Structural heterogeneity within the axis: the main cause in the etiology of dens fractures. A histomorphometric analysis of 37 normal and osteoporotic autopsy cases.

Fractures of the odontoid process are potentially serious injuries; Type II and III fractures, as described by Anderson and D'Alonzo, are seen in the emergency room especially in young adolescents and individuals over 60 years of age. The etiology of these fractures is still controversial. Malunion and nonunion in both types of fractures are presumed to be due to insufficient external or internal fixation, but this theory has not been fully explained. To examine these issues, the authors expanded their prior studies of the anatomy of the axis. For histomorphometric analysis of cancellous and cortical bone, the axis was removed in 37 autopsies (26 normal and 11 osteoporotic cases) and sectioned in the sagittal plane to a thickness of 1 mm using a surface-stained block-grinding technique. The base of the dens is the region of least resistance for fractures because of its reduced trabecular bone volume, a poorer trabecular interconnection, and a cortical thickness one-third that of the axis. In all cases, trabeculae were disconnected from the trabecular lattice, and in 30%, microcallus formations were demonstrated in the base of the dens. A special filigree type of trabeculae in the base of the dens is often seen in patients with osteoporosis; microarchitectural differences of cancellous bone between the base of the dens and the other regions of the axis are also markedly increased. The authors infer from the data that the bone structure of the axis is responsible for the location, distribution, and frequency of fractures of the odontoid process in normal healthy bone and this frequency is greatly increased in individuals with osteoporosis. The deficiency of bone mass within the base also suggests a new explanation for the occurrence of nonunions, even after treatment of fractures of the base of the dens.