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Treatment Algorithm for Dens Fractures: Non-Halo Immobilization, Anterior Screw Fixation, or Posterior Transarticular C1-C2 Fixation

Konieczny, Markus R., MD1; Gstrein, Arnold, MD1; Müller, Ernst J., MD1

doi: 10.2106/JBJS.K.01616
Scientific Articles
Supplementary Content

Background: The appropriate treatment of dens fractures is unclear. We established a staged treatment protocol for dens fractures and conducted a prospective study to evaluate the outcome of treatment based on this protocol.

Methods: We prospectively evaluated sixty-nine consecutive patients who presented to our institution with a dens fracture. The mean duration of follow-up was 9.7 months (range, six to fifty-eight months). Fractures were categorized as stable or unstable. Stable fractures were treated by immobilization in a rigid collar. Patients seventy-five years or older with unstable fractures, patients with a neurological deficit, and patients with Anderson and D’Alonzo type-III fractures underwent posterior transarticular C1-C2 stabilization. Unstable fractures in patients younger than seventy-five years were stabilized with direct anterior screw fixation. Thirty-one patients were treated with a Philadelphia collar, twenty-five with posterior transarticular fixation, and thirteen with direct anterior screw fixation.

Results: Fracture-healing or solid fusion of C1-C2 was documented in sixty-eight of sixty-nine treated patients at final follow-up. The remaining patient had a stable nonunion of the dens. Secondary procedures were performed in five patients.

Conclusions: Our treatment algorithm based on dens fracture type, fracture stability, and patient age was associated with a high success rate. Evaluating fracture stability is crucial when considering nonoperative treatment. External stabilization with a rigid cervical collar was adequate for stable fractures of the dens and was associated with a high healing rate. Posterior transarticular screw fixation of C1-C2 was associated with a high success rate, including in elderly patients.

Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

1Department of Traumatology, General Hospital Klagenfurt, Academic Teaching Hospital of the University of Graz, Schlossmannstrasse 11, 40225 Düsseldorf, Germany. E-mail address for M.R. Konieczny: E-mail address for A. Gstrein: E-mail address for E.J. Müller:

Copyright © 2012 by The Journal of Bone and Joint Surgery, Incorporated
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