title: The delayed presentation of atlantoaxial rotatory fixation in children: a review of the management.
abstract: OBJECTIVE
  Although atlantoaxial rotatory fixation (AARF) is a common cause of torticollis in children, the diagnosis may be delayed. The condition is characterised by a lack of rotation at the atlantoaxial joint which becomes fixed in a rotated and subluxed position. The management of children with a delayed presentation of this condition is controversial. This is a retrospective study of a group of such children.
  
  
  METHODS
  Children who were admitted to two institutions between 1988 and 2014 with a diagnosis of AARF were included. We identified 12 children (four boys, eight girls), with a mean age of 7.3 years (1.5 to 13.4), in whom the duration of symptoms on presentation was at least four weeks (four to 39). All were treated with halo traction followed by a period of cervical immobilisation in a halo vest or a Minerva jacket. We describe a simple modification to the halo traction that allows the child to move their head whilst maintaining traction. The mean follow-up was 59.6 weeks (24 to 156).
  
  
  RESULTS
  Despite the delay in referral, the subluxation was successfully reduced in all children. Only two children required atlantoaxial fusion.
  
  
  CONCLUSIONS
  The results of our study suggest that normal anatomy with restoration of movement may be achieved even in cases of AARF presenting late, obviating the need for fusion. We also show a simple modification to the halo traction that allows the child to move their head about while still maintaining traction.
  
  
  CONCLUSIONS
  Prompt diagnosis and management with halo traction (with a simple modification as described) is associated with good results in patients with AARF who present late. Cite this article: Bone Joint J 2016;98-B:715-20.
authors.affiliation: Mater Dei Hospital, Tal-Qroqq, Msida MSD2090, Malta.
authors.forename: M
authors.initials: M
authors.lastname: Mifsud
authors.affiliation: Mater Dei Hospital, Tal-Qroqq, Msida MSD2090, Malta.
authors.forename: M
authors.initials: M
authors.lastname: Abela
authors.affiliation: Royal Hospital for Sick Children, Dalnair Street, Yorkhill, Glasgow G3 8SJ, UK.
authors.forename: N I L
authors.initials: NI
authors.lastname: Wilson
mesh_terms: D000293:Adolescent; D001268:Atlanto-Axial Joint / Q000002:abnormalities*; D002648:Child; D002675:Child, Preschool; D000013:Congenital Abnormalities / Q000175:diagnosis*; D057210:Delayed Diagnosis; D005260:Female; D006801:Humans; D007103:Immobilization; D007223:Infant; D008297:Male; D012189:Retrospective Studies; D014103:Torticollis / Q000209:etiology* / Q000628:therapy*; D014143:Traction
keywords: atlantoaxial rotatory fixation; cervical spine; halo; paediatric; traction