Recurrent traumatic atlantoaxial rotatory subluxation: Case report

Introduction: Atlantoaxial rotatory subluxation (AARS) is not uncommon in paediatric emergencies, however, the complications might be fatal. Long onset before presentation is correlated with higher recurrence and persistent deformity. There is no consensus on the treatment of AARS yet. Selected patients may benefit from conservative approaches; however, retention might be difficult, and subluxation may recur. Presentation of case: A 6-year-old boy was admitted to our institution with AARS for three months before admission. Typical Cock-Robin position was observed. Computed tomography (CT) indicated AARS Fielding and Hawkins grade III. We treated the case conservatively by closed reduction and cervical traction using Gardner-Wells tongs. However, poor compliance resulted recurrence of subluxation, so we decided to fuse the atlantoaxial joint using transarticular screws, posterior wiring, and autologous bone grafting. Posterior fusion resulted in a satisfactory outcome, in which the wound healed accordingly. Six months of follow up examination revealed normal motoric and sensory function. The patient was able to perform daily activities with no significant issues. Discussion: Patients with fixed deformity of more than three weeks have a higher rate for recurrence or persistent deformity, as reduction is harder and difficult to maintain. The use of posterior wiring alone is limited in maintaining reduction, while using transarticular screws alone is considered better in maintaining reduction; however, not providing it. Conclusion: The use of posterior cervical fusion using C-wire, transarticular screws, and autologous bone grafting may be applied in recurrent case of AARS to ensure adequate reduction and fixation of the atlantoaxial joint.