Atlantoaxial Rotatory Subluxation in Children
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Elizabeth C Powell1, Jeffrey R Leonard, Cody S Olsen
1From the *Department of Pediatrics, Division of Emergency Medicine, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital, Chicago, IL; †Department of Surgery, Nationwide Children's Hospital, Ohio State University College of Medicine; ‡Central Data Management and Coordinating Center, University of Utah School of Medicine, Salt Lake City, UT; §Department of Pediatrics, Division of Emergency Medicine, and Department of Neurosurgery, Washington University in St. Louis School of Medicine, St. Louis Children's Hospital, St. Louis, MO; ∥Department of Pediatrics, Division of Emergency Medicine, Johns Hopkins School of Medicine, Johns Hopkins Children's Center, Baltimore, MD; and **Department of Pediatrics, Nationwide Children's Hospital, Ohio State University College of Medicine, Columbus, OH.
Insights
Atlantoaxial rotatory subluxation (AARS) in children often presents late with neck pain and torticollis, frequently caused by falls. Management strategies for pediatric AARS vary significantly across healthcare institutions.
Area of Science:
- Pediatric Emergency Medicine
- Orthopedic Surgery
- Trauma Surgery
Background:
- Atlantoaxial rotatory subluxation (AARS) is an uncommon pediatric cervical spine injury.
- Early recognition and appropriate management are crucial for optimal outcomes in pediatric patients.
Purpose of the Study:
- To characterize the injury circumstances, clinical presentations, and treatment modalities for pediatric AARS.
- To improve the recognition and management of AARS in children.
Main Methods:
- A subanalysis of a case-control study involving 17 hospitals within the Pediatric Emergency Care Applied Research Network (PECARN).
- Included children younger than 16 years diagnosed with AARS after blunt trauma (n=55).
- Compared AARS cases with controls having other cervical spine injuries (n=485) and normal cervical spine imaging (n=1060).
Main Results:
- Children with AARS were significantly younger than control groups.
- Falls were a common mechanism (36%), with delayed medical care presentation (21% >24 hours post-injury).
- Neck pain (67%) and torticollis (57%) were key clinical findings in AARS, more prevalent than in control groups. Management varied widely, including collars, traction, and halo devices.
Conclusions:
- Pediatric AARS often presents with delayed diagnosis, characterized by neck pain and torticollis, with falls as a frequent cause.
- Significant institutional variation exists in the management of pediatric AARS.
- Further research is necessary to establish standardized and optimal treatment protocols for this condition.
Objectives:
Pediatric cervical injuries are uncommon. This study was to describe injury circumstances, clinical findings, and management among children diagnosed with atlantoaxial rotatory subluxation (AARS) to aid in its recognition and management.
Methods:
Subanalysis of a large case-control study from January 2000 to December 2004 in 17 hospitals in the Pediatric Emergency Care Applied Research Network was performed. Cases were children younger than 16 years with AARS after blunt trauma (n = 55); controls were (a) children with other cervical spine injuries (other CSI, n = 485) and (b) those with normal imaging of the cervical spine (non-CSI, n = 1060).
Results:
Children with AARS were younger (mean [SD] age, 7.7 [3.8] vs 10.7 [4.6]; Wilcoxon P < 0.01). Falls accounted for 36% of injuries; there were no diving mechanisms (vs other CSI, falls 19%, Fisher exact P < 0.01, and diving 7%, P = 0.04). Children with AARS sought medical care more than 24 hours after the injury event (21% vs 1% for non-CSI controls, P < 0.01). Clinical findings associated with AARS included neck pain (67%) and torticollis (57%) versus other CSI, pain (47%) and torticollis (5%, P < 0.01) for each, and versus non-CSI controls, pain (33%) and torticollis (6%, P < 0.01) for each. Management of AARS included no intervention (n = 6, 11%), soft or rigid collar only (n = 24, 44%), traction (n = 14, 25%), halo (n = 9, 16%), internal fixation (n = 2, 4%), and varied across institutions (P = 0.02).
Conclusions:
Children with AARS often have a delayed presentation with neck pain and torticollis; falls are a common injury mechanism. Treatment varied across institutions. Further work is needed to identify optimal management.
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