Type ii odontoid fracture management,type 1 diabetes mellitus prognosis,diabetes in young adults symptoms,s keyes laser - Test Out

Scroll down to respond to the OrthopaedicsOne Poll: Because screw fixation is so technically challenging, fusion of an odontoid fracture should be the treatment of choiceTo fuse or not to fuse? The bimodal pattern of patient age (young or old) presenting with these injuries that result from either high- or low-energy trauma is important to consider when planning treatment.5,6 An overwhelming goal of surgery in spinal fracture care is to restore mechanical stability. The desire to maintain cervical motion following an odontoid fracture is attractive, and, thus, odontoid screw fixation has been increasingly reported. While odontoid screw fixation may be an attractive option to many patients presenting with Type II odontoid fractures, its practical use may be tempered by the aforementioned factors, as the procedure does present technical challenges even in experienced hands. The ability to achieve proper fracture realignment, as well as the ability to achieve screw fixation that satisfactorily stabilizes the fracture adhering to AO principles in lag screw fixation, will influence surgical success.
Often the head and neck need to be positioned in some extension to facilitate exposure to the inferior edge of C2. The procedure is often performed with biplanar fluoroscopy, which mandates modifications to the head support of conventional operating room tables.
The anterior neck needs to be widely draped, with the exposure through a standard left or right anterior Smith-Robinson approach to the cervical spine, but with a skin incision near C5-6. Attention to screw position - engaging as much of the bone in the remaining odontoid peg - and efforts to facilitate fracture compression using lag techniques are important to achieve. A cannulated screw system can facilitate insertion, although there is some risk to inadvertent advancement of the wire. Complications such as neurologic sequelae and loss of fracture fixation have been described, although many of these relate to early usage and inappropriate indications for this technique. The use of screw fixation in established odontoid fracture non-unions is also controversial. In summary, the main advantage to odontoid screw fixation is the preservation of cervical motion, which fusion surgery does not permit. Approximately 50% of axial rotation of the cervical spine occurs at the C1-C2 articulation. The mechanism of injury may be from forces causing extreme flexion, extension, or rotation.
Type I a€“ Type I injuries represent an avulsion fracture of the alar ligament from the dens.
Type III a€“ Type III injuries are fractures into the body of the axis and usually have a well-vascularized, broad cancellous surface area.
Wiring techniques a€“ Gallie or Brooks fusion techniques utilize a sublaminar C1 wire with either a C2 spinous process or a C2 laminar wire. C1-C2 fusion using Magerl transarticular screws a€“ The preoperative plan initially involves determining the feasibility of safely6 passing a screw across the C1-C2 joint without causing injury to the vertebral artery or the spinal canal.
Atlantoaxial fusion using C1 lateral mass and C2 pedicle fixation (Harms technique) a€“ This technique can be used preferentially, or as an alternative to the Magerl technique where the vertebral artery precludes safe passage of a C1-C2 transarticular screw.
C2 intralaminar fixation a€“ Bilateral crossing of C2 laminar screws can be used as an alternative to C2 pedicle fixation.
In summary, understanding of the anatomy and appropriate preoperative planning are mandatory for safe execution of any of the fusion techniques described above for C1-C2 instability.
Related ContentResources on Odontoid Fractures - To Fuse or Not to Fuse and related topics in OrthopaedicsOne spaces.
The classification of Anderson and D’Alonso (Figure 3), proposed in 1970 is the most accepted and widespread.
The type II fractures occur between the transverse ligament and the body of the axis, without extension to the articular facets of C2. Conservative treatment can be done by external immobilization with a rigid cervical-thoracic orthosis , plaster-type minerva or halo vest. In order to guide the indication of this technique, Grauer and colleagues divided the type II fractures into 3 subtypes according to fracture line. Isolated head injuries versus multiple trauma in pediatric patients: do the same indications for cervical spine evaluation apply?
The adequacy and cost effectiveness of routine resuscitation-area cervical-spine radiographs. Comparison of five-view and three-view cervical spine series in the evaluation of patients with cervical trauma.
Unsuspected upper cervical spine fractures associated with significant head trauma: role of CT.
The role and limitations of computed tomographic scanning in the evaluation of cervical trauma.
Diagnostic capabilities of magnetic resonance imaging and computed tomography in acute cervical spinal column injury. The value of retropharyngeal soft tissue measurements in trauma of the adult cervical spine.
Utility of prevertebral soft tissue measurements in identifying patients with cervical spine fractures. Methylprednisolone or naloxone treatment after acute spinal cord injury: 1-year follow-up data. Magnetic resonance imaging in the evaluation of spinal cord injury without radiographic abnormality in children.
Spinal cord injury without radiographic abnormality in children—the SCIWORA syndrome. In odontoid fractures, surgical stability can be achieved by either fracture fixation of the C2 body to the odontoid process or by arthrodesis of the C1-C2 motion segment.
Lessening or obviating the need for halo immobilization is desirable; additionally, autologous bone graft harvest is not needed. Computed tomography scan coronal (Figure 1A, top) and sagittal (Figure 1B, bottom) reformatted images of a 26-year-old female with a displaced Type II odontoid fracture following a high-energy motor-vehicle accident. Plain lateral (Figure 2a, top) and open-mouth odontoid AP (Figure 2b, bottom) view of the same patient 9 months after fracture reduction performed under image guidance and general anaesthesia followed by anterior odontoid screw fixation with two AO small fragment terminally threaded lag screws.
The risk of fracture non-union can be significant, particularly in some displaced Type II odontoid fractures. C1-C2 fusion is often an easier procedure to perform technically, while acknowledging that the procedure significantly reduces neck motion, particularly in rotation, by about 50%. Patient head and neck position need to be considered in the context of anaesthesia, fracture reduction, and steps to optimize spinal precautions. If fracture reduction is lost, for example with a posteriorly displaced fracture configuration, less extension should be utilized until provisionary fixation can be achieved. Gardner Well's Tongs or halo traction can maintain in-line C-spine control; using a radiolucent frame extension from the table to the patient's head as well as a low-profile frame extension will facilitate ease in positioning fluoroscopic equipment.
Thus, the appropriate trajectory for the drill and screw can be obtained allowing placement in the anterior inferior portion of the C2 vertebral body. Starting 2-3 mm lateral to the midline of C2 also helps in this regard and will allow placement of either one or two 3.5-mm screws that can engage bone on the far side of the fracture line. There does not appear to be significant differences biomechanically between one versus two screws in load-to failure stability.
In experienced hands, this technique can facilitate fracture healing and provide early spinal stability, thereby enhancing the recovery and rehabilitation for select patients. Instability at this level occurs most commonly as a result of fractures of the odontoid or bursting injuries of the atlas with disruption of the transverse ligament.


However, loss of C1-C2 motion may occur, despite one's best efforts, due to scarring of the transverse ligament related to the injury itself or less-than-anatomic alignment of the odontoid process. Fractures of the odontoid can be difficult to identify in the osteopenic skeleton of the older patient.
The importance of this injury is its potential association with an atlantooccipital dissociation. A tricortical iliac crest bone graft is placed on the C1 arch and over the C2 lamina, and it is maintained by the wire. CT axial and sagittal reconstruction views are invaluable in visualizing the path of the vertebral artery and measuring the relationship between the artery, the canal, and the joint (Figure 1). Lateral and open mouth odontoid view of a patient undergoing C1-C2 fusion by the Magerl technique. AP and lateral radiograph following fixation using the Harma€™s technique (lateral mass C1 screws and C2 pedicle screws).
This technique has the advantage of having less risk to the vertebral artery and may be advantageous if there is difficulty with pedicle fixation. With the numerous tools now available in the surgeon's armamentarium, when surgery is required, fusion can be performed safely with good clinical outcome. Besides the fracture, it is important to consider the clinical condition of the patient to decide the most appropriate type of treatment. With the conservative treatment, the pseudarthrosis risk varies from 26 to 80% in the literature. In patients with favorable fracture line and intact transverse ligament, osteosynthesis  with interfragmentary screw can be used.  (Figura4b). MRI shows also injury of the myelon.Control CT scan after installation of a halo vest shows even further dislocation of the dens. Views required to radiographically exclude a cervical spine fracture include a posteroanterior view, a lateral view and an odontoid view. The single portable cross-table lateral radiograph, which is sometimes obtained in the trauma room, should be abandoned. Except for the clay shoveler's fracture, they should be assumed to be unstable and warrant continued immobilization until definitive therapy can be arranged.
Any patient with a spinal cord injury should begin therapy with methylprednisolone within the first eight hours after the injury, with continued administration for up to 24 hours. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference.
Reductions performed with the patient awake provide the opportunity to clinically monitor neurologic status. The ability to have two C-arms in the operating room can facilitate the procedure, although more advanced intraoperative imaging and 3D technology may be available at certain centers. This will require cephalad retractors that expose the retropharyngeal space up to the level of C2-3. Internal fixation with one or two screws appears to provide approximately 50% of the initial strength of an unfractured odontoid11. The near fragment can be overdrilled with a 3.5-mm drill bit, tapping, and subsequent insertion of a partially threaded screw with or without a washer. In most cases, fractures can be identified on either the lateral cervical spine radiograph or open-mouth odontoid view.
This type of fracture occurs in the cortical bone caudad to the transverse ligament and above the cancellous body of the axis. Wires are less commonly used today as they are less biomechanically stable and do not control lateral bending, axial rotation, or anteroposterior translation compared to the newer Magerl or Harms techniques.2 Wiring techniques cannot be used in patients with posterior arch fractures of C1, and they require the use of postoperative halo-vest immobilization. The danger to the vertebral artery lies in the C2 body as it ascends from a more medial position laterally. Occur in a region of poor vascularization and are associated with an increased risk of pseudarthrosis. The type IIB fracture corresponds to a a fracture line that runs from antero-inferior to posterior-superior, or a transverse fracture. The lateral view must include all seven cervical vertebrae as well as the C7-T1 interspace, allowing visualization of the alignment of C7 and T1. This view is insufficient to exclude a cervical spine fracture and frequently must be repeated in the radiographic department.11,12 The patient's neck should remain immobilized until a full cervical spine series can be obtained in the radiographic department. Any patient found to have one spinal fracture should have an entire spine series, including views of the cervical spine, the thoracic spine and the lumbosacral spine.
Patients should receive methylprednisolone in a dosage of 30 mg per kg given intravenously over one hour. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Reduction and adjustments to neck position under anaesthesia provide less-immediate feedback while attempting to properly reduce a fracture and facilitate the necessary insertional screw trajectory.
Exposure of the inferior bony portion of C2 is performed with efforts to minimize disruption to the C2-3 disc.
Two screws may help control rotational stability, although it may be a challenge getting one, let alone two, screws in good position. In relatively osteopenic bone, tapping to the far fragment may not be necessary, although in healthier bone, this may be important to facilitate engagement of the far fragment and achieve fracture compression. The use of Herbert screws has been reported, although some consideration needs to be given as to how much torque should be applied to obtain adequate fracture compression and avoid stripping the thread while attempting to seat the terminal threads into the body of C2.
This technique is also contraindicated in patients with osteoporosis, nonunion, os odontoideum, or thoracic kyphosis. CT scans with sagittal and coronal reformations are useful for a better understanding of the fracture pattern and for surgical planning.
If the location is initially too medial, the pathway takes it very close to the C1-C2 joint; there may be little room for a screw to pass. The location of the C1 lateral mass is anterior to the overhang of the C1 posterior arch and the screw head must sit proud to allow connection to the rod. In the younger population, the odontoid fracture is the result of higher energy trauma such as auto accidents.
However, it also may be present in cranio-cervical dislocation, which are highly unstable lesions.
Risk factors for pseudoarthrosis are initial deviation greater than 4-6 mm, angulation greater than 10 °, and age at diagnosis above 65. The most common reason for a missed cervical spine injury is a cervical spine radiographic series that is technically inadequate. The anterior margin of the vertebral bodies, the posterior margin of the vertebral bodies, the spinolaminar line and the tips of the spinous processes (C2-C7) should all be aligned. Over the next 23 hours, intravenous methylprednisolone in a dosage of 5.4 mg per kg per hour should be administered. The potential expertise and availability of intraoperative neuro-monitoring needs to be considered and coordinated in advance of surgery, as should discussions with anaesthesia regarding intubation strategies. The role of fusion for odontoid fractures is well established, and a number of techniques are available to achieve the goals of treatment in a safe and effective manner.
The decision to pass a unilateral screw or to defer to another technique will depend on the location of the vertebral artery.


The entry point is the midpoint of the lateral mass directed straight anteriorly to the anterior arch of C1. Patients with significant risk factors for nonunion can be treated more safely in a surgical fashion.
The type IIC  corresponds to a fracture line running from anteroinferior to posterosuperior or there is significant comminution. Computed tomographic image through ring of C1 shows the anterior arch fracture (small arrow).
This therapy has been shown to improve outcomes and minimize cord injury,29 although it is not without its problems.
A further technical issue with this procedure mandates that C1 be reduced fully on C2 or the vertebral artery will be at risk for injury.
The C2 pedicle is cannulated and its orientation is 20 degrees cephalad to the transverse plane and 30 degrees medial to the sagittal plane. Hadley and colleagues have proposed the inclusion of subtype IIa in the classification of Anderson D’Alonso.
Once an injury to the spinal cord is diagnosed, methylprednisolone should be administered as soon as possible in an attempt to limit neurologic injury.Although cervical spine radiographs are almost routine in many emergency departments, not all trauma patients with a significant injury must have radiographs, even if they arrive at the emergency department on a backboard and wearing a cervical collar.
If all seven vertebrae and the C7-T1 junction are not visible, a swimmer's view, taken with one arm extended over the head, may allow adequate visualization of the cervical spine.
It is believed, however, that Type II fractures cause damage to the vascularity of the dens. The safest technique for cannulating the C2 pedicle is by direct exposure and palpation of the superior and medial edges of the pedicle.
This subtype refers to a fracture that has a anterior or posterior comminution (5% of cases). Any film series that does not include these three views and that does not visualize all seven cervical vertebrae and the junction of C7-T1 is inadequate. In children, it is not uncommon for a spinal cord injury to show no radiographic abnormalities. Cancellous bone graft is placed into the C1-C2 facet joint after decorticating the posterior portion of the joint. In chronic lesions, dynamic radiographs can be used to evaluate the mobility of the fragments.
This pattern of fracture is associated with an increased risk of pseudoarthrosis and therefore  surgical treatment is recommended. However, the criteria apply only to adults and to patients without mental status changes, including drug or alcohol intoxication. The patient should be maintained in cervical immobilization, and plain films should be repeated or computed tomographic (CT) scans obtained until all vertebrae are clearly visible. Although studies suggest that these criteria may also be used in the management of verbal children,7–9 caution is in order, since the study series are small, and the ability of children to complain about pain or sensory changes is variable.
The importance of obtaining all of these views and visualizing all of the vertebrae cannot be overemphasized. SCIWORA syndrome occurs when the elastic ligaments of a child's neck stretch during trauma. These include initial displacement of more than 5 mm, angulation greater than 10 degrees, posterior displacement and comminution, age greater than 40 years, delay in diagnosis, and smoking. As a result, the spinal cord also undergoes stretching, leading to neuronal injury or, in some cases, complete severing of the cord.31 This situation may account for up to 70 percent of spinal cord injuries in children and is most common in children younger than eight years.
A Type II fracture that cannot be reduced anatomically or maintained in a halo requires fusion.
The reconstructions in the sagittal (Figure 12) and coronal planes helps to choose  treatment  and surgical technique. These injuries frequently present as a malalignment of the cervical vertebrae on lateral views. Lateral radiograph reveals markedly increased prevertebral swelling (two short arrows) associated with the fracture at the posterior aspect of C2 pedicles (medium arrow).
C6 is viewed with lateral masses superimposed (straight lateral) with abrupt rotation of one C7 facet so that one lateral mass lies anterior to the others at this level.
However, up to 30 percent of patients have a delayed onset of neurologic abnormalities, which may not occur until up to four or five days after the injury. If there is a question of ligamentous injury (focal neck pain and minimal malalignment of the lateral cervical x-ray [meeting the criteria in Table 2]) and the cervical films show no evidence of instability or fracture, flexion-extension views should be obtained.17,19 These radiographs should only be obtained in conscious patients who are able to cooperate.
In patients with delayed symptoms, many have neurologic symptoms at the time of the injury, such as paresthesias or weakness, that have subsequently resolved.32It is important to inform the parents of young patients with neck trauma about this possibility so that they will be alert for any developing symptoms or signs. Only active motion should be allowed, with the patient limiting the motion of the neck based on the occurrence of pain. Spondylolisthesis of C6-C7 is again seen, with associated disc-space narrowing (small arrows) and widened distance between spinous processes at C6-C7 compared with adjacent levels (larger arrows).Confusion can sometimes result from pseudosubluxation, a physiologic misalignment that is due to ligamentous laxity, which can occur at the C2-C3 level and, less commonly, at the C3-C4 level.
If there is any question of an abnormality on the plain radiograph or if the patient has neck pain that seems to be disproportionate to the findings on plain films, a CT scan of the area in question should be obtained. If the degree of subluxation is within the normal limits listed in Table 2 and the neck is not tender at that level, flexion-extension views may clarify the situation. However, flexion-extension views should not be obtained until the entire cervical spine is otherwise cleared radiographically.After ensuring that the alignment is correct, the spinous processes are examined to be sure that there is no widening of the space between them.
Lateral radiograph shows a fracture through the base of the odontoid process (dens) with the dens and C1 posterior to C2 (arrow indicates fractured base of dens).While some studies have used magnetic resonance imaging (MRI) as an adjunct to plain films and CT scanning,23,24 the lack of wide availability and the relatively prolonged time required for MRI scanning limits its usefulness in the acute setting. In addition, if angulation is more than 11 degrees at any level of the cervical spine, a ligamentous injury or fracture should be assumed. An increase in this space is presumptive evidence of a fracture of C1 or of the odontoid process, although it may also represent ligamentous injury at this level.
If a fracture is not found on plain radiographs, a CT scan should be obtained for further investigation. The bony structures of the neck should be examined, with particular attention to the vertebral bodies and spinous processes.The retropharyngeal space (Figure 2) is now examined. The classic advice is that an enlarged retropharyngeal space (Table 2) indicates a spinous fracture. Finally, the craniocervical relationship is checked.ODONTOID VIEWThe dens is next examined for fractures. Artifacts may give the appearance of a fracture (either longitudinal or horizontal) through the dens.
If there is any question of a fracture, the view should be repeated to try to get the teeth out of the field. If it is not possible to exclude a fracture of the dens, thin-section CT scans or plain film tomography is indicated.Next, the lateral aspects of C1 are examined. Anteroposterior tomogram at the craniocervical junction demonstrates lateral mass of C1 (arrows) lying lateral to the lateral masses of C2 (arrowheads) on both the left and right sides as a result of spread of the ring of C1.ANTEROPOSTERIOR VIEWThe height of the cervical spines should be approximately equal on the anteroposterior view.



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