Abstract
Traumatic rotatory atlanto-axial dislocation and subluxations are rare injuries. The diagnosis is often missed or delayed because of subtle clinical signs. Head tilt makes the interpretation of plain radiographs difficult. Delayed diagnosis often results in chronic instability necessitating surgical stabilization. A hitherto undescribed clinical sign was evaluated which should lead to increased awareness and avoid delay in the diagnosis.
Why a new clinical sign?
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Easily missed injury
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Uncommon but not that uncommon
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Difficult to diagnose
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Needs high index of suspicion
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Not much emphasis given in training
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Radiographs usually inconclusive because of torticollis deformity Prerequisites for test
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Patient should be conscious
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A Lateral radiograph should not show any facet dislocations or fractures in cervical spine
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Explain the patient what you intend to do and he/she should report any paraesthesias, sensory or motor symptoms if felt during the test Clinical sign- Elastic Recoil:
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Supine patient
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Hold head carefully with hands on either side of the head
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Instruct patient to report any neurological deterioration
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Try to straighten the head tilt gently
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Once it is corrected, release the supporting hand towards tilt of the head taking care not to let the head overshoot the original position
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An elastic recoil of the head to previous position indicates a positive test
Methods: This study was carried out between 1997 to 2003. The test was applied to 59 patients presenting in Accident and Emergency. All this patients had head tilt even after the application of a hard cervical collar. All the 59 patients had CT scans to confirm or exclude the diagnosis of Rotatory atlanto axial dislocation/subluxation.
Results: The new clinical sign was found to be positive in all the fourteen patients with atlanto- axial rotatory dislocations/subluxations which was confirmed by CT scan. The test was also found to be positive in 5 patients with unilateral facet joint dislocation. The sensivity of the test in our study was 100%. The specificity was 89%, positive predictive value 0.73, negative predictive value 0.9 (90%).
Conclusion: This new clinical sign may help in early recognition of the injury and also act as an effective screen to indicate which patient needs a CT scan to confirm the diagnosis. This can also be applied in places where the CT scan facilities are not readily available especially in the developing nations.
Theses abstracts were prepared by Professor Roger Lemaire. Correspondence should be addressed to EFORT Central Office, Freihofstrasse 22, CH-8700 Küsnacht, Switzerland.
