Nonoperative Management of Types II and III Odontoid Fractures: The Philadelphia Collar versus the Halo Vest

Abstract

The nonoperative management of patients with Types II and III fractures of the odontoid process consists of a prolonged course of cervical immobilization. The need for rigid fixation, demonstrated by the routine use of the halo vest in many institutions, has never been rigorously substantiated. We retrospectively analyzed our results with the nonsurgical management of odontoid fractures to ascertain whether cranial fixation affected overall outcome. Fifty-four patients managed at the University of Virginia Health Sciences Center, Charlottesville, VA, between 1976 and 1994 were studied. All 18 patients with Type III fractures (5 treated in the collar, 18 in the halo vest) demonstrated fracture healing and late stability. Among 36 individuals with Type II fractures, 20 were treated in the halo vest and 16 were managed in the Philadelphia collar or similar orthoses. The overall rate of late surgical intervention, the stability to flexion and extension, and the rate of bony fracture healing were not statistically different between the methods of immobilization. The rate of bony union was not significantly higher in the halo vest group (74 versus 53%), even though patients managed in the Philadelphia collar were significantly older than those in the halo vest (mean, 68 versus 44 yr). In general, nonsurgical management of Type III odontoid fractures was recommended, accompanied by use of a cervical orthosis. The determination of operative versus nonoperative treatment for Type II fractures was made on the basis of fracture anatomy, patient age, other associated injuries, and patient preference. The lack of a significant difference in the need for late surgical procedures or late instability, improved patient comfort with the cervical orthosis, and elimination of the risk of halo-related complications favored the use of the rigid cervical orthosis in the majority of these cases.

C2-fractures: part I. Quantitative morphology of the C2 vertebra is a prerequisite for the radiographic assessment of posttraumatic C2-alignment and the investigation of clinical outcomes

“…In a current literature review [33], the incidence of malunion reported was low in type II and III odontoid fractures following halo treatment (5 and 10%, respectively). However, with the latter the articular facets of C2 are frequently affected and symptomatic malunion or segmental C1-2 deformation after nonsurgical treatment has been observed several times [5,10,13,14,20,24,26,29,33,35,36,42,55,57]. Clark [10] already stretched that type III odontoid fractures were 'not benign as previously reported'.…”

Halo-Fixateur - Indikationen und Komplikationen

“…Obwohl in der Literatur schon in den 70er Jahren von Johnson et al [14] der Halo-Fixateur als beste Orthese zur Ruhigstellung der oberen HWS beschrieben wird und auch Richter et al 2001 [24] in einer Studie an Leichenprä paraten die zuverlä ssige Immobilisation der oberen HWS mit dem Halo im Vergleich mit anderen Orthesen nachweisen konnte, gibt es auch gegenteilige Aussagen [2]. Trotz besserer Ergebnisse in der Behandlung mit dem Halo-Fixateur verglichen mit der Philadelphia-Orthese kommen manche Autoren ü berraschenderweise doch zu dem Ergebnis, dass sie die Philadelphia-Orthese dem Halo vorziehen [23]. Unbestritten ist unserer Meinung nach der geringe Komfort durch die Behandlung mit dem Halo-Fixateur und das immer noch deutliche Risiko von Komplikationen [3].…”

“…Auch die Behandlung und Pflege tracheotomierter Patienten ist mit dem Halo leichter als mit alternativen Verfahren. Letztendlich hat der Halo auch die hö chste Rigiditä t im Vergleich mit anderen externen Retentionsmö glichkeiten[2,5,14,15,23,24]. Obwohl z.…”

Traumatismos de la columna cervical alta: Clasificación tipológica, indicaciones terapéuticas y abordajes quirúrgicos (a propósito de 286 casos)

“…En la mayoría de las series publicadas en los últimos 80 años se describe un considerable número de fracasos en el tratamiento de las fracturas de la base de la AO independientemente de los métodos indirectos utilizados 21,45,58,78 . Entre otros se han implicado factores de déficit vascular o diferenciación trabecular deficitaria en la base de la AO para explicar estos fracasos 82 .…”

“…Un importante grupo de pacientes tratados con estos métodos indirectos no consigue su curación. Así, con ortesis cervicales la tasa de fusión es del 57% 78 , con halos craneotorácicos del 70% 58 ; un número muy importante de pacientes presentan pseudoartrosis del foco de fractura con estos métodos de tratamiento, lo que implica cronificación de la fractura y necesidad de cirugías posteriores. Con fusiones posteriores, la tasa de estabilización/fusión se acerca al 100% pero a costa del sacrificio funcional atloaxoideo de entrada.…”