Management of type III dens fracture

External immobilization with a halo vest is the traditional treatment of choice for type III fracture of the odontoid process of C2 (dens). With the evolution of new operative techniques and fixation devices, however, this policy is being questioned. We retrospectively reviewed a series of patients treated by operative and non-operative methods. The series included 22 men and 7 women and the most frequent cause of injury was traffic accidents. Twenty of these patients had normal motor power at the time of admission. Five had flaccid quadriplegia and one had flaccid quadriplegia combined with respiratory failure. Eighteen patients underwent posterior C1-C2 fusion, 17 with the Halifax clamp and one with wire by the Brooks method followed by 8 weeks of immobilization with a Philadelphia collar. Ten other patients received external immobilization with a halo vest for 12 to 16 weeks. One patient died before treatment. All patients achieved fusion and good stability at 6 months follow-up. There were 2 patients with wound infection in the immediate post-operative period. One side of the Halifax clamp was found loosened during the follow-up period for 1 patient, although he eventually had fusion of the fractured dens. In addition, pin-hole infection was found in 2 of the halo-treated patients. Overall, there were no major complications in either the operative or non-operative patients. Both external fixation with the halo vest and internal fixation are safe and effective for treating type III dens fractures. We now prefer internal fixation because the surgical risk is low and it avoids patient discomfort inherent with the halo vest.