J Orthop Sci (2010) 15:257–260
DOI 10.1007/s00776-009-1433-9
Case report
Unreduced atlantoaxial dislocation locked with a combined lateral
mass fracture
KYUNG-JIN SONG1, BYUNG-WAN CHOI2, JI-HUN SONG1, and BYUNG-RYEUL CHOI1
1
Department of Orthopedic Surgery, School of Medicine, Research Institute of Clinical Medicine, Chonbuk National University Hospital,
Jeonju, Korea
2
Department of Orthopedic Surgery, Gwangju Veterans Hospital, 880-1 Sanwol-dong, Gwangsan-gu, Gwangju 506-705, Korea
Introduction
Traumatic bilateral rotatory subluxation of the atlanto-
axial joints is a rare injury, and reduction is generally
achieved spontaneously and with ease by traction
therapy.1 On the other hand, the pathophysiology of
rotatory atlantoaxial subluxation is not well defined, but
it is common in children2 and is a consequence of spe-
cific anatomical features.3 The joint surface of the lateral
mass is shallower and more horizontally oriented in
children, and the relative elasticity of ligaments allows
a greater degree of deformity before failure. However,
traumatic atlantoaxial rotatory subluxation in adults
is rare owing to the unique biomechanical features of
the C1/2 articulation and the likely lethality of such
an injury before presentation at a trauma center.4–6
Atlantoaxial bilateral rotatory dislocation is uncom-
mon, particularly in adults, and most of the reported
cases have been in adults who have undergone surgery.7,8
To our knowledge, nonoperative management has
been reported in only two such adult cases,4,9 and in
both reduction was achieved by simple manipulation
(Table 1).
The authors report a case of type I traumatic rotatory
atlantoaxial injury in which complete reduction was suc-
cessfully achieved using closed maneuvers after failure
to achieve reduction by closed traction due to locking
of the dislocated atlas by a combined lateral mass frac-
ture of the axis.
Case report
A 58-year-old man was referred to our trauma center
with severe neck pain after being involved in an auto-
mobile accident at unknown speed. He was an unre-
Offprint requests to: B.W. Choi
Received: February 16, 2009 / Accepted: July 24, 2009
strained passenger in a car that had overturned, and he
had lost consciousness briefly (a matter of seconds)
after the injury.
On physical examination, he showed no appreciable
neurological distortion of the upper or lower extremi-
ties (e.g., motor weakness or sensory deficit), and his
cranial nerves were intact. However, his head was fixed
and rotated to the left side by about 40°, and he showed
a 20° lateral inclination to the same side.
Plain radiography suggested the presence of a signif-
icant rotational deformity of the atlas on the axis
(Fig. 1). Cervical spine computed tomography (CT)
with three-dimensional reformations and magnetic res-
onance imaging (MRI) scans were checked but showed
no appreciable increase in the atlanto-dens interval
(ADI). However, the inferior lateral mass of the right
atlas was dislocated anteriorly to the superolateral mass
of the axis on the same side and was locked by a com-
bined fracture of the superior lateral mass of the axis
(Fig. 2). There was no radiographic evidence of rupture
of the transverse ligament (Fig. 2C).
To achieve reduction, Gardner-Wells tongs skull
traction was applied after admission. We started by
increasing the traction weight to 7 kg and then increased
it incrementally to 20 kg while carefully observing the
patient’s reaction and checking for any neurological
change. The traction was kept in place for 7 days, but
reduction could not be achieved. Although muscle
relaxants and analgesics were given, the anterior and
posterior neck muscles showed consistent tension and
intermittent spasms. We believed that this tension pre-
vented reduction. Thus, anticipating reduction due to
the relaxation of neck muscle tension, we tried closed
reduction of the longitudinal axis of the atlantoaxial
joint using weight and manual traction under general
anesthesia. Once again, however, reduction could not
be achieved.
Subsequently, we achieved reduction by the method
planned before under the same anesthesia. First, we
258 K.-J. Song et al.: Unreduced atlantoaxial dislocation

Table 1. Cases of atlantoaxial dislocation in adults reported in the literature

Age Diagnostic
Reference (years) Sex Classification Dislocation method Traction period Definitive treatment
9
Born 29 M I Bilateral CT Immediate reduction Minerva orthosis for 2 months
Moore8 65 M I Bilateral CT Reduction within C1/2 posterior wiring and
24 h fusion
Waegeneers15 17 M I Unilateral CT 4 days Halo vest for 3 months
Castel4 41 M I Bilateral CT 10 days Minerva orthosis for 6 weeks
Kim7 34 M II Unilateral CT, MRI 24 h Open reduction, posterior
instrumented fusion
CT, computed tomography; MRI, magnetic resonance imaging

Fig. 1. Posttraumatic antero-

posterior (AP) and lateral
plain radiographs of the
patient. a The head was fixed
and rotated to the left side.
b A significant rotational
deformity of the atlas about
the axis is evident, and it
shows no appreciable increase
a b in the atlanto-dens interval
(arrow)

a b c

Fig. 2. a Computed tomography (CT) with three-dimensional articular facet of the atlas was locked by a combined fracture
reformations. The inferior articular facet of the right atlas was of the superior articular facet of the axis. c Magnetic reso-
dislocated anterior to the superior facet of the axis on the nance imaging, T2-weighted axial view. The transverse liga-
same side. b CT axial view shows that the dislocated inferior ment (arrow) was intact
K.-J. Song et al.: Unreduced atlantoaxial dislocation
a b
Fig. 3. Postreduction CT scan. a Three-dimensional CT shows complete reduction of the atlantoaxial joint. b CT sagittal view.
c CT axial view. The fracture fragment (arrows) on the right superior articular facet of the axis can be seen
overrotated the head to the left side over the dislocated
position and withdrew the lateral mass of the atlas,
which had locked. Manual reduction was then achieved
easily by rotating the head to the right side with exten-
sion and axial traction. The operator felt a “pop,” and
postreduction CT showed complete reduction of the
joint and fracture fragment on the right superior lateral
mass of the axis (Fig. 3).
No neurological abnormalities were evident after
reduction, and we applied a Halo vest. Two months
after reduction the Halo vest was removed, and we
recommended range of motion exercises. Radiographi-
cally, no C1/2 asymmetry was found on an open mouth
view and no anterior/posterior vertebral translation or
increase in ADI was observed on flexion/extension
lateral radiographs.
At his 12-month follow-up, no discomfort or limita-
tion of range of motion of the neck was found. The
patient experienced an excellent clinical outcome. He
and his family were informed that data from his case
would be submitted for publication.
Discussion
The articulation between the atlas and axis is the most
mobile part of the vertebral column and normally has
less stability than any other vertebral articulation. It is
stabilized by the transverse ligament and joint capsule
in the anteroposterior plane. Alar ligaments prevent
anterior shift of the atlas on the axis and excessive rota-
tion at the atlantoaxial joint.10
259
c
Ono et al. investigated the mechanism of atlantoaxial
rotatory fixation by CT. A few patients in their survey
presented with persistent atypical displacement between
C1/2. In these cases, there was persistent rotatory dis-
placement of the atlas within the occiput–atlas–axis
(C0–C1–C2) complex. Compensatory derotation of the
occiput and hypermobility of the C0/1 articulation,
which is limited to younger children, presumably pro-
duced such rotatory displacement of the atlas within the
C0–C1–C2 complex.11
In some cases, persistent displacement of the disloca-
tion can occur, as in our case. Infolding of the synovial
folds into joints, ligament contracture, muscle spasms,
and articular cartilage damage have been reported to
cause dislocation persistence.1,12 Born et al.9 postulated
that the anatomy of the C1/2 lateral mass is that of a
saddle-shaped joint, such that the posterior lip of C1 can
impinge on the anterosuperior surface of the C2 lateral
mass or actually lock onto the leading edge of the lateral
mass. In our case, the inferior lateral mass of the right
atlas was dislocated anteriorly in relation to the superior
lateral mass of the axis and locked with a combined
fracture of the superior lateral mass of the axis to act as
an obstacle to reduction. In terms of diagnosing atlan-
toaxial rotatory dislocation, CT is an excellent tool for
identifying abnormal atlantoaxial figures.9,11
The goals of treatment of such an injury are to prevent
or reverse neurological compromise, restore spinal sta-
bility, and eventually restore a normal, pain-free state.
In adults, reduction of a rotational deformity can usually
be achieved by skull tong traction.8,9 However, some
surgeons have found it difficult to achieve reduction,
260
and no reasonable data are available regarding the
optimal period of traction. Castel et al. achieved reduc-
tion after 10 days by neck manipulation,4 whereas Kim
et al.7 failed to obtain reduction by a closed method and
eventually achieved reduction by resorting to open
surgery. In our case, we failed to obtain reduction by
traction for 7 days. When reduction has been achieved
by simple traction, usually it is done within 24 h.2,3,8
Therefore, we recommend simple traction to achieve
reduction when a dislocation has been sustained for
more than 24 h.
Reduction maneuvers range from simple distraction
(with movements aimed at correcting lateral flexion and
rotation4) to the Levine and Edwards recommendation
of manipulation while the patient is awake after admin-
istering topical anesthetic in the posterior pharynx.
According to the Levine and Edwards method, a finger
presses in counterrotation to the dislocation on the
lateral mass of the atlas through the posterior wall of
the pharynx.13 However, in our experience, simple trac-
tion and attempts to rotate the head to the normal
anatomy are inadequate even under general anesthesia.
When performing a manipulation, it is important to
consider the mechanics of the dislocation. In our case,
we were able to draw out the lateral mass of the atlas
by overrotating the head to the affected side over the
dislocated position, which had locked due to fracture of
the lateral mass of the axis.
Whether to perform C1/2 fusion is another decision
the surgeon must make. If closed reduction fails, open
reduction and posterior C1/2 fusion can be used to sta-
bilize the reduction. However, the choice between con-
servative treatment and fusion depends on the stabilities
of the lesion and the transverse ligament, which is a
primary stabilizing component. Accordingly, it is impor-
tant to determine whether the transverse ligament is
torn or avulsed; MRI can be used to visualize the trans-
verse ligament directly on T2-weighted images and
gradient-echo images.14 Furthermore, when a loss of
continuity of the ligament and regions of high signal
intensity are observed, a tear is indicated.
Conclusion
Atlantoaxial joint fracture-dislocation after trauma can
occur in adults, and simple traction may be inadequate
K.-J. Song et al.: Unreduced atlantoaxial dislocation
for reduction. As in our case, satisfactory reduction can
be achieved by full relaxation of the neck muscles under
general anesthesia and cautious manual reduction,
given a complete understanding of the injury mecha-
nism and the nature of the dislocation.
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