Odontoid fractures are frequent in patients over 70 years of age, and in patients over 80 years of age they form the majority of spinal fractures. In a retrospective analysis of 23 geriatric (> 70 years) patients with a fracture of the odontoid, we compared some of the clinical features to a contemporary series of patients younger than 70 years of age. Whereas in the younger patients high-energy trauma accounted for the majority of the fractures, low-energy falls were the underlying cause in 90% of the odontoid fractures in the elderly. In contrast to the younger age group, in elderly patients predominantly type II fractures (95%) were identified. Anterior and posterior displacement were recorded with equal frequency on the first postinjury radiograph in the younger age group, whereas in geriatric patients displacement was mainly posterior. The number of associated injuries was significantly higher in younger patients. There was no difference in the occurrence of neurological deficits (13%) between the two age groups, and neurological compromise was mainly related to posterior dislocation of the odontoid in both groups. The overall complication rate was significantly higher in elderly patients (52.2% vs 32.7%), with an associated in-hospital mortality of 34.8%. Loss of reduction and non-union after non-operative treatment, a complicated postoperative course and complications due to associated injuries accounted primarily for this high complication rate. Elderly patients with a fracture of the odontoid are a high-risk group with a high morbidity and mortality rate. An aggressive diagnostic approach to detect unstable fractures and application of a halo device or early primary internal stabilisation of these fractures is recommended.