When Conservative Management Fails: Pediatric Type III Odontoid Fracture With Delayed Instability

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Introduction/Background: Pediatric cervical spine trauma is rare, with most injuries involving the upper cervical region. Type III odontoid fractures are commonly managed with external immobilization when atlantoaxial stability is preserved; however, radiographic progression and occult spinal cord compromise may still occur. Case presentation: A 7-year-old boy sustained high-energy cervical trauma after a fall from a three-story building. He reported mild, transient neck pain and had no neurological deficits. Cervical CT demonstrated a type III odontoid fracture extending to the right superior articular facet, associated with a single-line fracture of the left anterior arch of C1. Initial deformity was minimal (1 mm anterior translation and 6° anterior angulation), and he was treated with a rigid cervical collar. The patient was lost to follow-up and returned 3 months after injury; repeat CT showed marked deformity progression (42.5° anterior angulation and 4 mm translation). MRI revealed anterior spinal cord compression with intramedullary T2/STIR hyperintensity consistent with early radiological myelopathy, despite an unchanged and normal neurological examination. Given progressive instability and occult cord compromise, posterior C1–C2 stabilization with C1 decompression was performed under intraoperative neurophysiological monitoring. Postoperative recovery was uneventful. At 13 months, he remained neurologically intact, with solid fusion on CT and improvement of the intramedullary signal abnormality on MRI. Conclusions: Pediatric type III odontoid fractures may worsen during conservative management, and clinically silent cord compression with MRI evidence of myelopathy can occur. Timely, structured follow-up imaging is essential, and prompt stabilization should be considered when progression, instability, and/or cord compression is identified.

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