non union of odontoid fractures
TRANSCRIPT
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NON-UNION OF ODONTOID FRACTURES
: A CASE REPORT
Dr. TARUN KUMAR BADAMPROF . A.DEVADOSS ( Chief of Orthopaedics )
PROF. MUTHUKUMAR ( Neurosurgeon )
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NON-UNION OF ODONTOID FRACTURES
ANATOMY OF CRANIO-VERTEBRAL JUNCTION
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OSSEOUS AND LIGAMENTOUS STRUCTURES IN CRANIO-VERTEBRAL JUNCTION
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ANTERIOR VIEW
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LATERAL VIEW
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POSTERIOR VIEW
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ATLAS
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AXIS
TIP OF DENS
WAIST OF DENS
BODY OF DENS
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CRUCIFORM AND TRANSVERSE ATLANTAL
LIGAMENT
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ALAR AND APICAL LIGAMENTS
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BLOOD SUPPLY
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BLOOD SUPPLY OF AXIS VERTEBRAE
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DIGITAL SUBSTRACTION ANGIOGRAM
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Text
CLASSIFICATION OF ODONTOID FRACTURES
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CLASSIFICATION OF ODONTOID FRACTURES
ANDERSON AND D’ALONSO CLASSIFICATION
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TYPE I : Oblique avulsion # of the tip of the odontoid
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TYPE II : # through the waist of odontoid
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CT SCAN : Saggital view of Type II odontoid fracture
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TYPE III : # of the base of the odontoid extending into the superior articular facet
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CLINICAL FEATURES
Patient generally presents with h/o trauma
Neck pain after injury
Neurological deficits, if spinal canal is compromised
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RAIOLOGICAL INVESTIGATIONS
X - RAY :
A. Spino laminar line
B. Posterior vertebral line
C. Anterior vertebral line
D. Facetal joints, as stacked parallelograms
E. > 7mm at C2-C3
F. > 21mm at C5-C7
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CT SCAN
Displacement > 5mm
Angulation > 10 degrees
INDICATION OF SURGICAL INTERVENTION
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CT SCAN
ADI : Atlanto Dens Interval
< 3mm
PADI : Posterior Atlanto Dens Interval
>13 mm
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MANAGEMENT OF ODONTOID FRACTURES
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CONSERVATIVE MANAGEMENT
RUFF’S COLLAR
SOMI HALO VEST
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SURGICAL MANAGEMENT
1) Posterior Trans articular Screw
construct
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SURGICAL MANAGEMENT
2) Posterior C1 Lateral mass screw and C2 Pedicle screw Construct
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SURGICAL MANAGEMENT
3) Anterior Odontoid Screw fixation- ideal for Type II odontoid fractures- # line should pass from Antero-superior to Postero-inferior
surface
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COMPLICATIONS IN ODONTOID FRACTURES
NON UNION 40-50% in Type II #
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CASE REPORT
24yr old male
H/o fall from 20 ft ht
C/o Pain in the neck
Tenderness over C1,C2
NO NEUROLOGICAL DEFICITS
No h/o Bowel and Bladder dysfunction
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19/04/2014 X RAYS
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19/04/2014 CT SCAN
1-2 mm Displacement and No Angulation
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19/04/2014CT SCAN AND MRI SCAN
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DIAGNOSIS : Type II Odontoid fracture with Minimal displacement and Angulation, with No Neurological deficits
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Patient treated conservatively with Ruff’s collarMinimal displacementNo angulationNo neurological deficits
Patient reviewed every month
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11/07/2014 X RAY• Minimal Displacement
• Pre-vertebral soft tissue shadow is less
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16/08/20144 months post injury, patient started developing Neurological deficits in the form of Numbness of
upper limbs
Advised Surgery (Posterior Stabilisation of C1,C2), Patient was not willing for surgery
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15/09/20141 month later patient presented with deterioration of Neurological function with Increased numbness of Upper limbs
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19/09/2014Planned for Surgical intervention
Posterior C1-C2 fusion: Posterior C1 lateral mass screw and C2 pedicle screw construct was used
IIiac crest Bone grafting: Biological fixation
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20/09/2014 POD 1
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CT SCAN : POST-OP
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CORONAL VIEW
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POST-OPERATIVE PERIOD
Patient condition was stable Numbness decreased and Neurologically improved
Discharged on 12th day
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29/10/2014
Patient was stable and Neurologically improved
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DILEMMA
During the course of treating this patient, we had a doubt why Non-union has occurred in this patient
Is it mainly due to WATERSHED AREA or something else ?
Review of Literature has revealed some interesting facts …..
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ANGIOGRAPHIC AND POSTMORTEM SPECIMEN EVALUATION OF ODONTOID FRACTURES - JBJS Br , 2000
183 patients of Odontoid fractures have been treated conservatively ( 109 Type II and 74 Type III )
Union achieved 100% in Type III # , 54% in Type II #
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For evaluation of cause of Non-union, Selective Vertebral angiography and Digital Substraction Angiogram was done in 18 patients - 10 with acute # and 8 with established Non-union
It showed that blood supply to Odontoid was not affected
Histologically, No evidence of Avascular Necrosis of Odontoid process
Posterior ascending artery which is dominant branch from Vertebral artery is always intact
Anterior ascending branch of Vertebral artery is always cut, which doesn't affect the blood supply to Odontoid
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POST-MORTEM SPECIMEN EVALUATION
Findings :
A. Low Bone density
B. Less bony trabecular
C. Cortical bone
D. Less surface area
These might be responsible for the Non-union of the waist of Odontoid fractures
in the waist of odontoid
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Finally, Cause of Non-union is Multi-factorial and blood supply to odontoid process is not
compromised in Type II odontoid fractures
1. Transverse Atlantal ligament interposition2. Less Bony trabeculae and Bone density3. Late presentation to the Hospital4. Displacement of > 5mm and Angulation of >
10 degrees 5. Inadequate Immobilsation
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THANK YOU