Nonoperative treatment of displaced type II odontoid peg fractures with a Philadelphia collar

Although a consensus exists on the nonoperative management of types I and III odontoid peg fractures, treatment of type II fractures remains controversial. An increasing trend exists toward primary fixation of type II peg fractures due to a high rate of nonunion, especially if the displacement is >4 mm. This article reports the results of nonoperative treatment of patients with displaced odontoid peg fractures (>4 mm) using a Philadelphia collar.A retrospective review of clinical and radiological records was performed for nonoperatively treated patients who sustained displaced type II peg fractures between January 2003 and April 2008. The study group comprised 9 patients (2 men and 7 women), and all patients were treated with Philadelphia collars. Patients were followed up for an average of 24.8 months (range, 8-28 months) for clinical and radiological outcomes. Functional outcomes were measured according to the Smiley-Webster scale. Fractures united uneventfully in 6 patients, but nonunion developed in 3 patients. Average time to union was 12.3±2.94 weeks (95% confidence interval, 9.97-14.68 weeks; range, 10-16 weeks). No patient had clinical or radiological signs of instability or delayed onset myelopathy at follow-up. Three patients had excellent, 4 had good, and 2 had fair results as per the Smiley-Webster functional scoring system.Displaced type II peg fractures can be managed nonoperatively in patients who refuse surgery or those with multiple comorbidities. Adequate patient counseling and compliance with close clinicoradiological follow-up is paramount to avoid adverse clinical events and achieve an optimal functional outcome.