What is the treatment for a type 2 odontoid fracture?

Treatment of Type 2 Odontoid Fractures

For patients over 50 years of age with type II odontoid fractures, surgical stabilization and fusion should be strongly considered as initial treatment, as the risk of nonoperative treatment failure is 21 times greater compared to patients under 50 years. 1

Age-Based Treatment Algorithm

Patients Under 50 Years

• Nonoperative management with cervical collar or halo immobilization is reasonable, as this age group has significantly lower failure rates 1
• External immobilization alone can be sufficient when the fracture line direction is down and forward 2

Patients 50 Years and Older

• Surgical treatment is recommended due to the dramatically increased risk of nonunion (21-fold higher than younger patients) 1
• Among elderly patients aged 65-74 years, operative treatment demonstrates lower mortality (11% vs 25% nonoperative) and significantly better 3-month survival (6% mortality vs 18-34% in older cohorts) 1
• The protective effect of surgery diminishes with advancing age, with hazard ratios of 0.4 for ages 65-74,0.8 for ages 75-84, and 1.9 for ages over 85 1

Surgical Technique Selection

Anterior Odontoid Screw Fixation (AOSF)

This should be the first-line surgical approach for unstable odontoid fractures meeting specific criteria 2, 3:

• Indications:

  • Horizontal fracture line, down-and-back direction, or comminuted pattern 2
  • Displacement less than 7 mm 2
  • Reducible odontoid with intact transverse ligament 3
  • Favorable fracture line allowing adequate compression 3

• Advantages:

  • Preserves atlantoaxial motion 3
  • Fusion rate of 77% in elderly patients 4
  • Mean union time of 17.1 weeks 4
  • Lower morbidity and shorter operative duration 3

• Contraindications:

  • Severe atlantoaxial misalignment 3
  • Poor bone quality 3
  • Associated Jefferson fracture 2
  • Displacement greater than 7 mm 2

Posterior C1-C2 Fusion (PCIF)

This technique is indicated when anterior fixation is contraindicated 2, 3:

• Indications:

  • Odontoid fracture with Jefferson fracture 2
  • Dislocation greater than 7 mm 2
  • Severe atlantoaxial misalignment 3
  • Failed anterior screw fixation (salvage procedure) 3
  • Inveterate fracture with severe C1-C2 dislocation (Guo technique preferred) 2

• Advantages:

  • Higher fusion rate than AOSF 3
  • Allows direct open reduction of displaced fragments 3
  • Can reduce atlantoaxial subluxation 3

• Disadvantages:

  • Loss of atlantoaxial motion 3
  • Requires prone positioning 3
  • Longer operative duration 3

Nonoperative Management Considerations

While cervical collar or halo immobilization remains an option, guidelines explicitly do not prohibit this approach in patients over 50 years when individual circumstances warrant conservative treatment 1. However, clinicians must recognize:

• The 21-fold increased risk of treatment failure in patients over 50 years 1
• High rates of nonunion with conservative treatment 5
• Risk of delayed instability in some cases 5
• Overall 3-year mortality rate of 39% in elderly patients regardless of treatment 1

Critical Pitfalls to Avoid

• Do not assume age alone disqualifies surgical candidacy: Patients aged 65-74 years show the greatest mortality benefit from surgery, while those over 85 show minimal benefit 1
• Do not use AOSF in elderly patients with poor bone quality: This increases pseudarthrosis risk 3, 4
• Do not overlook postoperative dysphagia risk: Older patients have higher rates with anterior approaches 3
• Do not delay treatment decisions: Prolonged immobilization increases morbidity and mortality in elderly patients 5
• Consider Teriparatide therapy for symptomatic nonunions: This anabolic therapy has shown promise in achieving fusion within 12 weeks in elderly patients who fail initial treatment 5