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Fracture of odontoid process of the axis
FRACTURE
OF ODONTOID REPORT
CHARLES
PROCESS OF THE AXIS
OF CASE WITH
S. NORBURN,
M.D. AND J.
BONY UNION DONALD MACRAE,
M.D.
ASHEVILLE, N. C. A
REVIEW
of the Iiterature wiII impress upon anyone the importance of an earIv diagnosis and adequate treatment of aIi fractires of the odontoid process of the axis. Untreated patients, after the first few days, may have IittIe discomfort and may be abIe to go about their work as usua1, but in the great majority of instances these untreated cases terminate fataIIy in from a few weeks to many years, from injudicious movement or from myeIitis caused by irritation or caIIus. l The purpose of this paper is to describe a method of roentgenographic study when the diagnosis is in doubt; and aIso to report a case of odontoid fracture, which is unusua1 in that there was no dispIacement and in that it ended in recovery with bony union in the norma position. Mixter and Osgood after their extensive study doubted if bony union ever occurred.2
A
CASE REPORT The patient, D. J. K. is a white man, aged fifty-eight years, who weighed 194 Ib. On March 6, 193 I, he was thrown, head first, through the top of a touring car as it ran over an embankment. The soft dirt of a heId broke his faII and he did not Iose consciousness. He was taken to a hospita1, suffering from epistaxis and pain in the right chest, shouIder and neck. Examination showed that his right cIavicIe and one rib on the right side were fractured. There was considerable soreness in the back between the shouIders. At this time and during the foIIowing three weeks he had the symptom of being unable to raise his head from the piIIow without assistance.3 Rotation of the neck was Iimited and any motion caused some pain. There were no cord symptoms. Three weeks after the injury the patient was brought to our hospita1. At that time,
roentgenographic examination showed a fracture of the right cIavicle and a clouding of the mastoid ceIIs on the right. SeveraI fiIms were taken of the axis before the diagnosis of fracture of the base of the odontoid was finaIIy made. In addition to the standard views of the first and second cervica1 vertebrae, a IateraI exposure was made, with the head bent forward (ffexed) (Fig. I) and another with it bent backward (extended) (Fig. 2). The one in the ffexed position showed the odontoid to be tiIted backward, whiIe the one in the extended position showed it to be tiIted forward. The tiIting thus seen was contrary to what we expected to find. However, we explained it as foIIows: Most of the ffexion and extension in the neck takes pIace in the Iower cervica1 vertebrae. However, when either motion is forced, the atIanto-0ccipitaI articuIation moves to its Iimit and the atlas is carried forward in extension and backward in ffexion. In extreme ffexion or extension the atIas moves aImost as a rigid part of the occiput, revolving on an axis a short distance above the condyIes. Thus the anterior arch presses backward against the ondotoid during flexion and the check Iigament presses forward against the odontoid during extension. The standard view through the open mouth (Fig. 3) shows an obIique fracture through the base of the process. The patient was pIaced in a pIaster jacket, with a high collar extending up on the occiput and on either side to the ears and supporting the mandibIe in front. After about a week the jacket was split on either side to permit remova for bathing. It was, however, worn day and night. Three months after the injury, the patient was fitted with a ceIIuIoid jacket having a high coIIar. This was worn for about a month, when he began to wear a brace prescribed by Dr. A. P. C. Ashhurst. The brace consisted of a Ieather band about the forehead and occiput, supported by a stee1 rod attached to shouIder
444
\ti\
SMUES
Var..
XX[.
No.
3
Norburn
& MacRae-Fracture
and hip braces and passing along the spine, folIowing the normal curves. This brace permitted a very small degree of rotation, flexion
FIGS.
FIG.
I,
2 and
American
.lourn;rl
ul Surgery
433
later, that is, seven months after the injury, the brace was discarded. At the Iast examination nine months after
3. Roentgenographs
and tracings.
I. Lateral view. Head flexed, showing backward tilting of odontoid process.
FIG. 2. Lateral view. Head extended, showing forward tilting of odontoid. FIG. 3. Anteroposterior view, showing fracture line obliqucIy across base of odontoid.
and extension, but prevented any great or sudden motion, which might cause complete separation of the odontoid fragments. It was not worn at night. Three and a half months
the injury, the radiographs showed bony union in the norma position, with a dense line of caIIus at the site of the former fracture. (Figs. 4, 5, and 6.) The patient can turn his head
4B
6A
showGng bony union nine mc mths after injury. Head flexed. FIG. 4. Lateral-&w. FIG. 3. Lateral view. Head extended. No tilting of odontoid process is shown. FIG. 6. Anteroposterior view, showing dense cal1u.s formation aIong line of fracture.
NEW
SERIES VOL. XXI, No. 3
Norburn
& MacKaePmmFracture
from side to side through
about 75’. (While his neck is short ancI stout, his normaI rotation shouId he 90’ to IOO’.) There is aIso sIight limitation in extension and flexion. The patient has been advised not to move his head to the limit in any direction and he is carefuI to foIIou this advice. DISCUSSION
Union of odontoid process proper with the body of the axis occurs about the third year but it is not compIete unti1 a year or two Iater. The center of the junction is occupied by a smaI1 disk of cartiIage, which exists, surrounded by bone, unti1 advanced age.4 Because of this defect and its associated inherent weakness, most fractures of the odontoid occur at its base. there was sufficient In our patient trauma to fracture the odontoid process
A nlCriCnl1 Jo,,rn;,l 01Surrcrv_&$7
but for some reason the displacement was minimaI. We beIieve that the short, heavily muscIed neck of this individua1 acted as a spIint and pre\.ented dispIacement of the fragments or disIocation of the vertebrae which so frequentIy accompanies these fractures. When the roentgenographic examination does not present a cIear-cut picture of a fracture of the odontoid and such a fracture is suspected, we suggest that true IateraI fiIms be made in forced extension and forced flexion to demonstrate the mobiIity of the process. This examination, we beIie\-e, wiI1 be heIpfu1 in cIearing up doubtfu1 cases of fracture of the base of the odontoid. We are endebted to Dr. Henry li. Pancoast of Philadelphia for his courtes!- in reviewing our films.
REFERENCES 1. CORNER,
E. M. Rotary
dislocation
of the axis. Ann.
Surg., 413: 9, 1907. z. MIXTER, S. J., and OSGOOD, R. B. Traumatic Iesions of atIas and axis. Am. J. Orthop. Surg., 7: 348, 1910.
REFERENCES Homes,
S. J. Differential
OF
sex mortaIity
DR. MACKLIN and its genetic
basis. Proc. Sixtb Intern. Gong. Genetics, 1932, p. 85. PACK, G. T., and 1.~ FEVRE, R. G. The age and sex distribution
and incidence
of neopIasms
at the
3. KILIANI,0. G. Fracture of odontoid
process of the axis. Ann. Surg., 59: 297, 1914. 4. FRAZIER, C., and ALLEU, A. R. Surgery of the Spine and SpinaI Cord. N. Y., AppIeton, 1918, p. 29.
(CONTINUED
FROM
P. 445)
MemoriaI HospitaI, New York City. J. Cancer Kesearcr’,, 14: 167, 1930. STARK, M. B. The deveIopment and minute structure of certain hereditary tumors in Drosophila. Proc. Sixth Intern. Gong. Genetics, 1932, p. 192.
OF ODONTOID REPORT
CHARLES
PROCESS OF THE AXIS
OF CASE WITH
S. NORBURN,
M.D. AND J.
BONY UNION DONALD MACRAE,
M.D.
ASHEVILLE, N. C. A
REVIEW
of the Iiterature wiII impress upon anyone the importance of an earIv diagnosis and adequate treatment of aIi fractires of the odontoid process of the axis. Untreated patients, after the first few days, may have IittIe discomfort and may be abIe to go about their work as usua1, but in the great majority of instances these untreated cases terminate fataIIy in from a few weeks to many years, from injudicious movement or from myeIitis caused by irritation or caIIus. l The purpose of this paper is to describe a method of roentgenographic study when the diagnosis is in doubt; and aIso to report a case of odontoid fracture, which is unusua1 in that there was no dispIacement and in that it ended in recovery with bony union in the norma position. Mixter and Osgood after their extensive study doubted if bony union ever occurred.2
A
CASE REPORT The patient, D. J. K. is a white man, aged fifty-eight years, who weighed 194 Ib. On March 6, 193 I, he was thrown, head first, through the top of a touring car as it ran over an embankment. The soft dirt of a heId broke his faII and he did not Iose consciousness. He was taken to a hospita1, suffering from epistaxis and pain in the right chest, shouIder and neck. Examination showed that his right cIavicIe and one rib on the right side were fractured. There was considerable soreness in the back between the shouIders. At this time and during the foIIowing three weeks he had the symptom of being unable to raise his head from the piIIow without assistance.3 Rotation of the neck was Iimited and any motion caused some pain. There were no cord symptoms. Three weeks after the injury the patient was brought to our hospita1. At that time,
roentgenographic examination showed a fracture of the right cIavicle and a clouding of the mastoid ceIIs on the right. SeveraI fiIms were taken of the axis before the diagnosis of fracture of the base of the odontoid was finaIIy made. In addition to the standard views of the first and second cervica1 vertebrae, a IateraI exposure was made, with the head bent forward (ffexed) (Fig. I) and another with it bent backward (extended) (Fig. 2). The one in the ffexed position showed the odontoid to be tiIted backward, whiIe the one in the extended position showed it to be tiIted forward. The tiIting thus seen was contrary to what we expected to find. However, we explained it as foIIows: Most of the ffexion and extension in the neck takes pIace in the Iower cervica1 vertebrae. However, when either motion is forced, the atIanto-0ccipitaI articuIation moves to its Iimit and the atlas is carried forward in extension and backward in ffexion. In extreme ffexion or extension the atIas moves aImost as a rigid part of the occiput, revolving on an axis a short distance above the condyIes. Thus the anterior arch presses backward against the ondotoid during flexion and the check Iigament presses forward against the odontoid during extension. The standard view through the open mouth (Fig. 3) shows an obIique fracture through the base of the process. The patient was pIaced in a pIaster jacket, with a high collar extending up on the occiput and on either side to the ears and supporting the mandibIe in front. After about a week the jacket was split on either side to permit remova for bathing. It was, however, worn day and night. Three months after the injury, the patient was fitted with a ceIIuIoid jacket having a high coIIar. This was worn for about a month, when he began to wear a brace prescribed by Dr. A. P. C. Ashhurst. The brace consisted of a Ieather band about the forehead and occiput, supported by a stee1 rod attached to shouIder
444
\ti\
SMUES
Var..
XX[.
No.
3
Norburn
& MacRae-Fracture
and hip braces and passing along the spine, folIowing the normal curves. This brace permitted a very small degree of rotation, flexion
FIGS.
FIG.
I,
2 and
American
.lourn;rl
ul Surgery
433
later, that is, seven months after the injury, the brace was discarded. At the Iast examination nine months after
3. Roentgenographs
and tracings.
I. Lateral view. Head flexed, showing backward tilting of odontoid process.
FIG. 2. Lateral view. Head extended, showing forward tilting of odontoid. FIG. 3. Anteroposterior view, showing fracture line obliqucIy across base of odontoid.
and extension, but prevented any great or sudden motion, which might cause complete separation of the odontoid fragments. It was not worn at night. Three and a half months
the injury, the radiographs showed bony union in the norma position, with a dense line of caIIus at the site of the former fracture. (Figs. 4, 5, and 6.) The patient can turn his head
4B
6A
showGng bony union nine mc mths after injury. Head flexed. FIG. 4. Lateral-&w. FIG. 3. Lateral view. Head extended. No tilting of odontoid process is shown. FIG. 6. Anteroposterior view, showing dense cal1u.s formation aIong line of fracture.
NEW
SERIES VOL. XXI, No. 3
Norburn
& MacKaePmmFracture
from side to side through
about 75’. (While his neck is short ancI stout, his normaI rotation shouId he 90’ to IOO’.) There is aIso sIight limitation in extension and flexion. The patient has been advised not to move his head to the limit in any direction and he is carefuI to foIIou this advice. DISCUSSION
Union of odontoid process proper with the body of the axis occurs about the third year but it is not compIete unti1 a year or two Iater. The center of the junction is occupied by a smaI1 disk of cartiIage, which exists, surrounded by bone, unti1 advanced age.4 Because of this defect and its associated inherent weakness, most fractures of the odontoid occur at its base. there was sufficient In our patient trauma to fracture the odontoid process
A nlCriCnl1 Jo,,rn;,l 01Surrcrv_&$7
but for some reason the displacement was minimaI. We beIieve that the short, heavily muscIed neck of this individua1 acted as a spIint and pre\.ented dispIacement of the fragments or disIocation of the vertebrae which so frequentIy accompanies these fractures. When the roentgenographic examination does not present a cIear-cut picture of a fracture of the odontoid and such a fracture is suspected, we suggest that true IateraI fiIms be made in forced extension and forced flexion to demonstrate the mobiIity of the process. This examination, we beIie\-e, wiI1 be heIpfu1 in cIearing up doubtfu1 cases of fracture of the base of the odontoid. We are endebted to Dr. Henry li. Pancoast of Philadelphia for his courtes!- in reviewing our films.
REFERENCES 1. CORNER,
E. M. Rotary
dislocation
of the axis. Ann.
Surg., 413: 9, 1907. z. MIXTER, S. J., and OSGOOD, R. B. Traumatic Iesions of atIas and axis. Am. J. Orthop. Surg., 7: 348, 1910.
REFERENCES Homes,
S. J. Differential
OF
sex mortaIity
DR. MACKLIN and its genetic
basis. Proc. Sixtb Intern. Gong. Genetics, 1932, p. 85. PACK, G. T., and 1.~ FEVRE, R. G. The age and sex distribution
and incidence
of neopIasms
at the
3. KILIANI,0. G. Fracture of odontoid
process of the axis. Ann. Surg., 59: 297, 1914. 4. FRAZIER, C., and ALLEU, A. R. Surgery of the Spine and SpinaI Cord. N. Y., AppIeton, 1918, p. 29.
(CONTINUED
FROM
P. 445)
MemoriaI HospitaI, New York City. J. Cancer Kesearcr’,, 14: 167, 1930. STARK, M. B. The deveIopment and minute structure of certain hereditary tumors in Drosophila. Proc. Sixth Intern. Gong. Genetics, 1932, p. 192.