigid cervical collar represents the immediate first treatment. For type-I and type-III odontoid fractures this is generally adequate. This is also true for 90% of Hangman’s fractures. Halo-vest orthosis can be used as well for external fixation in certain cases of type-II odontoid fractures or angulated/displaced Hangman’s fractures but is not very well tolerated in the elderly population.

Internal Fixation

• Internal fixation can be achieved via anterior fixation or by a variety of posterior constructs.

Anterior

• An odontoid screw can be placed for type-II odontoid fractures in good alignment with an intact transverse ligament in the acute setting.  There is concern about the placement of the odontoid screw in the elderly population and instances of delayed non-union.

Posterior

• C1 to C2 transarticular screws
• C1 lateral mass and C2 pedicle screws
• C1 lateral mass and C2 pars interarticularis screws
• C1 to C2 wiring (also as an adjunct technique)

Posterior fixation technique selection requires significant review by neurosurgeon or orthopedic spine surgeon. It takes into consideration a variety of factors including surgeon experience, fracture location, vertebral artery location, biomechanical suitability, and anatomical variations. Vascular imaging is mandatory to illustrate the location of the vertebral artery in the V2 and V3 segments.

Collars and Halo Fixators

• The use of collars and halo fixators remains controversial. Soft collars have no stabilizing function, thus we do not recommend them in the early phase. However, they may be used for nonoperative treatment in stable fractures after an initial phase with a hard collar.
• Hard collars (Philadelphia, for example) may be used in the first phase for unstable fractures until a decision for further treatment is made. It may be used for 6 to 8 weeks in cases where nonoperative treatment is indicated. ^[rx–rx]

Anterior Odontoid Screw Fixation

• Initially described by Böhler,^rx] osteosyntheses with 1 or 2 screws by an anterior approach is a standard operative treatment in younger patients with good bone quality if adverse modifiers are absent.
• Patients are operated on in the supine position. With a minimal open incision, the preparation follows the anatomical structures for the standard anterior approach to the cervical spine.

Type II Odontoid Fracture/Odontoid Fracture, the odontoid process, or dens, is a superior projecting bony element from the second cervical vertebrae (C2, or the axis). The first cervical vertebrae (atlas) rotates around the odontoid process to provide the largest single component of lateral rotation of the cervical spine. Fracture of the odontoid process is classified into one of three types, which are type I, type II, or type III fractures, depending on the location and morphology of the fracture.[rx]

A hangman’s fracture is better described as bilateral fracture traversing the pars inter articularis of C2 with an associated traumatic subluxation of C2 on C3. It is the second most common fracture of the C2 vertebrae following a fracture of the odontoid process and is almost always stable without the need for surgical intervention. Steele’s rule of thirds states that the cross-sectional area at the level of the atlas may be divided into three equally represented parts: the dens, space, and the spinal cord. This increased area for the spinal cord at this level is what allows for the relative lack of neurologic injury associated with a hangman’s fracture. [rx]

Mechanisms of Type II Odontoid Fracture

Apart from hangings, the mechanism of injury—a sudden forceful hyperextension centered just under the chin—occurs mainly with deceleration injuries in which the victim’s face or chin strike an unyielding object with the neck in extension. The most common scenario is a frontal motor vehicle accident with an unrestrained passenger or driver, with the person striking the dashboard or windshield with their face or chin. Other scenarios include falls, diving injuries, and collisions between players in contact sports.

Although a hangman’s fracture is unstable, survival from this fracture is relatively common, as the fracture itself tends to expand the spinal canal at the C2 level. It is not unusual for patients to walk in for treatment and have such a fracture discovered on X-rays. Only if the force of the injury is severe enough that the vertebral body of C2 is severely subluxated from C3 does the spinal cord become crushed, usually between the vertebral body of C3 and the posterior elements of C1 and C2.

Types of Type II Odontoid Fracture

Type I Odontoid Fracture 

A type I odontoid fracture occurs when the rostral tip of the odontoid process is avulsed (broken or torn off). This injury commonly occurs due to pulling forces from the apical ligament attachment to the odontoid process. The apical ligament attaches the tip of the odontoid process to the foramen magnum (skull base).

Type II Odontoid Fracture

A type II odontoid fracture is a fracture through the base of the odontoid process. This injury occurs most typically when there is an excessive extension of the cervical spine, and the anterior arch of C1 pushes dorsally (backward) with sufficient force on the odontoid process (dens) to fracture the odontoid process at its base. Type II odontoid fractures can also occur with hyperflexion of the neck and the transverse ligament, pushing the odontoid process forward to the point of fracture.

Type III Odontoid Fracture

A type III odontoid fracture is a fracture through the body of the C2 vertebrae and may involve a variable portion of the C1 and C2 facets.  Type III odontoid fractures occur secondary to hyperextension or hyperflexion of the cervical spine in a similar manner to type II odontoid fractures. The difference is where the fracture line occurs.

C2 fractures can be divided into 2 kinds: Odontoid and Hangmen

Odontoid Fractures

Location

• Fracture through the dens, flexion or extension injury

Nomenclature

Anderson and D’Alonzo classification is the most ubiquitous.

• Type-1 fractures: Upper portion of the odontoid peg, above the transverse portion of the cruciform ligament, these are generally stable
• Type-2 fractures: These are the most common, the fracture through the based of the odontoid below the transverse portion of the cruciform ligament, they have a high risk of non-union
• Type-3 fractures: These fracture through the odontoid peg and into the body of C2, generally well tolerated

The Roy-Camille classification of odontoid fractures is another but less frequently used nomenclature format focusing on the direction of the fracture line.

Hangman’s Fractures

Location

• Fracture through the bilateral pars, generally from hyperextension and axial loading generally
• Stable 90% heal with immobilization alone

Nomenclature

Levine and Edwards Classification

• Type 1: Less than 3 mm subluxation of C2 on C3, due to axial loading, stable, rigid cervical collar treatment
• Type 2: disruption of the C2 to C3 disc, posterior longitudinal ligament, greater than 4 mm subluxation, greater than 11 degrees angulation, less than 5 mm requires a reduction in axial traction and halo fixation for 6 to 12 weeks while those greater than 5 mms can require surgery
• Type 2a: Less displacement more angular deformity, flexion injury, unstable, not suitable for axial traction, treatment in halo
• Type 3: C2 to C3 facet capsule disrupted, anterior longitudinal ligament disruption, unstable, may have deficit, surgical candidates.

Levine and Edwards Classification[rx]

Specifics

• Angulation in this system is measured as the angle between the inferior endplate of C2 and C3. Anterior subluxation of C2 on C3 greater than 3 mm serves as a marker for C2 to C3 intervertebral disc disruption. It is important to recognize that this grading system is not applicaple in the pediatric population.

Grading

• Type 1: Less than 3 mm subluxation of C2 on C3, due to axial loading, stable, rigid cervical collar treatment
• Type 2: Disruption of the C2 to C3 disc, posterior longitudinal ligament, greater than 4 mm subluxation, greater than 11 degrees angulation, less than 5 mm requires a reduction in axial traction and halo fixation for 6 to 12 weeks while those greater than 5 mm can require surgery
• Type 2a: Less displacement more angular deformity, flexion injury, unstable, not suitable for axial traction, treatment in halo
• Type 3: C2 to C3 facet capsule disrupted, anterior longitudinal ligament disruption, unstable, may have deficit, surgical candidates

Francis Grading System[rx]

Specifics

• Two factors are taken into consideration for the Francis Grading system: angulation and displacement. Angulation is measured by the degree of anterior angulation off of the posterior vertebral line drawn straight up from the C3 vertebral body. Displacement is measured by the amount of anterolisthesis, either greater than or less than 3.5 mm.

Grading

• Type 1: Less than 11 degrees of angulation and less than 3.5 mm of displacement
• Type 2: Greater than 11 degrees of angulation and less than 3.5 mm of displacement
• Type 3: Less than 11 degrees of angulation and greater than 3.5 mm displacement
• Type 4: Greater than 11 degrees of angulation and greater than 3.5 mm of displacement
• Type 5: Complete disc disruption

Typical versus Atypical Fractures

• It is important to recognize that not all C2, hangman’s type fractures can be described using these classification systems. A typical hangman’s fracture allows for separation of the anterior elements from the posterior elements of the C2 vertebrae, therefore increase the available space for the spinal cord.
• However, in the case of an atypical hangman’s fracture the posterior aspect of the C2 vertebral body, not the bilateral pars, is involved. This leads to a higher risk of neurologic injury as the space remaining for the spinal cord does not increase secondary to the fracture.

Causes of Type II Odontoid Fracture

• Odontoid fractures occur as a result of trauma to the cervical spine.
• high-energy trauma, which occurs as a result of a motor vehicle or diving accidents.
• trauma can occur after lower energy impacts such as falls from a standing position.
• hyperextension of the cervical spine, pushing the head and C1 vertebrae backward.
• forceful thrust are high enough (or the patient’s bone density is compromised secondary to osteopenia/osteoporosis),
• The odontoid fracture can also occur with hyperflexion of the cervical spine.
• The transverse ligament runs dorsal to (behind) the odontoid process and attaches to the lateral mass of C1 on either side.
• If the cervical spine is excessively flexed, then the transverse ligament can transmit the excessive anterior forces to the odontoid process and cause an odontoid fracture.[rx]
• Sudden forceful  fall down
• Road traffic accident
• Falls – Falling onto an outstretched hand is one of the most common causes of the broken cervical spine.
• Sports injuries – Many cervical spine fractures occur during contact sports or sports in which you might fall onto an outstretched hand — such as in-line skating or snowboarding.
• Motor vehicle crashes – Motor vehicle crashes can cause cervical spine to break, sometimes into many pieces, and often require surgical repair.
• Have osteoporosis –  a disease that weakens your bones
• Eave low muscle mass or poor muscle strength – or lack agility and have poor balance (these conditions make you more likely to fall)
• Walk or do other activities in the snow or on the ice – or do activities that require a lot of forwarding momenta, such as in-line skating and skiing.
• Previous pelvic fractures record.
• Wave an inadequate intake of calcium or vitamin D.
• Football or soccer, especially on artificial turf
• Athletic injury with a sports injury.
• Horseback riding
• Hockey
• Skiing
• Snowboarding
• Clumsiness in hands
• Gait imbalance
• Degenerative cervical spondylosis (CSM) 
  
• Compression usually caused by anterior degenerative changes (osteophytes, disc osteophyte complex)
• Degenerative spondylolisthesis and hypertrophy of ligamentum flavum may contribute
• The most common cause of cervical myelopathy.

Symptoms of Type II Odontoid Fracture

Symptoms of cervical spondylosis include:

• Neck stiffness and pain
• Numbness and weakness in the upper limbs
• Difficulty in walking, losing balance, or weakness in limbs
• Difficulty in turning the head fully or bending the neck, which may hinder drive
• Muscle spasms in neck and shoulders
• Headaches
• Grinding and popping feeling in the neck when rotating the head
• Loss of bladder and bowel control.
• neck pain and stiffness
• axial neck pain (oftentimes absent)
• occipital headache common
• extremity paresthesias
• diffuse nondermatomal numbness and tingling
• weakness and clumsiness
• weakness and decreased manual dexterity (dropping object, difficulty manipulating fine objects)
• Gait instability patient feels “unstable” on feet
• weakness walking up and downstairs
• gait changes are the most important clinical predictor
• urinary retention rare and only appear late in disease progression, not very useful in diagnosis due to the high prevalence of urinary conditions in this patient population
• Cervical pain aggravated by movement
• Referred pain (occiput, between the shoulder blades, upper limbs)
• Retro-orbital or temporal pain (from C1 to C2)
• Cervical stiffness—reversible or irreversible
• Vague numbness, tingling, or weakness in upper limbs
• Dizziness or vertigo
• Poor balance
• Rarely, syncope triggers a migraine, “pseudo-angina”

Diagnosis of Type II Odontoid Fracture

Laboratory tests should be ordered as an adjunct in overall medical status.

• Normalized hemoglobin,
• hematocrit,
• coagulation profile with prothrombin time (PT),
• partial thromboplastin time (PTT), and
• platelet counts will be needed for operative intervention.

In hospitals and countries without readily available advanced imaging capabilities, radiographs are critical to evaluate and assist in ruling out potential odontoid fractures.  Recommended views include:[rx]

• AP C-spine
• Lateral C-spine
• Open-mouth odontoid view

Although radiographs yield lower sensitivity and specificity rates when compared to computed tomogram (CT) scans, experienced clinicians and practitioners can still appreciate suspected injury without CT utilization.  In addition, in the setting of suspected occipito cervical instability (useful in type I odontoid fractures or the setting of os odontoideum), flexion-extension radiographs should be obtained.

X-ray

Evaluation of x-rays will provide limited but important information. Care must be taken to ensure proper radiographic imaging creates a picture from the occiput to the C7 through T1 disc space. This is essential in reviewing cervical spine trauma. Lateral, anteroposterior (AP) and open mouth odontoid views are necessary. Approximately, 93% of cervical spine injuries are apparent with combined, lateral, AP, and odontoid view radiographs. X-rays are an excellent modality for determining alignment during the immediate injury, post-operative period, as well as long-term, follow up.

Computed tomogram (CT) scan

CT scan is the most important modality for determining fracture etiology and ruling out an injury with regards to a C2 fracture. Even if plain films are negative and clinical suspicion is high a CT scan is warranted. CT scan does not directly evaluate the spinal cord, soft tissue, or ligamentous construct. It is important to recognize the importance that complete imaging will require dedicated thin-cut CT reconstructions. Non-contrast CT scan is adequate for evaluation of the bony anatomy for fracture. This can be coupled with a CT angiogram for evaluation of the vascular anatomy.

Magnetic resonance imaging (MRI) scan

Evaluation with MRI is important for the analysis of the ligamentous construct, disc space, spinal cord, nerve roots, and other soft tissue injuries. MRI is also useful for determining the acute nature of the fracture when this is otherwise unknown. This is done via non-contrasted imaging. T2 signal hyperintensities and STIR changes within the dens, ligaments, or soft tissue can illustrate an acute component.

Vascular Imaging

Vascular imaging may be indicated. The vertebral artery’s second segment (V2) runs through the transverse foramen of C2 to C6 while V3 runs extramurally exiting the C2 foramen across the sulcus arteriosus.  This can place it at risk for injury. Indeed, in one series 15% of patients with C1 to C2 fractures had a vertebral artery injury. Of which, type-III odontoid fractures posed the greatest risk. It is important to note that an untreated vertebral artery injury has a 24% stroke rate.

Advanced Imaging modalities

The imaging modality of choice is a CT of the cervical spine. The CT provides the best resolution of the bony elements allowing for identification and characterization of an odontoid fracture. If there is neurologic injury (paresthesia, weakness), then magnetic resonance imaging (MRI) without the contrast of the cervical spine should be obtained to assess the cervical cord for injuries.

Nuclear bone scan – a diagnostic procedure in which a radioactive substance is injected into the body to measure activity in the bones.  (The amount of radiation is small–less than the radiation in half of one CT scan.) This scan helps identify damaged bones.

Treatment of Type II Odontoid Fracture

The treatment of an odontoid fracture depends on the type of fracture and age of the patient.[rx][rx][rx][rx]

Non-Surgical Treatment

Treatment available can be broadly

• Skeletal traction – Available evidence suggests that treatment depends on the part of the pelvic fracture that is fractured. Traction may be useful for odontoid fracture because it counteracts the force of the muscle pulling the two separated parts together, and thus may decrease bleeding and pain.^[rx] Traction should not be used in the femoral neck and odontoid fracture or when there is any other trauma to the leg or pelvis.^[rx][rx] It is typically only a temporary measure used before surgery. It only considered the definitive treatment for patients with significant comorbidities that contraindicate surgical management.^[rx]
• Get medical help immediately – If you fall on an outstretched arm, get into a car accident or are hit while playing a sport and feel intense pain in your hip area, then get medical care immediately. You’ll innately know that something is seriously wrong because you won’t be able to lift your leg up. Other symptoms include immediate swelling and/or bruising near the fracture, grinding sounds with arm movements and potential numbness, and tingling in the leg.
• Apply ice – After you get home from the hospital odontoid fracture (regardless if you had surgery or not), you should apply a bag of crushed ice (or something cold) to your injured in order to reduce the swelling and numb the pain. Ice therapy is effective for acute (recent) injuries that involve swelling because it reduces blood flow by constricting local blood vessels. Apply the crushed ice to your odontoid fracture  for 15 minutes three to five times daily until the soreness and inflammation eventually fades away
• Lightly exercise after the pain fades – After a couple of weeks when the swelling has subsided and the pain has faded away, remove your arm sling for short periods and carefully move your hip joints in all different directions. Don’t aggravate the odontoid fracture so that it hurts, but gently reintroduce movements to the involved joints and muscles. Start cautiously, maybe starting with light, and then progress to holding light weights (five-pound weights to start).
• Practice stretching and strengthening exercises – of the fingers, leg if your doctor recommends them.
• A splint – which you might use for a few days to a week while the swelling goes down; if a splint is used initially, a cast is usually put on about a week later.
• A cast – which you might need for six to eight weeks or longer, depending on how bad the break is (you might need a second cast if the first one gets too loose after the swelling goes away.)
• Get a supportive arm sling – Due to their anatomical position, necks of odontoid fracture can’t be cast like a broken spine. Instead, a supportive arm sling or “figure-eight” splint is typically used for support and comfort, either immediately after the injury if it’s just a hairline fracture or following surgery, if it’s a complicated fracture.
• Get a referral to physical therapy – Once you’ve recovered and able to remove your arm sling splint for good, you’ll likely notice that the muscles surrounding your neck and lower chest look smaller and feel weaker. That’s because muscle tissue atrophies without movement. If this occurs, then you’ll need to get a referral for some physical rehabilitation. Rehab can start once you are cleared by your orthopedist, are pain-free, and can perform all the basic arm and necks movements. A physiotherapist or athletic trainer can show you specific rehabilitation exercises and stretches to restore your muscle strength, joint movements, and flexibility
• Rigid fixation – osteosynthesis with locking plate, hook plate fixation, fixation with a locking plate, coracoclavicular screws, Knowles pin fixation.
• Flexible fixation – simple k wire fixation, tension band wiring, suture anchors, vinyl tape, dacron arterial graft for ligament reconstruction.
• A splint – which you might use for a few days to a week while the swelling goes down; if a splint is used initially, a cast is usually put on about a week later.
• A cast – which you might need for six to eight weeks or longer, depending on how bad the break is (you might need a second cast if the first one gets too loose after the swelling goes away.)

Rest Your Leg – Once you’re discharged from the hospital in an arm sling, your top priority is to rest your and not further inflame the injury. Of course, the arm sling not only provides support, but it also restricts movement, which is why you should keep it on even during sleep. Avoiding the temptation to move your shoulder and arm will help the bone mend quicker and the pain fades away sooner.

Type I Odontoid Fracture

• Most consider a type I odontoid fracture a stable fracture and treatment for six to 12 weeks in a rigid cervical orthosis (hard cervical collar). Some have suggested that rarely a type I odontoid fracture may be unstable secondary to more extensive and unrecognized ligamentous injury, and flexion/extension x-rays should be obtained at the time of removal of the cervical collar after six to 12 weeks to ensure cervical stability.

Type II Odontoid Fracture[rx]

• Type II odontoid fractures are inherently unstable and have a lower union rate than type III odontoid fractures due to the lower surface area of a fractured bone in type II versus type III odontoid fractures.
• The configuration of type II odontoid fracture and age of patient also play important roles in treatment decisions. The current treatment options for a type II odontoid fracture include rigid cervical orthosis, halo vest immobilization, odontoid screw, transoral adenoidectomy, and posterior instrumentation.

Rigid Cervical Orthosis 

• A type II odontoid fracture is inherently unstable, and a rigid cervical orthosis is not the ideal treatment for such an injury. In the elderly population, many are not surgical candidates (due to comorbidities or poor bone quality), and the elderly typically poorly tolerate a halo vest immobilization. In such situations, a practitioner may attempt a rigid cervical orthosis, although union rates are low.

Halo Vest Immobilization

• If a patient is relatively young and healthy, and there is low risk for nonunion, then halo vest immobilization may be the best treatment for a type II odontoid fracture. Risk factors for nonunion include a fractured space greater than a few millimeters between the odontoid process and vertebral body, poor alignment of the odontoid process with respect to the vertebral body, and poor bone quality and/or health status of the patient.

Medication

• Antibiotic – Cefuroxime or Azithromycin, or  Flucloxacillin or any others cephalosporin/quinolone antibiotic must be used to prevent infection or clotted blood remove to prevent furthers swelling and edema
• NSAIDs – Prescription-strength drugs that reduce both pain and inflammation. Pain medicines and anti-inflammatory drugs help to relieve pain and stiffness, allowing for increased mobility and exercise. There are many common over-the-counter medicines called non-steroidal anti-inflammatory drugs (NSAIDs). They include and Ketorolac, Aceclofenac, Naproxen, Etoricoxib.
• Corticosteroids – Also known as oral steroids, these medications reduce inflammation.
• Muscle Relaxants –  These medications provide relief from associated muscle spasms.
• Neuropathic Agents – Drugs(pregabalin & gabapentin) that address neuropathic—or nerve-related—pain. This includes burning, numbness, and tingling.
• Opioids – Also known as narcotics, these medications are intense pain relievers that should only be used under a doctor’s careful supervision.
• Topical Medications – These prescription-strength creams, gels, ointments, patches, and sprays help relieve pain and inflammation through the skin.
• Calcium & vitamin D3 – to improve bone health and healing fracture. As a general rule, men and women age 50 and older should consume 1,200 milligrams of calcium a day, and 600 international units of vitamin D a day.
• Glucosamine & Diacerein, Chondroitin sulfate – can be used to tightening the loose tension, cartilage, ligament, and cartilage, ligament regenerate cartilage or inhabit the further degeneration of cartilage, ligament
• Dietary supplement-to remove general weakness & improved health.
• Antidepressants – A drug that blocks pain messages from your brain and boosts the effects of endorphins (your body’s natural painkillers).

Odontoid Screw

• An anterior odontoid osteosynthesis (odontoid screw) is a screw placed from the inferior anterior aspect of the C2 vertebral body, in a superior trajectory, and capturing the odontoid process and affixing it in place to allow bony fusion to occur.  The odontoid screw has an advantage of relative preservation of motion of the upper cervical spine while treating a type II odontoid fracture.
• A surgeon can only place the odontoid screw if there are acceptable alignment and minimal displacement of the odontoid process, the fracture line is oblique or perpendicular to the screw trajectory, the injury is relatively recent, and the patient has acceptable body habitus to place the odontoid screw.

Transoral Odontoidectomy

• In some situations, the odontoid process (dens) may be severely posteriorly displaced and compressing the spinal cord causing neurologic deficits. It is difficult and dangerous to reduce the odontoid process in a closed manner, so surgical removal of the odontoid process is required to relieve the compression of the spinal cord.
• This relief is commonly achieved through a transoral adenoidectomy, as the odontoid process commonly is located posterior to the oropharynx. If the odontoid process is removed, the cervical spine remains unstable, and the patient requires instrumented fusion, commonly from a posterior or combined anterior-posterior approach.

Posterior Instrumentation

If the patient has certain risk factors for nonunion, then posterior instrumentation may provide the best treatment option for a type II odontoid fracture. The risk factors include:

• More than a few millimeters gap between the odontoid process and the vertebral body
• Poor odontoid process alignment
• Poor bone quality, older fractures
• Older patients
• Failure of other treatment modalities
• Smoking

Posterior instrumented fusion techniques vary widely and include fusion limited to C1 and C2 as well as more extensive fusions. The fusion of only C1 and C2 will lead to approximately 50% reduction of the lateral rotation of the cervical spine.

Surgical Treatment

Treatment options include conservative management, cervical orthosis, halo-vest orthosis, and surgical procedures.[rx][rx][rx][rx]

External Fixation

• Rigid cervical collar represents the immediate first treatment. For type-I and type-III odontoid fractures this is generally adequate. This is also true for 90% of Hangman’s fractures. Halo-vest orthosis can be used as well for external fixation in certain cases of type-II odontoid fractures or angulated/displaced Hangman’s fractures but is not very well tolerated in the elderly population.

Internal Fixation

• Internal fixation can be achieved via anterior fixation or by a variety of posterior constructs.

Anterior

• An odontoid screw can be placed for type-II odontoid fractures in good alignment with an intact transverse ligament in the acute setting.  There is concern about the placement of the odontoid screw in the elderly population and instances of delayed non-union.

Posterior

• C1 to C2 transarticular screws
• C1 lateral mass and C2 pedicle screws
• C1 lateral mass and C2 pars interarticularis screws
• C1 to C2 wiring (also as an adjunct technique)

Posterior fixation technique selection requires significant review by neurosurgeon or orthopedic spine surgeon. It takes into consideration a variety of factors including surgeon experience, fracture location, vertebral artery location, biomechanical suitability, and anatomical variations. Vascular imaging is mandatory to illustrate the location of the vertebral artery in the V2 and V3 segments.

Collars and Halo Fixators

• The use of collars and halo fixators remains controversial. Soft collars have no stabilizing function, thus we do not recommend them in the early phase. However, they may be used for nonoperative treatment in stable fractures after an initial phase with a hard collar.
• Hard collars (Philadelphia, for example) may be used in the first phase for unstable fractures until a decision for further treatment is made. It may be used for 6 to 8 weeks in cases where nonoperative treatment is indicated. ^[rx–rx]

Anterior Odontoid Screw Fixation

• Initially described by Böhler,^rx] osteosyntheses with 1 or 2 screws by an anterior approach is a standard operative treatment in younger patients with good bone quality if adverse modifiers are absent.
• Patients are operated on in the supine position. With a minimal open incision, the preparation follows the anatomical structures for the standard anterior approach to the cervical spine.

Treatment of Odontoid Fracture/Odontoid Fracture, the odontoid process, or dens, is a superior projecting bony element from the second cervical vertebrae (C2, or the axis). The first cervical vertebrae (atlas) rotates around the odontoid process to provide the largest single component of lateral rotation of the cervical spine. Fracture of the odontoid process is classified into one of three types, which are type I, type II, or type III fractures, depending on the location and morphology of the fracture.[rx]

The odontoid fracture can also occur with hyperflexion of the cervical spine. The transverse ligament runs dorsal to (behind) the odontoid process and attaches to the lateral mass of C1 on either side. If the cervical spine is excessively flexed, then the transverse ligament can transmit the excessive anterior forces to the odontoid process and cause an odontoid fracture.[rx]

A hangman’s fracture is better described as bilateral fracture traversing the pars inter articularis of C2 with an associated traumatic subluxation of C2 on C3. It is the second most common fracture of the C2 vertebrae following a fracture of the odontoid process and is almost always stable without the need for surgical intervention. Steele’s rule of thirds states that the cross-sectional area at the level of the atlas may be divided into three equally represented parts: the dens, space, and the spinal cord. This increased area for the spinal cord at this level is what allows for the relative lack of neurologic injury associated with a hangman’s fracture. [rx]

Mechanisms of Odontoid Fracture

Apart from hangings, the mechanism of injury—a sudden forceful hyperextension centered just under the chin—occurs mainly with deceleration injuries in which the victim’s face or chin strike an unyielding object with the neck in extension. The most common scenario is a frontal motor vehicle accident with an unrestrained passenger or driver, with the person striking the dashboard or windshield with their face or chin. Other scenarios include falls, diving injuries, and collisions between players in contact sports.

Although a hangman’s fracture is unstable, survival from this fracture is relatively common, as the fracture itself tends to expand the spinal canal at the C2 level. It is not unusual for patients to walk in for treatment and have such a fracture discovered on X-rays. Only if the force of the injury is severe enough that the vertebral body of C2 is severely subluxated from C3 does the spinal cord become crushed, usually between the vertebral body of C3 and the posterior elements of C1 and C2.

Types of Odontoid Fracture

Type I Odontoid Fracture 

A type I odontoid fracture occurs when the rostral tip of the odontoid process is avulsed (broken or torn off). This injury commonly occurs due to pulling forces from the apical ligament attachment to the odontoid process. The apical ligament attaches the tip of the odontoid process to the foramen magnum (skull base).

Type II Odontoid Fracture

A type II odontoid fracture is a fracture through the base of the odontoid process. This injury occurs most typically when there is an excessive extension of the cervical spine, and the anterior arch of C1 pushes dorsally (backward) with sufficient force on the odontoid process (dens) to fracture the odontoid process at its base. Type II odontoid fractures can also occur with hyperflexion of the neck and the transverse ligament, pushing the odontoid process forward to the point of fracture.

Type III Odontoid Fracture

A type III odontoid fracture is a fracture through the body of the C2 vertebrae and may involve a variable portion of the C1 and C2 facets.  Type III odontoid fractures occur secondary to hyperextension or hyperflexion of the cervical spine in a similar manner to type II odontoid fractures. The difference is where the fracture line occurs.

C2 fractures can be divided into 2 kinds: Odontoid and Hangmen

Odontoid Fractures

Location

• Fracture through the dens, flexion or extension injury

Nomenclature

Anderson and D’Alonzo classification is the most ubiquitous.

• Type-1 fractures: Upper portion of the odontoid peg, above the transverse portion of the cruciform ligament, these are generally stable
• Type-2 fractures: These are the most common, the fracture through the based of the odontoid below the transverse portion of the cruciform ligament, they have a high risk of non-union
• Type-3 fractures: These fracture through the odontoid peg and into the body of C2, generally well tolerated

The Roy-Camille classification of odontoid fractures is another but less frequently used nomenclature format focusing on the direction of the fracture line.

Hangman’s Fractures

Location

• Fracture through the bilateral pars, generally from hyperextension and axial loading generally
• Stable 90% heal with immobilization alone

Nomenclature

Levine and Edwards Classification

• Type 1: Less than 3 mm subluxation of C2 on C3, due to axial loading, stable, rigid cervical collar treatment
• Type 2: disruption of the C2 to C3 disc, posterior longitudinal ligament, greater than 4 mm subluxation, greater than 11 degrees angulation, less than 5 mm requires a reduction in axial traction and halo fixation for 6 to 12 weeks while those greater than 5 mms can require surgery
• Type 2a: Less displacement more angular deformity, flexion injury, unstable, not suitable for axial traction, treatment in halo
• Type 3: C2 to C3 facet capsule disrupted, anterior longitudinal ligament disruption, unstable, may have deficit, surgical candidates.

Levine and Edwards Classification[rx]

Specifics

• Angulation in this system is measured as the angle between the inferior endplate of C2 and C3. Anterior subluxation of C2 on C3 greater than 3 mm serves as a marker for C2 to C3 intervertebral disc disruption. It is important to recognize that this grading system is not applicaple in the pediatric population.

Grading

• Type 1: Less than 3 mm subluxation of C2 on C3, due to axial loading, stable, rigid cervical collar treatment
• Type 2: Disruption of the C2 to C3 disc, posterior longitudinal ligament, greater than 4 mm subluxation, greater than 11 degrees angulation, less than 5 mm requires a reduction in axial traction and halo fixation for 6 to 12 weeks while those greater than 5 mm can require surgery
• Type 2a: Less displacement more angular deformity, flexion injury, unstable, not suitable for axial traction, treatment in halo
• Type 3: C2 to C3 facet capsule disrupted, anterior longitudinal ligament disruption, unstable, may have deficit, surgical candidates

Francis Grading System[rx]

Specifics

• Two factors are taken into consideration for the Francis Grading system: angulation and displacement. Angulation is measured by the degree of anterior angulation off of the posterior vertebral line drawn straight up from the C3 vertebral body. Displacement is measured by the amount of anterolisthesis, either greater than or less than 3.5 mm.

Grading

• Type 1: Less than 11 degrees of angulation and less than 3.5 mm of displacement
• Type 2: Greater than 11 degrees of angulation and less than 3.5 mm of displacement
• Type 3: Less than 11 degrees of angulation and greater than 3.5 mm displacement
• Type 4: Greater than 11 degrees of angulation and greater than 3.5 mm of displacement
• Type 5: Complete disc disruption

Typical versus Atypical Fractures

• It is important to recognize that not all C2, hangman’s type fractures can be described using these classification systems. A typical hangman’s fracture allows for separation of the anterior elements from the posterior elements of the C2 vertebrae, therefore increase the available space for the spinal cord.
• However, in the case of an atypical hangman’s fracture the posterior aspect of the C2 vertebral body, not the bilateral pars, is involved. This leads to a higher risk of neurologic injury as the space remaining for the spinal cord does not increase secondary to the fracture.

Causes of Odontoid Fracture

• Odontoid fractures occur as a result of trauma to the cervical spine.
• high-energy trauma, which occurs as a result of a motor vehicle or diving accidents.
• trauma can occur after lower energy impacts such as falls from a standing position.
• hyperextension of the cervical spine, pushing the head and C1 vertebrae backward.
• forceful thrust are high enough (or the patient’s bone density is compromised secondary to osteopenia/osteoporosis),
• The odontoid fracture can also occur with hyperflexion of the cervical spine.
• The transverse ligament runs dorsal to (behind) the odontoid process and attaches to the lateral mass of C1 on either side.
• If the cervical spine is excessively flexed, then the transverse ligament can transmit the excessive anterior forces to the odontoid process and cause an odontoid fracture.[rx]
• Sudden forceful  fall down
• Road traffic accident
• Falls – Falling onto an outstretched hand is one of the most common causes of the broken cervical spine.
• Sports injuries – Many cervical spine fractures occur during contact sports or sports in which you might fall onto an outstretched hand — such as in-line skating or snowboarding.
• Motor vehicle crashes – Motor vehicle crashes can cause cervical spine to break, sometimes into many pieces, and often require surgical repair.
• Have osteoporosis –  a disease that weakens your bones
• Eave low muscle mass or poor muscle strength – or lack agility and have poor balance (these conditions make you more likely to fall)
• Walk or do other activities in the snow or on the ice – or do activities that require a lot of forwarding momenta, such as in-line skating and skiing.
• Previous pelvic fractures record.
• Wave an inadequate intake of calcium or vitamin D.
• Football or soccer, especially on artificial turf
• Athletic injury with a sports injury.
• Horseback riding
• Hockey
• Skiing
• Snowboarding
• Clumsiness in hands
• Gait imbalance
• Degenerative cervical spondylosis (CSM) 
  
• Compression usually caused by anterior degenerative changes (osteophytes, disc osteophyte complex)
• Degenerative spondylolisthesis and hypertrophy of ligamentum flavum may contribute
• The most common cause of cervical myelopathy.

Symptoms of Odontoid Fracture

Symptoms of cervical spondylosis include:

• Neck stiffness and pain
• Numbness and weakness in the upper limbs
• Difficulty in walking, losing balance, or weakness in limbs
• Difficulty in turning the head fully or bending the neck, which may hinder drive
• Muscle spasms in neck and shoulders
• Headaches
• Grinding and popping feeling in the neck when rotating the head
• Loss of bladder and bowel control.
• neck pain and stiffness
• axial neck pain (oftentimes absent)
• occipital headache common
• extremity paresthesias
• diffuse nondermatomal numbness and tingling
• weakness and clumsiness
• weakness and decreased manual dexterity (dropping object, difficulty manipulating fine objects)
• Gait instability patient feels “unstable” on feet
• weakness walking up and downstairs
• gait changes are the most important clinical predictor
• urinary retention rare and only appear late in disease progression, not very useful in diagnosis due to the high prevalence of urinary conditions in this patient population
• Cervical pain aggravated by movement
• Referred pain (occiput, between the shoulder blades, upper limbs)
• Retro-orbital or temporal pain (from C1 to C2)
• Cervical stiffness—reversible or irreversible
• Vague numbness, tingling, or weakness in upper limbs
• Dizziness or vertigo
• Poor balance
• Rarely, syncope triggers a migraine, “pseudo-angina”

Diagnosis of Odontoid Fracture

Laboratory tests should be ordered as an adjunct in overall medical status.

• Normalized hemoglobin,
• hematocrit,
• coagulation profile with prothrombin time (PT),
• partial thromboplastin time (PTT), and
• platelet counts will be needed for operative intervention.

In hospitals and countries without readily available advanced imaging capabilities, radiographs are critical to evaluate and assist in ruling out potential odontoid fractures.  Recommended views include:[rx]

• AP C-spine
• Lateral C-spine
• Open-mouth odontoid view

Although radiographs yield lower sensitivity and specificity rates when compared to computed tomogram (CT) scans, experienced clinicians and practitioners can still appreciate suspected injury without CT utilization.  In addition, in the setting of suspected occipito cervical instability (useful in type I odontoid fractures or the setting of os odontoideum), flexion-extension radiographs should be obtained.

X-ray

Evaluation of x-rays will provide limited but important information. Care must be taken to ensure proper radiographic imaging creates a picture from the occiput to the C7 through T1 disc space. This is essential in reviewing cervical spine trauma. Lateral, anteroposterior (AP) and open mouth odontoid views are necessary. Approximately, 93% of cervical spine injuries are apparent with combined, lateral, AP, and odontoid view radiographs. X-rays are an excellent modality for determining alignment during the immediate injury, post-operative period, as well as long-term, follow up.

Computed tomogram (CT) scan

CT scan is the most important modality for determining fracture etiology and ruling out an injury with regards to a C2 fracture. Even if plain films are negative and clinical suspicion is high a CT scan is warranted. CT scan does not directly evaluate the spinal cord, soft tissue, or ligamentous construct. It is important to recognize the importance that complete imaging will require dedicated thin-cut CT reconstructions. Non-contrast CT scan is adequate for evaluation of the bony anatomy for fracture. This can be coupled with a CT angiogram for evaluation of the vascular anatomy.

Magnetic resonance imaging (MRI) scan

Evaluation with MRI is important for the analysis of the ligamentous construct, disc space, spinal cord, nerve roots, and other soft tissue injuries. MRI is also useful for determining the acute nature of the fracture when this is otherwise unknown. This is done via non-contrasted imaging. T2 signal hyperintensities and STIR changes within the dens, ligaments, or soft tissue can illustrate an acute component.

Vascular Imaging

Vascular imaging may be indicated. The vertebral artery’s second segment (V2) runs through the transverse foramen of C2 to C6 while V3 runs extramurally exiting the C2 foramen across the sulcus arteriosus.  This can place it at risk for injury. Indeed, in one series 15% of patients with C1 to C2 fractures had a vertebral artery injury. Of which, type-III odontoid fractures posed the greatest risk. It is important to note that an untreated vertebral artery injury has a 24% stroke rate.

Advanced Imaging modalities

The imaging modality of choice is a CT of the cervical spine. The CT provides the best resolution of the bony elements allowing for identification and characterization of an odontoid fracture. If there is neurologic injury (paresthesia, weakness), then magnetic resonance imaging (MRI) without the contrast of the cervical spine should be obtained to assess the cervical cord for injuries.

Nuclear bone scan – a diagnostic procedure in which a radioactive substance is injected into the body to measure activity in the bones.  (The amount of radiation is small–less than the radiation in half of one CT scan.) This scan helps identify damaged bones.

Treatment of Odontoid Fracture

The treatment of an odontoid fracture depends on the type of fracture and age of the patient.[rx][rx][rx][rx]

Non-Surgical Treatment

Treatment available can be broadly

• Skeletal traction – Available evidence suggests that treatment depends on the part of the pelvic fracture that is fractured. Traction may be useful for odontoid fracture because it counteracts the force of the muscle pulling the two separated parts together, and thus may decrease bleeding and pain.^[rx] Traction should not be used in the femoral neck and odontoid fracture or when there is any other trauma to the leg or pelvis.^[rx][rx] It is typically only a temporary measure used before surgery. It only considered the definitive treatment for patients with significant comorbidities that contraindicate surgical management.^[rx]
• Get medical help immediately – If you fall on an outstretched arm, get into a car accident or are hit while playing a sport and feel intense pain in your hip area, then get medical care immediately. You’ll innately know that something is seriously wrong because you won’t be able to lift your leg up. Other symptoms include immediate swelling and/or bruising near the fracture, grinding sounds with arm movements and potential numbness, and tingling in the leg.
• Apply ice – After you get home from the hospital odontoid fracture (regardless if you had surgery or not), you should apply a bag of crushed ice (or something cold) to your injured in order to reduce the swelling and numb the pain. Ice therapy is effective for acute (recent) injuries that involve swelling because it reduces blood flow by constricting local blood vessels. Apply the crushed ice to your odontoid fracture  for 15 minutes three to five times daily until the soreness and inflammation eventually fades away
• Lightly exercise after the pain fades – After a couple of weeks when the swelling has subsided and the pain has faded away, remove your arm sling for short periods and carefully move your hip joints in all different directions. Don’t aggravate the odontoid fracture so that it hurts, but gently reintroduce movements to the involved joints and muscles. Start cautiously, maybe starting with light, and then progress to holding light weights (five-pound weights to start).
• Practice stretching and strengthening exercises – of the fingers, leg if your doctor recommends them.
• A splint – which you might use for a few days to a week while the swelling goes down; if a splint is used initially, a cast is usually put on about a week later.
• A cast – which you might need for six to eight weeks or longer, depending on how bad the break is (you might need a second cast if the first one gets too loose after the swelling goes away.)
• Get a supportive arm sling – Due to their anatomical position, necks of odontoid fracture can’t be cast like a broken spine. Instead, a supportive arm sling or “figure-eight” splint is typically used for support and comfort, either immediately after the injury if it’s just a hairline fracture or following surgery, if it’s a complicated fracture.
• Get a referral to physical therapy – Once you’ve recovered and able to remove your arm sling splint for good, you’ll likely notice that the muscles surrounding your neck and lower chest look smaller and feel weaker. That’s because muscle tissue atrophies without movement. If this occurs, then you’ll need to get a referral for some physical rehabilitation. Rehab can start once you are cleared by your orthopedist, are pain-free, and can perform all the basic arm and necks movements. A physiotherapist or athletic trainer can show you specific rehabilitation exercises and stretches to restore your muscle strength, joint movements, and flexibility
• Rigid fixation – osteosynthesis with locking plate, hook plate fixation, fixation with a locking plate, coracoclavicular screws, Knowles pin fixation.
• Flexible fixation – simple k wire fixation, tension band wiring, suture anchors, vinyl tape, dacron arterial graft for ligament reconstruction.
• A splint – which you might use for a few days to a week while the swelling goes down; if a splint is used initially, a cast is usually put on about a week later.
• A cast – which you might need for six to eight weeks or longer, depending on how bad the break is (you might need a second cast if the first one gets too loose after the swelling goes away.)

Rest Your Leg – Once you’re discharged from the hospital in an arm sling, your top priority is to rest your and not further inflame the injury. Of course, the arm sling not only provides support, but it also restricts movement, which is why you should keep it on even during sleep. Avoiding the temptation to move your shoulder and arm will help the bone mend quicker and the pain fades away sooner.

Type I Odontoid Fracture

• Most consider a type I odontoid fracture a stable fracture and treatment for six to 12 weeks in a rigid cervical orthosis (hard cervical collar). Some have suggested that rarely a type I odontoid fracture may be unstable secondary to more extensive and unrecognized ligamentous injury, and flexion/extension x-rays should be obtained at the time of removal of the cervical collar after six to 12 weeks to ensure cervical stability.

Type II Odontoid Fracture[rx]

• Type II odontoid fractures are inherently unstable and have a lower union rate than type III odontoid fractures due to the lower surface area of a fractured bone in type II versus type III odontoid fractures.
• The configuration of type II odontoid fracture and age of patient also play important roles in treatment decisions. The current treatment options for a type II odontoid fracture include rigid cervical orthosis, halo vest immobilization, odontoid screw, transoral adenoidectomy, and posterior instrumentation.

Rigid Cervical Orthosis 

• A type II odontoid fracture is inherently unstable, and a rigid cervical orthosis is not the ideal treatment for such an injury. In the elderly population, many are not surgical candidates (due to comorbidities or poor bone quality), and the elderly typically poorly tolerate a halo vest immobilization. In such situations, a practitioner may attempt a rigid cervical orthosis, although union rates are low.

Halo Vest Immobilization

• If a patient is relatively young and healthy, and there is low risk for nonunion, then halo vest immobilization may be the best treatment for a type II odontoid fracture. Risk factors for nonunion include a fractured space greater than a few millimeters between the odontoid process and vertebral body, poor alignment of the odontoid process with respect to the vertebral body, and poor bone quality and/or health status of the patient.

Medication

• Antibiotic – Cefuroxime or Azithromycin, or  Flucloxacillin or any others cephalosporin/quinolone antibiotic must be used to prevent infection or clotted blood remove to prevent furthers swelling and edema
• NSAIDs – Prescription-strength drugs that reduce both pain and inflammation. Pain medicines and anti-inflammatory drugs help to relieve pain and stiffness, allowing for increased mobility and exercise. There are many common over-the-counter medicines called non-steroidal anti-inflammatory drugs (NSAIDs). They include and Ketorolac, Aceclofenac, Naproxen, Etoricoxib.
• Corticosteroids – Also known as oral steroids, these medications reduce inflammation.
• Muscle Relaxants –  These medications provide relief from associated muscle spasms.
• Neuropathic Agents – Drugs(pregabalin & gabapentin) that address neuropathic—or nerve-related—pain. This includes burning, numbness, and tingling.
• Opioids – Also known as narcotics, these medications are intense pain relievers that should only be used under a doctor’s careful supervision.
• Topical Medications – These prescription-strength creams, gels, ointments, patches, and sprays help relieve pain and inflammation through the skin.
• Calcium & vitamin D3 – to improve bone health and healing fracture. As a general rule, men and women age 50 and older should consume 1,200 milligrams of calcium a day, and 600 international units of vitamin D a day.
• Glucosamine & Diacerein, Chondroitin sulfate – can be used to tightening the loose tension, cartilage, ligament, and cartilage, ligament regenerate cartilage or inhabit the further degeneration of cartilage, ligament
• Dietary supplement-to remove general weakness & improved health.
• Antidepressants – A drug that blocks pain messages from your brain and boosts the effects of endorphins (your body’s natural painkillers).

Odontoid Screw

• An anterior odontoid osteosynthesis (odontoid screw) is a screw placed from the inferior anterior aspect of the C2 vertebral body, in a superior trajectory, and capturing the odontoid process and affixing it in place to allow bony fusion to occur.  The odontoid screw has an advantage of relative preservation of motion of the upper cervical spine while treating a type II odontoid fracture.
• A surgeon can only place the odontoid screw if there are acceptable alignment and minimal displacement of the odontoid process, the fracture line is oblique or perpendicular to the screw trajectory, the injury is relatively recent, and the patient has acceptable body habitus to place the odontoid screw.

Transoral Odontoidectomy

• In some situations, the odontoid process (dens) may be severely posteriorly displaced and compressing the spinal cord causing neurologic deficits. It is difficult and dangerous to reduce the odontoid process in a closed manner, so surgical removal of the odontoid process is required to relieve the compression of the spinal cord.
• This relief is commonly achieved through a transoral adenoidectomy, as the odontoid process commonly is located posterior to the oropharynx. If the odontoid process is removed, the cervical spine remains unstable, and the patient requires instrumented fusion, commonly from a posterior or combined anterior-posterior approach.

Posterior Instrumentation

If the patient has certain risk factors for nonunion, then posterior instrumentation may provide the best treatment option for a type II odontoid fracture. The risk factors include:

• More than a few millimeters gap between the odontoid process and the vertebral body
• Poor odontoid process alignment
• Poor bone quality, older fractures
• Older patients
• Failure of other treatment modalities
• Smoking

Posterior instrumented fusion techniques vary widely and include fusion limited to C1 and C2 as well as more extensive fusions. The fusion of only C1 and C2 will lead to approximately 50% reduction of the lateral rotation of the cervical spine.

Surgical Treatment

Treatment options include conservative management, cervical orthosis, halo-vest orthosis, and surgical procedures.[rx][rx][rx][rx]

External Fixation

• Rigid cervical collar represents the immediate first treatment. For type-I and type-III odontoid fractures this is generally adequate. This is also true for 90% of Hangman’s fractures. Halo-vest orthosis can be used as well for external fixation in certain cases of type-II odontoid fractures or angulated/displaced Hangman’s fractures but is not very well tolerated in the elderly population.

Internal Fixation

• Internal fixation can be achieved via anterior fixation or by a variety of posterior constructs.

Anterior

• An odontoid screw can be placed for type-II odontoid fractures in good alignment with an intact transverse ligament in the acute setting.  There is concern about the placement of the odontoid screw in the elderly population and instances of delayed non-union.

Posterior

• C1 to C2 transarticular screws
• C1 lateral mass and C2 pedicle screws
• C1 lateral mass and C2 pars interarticularis screws
• C1 to C2 wiring (also as an adjunct technique)

Posterior fixation technique selection requires significant review by neurosurgeon or orthopedic spine surgeon. It takes into consideration a variety of factors including surgeon experience, fracture location, vertebral artery location, biomechanical suitability, and anatomical variations. Vascular imaging is mandatory to illustrate the location of the vertebral artery in the V2 and V3 segments.

Collars and Halo Fixators

• The use of collars and halo fixators remains controversial. Soft collars have no stabilizing function, thus we do not recommend them in the early phase. However, they may be used for nonoperative treatment in stable fractures after an initial phase with a hard collar.
• Hard collars (Philadelphia, for example) may be used in the first phase for unstable fractures until a decision for further treatment is made. It may be used for 6 to 8 weeks in cases where nonoperative treatment is indicated. ^[rx–rx]

Anterior Odontoid Screw Fixation

• Initially described by Böhler,^rx] osteosyntheses with 1 or 2 screws by an anterior approach is a standard operative treatment in younger patients with good bone quality if adverse modifiers are absent.
• Patients are operated on in the supine position. With a minimal open incision, the preparation follows the anatomical structures for the standard anterior approach to the cervical spine.

Test Diagnosis of Odontoid Fracture/Odontoid Fracture, the odontoid process, or dens, is a superior projecting bony element from the second cervical vertebrae (C2, or the axis). The first cervical vertebrae (atlas) rotates around the odontoid process to provide the largest single component of lateral rotation of the cervical spine. Fracture of the odontoid process is classified into one of three types, which are type I, type II, or type III fractures, depending on the location and morphology of the fracture.[rx]

The odontoid fracture can also occur with hyperflexion of the cervical spine. The transverse ligament runs dorsal to (behind) the odontoid process and attaches to the lateral mass of C1 on either side. If the cervical spine is excessively flexed, then the transverse ligament can transmit the excessive anterior forces to the odontoid process and cause an odontoid fracture.[rx]

A hangman’s fracture is better described as bilateral fracture traversing the pars inter articularis of C2 with an associated traumatic subluxation of C2 on C3. It is the second most common fracture of the C2 vertebrae following a fracture of the odontoid process and is almost always stable without the need for surgical intervention. Steele’s rule of thirds states that the cross-sectional area at the level of the atlas may be divided into three equally represented parts: the dens, space, and the spinal cord. This increased area for the spinal cord at this level is what allows for the relative lack of neurologic injury associated with a hangman’s fracture. [rx]

Mechanisms of Odontoid Fracture

Apart from hangings, the mechanism of injury—a sudden forceful hyperextension centered just under the chin—occurs mainly with deceleration injuries in which the victim’s face or chin strike an unyielding object with the neck in extension. The most common scenario is a frontal motor vehicle accident with an unrestrained passenger or driver, with the person striking the dashboard or windshield with their face or chin. Other scenarios include falls, diving injuries, and collisions between players in contact sports.

Although a hangman’s fracture is unstable, survival from this fracture is relatively common, as the fracture itself tends to expand the spinal canal at the C2 level. It is not unusual for patients to walk in for treatment and have such a fracture discovered on X-rays. Only if the force of the injury is severe enough that the vertebral body of C2 is severely subluxated from C3 does the spinal cord become crushed, usually between the vertebral body of C3 and the posterior elements of C1 and C2.

Types of Odontoid Fracture

Type I Odontoid Fracture 

A type I odontoid fracture occurs when the rostral tip of the odontoid process is avulsed (broken or torn off). This injury commonly occurs due to pulling forces from the apical ligament attachment to the odontoid process. The apical ligament attaches the tip of the odontoid process to the foramen magnum (skull base).

Type II Odontoid Fracture

A type II odontoid fracture is a fracture through the base of the odontoid process. This injury occurs most typically when there is an excessive extension of the cervical spine, and the anterior arch of C1 pushes dorsally (backward) with sufficient force on the odontoid process (dens) to fracture the odontoid process at its base. Type II odontoid fractures can also occur with hyperflexion of the neck and the transverse ligament, pushing the odontoid process forward to the point of fracture.

Type III Odontoid Fracture

A type III odontoid fracture is a fracture through the body of the C2 vertebrae and may involve a variable portion of the C1 and C2 facets.  Type III odontoid fractures occur secondary to hyperextension or hyperflexion of the cervical spine in a similar manner to type II odontoid fractures. The difference is where the fracture line occurs.

C2 fractures can be divided into 2 kinds: Odontoid and Hangmen

Odontoid Fractures

Location

• Fracture through the dens, flexion or extension injury

Nomenclature

Anderson and D’Alonzo classification is the most ubiquitous.

• Type-1 fractures: Upper portion of the odontoid peg, above the transverse portion of the cruciform ligament, these are generally stable
• Type-2 fractures: These are the most common, the fracture through the based of the odontoid below the transverse portion of the cruciform ligament, they have a high risk of non-union
• Type-3 fractures: These fracture through the odontoid peg and into the body of C2, generally well tolerated

The Roy-Camille classification of odontoid fractures is another but less frequently used nomenclature format focusing on the direction of the fracture line.

Hangman’s Fractures

Location

• Fracture through the bilateral pars, generally from hyperextension and axial loading generally
• Stable 90% heal with immobilization alone

Nomenclature

Levine and Edwards Classification

• Type 1: Less than 3 mm subluxation of C2 on C3, due to axial loading, stable, rigid cervical collar treatment
• Type 2: disruption of the C2 to C3 disc, posterior longitudinal ligament, greater than 4 mm subluxation, greater than 11 degrees angulation, less than 5 mm requires a reduction in axial traction and halo fixation for 6 to 12 weeks while those greater than 5 mms can require surgery
• Type 2a: Less displacement more angular deformity, flexion injury, unstable, not suitable for axial traction, treatment in halo
• Type 3: C2 to C3 facet capsule disrupted, anterior longitudinal ligament disruption, unstable, may have deficit, surgical candidates.

Levine and Edwards Classification[rx]

Specifics

• Angulation in this system is measured as the angle between the inferior endplate of C2 and C3. Anterior subluxation of C2 on C3 greater than 3 mm serves as a marker for C2 to C3 intervertebral disc disruption. It is important to recognize that this grading system is not applicaple in the pediatric population.

Grading

• Type 1: Less than 3 mm subluxation of C2 on C3, due to axial loading, stable, rigid cervical collar treatment
• Type 2: Disruption of the C2 to C3 disc, posterior longitudinal ligament, greater than 4 mm subluxation, greater than 11 degrees angulation, less than 5 mm requires a reduction in axial traction and halo fixation for 6 to 12 weeks while those greater than 5 mm can require surgery
• Type 2a: Less displacement more angular deformity, flexion injury, unstable, not suitable for axial traction, treatment in halo
• Type 3: C2 to C3 facet capsule disrupted, anterior longitudinal ligament disruption, unstable, may have deficit, surgical candidates

Francis Grading System[rx]

Specifics

• Two factors are taken into consideration for the Francis Grading system: angulation and displacement. Angulation is measured by the degree of anterior angulation off of the posterior vertebral line drawn straight up from the C3 vertebral body. Displacement is measured by the amount of anterolisthesis, either greater than or less than 3.5 mm.

Grading

• Type 1: Less than 11 degrees of angulation and less than 3.5 mm of displacement
• Type 2: Greater than 11 degrees of angulation and less than 3.5 mm of displacement
• Type 3: Less than 11 degrees of angulation and greater than 3.5 mm displacement
• Type 4: Greater than 11 degrees of angulation and greater than 3.5 mm of displacement
• Type 5: Complete disc disruption

Typical versus Atypical Fractures

• It is important to recognize that not all C2, hangman’s type fractures can be described using these classification systems. A typical hangman’s fracture allows for separation of the anterior elements from the posterior elements of the C2 vertebrae, therefore increase the available space for the spinal cord.
• However, in the case of an atypical hangman’s fracture the posterior aspect of the C2 vertebral body, not the bilateral pars, is involved. This leads to a higher risk of neurologic injury as the space remaining for the spinal cord does not increase secondary to the fracture.

Causes of Odontoid Fracture

• Odontoid fractures occur as a result of trauma to the cervical spine.
• high-energy trauma, which occurs as a result of a motor vehicle or diving accidents.
• trauma can occur after lower energy impacts such as falls from a standing position.
• hyperextension of the cervical spine, pushing the head and C1 vertebrae backward.
• forceful thrust are high enough (or the patient’s bone density is compromised secondary to osteopenia/osteoporosis),
• The odontoid fracture can also occur with hyperflexion of the cervical spine.
• The transverse ligament runs dorsal to (behind) the odontoid process and attaches to the lateral mass of C1 on either side.
• If the cervical spine is excessively flexed, then the transverse ligament can transmit the excessive anterior forces to the odontoid process and cause an odontoid fracture.[rx]
• Sudden forceful  fall down
• Road traffic accident
• Falls – Falling onto an outstretched hand is one of the most common causes of the broken cervical spine.
• Sports injuries – Many cervical spine fractures occur during contact sports or sports in which you might fall onto an outstretched hand — such as in-line skating or snowboarding.
• Motor vehicle crashes – Motor vehicle crashes can cause cervical spine to break, sometimes into many pieces, and often require surgical repair.
• Have osteoporosis –  a disease that weakens your bones
• Eave low muscle mass or poor muscle strength – or lack agility and have poor balance (these conditions make you more likely to fall)
• Walk or do other activities in the snow or on the ice – or do activities that require a lot of forwarding momenta, such as in-line skating and skiing.
• Previous pelvic fractures record.
• Wave an inadequate intake of calcium or vitamin D.
• Football or soccer, especially on artificial turf
• Athletic injury with a sports injury.
• Horseback riding
• Hockey
• Skiing
• Snowboarding
• Clumsiness in hands
• Gait imbalance
• Degenerative cervical spondylosis (CSM) 
  
• Compression usually caused by anterior degenerative changes (osteophytes, disc osteophyte complex)
• Degenerative spondylolisthesis and hypertrophy of ligamentum flavum may contribute
• The most common cause of cervical myelopathy.

Symptoms of Odontoid Fracture

Symptoms of cervical spondylosis include:

• Neck stiffness and pain
• Numbness and weakness in the upper limbs
• Difficulty in walking, losing balance, or weakness in limbs
• Difficulty in turning the head fully or bending the neck, which may hinder drive
• Muscle spasms in neck and shoulders
• Headaches
• Grinding and popping feeling in the neck when rotating the head
• Loss of bladder and bowel control.
• neck pain and stiffness
• axial neck pain (oftentimes absent)
• occipital headache common
• extremity paresthesias
• diffuse nondermatomal numbness and tingling
• weakness and clumsiness
• weakness and decreased manual dexterity (dropping object, difficulty manipulating fine objects)
• Gait instability patient feels “unstable” on feet
• weakness walking up and downstairs
• gait changes are the most important clinical predictor
• urinary retention rare and only appear late in disease progression, not very useful in diagnosis due to the high prevalence of urinary conditions in this patient population
• Cervical pain aggravated by movement
• Referred pain (occiput, between the shoulder blades, upper limbs)
• Retro-orbital or temporal pain (from C1 to C2)
• Cervical stiffness—reversible or irreversible
• Vague numbness, tingling, or weakness in upper limbs
• Dizziness or vertigo
• Poor balance
• Rarely, syncope triggers a migraine, “pseudo-angina”

Diagnosis of Odontoid Fracture

Laboratory tests should be ordered as an adjunct in overall medical status.

• Normalized hemoglobin,
• hematocrit,
• coagulation profile with prothrombin time (PT),
• partial thromboplastin time (PTT), and
• platelet counts will be needed for operative intervention.

In hospitals and countries without readily available advanced imaging capabilities, radiographs are critical to evaluate and assist in ruling out potential odontoid fractures.  Recommended views include:[rx]

• AP C-spine
• Lateral C-spine
• Open-mouth odontoid view

Although radiographs yield lower sensitivity and specificity rates when compared to computed tomogram (CT) scans, experienced clinicians and practitioners can still appreciate suspected injury without CT utilization.  In addition, in the setting of suspected occipito cervical instability (useful in type I odontoid fractures or the setting of os odontoideum), flexion-extension radiographs should be obtained.

X-ray

Evaluation of x-rays will provide limited but important information. Care must be taken to ensure proper radiographic imaging creates a picture from the occiput to the C7 through T1 disc space. This is essential in reviewing cervical spine trauma. Lateral, anteroposterior (AP) and open mouth odontoid views are necessary. Approximately, 93% of cervical spine injuries are apparent with combined, lateral, AP, and odontoid view radiographs. X-rays are an excellent modality for determining alignment during the immediate injury, post-operative period, as well as long-term, follow up.

Computed tomogram (CT) scan

CT scan is the most important modality for determining fracture etiology and ruling out an injury with regards to a C2 fracture. Even if plain films are negative and clinical suspicion is high a CT scan is warranted. CT scan does not directly evaluate the spinal cord, soft tissue, or ligamentous construct. It is important to recognize the importance that complete imaging will require dedicated thin-cut CT reconstructions. Non-contrast CT scan is adequate for evaluation of the bony anatomy for fracture. This can be coupled with a CT angiogram for evaluation of the vascular anatomy.

Magnetic resonance imaging (MRI) scan

Evaluation with MRI is important for the analysis of the ligamentous construct, disc space, spinal cord, nerve roots, and other soft tissue injuries. MRI is also useful for determining the acute nature of the fracture when this is otherwise unknown. This is done via non-contrasted imaging. T2 signal hyperintensities and STIR changes within the dens, ligaments, or soft tissue can illustrate an acute component.

Vascular Imaging

Vascular imaging may be indicated. The vertebral artery’s second segment (V2) runs through the transverse foramen of C2 to C6 while V3 runs extramurally exiting the C2 foramen across the sulcus arteriosus.  This can place it at risk for injury. Indeed, in one series 15% of patients with C1 to C2 fractures had a vertebral artery injury. Of which, type-III odontoid fractures posed the greatest risk. It is important to note that an untreated vertebral artery injury has a 24% stroke rate.

Advanced Imaging modalities

The imaging modality of choice is a CT of the cervical spine. The CT provides the best resolution of the bony elements allowing for identification and characterization of an odontoid fracture. If there is neurologic injury (paresthesia, weakness), then magnetic resonance imaging (MRI) without the contrast of the cervical spine should be obtained to assess the cervical cord for injuries.

Nuclear bone scan – a diagnostic procedure in which a radioactive substance is injected into the body to measure activity in the bones.  (The amount of radiation is small–less than the radiation in half of one CT scan.) This scan helps identify damaged bones.

Treatment of Odontoid Fracture

The treatment of an odontoid fracture depends on the type of fracture and age of the patient.[rx][rx][rx][rx]

Non-Surgical Treatment

Treatment available can be broadly

• Skeletal traction – Available evidence suggests that treatment depends on the part of the pelvic fracture that is fractured. Traction may be useful for odontoid fracture because it counteracts the force of the muscle pulling the two separated parts together, and thus may decrease bleeding and pain.^[rx] Traction should not be used in the femoral neck and odontoid fracture or when there is any other trauma to the leg or pelvis.^[rx][rx] It is typically only a temporary measure used before surgery. It only considered the definitive treatment for patients with significant comorbidities that contraindicate surgical management.^[rx]
• Get medical help immediately – If you fall on an outstretched arm, get into a car accident or are hit while playing a sport and feel intense pain in your hip area, then get medical care immediately. You’ll innately know that something is seriously wrong because you won’t be able to lift your leg up. Other symptoms include immediate swelling and/or bruising near the fracture, grinding sounds with arm movements and potential numbness, and tingling in the leg.
• Apply ice – After you get home from the hospital odontoid fracture (regardless if you had surgery or not), you should apply a bag of crushed ice (or something cold) to your injured in order to reduce the swelling and numb the pain. Ice therapy is effective for acute (recent) injuries that involve swelling because it reduces blood flow by constricting local blood vessels. Apply the crushed ice to your odontoid fracture  for 15 minutes three to five times daily until the soreness and inflammation eventually fades away
• Lightly exercise after the pain fades – After a couple of weeks when the swelling has subsided and the pain has faded away, remove your arm sling for short periods and carefully move your hip joints in all different directions. Don’t aggravate the odontoid fracture so that it hurts, but gently reintroduce movements to the involved joints and muscles. Start cautiously, maybe starting with light, and then progress to holding light weights (five-pound weights to start).
• Practice stretching and strengthening exercises – of the fingers, leg if your doctor recommends them.
• A splint – which you might use for a few days to a week while the swelling goes down; if a splint is used initially, a cast is usually put on about a week later.
• A cast – which you might need for six to eight weeks or longer, depending on how bad the break is (you might need a second cast if the first one gets too loose after the swelling goes away.)
• Get a supportive arm sling – Due to their anatomical position, necks of odontoid fracture can’t be cast like a broken spine. Instead, a supportive arm sling or “figure-eight” splint is typically used for support and comfort, either immediately after the injury if it’s just a hairline fracture or following surgery, if it’s a complicated fracture.
• Get a referral to physical therapy – Once you’ve recovered and able to remove your arm sling splint for good, you’ll likely notice that the muscles surrounding your neck and lower chest look smaller and feel weaker. That’s because muscle tissue atrophies without movement. If this occurs, then you’ll need to get a referral for some physical rehabilitation. Rehab can start once you are cleared by your orthopedist, are pain-free, and can perform all the basic arm and necks movements. A physiotherapist or athletic trainer can show you specific rehabilitation exercises and stretches to restore your muscle strength, joint movements, and flexibility
• Rigid fixation – osteosynthesis with locking plate, hook plate fixation, fixation with a locking plate, coracoclavicular screws, Knowles pin fixation.
• Flexible fixation – simple k wire fixation, tension band wiring, suture anchors, vinyl tape, dacron arterial graft for ligament reconstruction.
• A splint – which you might use for a few days to a week while the swelling goes down; if a splint is used initially, a cast is usually put on about a week later.
• A cast – which you might need for six to eight weeks or longer, depending on how bad the break is (you might need a second cast if the first one gets too loose after the swelling goes away.)

Rest Your Leg – Once you’re discharged from the hospital in an arm sling, your top priority is to rest your and not further inflame the injury. Of course, the arm sling not only provides support, but it also restricts movement, which is why you should keep it on even during sleep. Avoiding the temptation to move your shoulder and arm will help the bone mend quicker and the pain fades away sooner.

Type I Odontoid Fracture

• Most consider a type I odontoid fracture a stable fracture and treatment for six to 12 weeks in a rigid cervical orthosis (hard cervical collar). Some have suggested that rarely a type I odontoid fracture may be unstable secondary to more extensive and unrecognized ligamentous injury, and flexion/extension x-rays should be obtained at the time of removal of the cervical collar after six to 12 weeks to ensure cervical stability.

Type II Odontoid Fracture[rx]

• Type II odontoid fractures are inherently unstable and have a lower union rate than type III odontoid fractures due to the lower surface area of a fractured bone in type II versus type III odontoid fractures.
• The configuration of type II odontoid fracture and age of patient also play important roles in treatment decisions. The current treatment options for a type II odontoid fracture include rigid cervical orthosis, halo vest immobilization, odontoid screw, transoral adenoidectomy, and posterior instrumentation.

Rigid Cervical Orthosis 

• A type II odontoid fracture is inherently unstable, and a rigid cervical orthosis is not the ideal treatment for such an injury. In the elderly population, many are not surgical candidates (due to comorbidities or poor bone quality), and the elderly typically poorly tolerate a halo vest immobilization. In such situations, a practitioner may attempt a rigid cervical orthosis, although union rates are low.

Halo Vest Immobilization

• If a patient is relatively young and healthy, and there is low risk for nonunion, then halo vest immobilization may be the best treatment for a type II odontoid fracture. Risk factors for nonunion include a fractured space greater than a few millimeters between the odontoid process and vertebral body, poor alignment of the odontoid process with respect to the vertebral body, and poor bone quality and/or health status of the patient.

Medication

• Antibiotic – Cefuroxime or Azithromycin, or  Flucloxacillin or any others cephalosporin/quinolone antibiotic must be used to prevent infection or clotted blood remove to prevent furthers swelling and edema
• NSAIDs – Prescription-strength drugs that reduce both pain and inflammation. Pain medicines and anti-inflammatory drugs help to relieve pain and stiffness, allowing for increased mobility and exercise. There are many common over-the-counter medicines called non-steroidal anti-inflammatory drugs (NSAIDs). They include and Ketorolac, Aceclofenac, Naproxen, Etoricoxib.
• Corticosteroids – Also known as oral steroids, these medications reduce inflammation.
• Muscle Relaxants –  These medications provide relief from associated muscle spasms.
• Neuropathic Agents – Drugs(pregabalin & gabapentin) that address neuropathic—or nerve-related—pain. This includes burning, numbness, and tingling.
• Opioids – Also known as narcotics, these medications are intense pain relievers that should only be used under a doctor’s careful supervision.
• Topical Medications – These prescription-strength creams, gels, ointments, patches, and sprays help relieve pain and inflammation through the skin.
• Calcium & vitamin D3 – to improve bone health and healing fracture. As a general rule, men and women age 50 and older should consume 1,200 milligrams of calcium a day, and 600 international units of vitamin D a day.
• Glucosamine & Diacerein, Chondroitin sulfate – can be used to tightening the loose tension, cartilage, ligament, and cartilage, ligament regenerate cartilage or inhabit the further degeneration of cartilage, ligament
• Dietary supplement-to remove general weakness & improved health.
• Antidepressants – A drug that blocks pain messages from your brain and boosts the effects of endorphins (your body’s natural painkillers).

Odontoid Screw

• An anterior odontoid osteosynthesis (odontoid screw) is a screw placed from the inferior anterior aspect of the C2 vertebral body, in a superior trajectory, and capturing the odontoid process and affixing it in place to allow bony fusion to occur.  The odontoid screw has an advantage of relative preservation of motion of the upper cervical spine while treating a type II odontoid fracture.
• A surgeon can only place the odontoid screw if there are acceptable alignment and minimal displacement of the odontoid process, the fracture line is oblique or perpendicular to the screw trajectory, the injury is relatively recent, and the patient has acceptable body habitus to place the odontoid screw.

Transoral Odontoidectomy

• In some situations, the odontoid process (dens) may be severely posteriorly displaced and compressing the spinal cord causing neurologic deficits. It is difficult and dangerous to reduce the odontoid process in a closed manner, so surgical removal of the odontoid process is required to relieve the compression of the spinal cord.
• This relief is commonly achieved through a transoral adenoidectomy, as the odontoid process commonly is located posterior to the oropharynx. If the odontoid process is removed, the cervical spine remains unstable, and the patient requires instrumented fusion, commonly from a posterior or combined anterior-posterior approach.

Posterior Instrumentation

If the patient has certain risk factors for nonunion, then posterior instrumentation may provide the best treatment option for a type II odontoid fracture. The risk factors include:

• More than a few millimeters gap between the odontoid process and the vertebral body
• Poor odontoid process alignment
• Poor bone quality, older fractures
• Older patients
• Failure of other treatment modalities
• Smoking

Posterior instrumented fusion techniques vary widely and include fusion limited to C1 and C2 as well as more extensive fusions. The fusion of only C1 and C2 will lead to approximately 50% reduction of the lateral rotation of the cervical spine.

Surgical Treatment

Treatment options include conservative management, cervical orthosis, halo-vest orthosis, and surgical procedures.[rx][rx][rx][rx]

External Fixation

• Rigid cervical collar represents the immediate first treatment. For type-I and type-III odontoid fractures this is generally adequate. This is also true for 90% of Hangman’s fractures. Halo-vest orthosis can be used as well for external fixation in certain cases of type-II odontoid fractures or angulated/displaced Hangman’s fractures but is not very well tolerated in the elderly population.

Internal Fixation

• Internal fixation can be achieved via anterior fixation or by a variety of posterior constructs.

Anterior

• An odontoid screw can be placed for type-II odontoid fractures in good alignment with an intact transverse ligament in the acute setting.  There is concern about the placement of the odontoid screw in the elderly population and instances of delayed non-union.

Posterior

• C1 to C2 transarticular screws
• C1 lateral mass and C2 pedicle screws
• C1 lateral mass and C2 pars interarticularis screws
• C1 to C2 wiring (also as an adjunct technique)

Posterior fixation technique selection requires significant review by neurosurgeon or orthopedic spine surgeon. It takes into consideration a variety of factors including surgeon experience, fracture location, vertebral artery location, biomechanical suitability, and anatomical variations. Vascular imaging is mandatory to illustrate the location of the vertebral artery in the V2 and V3 segments.

Collars and Halo Fixators

• The use of collars and halo fixators remains controversial. Soft collars have no stabilizing function, thus we do not recommend them in the early phase. However, they may be used for nonoperative treatment in stable fractures after an initial phase with a hard collar.
• Hard collars (Philadelphia, for example) may be used in the first phase for unstable fractures until a decision for further treatment is made. It may be used for 6 to 8 weeks in cases where nonoperative treatment is indicated. ^[rx–rx]

Anterior Odontoid Screw Fixation

• Initially described by Böhler,^rx] osteosyntheses with 1 or 2 screws by an anterior approach is a standard operative treatment in younger patients with good bone quality if adverse modifiers are absent.
• Patients are operated on in the supine position. With a minimal open incision, the preparation follows the anatomical structures for the standard anterior approach to the cervical spine.

What Is Odontoid Fracture?/Odontoid Fracture, the odontoid process, or dens, is a superior projecting bony element from the second cervical vertebrae (C2, or the axis). The first cervical vertebrae (atlas) rotates around the odontoid process to provide the largest single component of lateral rotation of the cervical spine. Fracture of the odontoid process is classified into one of three types, which are type I, type II, or type III fractures, depending on the location and morphology of the fracture.[rx]

The odontoid fracture can also occur with hyperflexion of the cervical spine. The transverse ligament runs dorsal to (behind) the odontoid process and attaches to the lateral mass of C1 on either side. If the cervical spine is excessively flexed, then the transverse ligament can transmit the excessive anterior forces to the odontoid process and cause an odontoid fracture.[rx]

A hangman’s fracture is better described as bilateral fracture traversing the pars inter articularis of C2 with an associated traumatic subluxation of C2 on C3. It is the second most common fracture of the C2 vertebrae following a fracture of the odontoid process and is almost always stable without the need for surgical intervention. Steele’s rule of thirds states that the cross-sectional area at the level of the atlas may be divided into three equally represented parts: the dens, space, and the spinal cord. This increased area for the spinal cord at this level is what allows for the relative lack of neurologic injury associated with a hangman’s fracture. [rx]

Mechanisms of Odontoid Fracture

Apart from hangings, the mechanism of injury—a sudden forceful hyperextension centered just under the chin—occurs mainly with deceleration injuries in which the victim’s face or chin strike an unyielding object with the neck in extension. The most common scenario is a frontal motor vehicle accident with an unrestrained passenger or driver, with the person striking the dashboard or windshield with their face or chin. Other scenarios include falls, diving injuries, and collisions between players in contact sports.

Although a hangman’s fracture is unstable, survival from this fracture is relatively common, as the fracture itself tends to expand the spinal canal at the C2 level. It is not unusual for patients to walk in for treatment and have such a fracture discovered on X-rays. Only if the force of the injury is severe enough that the vertebral body of C2 is severely subluxated from C3 does the spinal cord become crushed, usually between the vertebral body of C3 and the posterior elements of C1 and C2.

Types of Odontoid Fracture

Type I Odontoid Fracture 

A type I odontoid fracture occurs when the rostral tip of the odontoid process is avulsed (broken or torn off). This injury commonly occurs due to pulling forces from the apical ligament attachment to the odontoid process. The apical ligament attaches the tip of the odontoid process to the foramen magnum (skull base).

Type II Odontoid Fracture

A type II odontoid fracture is a fracture through the base of the odontoid process. This injury occurs most typically when there is an excessive extension of the cervical spine, and the anterior arch of C1 pushes dorsally (backward) with sufficient force on the odontoid process (dens) to fracture the odontoid process at its base. Type II odontoid fractures can also occur with hyperflexion of the neck and the transverse ligament, pushing the odontoid process forward to the point of fracture.

Type III Odontoid Fracture

A type III odontoid fracture is a fracture through the body of the C2 vertebrae and may involve a variable portion of the C1 and C2 facets.  Type III odontoid fractures occur secondary to hyperextension or hyperflexion of the cervical spine in a similar manner to type II odontoid fractures. The difference is where the fracture line occurs.

C2 fractures can be divided into 2 kinds: Odontoid and Hangmen

Odontoid Fractures

Location

• Fracture through the dens, flexion or extension injury

Nomenclature

Anderson and D’Alonzo classification is the most ubiquitous.

• Type-1 fractures: Upper portion of the odontoid peg, above the transverse portion of the cruciform ligament, these are generally stable
• Type-2 fractures: These are the most common, the fracture through the based of the odontoid below the transverse portion of the cruciform ligament, they have a high risk of non-union
• Type-3 fractures: These fracture through the odontoid peg and into the body of C2, generally well tolerated

The Roy-Camille classification of odontoid fractures is another but less frequently used nomenclature format focusing on the direction of the fracture line.

Hangman’s Fractures

Location

• Fracture through the bilateral pars, generally from hyperextension and axial loading generally
• Stable 90% heal with immobilization alone

Nomenclature

Levine and Edwards Classification

• Type 1: Less than 3 mm subluxation of C2 on C3, due to axial loading, stable, rigid cervical collar treatment
• Type 2: disruption of the C2 to C3 disc, posterior longitudinal ligament, greater than 4 mm subluxation, greater than 11 degrees angulation, less than 5 mm requires a reduction in axial traction and halo fixation for 6 to 12 weeks while those greater than 5 mms can require surgery
• Type 2a: Less displacement more angular deformity, flexion injury, unstable, not suitable for axial traction, treatment in halo
• Type 3: C2 to C3 facet capsule disrupted, anterior longitudinal ligament disruption, unstable, may have deficit, surgical candidates.

Levine and Edwards Classification[rx]

Specifics

• Angulation in this system is measured as the angle between the inferior endplate of C2 and C3. Anterior subluxation of C2 on C3 greater than 3 mm serves as a marker for C2 to C3 intervertebral disc disruption. It is important to recognize that this grading system is not applicaple in the pediatric population.

Grading

• Type 1: Less than 3 mm subluxation of C2 on C3, due to axial loading, stable, rigid cervical collar treatment
• Type 2: Disruption of the C2 to C3 disc, posterior longitudinal ligament, greater than 4 mm subluxation, greater than 11 degrees angulation, less than 5 mm requires a reduction in axial traction and halo fixation for 6 to 12 weeks while those greater than 5 mm can require surgery
• Type 2a: Less displacement more angular deformity, flexion injury, unstable, not suitable for axial traction, treatment in halo
• Type 3: C2 to C3 facet capsule disrupted, anterior longitudinal ligament disruption, unstable, may have deficit, surgical candidates

Francis Grading System[rx]

Specifics

• Two factors are taken into consideration for the Francis Grading system: angulation and displacement. Angulation is measured by the degree of anterior angulation off of the posterior vertebral line drawn straight up from the C3 vertebral body. Displacement is measured by the amount of anterolisthesis, either greater than or less than 3.5 mm.

Grading

• Type 1: Less than 11 degrees of angulation and less than 3.5 mm of displacement
• Type 2: Greater than 11 degrees of angulation and less than 3.5 mm of displacement
• Type 3: Less than 11 degrees of angulation and greater than 3.5 mm displacement
• Type 4: Greater than 11 degrees of angulation and greater than 3.5 mm of displacement
• Type 5: Complete disc disruption

Typical versus Atypical Fractures

• It is important to recognize that not all C2, hangman’s type fractures can be described using these classification systems. A typical hangman’s fracture allows for separation of the anterior elements from the posterior elements of the C2 vertebrae, therefore increase the available space for the spinal cord.
• However, in the case of an atypical hangman’s fracture the posterior aspect of the C2 vertebral body, not the bilateral pars, is involved. This leads to a higher risk of neurologic injury as the space remaining for the spinal cord does not increase secondary to the fracture.

Causes of Odontoid Fracture

• Odontoid fractures occur as a result of trauma to the cervical spine.
• high-energy trauma, which occurs as a result of a motor vehicle or diving accidents.
• trauma can occur after lower energy impacts such as falls from a standing position.
• hyperextension of the cervical spine, pushing the head and C1 vertebrae backward.
• forceful thrust are high enough (or the patient’s bone density is compromised secondary to osteopenia/osteoporosis),
• The odontoid fracture can also occur with hyperflexion of the cervical spine.
• The transverse ligament runs dorsal to (behind) the odontoid process and attaches to the lateral mass of C1 on either side.
• If the cervical spine is excessively flexed, then the transverse ligament can transmit the excessive anterior forces to the odontoid process and cause an odontoid fracture.[rx]
• Sudden forceful  fall down
• Road traffic accident
• Falls – Falling onto an outstretched hand is one of the most common causes of the broken cervical spine.
• Sports injuries – Many cervical spine fractures occur during contact sports or sports in which you might fall onto an outstretched hand — such as in-line skating or snowboarding.
• Motor vehicle crashes – Motor vehicle crashes can cause cervical spine to break, sometimes into many pieces, and often require surgical repair.
• Have osteoporosis –  a disease that weakens your bones
• Eave low muscle mass or poor muscle strength – or lack agility and have poor balance (these conditions make you more likely to fall)
• Walk or do other activities in the snow or on the ice – or do activities that require a lot of forwarding momenta, such as in-line skating and skiing.
• Previous pelvic fractures record.
• Wave an inadequate intake of calcium or vitamin D.
• Football or soccer, especially on artificial turf
• Athletic injury with a sports injury.
• Horseback riding
• Hockey
• Skiing
• Snowboarding
• Clumsiness in hands
• Gait imbalance
• Degenerative cervical spondylosis (CSM) 
  
• Compression usually caused by anterior degenerative changes (osteophytes, disc osteophyte complex)
• Degenerative spondylolisthesis and hypertrophy of ligamentum flavum may contribute
• The most common cause of cervical myelopathy.

Symptoms of Odontoid Fracture

Symptoms of cervical spondylosis include:

• Neck stiffness and pain
• Numbness and weakness in the upper limbs
• Difficulty in walking, losing balance, or weakness in limbs
• Difficulty in turning the head fully or bending the neck, which may hinder drive
• Muscle spasms in neck and shoulders
• Headaches
• Grinding and popping feeling in the neck when rotating the head
• Loss of bladder and bowel control.
• neck pain and stiffness
• axial neck pain (oftentimes absent)
• occipital headache common
• extremity paresthesias
• diffuse nondermatomal numbness and tingling
• weakness and clumsiness
• weakness and decreased manual dexterity (dropping object, difficulty manipulating fine objects)
• Gait instability patient feels “unstable” on feet
• weakness walking up and downstairs
• gait changes are the most important clinical predictor
• urinary retention rare and only appear late in disease progression, not very useful in diagnosis due to the high prevalence of urinary conditions in this patient population
• Cervical pain aggravated by movement
• Referred pain (occiput, between the shoulder blades, upper limbs)
• Retro-orbital or temporal pain (from C1 to C2)
• Cervical stiffness—reversible or irreversible
• Vague numbness, tingling, or weakness in upper limbs
• Dizziness or vertigo
• Poor balance
• Rarely, syncope triggers a migraine, “pseudo-angina”

Diagnosis of Odontoid Fracture

Laboratory tests should be ordered as an adjunct in overall medical status.

• Normalized hemoglobin,
• hematocrit,
• coagulation profile with prothrombin time (PT),
• partial thromboplastin time (PTT), and
• platelet counts will be needed for operative intervention.

In hospitals and countries without readily available advanced imaging capabilities, radiographs are critical to evaluate and assist in ruling out potential odontoid fractures.  Recommended views include:[rx]

• AP C-spine
• Lateral C-spine
• Open-mouth odontoid view

Although radiographs yield lower sensitivity and specificity rates when compared to computed tomogram (CT) scans, experienced clinicians and practitioners can still appreciate suspected injury without CT utilization.  In addition, in the setting of suspected occipito cervical instability (useful in type I odontoid fractures or the setting of os odontoideum), flexion-extension radiographs should be obtained.

X-ray

Evaluation of x-rays will provide limited but important information. Care must be taken to ensure proper radiographic imaging creates a picture from the occiput to the C7 through T1 disc space. This is essential in reviewing cervical spine trauma. Lateral, anteroposterior (AP) and open mouth odontoid views are necessary. Approximately, 93% of cervical spine injuries are apparent with combined, lateral, AP, and odontoid view radiographs. X-rays are an excellent modality for determining alignment during the immediate injury, post-operative period, as well as long-term, follow up.

Computed tomogram (CT) scan

CT scan is the most important modality for determining fracture etiology and ruling out an injury with regards to a C2 fracture. Even if plain films are negative and clinical suspicion is high a CT scan is warranted. CT scan does not directly evaluate the spinal cord, soft tissue, or ligamentous construct. It is important to recognize the importance that complete imaging will require dedicated thin-cut CT reconstructions. Non-contrast CT scan is adequate for evaluation of the bony anatomy for fracture. This can be coupled with a CT angiogram for evaluation of the vascular anatomy.

Magnetic resonance imaging (MRI) scan

Evaluation with MRI is important for the analysis of the ligamentous construct, disc space, spinal cord, nerve roots, and other soft tissue injuries. MRI is also useful for determining the acute nature of the fracture when this is otherwise unknown. This is done via non-contrasted imaging. T2 signal hyperintensities and STIR changes within the dens, ligaments, or soft tissue can illustrate an acute component.

Vascular Imaging

Vascular imaging may be indicated. The vertebral artery’s second segment (V2) runs through the transverse foramen of C2 to C6 while V3 runs extramurally exiting the C2 foramen across the sulcus arteriosus.  This can place it at risk for injury. Indeed, in one series 15% of patients with C1 to C2 fractures had a vertebral artery injury. Of which, type-III odontoid fractures posed the greatest risk. It is important to note that an untreated vertebral artery injury has a 24% stroke rate.

Advanced Imaging modalities

The imaging modality of choice is a CT of the cervical spine. The CT provides the best resolution of the bony elements allowing for identification and characterization of an odontoid fracture. If there is neurologic injury (paresthesia, weakness), then magnetic resonance imaging (MRI) without the contrast of the cervical spine should be obtained to assess the cervical cord for injuries.

Nuclear bone scan – a diagnostic procedure in which a radioactive substance is injected into the body to measure activity in the bones.  (The amount of radiation is small–less than the radiation in half of one CT scan.) This scan helps identify damaged bones.

Treatment of Odontoid Fracture

The treatment of an odontoid fracture depends on the type of fracture and age of the patient.[rx][rx][rx][rx]

Non-Surgical Treatment

Treatment available can be broadly

• Skeletal traction – Available evidence suggests that treatment depends on the part of the pelvic fracture that is fractured. Traction may be useful for odontoid fracture because it counteracts the force of the muscle pulling the two separated parts together, and thus may decrease bleeding and pain.^[rx] Traction should not be used in the femoral neck and odontoid fracture or when there is any other trauma to the leg or pelvis.^[rx][rx] It is typically only a temporary measure used before surgery. It only considered the definitive treatment for patients with significant comorbidities that contraindicate surgical management.^[rx]
• Get medical help immediately – If you fall on an outstretched arm, get into a car accident or are hit while playing a sport and feel intense pain in your hip area, then get medical care immediately. You’ll innately know that something is seriously wrong because you won’t be able to lift your leg up. Other symptoms include immediate swelling and/or bruising near the fracture, grinding sounds with arm movements and potential numbness, and tingling in the leg.
• Apply ice – After you get home from the hospital odontoid fracture (regardless if you had surgery or not), you should apply a bag of crushed ice (or something cold) to your injured in order to reduce the swelling and numb the pain. Ice therapy is effective for acute (recent) injuries that involve swelling because it reduces blood flow by constricting local blood vessels. Apply the crushed ice to your odontoid fracture  for 15 minutes three to five times daily until the soreness and inflammation eventually fades away
• Lightly exercise after the pain fades – After a couple of weeks when the swelling has subsided and the pain has faded away, remove your arm sling for short periods and carefully move your hip joints in all different directions. Don’t aggravate the odontoid fracture so that it hurts, but gently reintroduce movements to the involved joints and muscles. Start cautiously, maybe starting with light, and then progress to holding light weights (five-pound weights to start).
• Practice stretching and strengthening exercises – of the fingers, leg if your doctor recommends them.
• A splint – which you might use for a few days to a week while the swelling goes down; if a splint is used initially, a cast is usually put on about a week later.
• A cast – which you might need for six to eight weeks or longer, depending on how bad the break is (you might need a second cast if the first one gets too loose after the swelling goes away.)
• Get a supportive arm sling – Due to their anatomical position, necks of odontoid fracture can’t be cast like a broken spine. Instead, a supportive arm sling or “figure-eight” splint is typically used for support and comfort, either immediately after the injury if it’s just a hairline fracture or following surgery, if it’s a complicated fracture.
• Get a referral to physical therapy – Once you’ve recovered and able to remove your arm sling splint for good, you’ll likely notice that the muscles surrounding your neck and lower chest look smaller and feel weaker. That’s because muscle tissue atrophies without movement. If this occurs, then you’ll need to get a referral for some physical rehabilitation. Rehab can start once you are cleared by your orthopedist, are pain-free, and can perform all the basic arm and necks movements. A physiotherapist or athletic trainer can show you specific rehabilitation exercises and stretches to restore your muscle strength, joint movements, and flexibility
• Rigid fixation – osteosynthesis with locking plate, hook plate fixation, fixation with a locking plate, coracoclavicular screws, Knowles pin fixation.
• Flexible fixation – simple k wire fixation, tension band wiring, suture anchors, vinyl tape, dacron arterial graft for ligament reconstruction.
• A splint – which you might use for a few days to a week while the swelling goes down; if a splint is used initially, a cast is usually put on about a week later.
• A cast – which you might need for six to eight weeks or longer, depending on how bad the break is (you might need a second cast if the first one gets too loose after the swelling goes away.)

Rest Your Leg – Once you’re discharged from the hospital in an arm sling, your top priority is to rest your and not further inflame the injury. Of course, the arm sling not only provides support, but it also restricts movement, which is why you should keep it on even during sleep. Avoiding the temptation to move your shoulder and arm will help the bone mend quicker and the pain fades away sooner.

Type I Odontoid Fracture

• Most consider a type I odontoid fracture a stable fracture and treatment for six to 12 weeks in a rigid cervical orthosis (hard cervical collar). Some have suggested that rarely a type I odontoid fracture may be unstable secondary to more extensive and unrecognized ligamentous injury, and flexion/extension x-rays should be obtained at the time of removal of the cervical collar after six to 12 weeks to ensure cervical stability.

Type II Odontoid Fracture[rx]

• Type II odontoid fractures are inherently unstable and have a lower union rate than type III odontoid fractures due to the lower surface area of a fractured bone in type II versus type III odontoid fractures.
• The configuration of type II odontoid fracture and age of patient also play important roles in treatment decisions. The current treatment options for a type II odontoid fracture include rigid cervical orthosis, halo vest immobilization, odontoid screw, transoral adenoidectomy, and posterior instrumentation.

Rigid Cervical Orthosis 

• A type II odontoid fracture is inherently unstable, and a rigid cervical orthosis is not the ideal treatment for such an injury. In the elderly population, many are not surgical candidates (due to comorbidities or poor bone quality), and the elderly typically poorly tolerate a halo vest immobilization. In such situations, a practitioner may attempt a rigid cervical orthosis, although union rates are low.

Halo Vest Immobilization

• If a patient is relatively young and healthy, and there is low risk for nonunion, then halo vest immobilization may be the best treatment for a type II odontoid fracture. Risk factors for nonunion include a fractured space greater than a few millimeters between the odontoid process and vertebral body, poor alignment of the odontoid process with respect to the vertebral body, and poor bone quality and/or health status of the patient.

Medication

• Antibiotic – Cefuroxime or Azithromycin, or  Flucloxacillin or any others cephalosporin/quinolone antibiotic must be used to prevent infection or clotted blood remove to prevent furthers swelling and edema
• NSAIDs – Prescription-strength drugs that reduce both pain and inflammation. Pain medicines and anti-inflammatory drugs help to relieve pain and stiffness, allowing for increased mobility and exercise. There are many common over-the-counter medicines called non-steroidal anti-inflammatory drugs (NSAIDs). They include and Ketorolac, Aceclofenac, Naproxen, Etoricoxib.
• Corticosteroids – Also known as oral steroids, these medications reduce inflammation.
• Muscle Relaxants –  These medications provide relief from associated muscle spasms.
• Neuropathic Agents – Drugs(pregabalin & gabapentin) that address neuropathic—or nerve-related—pain. This includes burning, numbness, and tingling.
• Opioids – Also known as narcotics, these medications are intense pain relievers that should only be used under a doctor’s careful supervision.
• Topical Medications – These prescription-strength creams, gels, ointments, patches, and sprays help relieve pain and inflammation through the skin.
• Calcium & vitamin D3 – to improve bone health and healing fracture. As a general rule, men and women age 50 and older should consume 1,200 milligrams of calcium a day, and 600 international units of vitamin D a day.
• Glucosamine & Diacerein, Chondroitin sulfate – can be used to tightening the loose tension, cartilage, ligament, and cartilage, ligament regenerate cartilage or inhabit the further degeneration of cartilage, ligament
• Dietary supplement-to remove general weakness & improved health.
• Antidepressants – A drug that blocks pain messages from your brain and boosts the effects of endorphins (your body’s natural painkillers).

Odontoid Screw

• An anterior odontoid osteosynthesis (odontoid screw) is a screw placed from the inferior anterior aspect of the C2 vertebral body, in a superior trajectory, and capturing the odontoid process and affixing it in place to allow bony fusion to occur.  The odontoid screw has an advantage of relative preservation of motion of the upper cervical spine while treating a type II odontoid fracture.
• A surgeon can only place the odontoid screw if there are acceptable alignment and minimal displacement of the odontoid process, the fracture line is oblique or perpendicular to the screw trajectory, the injury is relatively recent, and the patient has acceptable body habitus to place the odontoid screw.

Transoral Odontoidectomy

• In some situations, the odontoid process (dens) may be severely posteriorly displaced and compressing the spinal cord causing neurologic deficits. It is difficult and dangerous to reduce the odontoid process in a closed manner, so surgical removal of the odontoid process is required to relieve the compression of the spinal cord.
• This relief is commonly achieved through a transoral adenoidectomy, as the odontoid process commonly is located posterior to the oropharynx. If the odontoid process is removed, the cervical spine remains unstable, and the patient requires instrumented fusion, commonly from a posterior or combined anterior-posterior approach.

Posterior Instrumentation

If the patient has certain risk factors for nonunion, then posterior instrumentation may provide the best treatment option for a type II odontoid fracture. The risk factors include:

• More than a few millimeters gap between the odontoid process and the vertebral body
• Poor odontoid process alignment
• Poor bone quality, older fractures
• Older patients
• Failure of other treatment modalities
• Smoking

Posterior instrumented fusion techniques vary widely and include fusion limited to C1 and C2 as well as more extensive fusions. The fusion of only C1 and C2 will lead to approximately 50% reduction of the lateral rotation of the cervical spine.

Surgical Treatment

Treatment options include conservative management, cervical orthosis, halo-vest orthosis, and surgical procedures.[rx][rx][rx][rx]

External Fixation

• Rigid cervical collar represents the immediate first treatment. For type-I and type-III odontoid fractures this is generally adequate. This is also true for 90% of Hangman’s fractures. Halo-vest orthosis can be used as well for external fixation in certain cases of type-II odontoid fractures or angulated/displaced Hangman’s fractures but is not very well tolerated in the elderly population.

Internal Fixation

• Internal fixation can be achieved via anterior fixation or by a variety of posterior constructs.

Anterior

• An odontoid screw can be placed for type-II odontoid fractures in good alignment with an intact transverse ligament in the acute setting.  There is concern about the placement of the odontoid screw in the elderly population and instances of delayed non-union.

Posterior

• C1 to C2 transarticular screws
• C1 lateral mass and C2 pedicle screws
• C1 lateral mass and C2 pars interarticularis screws
• C1 to C2 wiring (also as an adjunct technique)

Posterior fixation technique selection requires significant review by neurosurgeon or orthopedic spine surgeon. It takes into consideration a variety of factors including surgeon experience, fracture location, vertebral artery location, biomechanical suitability, and anatomical variations. Vascular imaging is mandatory to illustrate the location of the vertebral artery in the V2 and V3 segments.

Collars and Halo Fixators

• The use of collars and halo fixators remains controversial. Soft collars have no stabilizing function, thus we do not recommend them in the early phase. However, they may be used for nonoperative treatment in stable fractures after an initial phase with a hard collar.
• Hard collars (Philadelphia, for example) may be used in the first phase for unstable fractures until a decision for further treatment is made. It may be used for 6 to 8 weeks in cases where nonoperative treatment is indicated. ^[rx–rx]

Anterior Odontoid Screw Fixation

• Initially described by Böhler,^rx] osteosyntheses with 1 or 2 screws by an anterior approach is a standard operative treatment in younger patients with good bone quality if adverse modifiers are absent.
• Patients are operated on in the supine position. With a minimal open incision, the preparation follows the anatomical structures for the standard anterior approach to the cervical spine.