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Care of Axis (C2) Fractures

IOANNIS KARAMPELAS, MDNEUROSCIENCE DEPARTMENT

ST CLOUD HOSPITAL, MNAPRIL 2018

10 days ago….

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But, it’s coming this weekend….

Topics:

C2 Fractures

Conservative vs Surgical Management

Halo Vest Treatment

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Anatomy

Axis2ND Cervical Vertebra

Αξων = Axon

(it’s all greek to me!)

something around which a structure revolves

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Odontoid Process

of 2ND Cervical Vertebra

Οδωντας = Tooth

(it’s all greek to me again!)

Two main types of Axis (C2) Fractures

Odontoid (Dens) Fracture

and

Traumatic Spondylolisthesis of C2(Hangman’s Fracture)

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Odontoid Fracture

15% of all cervical fractures

Usually due to hyperflexion with anterior displacement

Commonly associated with C1 fx

Neurologic deficit in 15-25% of cases

Odontoid fracture typesI II III

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Odontoid fracture types:Subtype II a

Comminuted fx that involves the base of the odontoid

Associated with severe Instability

Treatment of Odontoid FracturesFactors to consider

Fracture typeDegree of (initial)dens displacementExtent of angulation at the fracture sitePatient’s age and medical condition

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Non operative treatment ofC2 fractures

Cervical Hard Collar Traction Minerva Cast Halo vest jacket

Non operative means of therapy are primarily indicated for

Type I and Type II fractures (but not perhaps for Type IIa)

Why is it so hard to treat Type II fractures without surgery?

Because the dens is displaced and it is very difficult to immobilize the fracture fragments so they are aligned

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Operative Treatment of Odontoid Fractures

Primarily indicated for Type II and Type III fractures (so, Type II, which is the commonest variety,

can be treated either way)

Should be considered in cases of:- Dens displacement of 5 mm or more (non union rate 86% vs 18% )

- -dens fracture type Iia- Inability to achieve fracture reduction via conservative means/external immobilization

Surgical options (I)

Anterior dens screw fixation (Type II fractures especially, up to 89% fusion rate)

Anterior atlantoaxial screw fixation and fusion Posterior atlantoaxial fusion (Gallie or Brooks) Posterior atlantoaxial screw fixation and fusion Posterior atlas and axis screw-rod fixation and fusion

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Anterior dens screw fixation

Anterior atlantoaxial screw fixation and fusion

Anterior dens screw fixation

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Posterior atlantoaxial fusion

Gallie

or

Brooks

Posterior atlantoaxial screw fixation and fusion

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Posterior atlas and axis screw-rod fixation and fusion

Posterior atlas and axis screw-rod fixation and fusion

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Management of dens fractures in the elderly (> 60 yrs of age…)

Type II fxs treated with external immobilization: Fusion rate: 23%

Posterior C1-C2 surgery results in 86% fusion rate

Anterior odontoid screw or hard collar: fusion rate 20%

Halo vest is poorly tolerated in patients older than 75 yrs of age

Halo vest treatment has a 23x higher rate of fusion success in pts younger than 50 yrs of age in Type II fxs

Hangman’s fracture

Hyperextension injury

Common in MVAs, diving and falls

It is a fracture of the pedicles of the axis

It can result in spondylolisthesis of the axis

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Pedicle Fracture resulting in “spondylolisthesis” of the fracture segments

Hangman’s fracture Classification

Type 1 Type 2 Type 2a Type 365% 28% 7%

Treatment of Hangman’s Fracture

Mostly Nonsurgical- Cervical ImmobilizationHard C spine collar or Halo Vest treatmentMost fractures will heal with 12 weeks of immobilization

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Halo vest therapy A form of external

spinal orthosis Attached the skull to

provide traction and spinal stability

Indicated for Type I and Type III fractures

Pin site care

Check for pin migration:

Listen for patient complaint ofpain at pin site

Look for skin build up ontop of pin

Look for a pin track under the pin

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Pin site care

Check for pin site infection

Administer oral antibioticsuntil resolved.

If does not resolve inappropriate time:

1. Insert and torque a new, sterile,pin in an adjacent pin site.

2. Then, remove and discard old pin.

Skin care

Patients should be checked oftenfor signs of a developing problem.

Wash daily.

Neurologically compromisedpatients are at increased risk forskin complications.

Their skin should be examined daily.

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Halo vest therapy complications

• Pin loosening 36%• Pin infection 20%• Severe pin discomfort 18%• Pressure sores 11%• Severe scars 9%• Nerve injury 2%• Dysphagia 1%• Bleeding pin sites 1%• Dural puncture 1%

What is

THE NUMBER ONE QUESTION

when a patient comes to the floor on a halo vest??

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Where is the torque wrench?????????!!!!!!!!!!!!!!!!!!

Why?

You cannot do CPR on a patient with the halo on…

CentraCare takes CARE….Patient walks in to our clinic with this…

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Gets treatment at CentraCare for a week, leaves hospital fully ambulatory and six months later…

Thank YOU TEAM!!!!

OR teamAnesthesia teamTransport teamXray/ Radiology teamPhysical therapy teamNutrition teamAnd………..

NURSING TEAM!!!!!!