• Markus R Konieczny, Arnold Gstrein, and Ernst J Müller.
• Department of Traumatology, General Hospital Klagenfurt, Academic Teaching Hospital of the University of Graz, Schlossmannstrasse 11, 40225 Düsseldorf, Germany. Markus@Konieczny.net
• J Bone Joint Surg Am. 2012 Oct 3;94(19):e144(1-6).

BackgroundThe 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.MethodsWe 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.ResultsFracture-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.ConclusionsOur 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 EvidenceTherapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

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