Written by: Adam Eckburg, MD (NUEM ‘29) Edited by: Zemenay Bekele, MD (NUEM ‘27)
Expert Commentary by: Matthew R. Levine, MD (NUEM)
Expert Commentary
Dr. Eckburg has provided a handy quick reference for this fracture that, as stated, is particularly common at extremes of age. Kids < 6 years old are prone to odontoid fractures because of:
● Relatively larger head size leads to a higher fulcrum
● Ligamentous laxity in that age
● Unfused odontoid growth plates making the upper cervical spine more biomechanically vulnerable
By adolescence, as the spine matures, fractures are more likely to be subaxial as in typical adults. Elderly patients get odontoid fractures more often because osteoporosis weakens the bone, frailty increases fall risk, and low-energy impacts are more likely to cause fractures in a cervical spine that is less stable with age.
Plain films are not the gold standard. Odontoid fractures, particularly at the base of the dens (type II), can be difficult to visualize on standard lateral cervical spine radiographs because the fracture line may be small, displaced, or obscured by surrounding anatomy. Prevertebral soft tissue swelling (>10 mm at C1 or C2) on the lateral view may be the only finding sometimes. However up to 20% of those with C2 fractures still do not manifest this. Flexion–extension films may be requested to assess atlantoaxial (in)stability, especially in Type I fractures, but not for detecting the fracture itself.
The open-mouth view is the only plain-film projection that directly visualizes the atlas (C1), axis (C2), and odontoid process, allowing assessment of the atlanto-dens interval, symmetry of C1 lateral masses, and integrity of the dens. Quality open mouth views can be difficult to obtain, particularly in the presence of an uncooperative patient or a cervical collar that limits mouth opening. Years ago, before CT scan was the initial imaging modality for c-spine injury screening, we would be called upon to help the technicians get better open mouth views by temporarily removing the collars; and, in uncooperative patients, using improvised devices to manually maintain mouth opening! Now we just get CTs.
CT remains the preferred initial imaging modality for suspected odontoid fractures because it provides multiplanar views and better detection of subtle or displaced fractures.
Check out our odontoid fracture case on our NUEM Orthopedics Teaching File:
Spine Case 10: Orthopedic Teaching: Feinberg School of Medicine
Dr. Matthew R. Levine, MD
Emergency Medicine, Northwestern Memorial Hospital
Associate Professor of Emergency Medicine, Feinberg School of Medicine
How To Cite This Post:
[Peer-Reviewed, Web Publication] Eckburg, A. Bekele, Z. (2026, May 26). Odontoid Process Fractures [NUEM Blog. Expert Commentary by Levine, Matthew R]. Retrieved from http://www.nuemblog.com/blog/.
