Odontoid Fractures: A Standard Review of Current Concepts and Treatment Recommendations

Ali Nourbakhsh, MD; Zachary C. Hanson, MD


J Am Acad Orthop Surg. 2022;30(6):e561-e572. 

In This Article

Abstract and Introduction


Odontoid fractures represent the most common fractures involving C2 and the most common cervical spine fractures in patients older than 65 years. Despite their increasing frequency, optimal management of these injuries remain a subject to debate. Although types I and III injuries have relatively good healing potential with nonsurgical treatment, type II fractures carry a higher risk for nonunion. In particular, elderly patients are at risk for nonunion or fibrous malunion after nonsurgical treatment; however, increased medical comorbidities and poor bone quality also increase the risks of surgery in this cohort. The high morbidity and mortality associated with these injuries has made it an area of particular interest among spine surgeons. The purpose of this review was to summarize the pathophysiology, evaluation, and diagnosis of these injuries and to review controversies in management and considerations for treatment based on the most recent available literature.


Odontoid fractures are the most common fractures of the axis (C2), representing approximately 10% to 20% of all cervical spine injuries, and are the most common type of cervical spine fracture in patients older than 65 years.[1,2] Odontoid fractures are reaching epidemic proportions among elderly patients, with an incidence growing faster than that of any other spine fractures.[3] These injuries in the aging population are associated with worsened quality of life and mortality rates similar to that of hip fractures.[3–5] Despite the increasing burden these injuries pose to patients and the healthcare system, the optimal treatment strategy has remained unclear. Treatment options range from external immobilization in a rigid cervical collar or halo vest to surgical stabilization. Patients' age, comorbidities, and risk factors for nonunion are all important to consider in the management of these injuries.

The purpose of this article was to review the pathoanatomy, evaluation, diagnosis, and management of these injuries; discuss points of controversy regarding treatment; and summarize recent literature that has furthered our understanding of these injuries and their outcomes.