Background Surgical fixation is recommended for type II and III odontoid fractures (OFx) with major translation of the odontoid fragment, regardless of the patient’s age, and for all type II OFx in patients aged ≥50 years. The level of compliance with this recommendation is unknown, and our hypothesis is that open surgical fixation is less frequently performed than recommended. We suspect that this discrepancy might be due to the older age and comorbidities among patients with OFx. Methods We present a prospective observational cohort study of all patients in the southeastern Norwegian population (3.0 million) diagnosed with a traumatic OFx in the period from 2015 to 2018. Results Three hundred thirty-six patients with an OFx were diagnosed, resulting in an overall incidence of 2.8/100000 persons/year. The median age of the patients was 80 years, and 45% were females. According to the Anderson and D’Alonzo classification, the OFx were type II in 199 patients (59%) and type III in 137 patients (41%). The primary fracture treatment was rigid collar alone in 79% of patients and open surgical fixation in 21%. In the multivariate analysis, the following parameters were significantly associated with surgery as the primary treatment: independent living, less serious comorbidities prior to the injury, type II OFx and major sagittal translation of the odontoid fragment. Conversion from external immobilization alone to subsequent open surgical fixation was performed in 10% of patients. Significant differences the in conversion rate were not observed between patients with type II and III fractures. The level of compliance with the treatment recommendations for OFx was low. The main deviation was the underuse of primary surgical fixation for type II OFx. The most common reasons listed for choosing primary external immobilization instead of primary surgical fixation were an older age and comorbidities. Conclusion Major comorbidities and an older age appear to be significant factors contributing to physicians’ decision to refrain from the surgical fixation of OFx. Hence, comorbidities and age should be considered for inclusion in the decision tree for the choice of treatment for OFx in future guidelines.

BackgroundIn 2000 the Scandinavian Neurotrauma Committee published guidelines for safe and cost-effective management of minimal, mild and moderate head injured patients.The aims of this study were to investigate to what extent the head injury population is under the influence of alcohol, and to evaluate whether the physicians' compliance to the guidelines is affected when patients are influenced by alcohol.MethodsThis study included adult patients (≥15 years) referred to a Norwegian University Hospital with minimal, mild and moderate head injuries classified according to the Head Injury Severity Scale (HISS). Information on alcohol consumption was recorded, and in most of these patients blood alcohol concentration (BAC) was measured. Compliance with the abovementioned guidelines was registered.ResultsThe study includes 860 patients. 35.8% of the patients had consumed alcohol, and 92.1% of these patients had a BAC ≥ 1.00‰. Young age, male gender, trauma occurring during the weekends, mild and moderate head injuries were independent factors significantly associated with being under the influence of alcohol. Guideline compliance was 60.5%, and over-triage was the main violation. The guideline compliance showed no significant correlation to alcohol consumption or to BAC-level.ConclusionsThis study confirms that alcohol consumption is common among patients with head injuries. The physicians' guideline compliance was not affected by the patients' alcohol consumption, and alcohol influence could therefore not explain the low guideline compliance.

BackgroundThe Scandinavian guidelines for management of minimal, mild and moderate head injuries were developed to provide safe and cost effective assessment of head injured patients. In a previous study conducted one year after publication and implementation of the guidelines (2003), we showed low compliance, involving over-triage with computed tomography (CT) and hospital admissions. The aim of the present study was to investigate guideline compliance after an educational intervention.MethodsWe evaluated guideline compliance in the management of head injured patients referred to the University Hospital of Stavanger, Norway. The findings from the previous study in 2003 were communicated to the hospitals physicians, and a feed-back loop training program for guideline implementation was conducted. All patients managed during the months January through June in the years 2005, 2007 and 2009 were then identified with an electronic search in the hospitals patient administrative database, and the patient files were reviewed. Patients were classified according to the Head Injury Severity Scale, and the management was classified as compliant or not with the guideline.ResultsThe 1 180 patients were 759 (64%) males and 421 (36%) females with a mean age of 31.5 (range 0-97) years. Over all, 738 (63%) patients were managed in accordance with the guidelines and 442 (37%) were not. Compliance was not significantly different between minimal (56%) and mild (59%) injuries, while most moderate (93%) injuries were managed in accordance with the guidelines (p < 0.05). Noncompliance was caused by overtriage in 362 cases (30%) and undertriage in 80 (7%). Guideline compliance was 54% in 2005, 71% in 2007, and 64% in 2009.ConclusionsThis study shows higher guideline compliance after an educational intervention involving feed-back on performance. A substantial number of patients are exposed to over-triage, involving unnecessary radiation from CT examinations, and unnecessary costs from hospital admissions.

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