We present seven children with atlantoaxial rotatory fixation (AARF) of more than three months’ duration after an injury to the upper cervical spine. The deformity was irreducible by skull traction. MRI and MR angiography (MRA) of the vertebral arteries were performed in four children. The patients were neurologically intact. Thrombosis of the ipsilateral vertebral artery was noted in two patients. The deformity was gradually corrected and stabilised after transoral release of the atlantoaxial complex, skull traction and posterior atlantoaxial fusion. Soft-tissue interposition and contractures within the atlantoaxial complex prevented closed reduction. MRI and MRA of the vertebral arteries were useful in elucidating the pathology of chronic atlantoaxial rotatory fixation

Aims. 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. Patients and 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. Conclusion. 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. Take home message: 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