title: Successful conservative treatment for neglected rotatory atlantoaxial dislocation.
abstract: BACKGROUND
  Rotatory atlantoaxial subluxation (RAS) is a rare condition that is often misdiagnosed and therefore incorrectly managed. We describe our experience and propose an algorithm for treating neglected RAS nonoperatively.
  
  
  METHODS
  All consecutive children with neglected (>6 wk) RAS were treated in our department between 2005 and 2010 by cervical traction using a Gleason traction device and nonsteroidal anti-inflammatory drugs and muscle relaxants. When reduction was not achieved, the Gleason device was replaced by a halo device without manipulative reduction, and weight was added as necessary until reduction was successful. Fixation of reduction was either by a sternooccipital mandibular immobilizer or a halo vest for 3 to 4 months.
  
  
  RESULTS
  All 5 children (4 boys and 1 girl, aged 4 to 11 y) were successfully treated for neglected RAS. The mean duration from symptom onset (eg, limited neck range of motion, discomfort) to treatment initiation was 11.6 weeks (range, 6 to 16 wk). Closed reduction was achieved by a Gleason or a noninvasive halo device within 1 to 2 weeks in 4 cases. The fifth case was reduced after 5 weeks of traction using a halo with a 5 kg weight. All children had symmetrical full range of motion, normal neurological examination, and were fully engaged in educational and sports activities without recurrent dislocations at final follow-up (mean, 30 mo; range, 18 to 49 mo).
  
  
  CONCLUSIONS
  Conservative treatment by gradual and prolonged traction without manipulative reduction in neglected RAS might be a successful method. Reduction can often be achieved within 2 weeks of treatment onset.
  
  
  METHODS
  Level IV (retrospective case series).
authors: Department of Orthopaedic Surgery, Dana Children's Hospital, Tel Aviv Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
authors: Ofir
authors: O
authors: Chechik
authors: Shlomo
authors: S
authors: Wientroub
authors: Barry
authors: B
authors: Danino
authors: David E
authors: DE
authors: Lebel
authors: Dror
authors: D
authors: Ovadia
mesh_terms: D000465:Algorithms; D001268:Atlanto-Axial Joint / Q000293:injuries*; D002648:Child; D002675:Child, Preschool; D003951:Diagnostic Errors; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D004204:Joint Dislocations / Q000175:diagnosis / Q000473:pathology / Q000628:therapy*; D008297:Male; D009333:Neck / Q000473:pathology; D016059:Range of Motion, Articular; D012189:Retrospective Studies; D013997:Time Factors; D014143:Traction / Q000379:methods*; D016896:Treatment Outcome