FRACTURES OF THE DENS [ODONTOID PROCESSJ

An Analysis of Thirty-seven Cases

JOSEPH SCHATZKER,* CECIL H. RORABECK,t and JAMES P. WADDELL4 TORONTO, CANADA

Fractures of the dens [odontoid process] and their treatment remain an unsolved problem
(Cone and Turner 1937; Gallie 1939; Hadley 1948; Amyes and Anderson 1956: Blockey and
Purser 1956; Alexander, Forsyth, Davis and Nashold 1958; Rogers 1961). The injury is
potentially lethal and has at times resulted in grave neurological complications (Osgood and
Lund 1928; Alexander et al. 1958; Schlesinger and Taveras 1958; Dastur, Wadia, Desai and
Sinh 1965). Withtheadvent ofradiology, this fracture has been diagnosed early with increasing
frequency. Despite early recognition treatment has resulted in an alarmingly high rate of
non-union (Blockey and Purser 1956). This study was undertaken in the hope that a careful
analysis of the case material would allow the authors to decide what factors were responsible
for the high rate of non-union, and in what way treatment could be improved to prevent it.

ANATOMY
The dens is the key-stone in the stability of the atlanto-axial articulation (Fig. 1). In
conjunction with the transverse ligament and the anterior arch of the atlas, it prevents anterior
and posterior dislocation of the atlas on the axis. The apophysial joints of the atlanto-axial

FIG. 1
Coronal section of human dens with anterior arch of the
atlas removed to illustrate the anatomical relationships and
ligamentous attachments of the dens.

joint lie in a horizontal plane, are designed for motion and hence confer little if any antero-
posterior stability. Thus with a fracture of the dens, stability is lost and anterior or posterior
subluxation or dislocation may occur.
The Iigamentous attachments are important in the pathomechanics of fractures of the
dens (Fig. 1). From the superior aspect, the apical and paired alar ligaments fan out in a
cephalad direction to their attachments on the anterior lip of the foramen magnum and
occipital condyles respectively. An extremely strong band of tissue, the transverse ligament,

* Orthopaedic Surgeon, the Wellesley Hospital, Toronto, Canada. Associate, Department of Surgery, the
University of Toronto, Toronto, Canada.
Research Fellow, Department of Orthopaedic Surgery, the Wellesley Hospital, Toronto, Canada.
Senior Assistant Resident, Department of Surgery, the Toronto General Hospital, Toronto, Canada.

392 THE JOURNAL OF BONE AND JOINT SURGERY

 FRACTURES OF THE DENS 393

arises from the antero-medial aspect of the lateral masses of the atlas and curves posteriorly
around the dens, being separated from it by a synovial joint. In addition, a ligamentous
band arises in conjunction with the transverse ligament and passes directly to its attachment
on the lateral aspect of the dens immediately above its base, at the level of the medial limit
of the apophysial articulations (Figs. 1 and 2). This band is the accessory ligament. We have

Dens

Accessory Central vessels

Ligament
and vessels

FIG. 2
Transverse section through a human dens at the level of the
transverse ligament to illustrate the origin and insertion of
the accessory ligaments and vessels.

FIG. 3
A coronal section of a human dens to demonstrate the
insertion of the accessory ligament (arrow) at its base.

consistently demonstrated it in human cadavers (Fig. 3). Its importance until now has remained
unrecognised.
MORTALITY
Gowers (quoted by Scudder 1901) stimulated considerable interest in fractures of the dens
when he stated that perhaps one person in fifty, thus injured, recovers. In 1928 Osgood and Lund
surveyed the world literature and analysed the fifty-five reported cases. They reported a mortality

VOL. 53B, NO. 3, AUGUST 1971

394 J. SCHATZKER, C. H. RORABECK AND J. P. WADDELL

rate of over 50 per cent. This probably more than anything else led to the widespread belief that
fractures of the dens commonly terminated in death. Alexander (1958) corroborated Osgood
and Lunds findings when they too reported a mortality rate approaching 50 per cent. More
recently Amyes and Anderson (1956) and Schiller and Nieda (1957) reported a mortality
rate of 5 per cent and 8 per cent respectively. Mortality figures, however, are often misleading,
for a person dying instantly as a result of this injury seldom has a cervical radiograph. Thus
the injury may be missed by both the clinician and the pathologist.

PATHOMECHANICS
The pathomechanics of fractures of the dens are uncertain (Wood-Jones 1913, W#{252}sthoff
1923, Watson Jones 1932, Willard and Nicholson 1941, Bull 1942, Fang and Ong 1962).
Several investigators have attempted to reproduce the fracture experimentally (Fritzsche 1913,
Kolisko 1916, WUsthoff 1923). Fritzsche (1913) alone was successful and then only in one case.
His experiments on cadavers were designed to imitate judicial hanging. He succeeded in

16
15
10

1, I,

C C

ci 6-
a- a-

0 0

1, .
-
E 6-
E
3 z
z
2

TRAFFIC
ACCIDENT FALL OTHER
11-20 31-0 51-60 71-80

AGE (YEARS) Mode of Injury

FIG. 4 FIG. 5
Age incidence by decades. Mechanism of injury.

avulsing the dens and concluded that the mechanism of injury was one of distraction of the
head from the upper cervical vertebrae, with subsequent avulsion of the dens by the alar
ligament. He noted that the alar and apical ligaments became tight at the extremes of fiexion,
extension and rotation of the head. Thus any impact on the head forcing it into one of these
extreme positions might result in avulsion of the dens. W#{252}sthoff (1923) stated that fractures
of the dens were the result of a shearing force imparted by the powerful transverse ligament
behind it. He based this conclusion on post-mortem findings of fractures of the dens with an
intact transverse ligament and disagreed with Smith (1871) who demonstrated that the dens
was stronger than the transverse ligament.
A review of the literature suggests that the fractures are not the result of a simple shear
or simple avulsion. It seems likely that the dens may indeed break as a result of a combination
of these forces and that displacement is the result of the shearing force. This view is supported

THE JOURNAL OF BONE AND JOINT SURGERY

 FRACTURES OF THE DENS 395

by the evidence of Amyes and Anderson (1956) and Estridge and Smith (1967). Amyes and
Anderson (1956), in two of their patients treated with skull traction, were able to distract
the dens fragment and could reduce the distraction by reducing the pull. Estridge and Smith
( 1967), the first and only surgeons so far to explore an ununited fracture of the dens trans-orally,
noted that the pseudarthrosis could be distracted. This strongly suggests that the dens is not
a loose fragment but retains its attachment to the alar and apical ligaments.

CLINICAL STUDY

This study is an analysis of thirty-seven cases of fracture of the dens which occurred
between 1962 and 1969 inclusive. Of the thirty-seven cases, twenty-eight were in men and
nine in women. Their ages ranged from nineteen to eighty-two years with an average of
forty-six. The peak incidence occurred between the ages of fifty and sixty years (Fig. 4). Ten
of our thirty-seven patients were within this age range. The remaining twenty-seven were
fairly evenly distributed throughout the remaining decades. No children were included in
this study.
MECHANISM OF INJURY

An analysis of the mechanism of injury suggests that this fracture is the result of high
velocity force (Fig. 5). Fifteen of our thirty-seven patients sustained the fracture in a fall.
Most fell down a flight of stairs, many while drunk. Sixteen sustained the fracture in a motor
vehicle accident. Of the remaining six, one was a pedestrian hit by a motor vehicle while
crossing a street, another was a paranoid schizophrenic who fractured the dens while banging
his head against a brick wall, a third and fourth were struck on the head by a falling tree,
and in the fifth and sixth the mechanism was uncertain.

TABLE I
ASSOCIATED FRACTURES

Bone involved Number of

Mandible (compound) . 1

Posterior arch of atlas . 2

Fifth cervical vertebral body

Scapula and clavicle . .

Skull - . . . 1

Patella . . . . 1

Talus . . . . 1

Total . . . 8

CLINICAL FEATURES
Fractures of the dens are difficult to diagnose. History and physical examination usually
point to the neck as the site of injury but do not localise the level. In our patients the most
common symptom was high posterior cervical pain, at times radiating in the distribution
of the greater occipital nerve. Thirty of our patients complained of neck pain. Six were
unconscious at the time of admission and one patient denied any symptoms whatever: he
came to the Emergency Department at the suggestion of his employer. All patients who
complained of high posterior cervical pain had associated paravertebral muscle spasm with
limitation of movement and tenderness on palpation over the upper cervical spines. These

VOL. 53 B, NO. 3, AUGUST 1971

396 J. SCHATZKER, C. H. RORABECK AND J. P. WADDELL

findings varied in accordance with the severity of the patients complaints. Thirty-three of
the thirty-seven showed no peripheral neurological abnormality. Three patients who were
unconscious on admission showed some exaggeration of tendon reflexes with a positive
Babinski sign. A fourth complained of transient paraesthesiae in his upper extremities brought
on by movement of the neck, although no neurological abnormalities were found. Only eight
of the thirty-seven had other fractures (Table 1).

DIAGNOSIS

The diagnosis of a broken dens can only be made radiologically. If such a fracture is
suspected, antero-posterior and lateral radiographs of the dens must be taken. Flexion and
extension views must be avoided for they may result in fatal displacement. The lateral view
of the dens is usually much more helpful in the diagnosis of fracture than the trans-oral view,

FIG. 6
Antero-posterior tomograph showing a fracture through the base of the dens. This
fracture was not visible in standard antero-posterior and lateral radiographs.

because in this view the dens is often obscured by the mandible or teeth. If any doubt exists,
tomography must be carried out (Fig. 6). In two of our thirty-seven cases the fracture was so
indistinct that a conclusive diagnosis was impossible. Both these patients returned at a later
date because of persisting symptoms, and tomography revealed a fracture in both.

RESULTS
The average duration of follow-up was l28 months and the median seven months, with
the minimum being two and a half months and the maximum seven years. Eleven
additional
cases were excluded from the series because of inadequate follow-up. Union, if it took place,
occurred by the tenth week. No diagnosis of non-union was made on the basis of a follow-up
shorter than twelve weeks. The shortest follow-up of our cases of non-union was three months
and the longest seven years, the average being 16-8 and the median nine months. Our criteria
for making the diagnosis of non-union of a fracture of the dens were as follows: 1) a defect
in the dens with contiguous sclerosis of both fragments (vascular pseudarthrosis) (Fig. 7); 2)

THE JOURNAL OF BONE AND JOINT SURGERY

 FRACTURES OF THE DENS 397

Fci. 7
Figure 7-Lateral tomograph showing established non-union of fracture of the dens. Note the marked sclerosis
on the contiguous surfaces of the defect. This is an example of a vascular hypertrophic pseudarthrosis.
Figure 8-Lateral radiograph showing established non-union of fracture of the dens. Note the marked
resorption on the adjacent surfaces of the fracture site. This is an example of atrophic pseudarthrosis,
previously called rarefying osteitis of the dens (Heublein 1944).

a defect in the dens with contiguous resorption of both fragments (rarefying osteitis or atrophic
pseudarthrosis) (Fig. 8); 3) a defect in the dens with definite loss of cortical continuity (Fig. 9);

FIG. 9
A lateral radiograph showing established non-union
of fracture of the dens. Note the defect in cortical
continuity both anteriorly and posteriorly.

4) demonstrable movement of the dens fragment OD flexion-extension radiographs (Fig. 10).

On the above radiological criteria, twenty-three of the thirty-seven fractures (62 per cent)
went on to non-union. Of the twenty-three non-unions, fourteen (61 per cent) were of the

VOL. 53B, NO. 3, AUGUST 1971

C
398 J. SCHATZKER, C. H. RORABECK AND J. P. WADDELL

vascular hypertrophic type and nine (39 per cent) were of the atrophic type referred to in the
literature as rarefying osteitis (Heublein 1944). No correlation existed between the type of
pseudarthrosis and the form of treatment.

FIG. 10
Lateral flexion-extension radiographs showing established non-union of fracture of the dens.
Note the movement of the dens.

FIG. Ii
Radiograph of necropsy specimen showing the Gallie fusion.

ANALYSIS OF POSSIBLE CAUSES OF NON-UNION

Method of treatment-We divided our patients into those treated by closed methods (twenty-
two patients) and those treated by operation (fifteen patients). Closed treatment usually
consisted of four to six weeks of skull or head halter traction followed by a further period of
six weeks in a Minerva jacket or a four poster collar. This form of treatment is deemed

THE JOURNAL OF BONE AND JOINT SURGERY

 FRACTURES OF THE DENS 399

14

U, 9-
C
. 8
U,

36.4 63.6 #{149}. 6

a-

z
. 40.0 60.0

Union Non- Union Union Non- Union

FIG. 12 FIG. 13

The rate of non-union in The rate of non-union in

patients treated by closed patients treated by operation.
methods.

7,
6
J1
C

a-

__________
0

46.2 53.8
E
z 100

Union Non-Union Union Non-Union

FAILED FUSION SOLID FUSION

FIG. 14
The rate of non-union in patients who underwent
operation for atlanto-axial fusion.

18

U,

.I

.7, 7.
E 5
Z 58.3 41.7 28.0 72.0

Union Non-Union Jnion Non-Union

UNDISPLACED DISPLACED

FIG. 15
The influence of displacement on the rate of non-union of
fractures of the dens.

VOL. 53 B, NO. 3, AUGUST 1971

400 J. SCHATZKER, C. H. RORABECK AND J. P. WADDELL

adequate (Blockey and Purser 1956). In one case the method of conservative treatment used
was considered inadequate. This patient was treated with cervical ruffs for six weeks: at
three months there was non-union with instability on flexion-extension radiographs.
In all but one case, treatment by operation consisted of a posterior atlanto-axial (the
so-called Gallie) fusion, carried out usually after an initial period of traction (Fig. I 1 ). The
remaining patient was treated by occipito-axial fusion. In all cases flexion-extension
radiographs were done three months after operation.
Fourteen of the twenty-two fractures (64 per cent) treated by closed methods went on to
non-union (Fig. 12). Nine of the fifteen fractures (60 per cent) treated by operation failed to
unite (Fig. 1 3). Two fusions failed, and movement at the atlanto-axial articulation was easily
demonstrated on flexion-extension radiographs. In these two patients the dens failed to unite,
thereby reducing the sample size for the operative series to thirteen. In seven patients
considered to have a solid atlanto-axial fusion, the dens failed to unite, a rate of non-union
of 54 per cent (Fig. 14). This rate of non-union is 1 5 per cent lower than that in patients
treated by closed methods. We also observed that a successful atlanto-axial fusion did not
prevent some redisplacement of the fracture of the dens. The redisplacement of the dens was
not significant and occurred, of course, before the fusion between the atlas and axis became
solid. From our study it seems that an atlanto-axial fusion does not secure a rate of union
of fractures of the dens significantly higher than that obtained by closed methods.
Displacement-A fracture was considered displaced if cortical alignment was lost, regardless
of the degree of malalignment. Twenty-five of the thirty-seven fractures were displaced.
Sixteen were displaced anteriorly and nine posteriorly at the time of the initial radiological
examination. Eighteen of the twenty-five displaced fractures (72 per cent) developed non-union
and five of the twelve undisplaced fractures (42 per cent) developed non-union (Fig. 1 5). It
appears that displacement is associated with an increased incidence of non-union. Such a
difference in incidence would occur purely by chance only 7 per cent of the time. In other
words we can say with a 93 per cent level of confidence that the rate of non-union is higher
when there is displacement.
We also correlated the amount of displacement in millimetres with the rate of non-union.
The rate of non-union appears to increase with a
100- corresponding increase in the amount of displace-
ment, although the number in each category is too
small to be statistically significant (Fig. 16).
The direction of displacement seems to have a
direct bearing on the rate of non-union. Ten of the
C sixteen fractures with anterior displacement (63 per
0
C cent) went on to non-union (Fig. 17). In contrast to
this, 89 per cent of the posteriorly displaced fractures
0 failed to unite. The numbers are not large enough to
z
I
be statistically significant, but the results suggest that
ci this aspect should be examined further. The results
C indicated an 83 per cent level of confidence as compared
U
I-
to the generally accepted level of 95 per cent for
a. - I statistical significance.

III FIG. 16
Graph correlating the percentage of non-union with the amount
I1
of displacement of twenty-five displaced fractures of the dens.
I The bar graphs at the bottom of the graph represent the number
11 1r4i [1 of patients whose fractures displaced a given amount. In one
TTifu I1 case with a fracture displaced 7 millimetres there was bony union
1 2 3 1. 5 6 7 8 9 10 of the fracture of the dens. If that one case is excluded, there is
Disp(cicemenl (miLLimetres) a definite increase in the incidence of non-union with increasing
amounts of displacement.
FIG. 16
THE JOURNAL OF BONE AND JOINT SURGERY
 FRACTURES OF THE DENS 401

Level of fracture-We observed in experiments on dogs that if the dens were cut above
the attachment of the accessory ligament the fragments failed to unite, whereas if the section
were made below the attachment of the accessory ligament the fragments always united
(Fig. 18). We therefore classified fractures of the dens as high and low. The accessory

10-

U
U 8-
C
.
. .
a. 6 a.
5 0
I-

.0 37.5 62.5 88.9

E E
z z

111.1 1
Union Non-Union Union Non-Union
ANTERIOR POSTERIOR

FIG. 17
A graph comparing the incidence of non-union of sixteen
anteriorly displaced fractures and nine posterior displaced
fractures.

ligament is attached to the lateral aspect of the dens immediately above the base at the level
of the medial aspect of the apophysial joint (Figs. 1 and 2). Consequently any fracture which
was at this level or below was classified as low (Fig. 19). Those fractures which were oblique
and started above the attachment of the accessory ligament on one side, were classified as
high (Fig. 20). Of the twenty-eight low fractures, seventeen (61 per cent) went on to non-
union (Fig. 21). Of the nine high fractures, six (67 per cent) went on to non-union. The
results of this study suggest that the level of the fracture has no bearing on union.

LIGAMENT

FIG. 18
Diagram illustrating the experimental hypothesis.

Age-We subdivided our patients into groups by decades. Although there appears to be a
higher incidence of non-union in patients over sixty years old, the number of patients in each
group is too small for any statistically valid conclusion.

DISCUSSION
Although an incidence of non-union of fracture of the dens as low as 5 per cent has been
reported (Amyes and Anderson 1956), the results of this study indicate an incidence of
non-union of 63 per cent.

VOL. 53 B, NO. 3, AUGUST 1971

402 J. SCHATZKER, C. H. RORABECK AND J. P. WADDELL

FIG. 19 FIG. 20
Figure 19-Trans-oral radiograph of a low fracture of the dens. Figure 20-Trans-oral radiograph
of a high fracture of the dens.

l1

.0
E
z

Union Non-Union Union Non-Union

LOW HIGH

FIG. 21
Rate of non-union of twenty-eight low and
nine high fractures of the dens.

FIG. 22
Coronal section through human dens. This dens was injected after death with micropaque.
Note the distribution of vessels within the bone.

THE JOURNAL OF BONE AND JOINT SURGERY

 FRACTURES OF THE DENS 403

The possibility that the blood supply of the dens was an important factor was considered.
In order to explore this, microangiography was done on human necropsy material.
The dens derives its blood supply from two main sources: 1) central arteries which enter
the body of the axis on its anterior aspect and ascend into the dens through its centre, and
2) very prominent peripheral arteries which reach the dens through the accessory ligaments
(Fig. 22). In addition, some blood vessels enter the dens at its tip through the apical and alar
ligaments. It was impossible to show with certainty what areas of the dens were supplied by
these vessels or whether any anastomoses existed between the vessels which entered the dens
through the apical and alar ligaments and the central and peripheral arteries. It was thought
that with fracture of the dens above or at the level of the accessory ligaments the upper
fragment might be rendered totally or partially avascular. That would of course account for
the high incidence of non-union (Fig. 1 8). A later study showed this conjecture to be false:
it was shown in dogs that vessels in the apical and alar ligaments could either keep the dens
alive, or could at least be responsible for its rapid revascularisation after fracture (Schatzker,
Rorabeck and Waddell 1970).
It was also noted that after experimental section ofthe dens ofthe dog above the attachment
of the accessory ligament, the upper fragment became considerably displaced upwards towards
the foramen magnum. When the section was at the level of or below the accessory ligament,
the dens remained relatively undisplaced and movement of the head caused much less
movement of the dens through the alar and apical ligaments. This suggests that the accessory
ligament has two very important functions : 1) to carry a profuse blood supply to the dens
through the peripheral arteries, and 2) to stabilise the dens in the event of a low fracture.
The latter experimental observation could not be substantiated from our clinical study.
Blockey and Purser (1956) stated that failure of union in fractures of the dens was not
related to the displacement of the upper fragment. Although our results may not be statistically
significant they suggest a divergence from Blockey and Pursers conclusions. In our series
89 per cent of the fractures with posterior displacement failed to unite as compared with
63 per cent of those with anterior displacement (93 per cent confidence).
Although initial displacement can usually be completely or almost completely corrected
by skull traction, redisplacement can occur even after six weeks of traction. A Minerva jacket
does not protect against redisplacement. One patient in our series, after six weeks of skull
traction, was put in a Minervajacket. While he was in plaster his fracture redisplaced posteriorly
and three months after injury he developed weakness in his upper limbs. The fragment was
sufficiently mobile to permit virtually complete reduction. Atlanto-axial fusion was done later.
Some definite conclusions can be drawn from this study. The aim of treatment of fracture
of the dens is to secure union of the fracture or stability of the atlanto-axial articulation.
Unfortunately 89 per cent of fractures with posterior displacement go on to non-union, as
do almost all fractures that are displaced five millimetres or more. Thus, non-union is almost
certain to occur after closed methods of treatment of the displaced and in particular posteriorly
displaced fractures. We agree with Blockey and Purser (1956) that pseudarthrosis of the dens
does not necessarily imply gross instability at the atlanto-axial joint. The stability might not
be adequate in the event of a motor vehicle accident or a fall. We have no record of death or
tetraplegia occurring in any patient with established non-union, but none of these patients was
involved in a second accident. We feel that when there is pseudarthrosis of the dens stability
is inadequate. We do not think that pseudarthrosis should be accepted as a satisfactory result
of treatment.
Forty-two per cent of the undisplaced fractures of the dens went on to non-union. Thus,
even in this group the results of closed methods of treatment were less than satisfactory. We
do not of course advocate that every patient with fracture of the dens should be subjected to
operation. Many of these fractures occur in the elderly, in whom operation may be contra-
indicated. We do feel, however, that 64 per cent incidence of non-union after apparently

VOL. 53 B, NO. 3, AUGUST 1971

404 J. SCHATZKER, C. H. RORABECK AND J. P. WADDELL

adequate closed treatment is unacceptable, and we think that stability should be secured in
all patients who expect to lead a normal life and to be subjected to the ordinary hazards of
that life. We feel that a patient with an undisplaced fracture of the dens should be initially
protected in cervical halter traction. In the case of a displaced fracture skull traction should
be instituted as an emergency measure. This will relieve the cord from the danger of
compression and will reduce the displacement. After one to two weeks, during which post-
traumatic oedema will subside, a posterior atlanto-axial fusion should be performed. In the
case of posterior displacement, skull traction or the halo apparatus should be used after
operation, because the posterior wire confers little stability. We find no reason for including
the occiput in the fusion.
Our experimental work has shown conclusively that atlanto-axial fusion does not
immobilise the broken dens. However, a pseudarthrosis is not significant when there is sound
atlanto-axial fusion. So long as the apical and alar ligaments are intact, flexion, extension and
rotation at the atlanto-occipital joint cause movement of the dens. In most fractures
immobilisation is necessary to obtain union. The halo apparatus might well be the best
method of treatment in patients who are not fit for operation.

SUMMARY
I . Thirty-seven cases of fracture of the dens have been studied.
2. The incidence of non-union was high: 64 per cent after apparently adequate closed
treatment.
3. Possible causes of the high incidence of non-union have been studied : attention is drawn
to the effect of displacement and to that of posterior displacement in particular.
4. Non-union of the dens with potential instability at the atlanto-axial joint is not
acceptable in a patient who expects to lead a normal active life.
5. Atlanto-axial fusion is the method of choice in the treatment of instability ; once that has
been secured, pseudarthrosis of the dens is no longer significant.

We wish to thank the surgeons of the University of Toronto Teaching Hospitals for permitting us to present
their cases. We would also like to thank Mr Paul Pallan for the statistical analysis, and Miss Marlene Bliss for
the preparation of all illustrations.

REFERENCES

ALEXANDER, E., FORSYTH, H. F., DAVIS, C. H., and NASI-IOLD, B. S. (1958): Dislocation of the Atlas on the
Axis, The Value of Early Fusion of CI, C2 and C3. Journal of Neurosurgery, 15, 353.
AMYES, E. W., and ANDERSON, F. M. (1956): Fracture of the Odontoid Process. Archives of Surgery, 72, 377.
BLOCKEY, N. J., and PURSER, D. W. (1956): Fractures of the Odontoid Process of the Axis. Journal of Bone
and Joint Surgery, 38-B, 794.
BULL, G. M. (1942): The Syndrome
of Atlanto-axial Dislocation. Clinical Proceedings, 1, 336.
CONE, W., and G. (1937):
TURNER, W. The Treatment of Fracture-dislocation of the Cervical Vertebrae by
Skeletal Traction and Fusion. Journal of Bone and Joint Surgery, 19, 584.
DASTUR, B. K., WADIA, N. H., DESAI, A. D., and SINH, G. (1965): Medullospinal Compression due to
Atlanto-axial Dislocation and Sudden Haematomyelia during Decompression: Pathology, Pathogenesis
and Clinical Correlations. Brain, 88, 897.
ESTRIDGE, M. N., and SMITH, R. A. (1967): Transoral Fusion of Odontoid Fracture. Journal of Neurosurgery,
27, 462.
FANG, H. S. Y., and ONG, G. B. (1962): Direct Anterior Approach to the Upper Cervical Spine. Journal of
Bone and Joi,zt Surgery, 44-A, 1588.
FRITZSCHE, E. (1913): Uber die Frakturen des Zahnfortsatzes des Epistropheus. Neue r#{246}ntgenographische
Darstellung des Processus odontoideus. Deutsche Zeitschrift f#{252}r
Chirurgie, 120, 7.
GALLIE, W. E. (1939): Fractures and Dislocations of the Cervical Spine. AnzericaizJournalofSurgeri, 46, 495.
HADLEY, L. A. (1948): Atlanto-occipital Fusion, Ossiculum Terminale and Occipital Vertebra as Related to
Basilar Impression with Neurological Symptoms. American Journal of Roe,ztgenology and Radium Therapy,
59, 511.

THE JOURNAL OF BONE AND JOINT SURGERY

 FRACTURES OF THE DENS 405

HEUBLEIN, G. W. (1944): The Roentgen Diagnosis of Traumatic Lesions of the Cervical Spine. Journal of the
America,: Medical Association, 126, 950.
KOLISKO, A. (1916): Ober den Bruch des Processus odontoides des 2. Halswirbels bei Stirntrauma. Virchows
Archiv f#{252}r
pathologische Anatomie und physiologie und f#{252}rklinische Medizin, 222, 1.
OSGOOD, R. B., and LUND, C. C. (1928): Fractures of the Odontoid Process. New England Journal of Medicine,
198, 61.
ROGERS, L. (1961): Spontaneous Atlanto-axial Dislocation. Pathogenesis and Treatment with Report of a
New Operative Procedure. The British Journal of Surgery, 49, 63.
SCHATZKER, J., RORABECK, C., and WADDELL, J. (1970): Experimental Osteotomies of the Canine Odontoid:
A Study of Fracture Healing. Unpublished.
SCHILLER, F., and NIEDA, I. (1957): Malformation of the Odontoid Process. California Medicine, 86, 394.
SCHLESINGER, E. B., and TAVERAS, J. M. (1958): Lesions of the Odontoid and Their Management. America,:
Journal of Surgery, 95, 641.
SCUDDER, C. L. (1901): The Treatment of Fractures. Second edition. Philadelphia: W. B. Saunders.
SMITH, 5. (1871): Fractures of the Odontoid Process. American Journal of the Medical Sciences, n.s. 62, 338.
WATSON JONES, R. (1932): Spontaneous Hyperaemic Dislocation of the Atlas. Proceedings of the Royal Society
of Medicine, 25, 586.
WILLARD, D. P., and NICHOLSON, J. T. (1941): Dislocation of the First Cervical Vertebra. Annals of Surgery,
113,464.
WOOD-JONES, F. (1913): The Ideal Lesion Produced by Judicial Hanging. Lancet, 1, 53.
WUSTHOFF, R. (1923): Uber die Luxationsfraktur im unteren Kopfgelenk. (Atlas-Epistropheus-Gelenk.)
Deutsche Zeitschrift f#{252}rChirurgie, 183, 73.

VOL. 53 B, NO. 3, AUGUST 1971