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PED-EM-L  September 2000

PED-EM-L September 2000

Subject:

Alanto-axial rotatory subluxation - part 2.

From:

Jeffrey Mann <[log in to unmask]>

Reply-To:

Jeffrey Mann <[log in to unmask]>

Date:

Fri, 1 Sep 2000 09:24:32 -0400

Content-Type:

text/plain

Parts/Attachments:

Parts/Attachments

text/plain (127 lines)

I copied this section from Canale: Campbell's Operative Orthopaedics,
Ninth Edition, Copyright  1998 Mosby, Inc.

Atlantoaxial Rotatory Subluxation

Atlantoaxial rotatory subluxation is a common cause of childhood
torticollis, but the subluxation and torticollis usually are temporary.
Rarely do they persist and become what is best described as atlantoaxial
rotatory "fixation". Atlantoaxial rotatory subluxation occurs when
normal motion between the atlas and axis becomes limited or fixed, and
it can occur spontaneously, can be associated with minor trauma, or can
follow an upper respiratory tract infection. The cause of this
subluxation is not completely understood. Watson-Jones suggested that
hyperemic decalcification of the arch of the atlas causes attachments of
the transverse ligaments to be inadequate, thus allowing rotatory
subluxation. Coutts believes that synovial fringes become inflamed and
act as an obstruction to reduction of subluxation. Firrani-Gallotta and
Luzzatti believe that subluxation is caused by disruption of one or both
of the alar ligaments with an intact transverse ligament. Kawabe,
Hirotani, and Tanaka reported a meniscus-like synovial fold in the C1-C2
facet joints that caused subluxation. They believe anatomical
differences in the dens facet angle in children and adults account for
this condition's appearance primarily in children. Most authors now
agree that the subluxation is related to increased laxity of the alar
and transverse ligaments and capsular structures caused by inflammation
or trauma.

Fielding and Hawkins classified atlantoaxial rotatory subluxation into
four types (Fig. 58-26) (Figure Not Available) : type I, simple rotatory
displacement without anterior shift of C1; type II, rotatory
displacement with an anterior shift of C1 on C2 of 5 mm or less; type
III, rotatory displacement with an anterior shift of C1 on C2 greater
than 5 mm; and type IV, rotatory displacement with a posterior shift.
Type I displacement is the most common and occurs primarily in children.
Type II is less common but has greater potential for neurological
damage. Types III and IV are rare but have high potential for
neurological damage.

Atlantoaxial rotatory subluxation usually occurs in children after an
upper respiratory tract infection or minor or major trauma. The head is
tilted to one side and rotated to the opposite side with the neck
slightly flexed (the "cock robin" position). The sternocleidomastoid
muscle on the long side is often in spasm in an attempt to correct this
deformity. When the subluxation is acute, attempts to move the head
cause pain. Patients are able to increase the deformity but cannot
correct the deformity past the midline. With time, muscle spasms subside
and the torticollis becomes less painful, but the deformity persists. A
careful neurological examination should determine any neurological
compression or vertebral artery compromise.

ROENTGENOGRAPHIC FINDINGS

Adequate roentgenograms of the cervical spine may be difficult to obtain
in children with torticollis. Initial examination should include
anteroposterior and odontoid views of the cervical spine. On the
open-mouth odontoid view the lateral mass that is rotated forward
appears wider and closer to the midline, and the opposite lateral mass
appears narrower and farther away from the midline (Fig. 58-27) . One of
the facet joints of the atlas and axis may be obscured by apparent
overlapping. On the lateral view the anteriorly rotated lateral mass
appears wedge shaped in front of the odontoid. The posterior arch of the
atlas may appear to be assimilated into the occiput because of the head
tilt. Lateral flexion and extension views should be obtained to document
any atlantoaxial instability. If the atlantoaxial articulation cannot be
seen on routine roentgenograms, tomograms should be obtained.
Cineradiography confirms the diagnosis by demonstrating the movement of
atlas and axis as a single unit but is difficult to perform during the
acute stage because movement of the neck is painful. Computed tomography
with the head rotated as far to the left and right as possible during
scanning to confirm the loss of normal rotation at the atlantoaxial
joint confirms the diagnosis of rotatory subluxation.

TREATMENT

Phillips and Hensinger base their treatment plan on the duration of the
subluxation (see the box on p. 2841). If rotatory subluxation has
existed less than 1 week, immobilization in a soft collar, analgesics,
and bed rest for 1 week are recommended. If reduction does not occur
spontaneously,

                     Treatment plan for rotatory subluxation
                            (Phillips and Hensinger)

                        Present < 1 week: immobilization in soft
                        collar, analgesics, bed rest for 1 week;
                        no spontaneous reduction:
                        hospitalization, traction

                        Present > 1 week but < 1 month:
                        hospitalization, cervical traction (head
                        halter), cervical collar 4 to 6 weeks

                        Present > 1 month: hospitalization,
                        cervical traction (skeletal), cervical
                        collar 4 to 6 weeks

                        Nonoperative treatment is used only if
                        roentgenogram shows no significant
                        anterior displacement or instability

hospitalization and traction are indicated. When rotatory subluxation is
present for longer than 1 week but less than 1 month, hospitalization
and cervical traction are indicated. Head halter traction generally is
used, but when torticollis persists longer than 1 month, skeletal
traction may be required. Traction is maintained until the deformity
corrects, and then a cervical collar is worn for 4 to 6 weeks.
Nonoperative treatment should be used only if no significant anterior
displacement or instability is seen on roentgenographic evaluation.

Fielding listed the following as indications for operative treatment:
(1) neurological involvement, (2) anterior displacement, (3) failure to
achieve and maintain correction if the deformity exists for longer than
3 months, and (4) recurrence of the deformity after an adequate trial of
conservative management consisting of at least 6 weeks of
immobilization. When operative treatment is indicated, a C1-C2 posterior
fusion is performed (Fig. 58-28) . Fielding and Hawkins recommend
preoperative traction for 2 to 3 weeks to correct the deformity as much
as possible. Fusion is performed with the head in a neutral position.
Fielding and Hawkins recommend 6 weeks of traction after surgery to
maintain correction while the fusion becomes solid. This also can be
accomplished with a halo cast or vest. Immobilization is continued until
there is roentgenographic evidence of fusion.

For more information, send mail to [log in to unmask] with the message: info PED-EM-L
The URL for the PED-EM-L Web Page is:
  http://www.brown.edu/Administration/Emergency_Medicine/ped-em-l.html

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