title: Treatment algorithm for dens fractures: non-halo immobilization, anterior screw fixation, or posterior transarticular C1-C2 fixation.
abstract: 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.
  
  
  METHODS
  Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
authors.affiliation: Department of Traumatology, General Hospital Klagenfurt, Academic Teaching Hospital of the University of Graz, Schlossmannstrasse 11, 40225 Düsseldorf, Germany. Markus@Konieczny.net
authors.forename: Markus R
authors.initials: MR
authors.lastname: Konieczny
authors.forename: Arnold
authors.initials: A
authors.lastname: Gstrein
authors.forename: Ernst J
authors.initials: EJ
authors.lastname: Müller
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000465:Algorithms; D001863:Bone Screws; D002574:Cervical Vertebrae / Q000293:injuries / Q000601:surgery*; D015331:Cohort Studies; D005260:Female; D005500:Follow-Up Studies; D005593:Fracture Fixation, Internal / Q000295:instrumentation / Q000379:methods*; D017102:Fracture Healing / Q000502:physiology; D006801:Humans; D007103:Immobilization / Q000379:methods; D015601:Injury Severity Score; D008297:Male; D008875:Middle Aged; D009809:Odontoid Process / Q000293:injuries / Q000601:surgery*; D011182:Postoperative Care / Q000379:methods; D011446:Prospective Studies; D016059:Range of Motion, Articular / Q000502:physiology*; D018570:Risk Assessment; D016103:Spinal Fractures / Q000000981:diagnostic imaging / Q000601:surgery*; D013123:Spinal Fusion / Q000295:instrumentation / Q000379:methods; D013997:Time Factors; D014057:Tomography, X-Ray Computed / Q000379:methods; D016896:Treatment Outcome; D055815:Young Adult