Posttraumatic Atlantoaxial Rotatory Subluxation in a Child

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Dear Editor, A 3-year-old boy presented with an alleged history of falling head first from a bike 3 h before and sustained injury to the head. He had a history of loss of consciousness for 5 min, with generalized tonic–clonic movements of all limbs, with frothing from the mouth and uprolling of eyes, lasting for 2 min. He had a normal perinatal period and development. Upon arrival at emergency, he had a Glasgow Coma Scale of 14/15 and normal neurological and systemic examination. Noncontrast computed tomography (CT) head with cervical spine screening revealed rotation of lateral mass of atlas (C1) on axis (C2) with no anterior dislocation suggestive of type 1 atlantoaxial rotatory subluxation (AARS) (Fielding and Hawkins classification). He was managed conservatively after neurosurgical consultation and discharged on oral analgesics with a soft cervical collar for 2-week duration. On follow-up, he did not have any torticollis or neck pain. Posttraumatic AARS, also known as traumatic torticollis, is due to rotatory dislocation or subluxation of the atlantoaxial (C1–C2) joint in a malrotated position.[1] AARS is rare in children but of higher incidence than adults due to the anatomical predisposition of lax ligaments, large head size, horizontally aligned facet joints of C1–C2, and robust synovium causing hypermobility.[2] The classification of AARS into four types (I–IV) was proposed by the American Orthopedic Surgeons Fielding and Hawkins in 1977.[3] Type-I, the most common of AARS is a pure rotatory fixation without anterior subluxation, Type-II includes ligamentous disruption of the transverse ligament, with 3–5 mm anterior displacement of the anterior arch of C1, Type-III is similar to Type-II, but with anterior displacement >5 mm, and Type-IV, the rarest of AARS is the rotatory fixation with posterior displacement.[1–3] The etiologies of pediatric AARS are neck trauma, congenital craniovertebral junction anomalies, and clavicular fractures.[1,2,4] The imaging of choice in pediatric AARS is cervical CT with three-dimensional reconstruction.[2] Posttraumatic AARS are managed conservatively in most of the cases and surgical interventions are preferred only in children with unstable deformities, significant structural deformities, or progressive focal deficits.[1,2,5,6] Surgical options are also considered in patients with Down syndrome and rheumatoid arthritis.[1] Persistent torticollis in a child after minor trauma should make the treating clinicians consider AARS. The recurrence of AARS is greater in patients with >3 months of symptoms. Timely diagnosis and prompt treatment initiation are essential, as it has greater chances of treatment success, missing which may result in chronic deformity.[1,6] Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form the legal guardians of the patient have given their consent for his images and other clinical information to be reported in the journal. They understand that his name and initials will not be published and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed. Research quality and ethics statement The authors followed applicable EQUATOR Network (https://www.equator-network.org/) guidelines, notably the CARE guideline, during the conduct of this report. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

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