The management of odontoid fractures through the lens of evolution in classification schemes: A systematic review with illustrative case examples

Introduction

Odontoid fractures account for approximately 15% of all cervical spine fractures. Despite numerous classification systems, controversy persists regarding the ideal treatment of these fractures, especially in elderly and medically frail patients.

Research question

This article aims to provide a systematic review of odontoid fracture classifications and assess their clinical applicability.

Material and methods

A systematic literature review was conducted in PubMed, Embase, and Cochrane databases using the terms “odontoid”, “fracture”, and “classification”. Articles published between 1974 and 2024 were analyzed and those containing odontoid fracture classifications were included.

Results

Four hundred and fifty-seven articles were identified, and 32 were selected for detailed investigation. Seven articles were selected after reviewing the full text, and four additional articles cited in the references were included, from which two were published before 1974. A total of eleven classification systems were found in the literature. The classifications were based on the position and direction of the fracture line, displacement, angulation, embryology, and odontoid anatomy. The AO Spine Classification System was among the more recent frameworks reviewed and analyzes the presence of ligamentous injury or translation.

Discussion and conclusions

Anderson and D'Alonzo, Roy-Camille, Grauer, and the AO Spine Classification System are the most commonly applied in clinical practice. However, existing systems lack specific considerations for osteoporosis and the medical frailty of elderly patients, who constitute a substantial portion of cases. Future classification systems should address these factors to better guide treatment for this population.