NONOPERATIVE MANAGEMENT OF TYPE-II AND TYPE-III ODONTOID FRACTURES - THE PHILADELPHIA COLLAR VERSUS THE HALO VEST

THE NONOPERATIVE MANAGEMENT of patients with Types II and III fracture s of the odontoid process consists of a prolonged course of cervical i mmobilization. The need for rigid fixation, demonstrated by the routin e use of the halo vest in many institutions, has never been rigorously substantiated. We retrospectively analyzed our results with the nonsu rgical management of odontoid fractures to ascertain whether cranial f ixation affected overall outcome. Fifty-four patients managed at the U niversity of Virginia Health Sciences Center, Charlottesville, VA, bet ween 1976 and 1994 were studied. All 18 patients with Type III fractur es (5 treated in the collar, 18 in the halo vest) demonstrated fractur e healing and late stability. Among 36 individuals with Type II fractu res, 20 were treated in the halo vest and 16 were managed in the Phila delphia 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 met hods of immobilization. The rate of bony union was not significantly h igher in the halo vest group (74 versus 53%), even though patients man aged in the Philadelphia collar were significantly older than those in the halo vest (mean, 68 versus 44 yr). In general, nonsurgical manage ment of Type III odontoid fractures was recommended, accompanied by us e of a cervical orthosis. The determination of operative versus nonope rative treatment for Type II fractures was made on the basis of fractu re anatomy, patient age, other associated injuries, and patient prefer ence. The lack of a significant difference in the need for late surgic al procedures or late instability, improved patient comfort with the c ervical orthosis, and elimination of the risk of halo-related complica tions favored the use of the rigid cervical orthosis in the majority o f these cases.