Atlantoaxial rotatory displacement in children

Table 1 Radiographic findings (n = 47)

Pt. #	Rotation	Presenting position (P)(maximum rotation towards presenting side)				Neutral (Po)(partially corrected position)				Corrected position (P-)(best corrected position)				% Correction	Pang class	Rad int	Radiologist
		Oc	C1	C2	C1C2	Oc	C1	C2	C1C2	Oc	C1	C2	C1C2
1a	R	30	26	-3	29	-1	-7	-31	26	-22	-18	-42	24	17%	1	Yes	4
1b	L	45	54	31	26	13	11	-20	31	-23	-9	-39	30	15%	1	Yes	1
2a	L	17	30	-3	27	-3	8	-21	27	-15	-5	-29	24	11%	1	ND	1
3a	L	38	37	8	29	20	19	-7	26	-2	-1	-23	22	24%	2	Yes	3
4	L	24	23	-2	25	16	18	-5	23	-10	-11	-12	1	96%	2	Yes	2
5	L	29	30	-4	34	4	-5	-11	6	-30	-32	-36	4	88%	2	ND	7
6	L	23	25	10	15	2	2	-12	14	-20	-23	-28	5	66%	2	No	1
7a	R	18	23	2	21	-2	8	-11	19	-19	-11	-15	4	81%	2	Yes	2
8a	R	25	26	14	12	7	9	6	3	-3	-6	-8	2	83%	2	ND	7
9	L	24	30	6	24	4	12	-8	20	-34	-31	-33	2	92%	2	No	3
10b	R	16	23	-6	29	-4	7	-9	16	-22	-7	-22	15	91%	2	Yes	2
11c	L	21	26	1	25	-7	1	-15	16	-25	-16	-21	5	NA	2	Yes	5
2b	L	53	64	32	32	-2	16	-12	28	-61	-47	-45	-2	NA	3	Yes	1
12	L	10	12	-3	15	-2	-4	-4	0	-13	-20	-8	-12	NA	4	No	1
13	L	67	69	35	34	-6	-9	-9	0	-80	-75	-42	-33	NA	4	No	2
14	R	73	76	38	38	2	11	6	5	-58	-52	-20	-32	NA	4	No	1
15	R	34	36	11	25	8	10	6	4	-48	-45	-19	-26	NA	4	No	7
7b	R	27	27	2	25	-10	-10	-7	-3	-30	-32	-17	-15	NA	4	Yes	1
16	R	22	23	2	21	-1	-1	-3	2	-20	-18	-9	-9	NA	4	ND	7
17	R	33	28	3	25	-1	-3	-5	2	-38	-38	-23	-15	NA	4	ND	4
18	R	44	49	16	33	5	10	5	5	-33	-27	-4	-23	NA	4	No	5
19	R	18	17	-7	24	-7	-7	-6	-1	-28	-30	-21	-9	NA	4	No	1
20a	L	24	27	14	13	-6	-1	3	-4	-71	-70	-34	-36	NA	4	ND	3
20b	L	76	73	41	32	-5	1	3	2	-71	-72	-34	-38	NA	4	No	1
21	R	47	46	11	35	-2	-3	7	-10	-29	-28	-1	-27	NA	4	No	2
22	L	20	32	10	22	8	17	6	14	-20	-10	2	-12	NA	4	ND	3
23	L	32	35	21	14	-1	-1	2	-3	-28	-27	-5	-22	NA	4	No	2
24	L	9	11	6	5	9	-12	-6	-6	-22	-27	-13	-14	NA	4	No	7
25	L	27	27	24	19	5	-3	-1	-2	-20	-24	-13	-11	NA	4	No	1
26a	L	15	17	5	12	15	14	6	8	-21	-19	-4	-15	NA	4	ND	7
26b	L	23	25	5	20	7	8	5	3	-29	-29	-7	-22	NA	4	ND	3
27a	L	27	26	3	23	1	1	-5	6	-64	-55	-22	-33	NA	4	ND	1
27b	L	24	20	7	13	-3	-6	3	-9	-30	-35	-11	-24	NA	4	No	3
3b	R	37	40	9	31	16	18	-16	34	-12	-14	12	-26	NA	4	Yes	3
8b	L	18	18	12	9	-6	-9	-12	3	-21	-25	-20	-5	NA	5	ND	5
28	R	18	16	-12	28	1	-2	-14	12	-23	-26	-15	-11	NA	5	No	1
29	L	66	60	16	45	1	4	-6	10	-69	-62	-35	-27	NA	5	No	2
30	R	31	28	6	22	-3	-2	-9	7	-42	-43	-25	-18	NA	5	No	1
31	L	23	25	6	19	3	1	-7	8	-20	-27	-9	-18	NA	5	Yes	2
10a	R	30	34	3	31	-2	7	-7	14	-29	-25	-21	-4	NA	5	Yes	2
11a	L	21	26	1	25	7	0	-12	12	-34	-32	-20	-12	NA	5	Yes	1
11b	L	33	40	14	26	-6	-6	-7	1	-62	-47	-30	-17	NA	5	Yes	6
32	R	25	25	1	24	2	6	-13	7	-25	-27	-19	-8	NA	5	No	3
33	R	29	29	7	22	-2	-4	-9	5	-27	-27	-19	-8	NA	5	No	7
34	L	22	20	23	3	3	2	-3	5	-29	-27	-23	-4	NA	5	No	7
35a	L	21	23	6	17	4	3	-7	10	-18	-16	-12	-6	NA	5	Yes	2
35b	L	41	45	5	40	-1	2	-1	3	-50	-53	-18	-25	NA	5	Yes	1

A variety of data was collected from the imaging studies including patient number, presenting side, measurement angles (occipital, C1, C2, C1C2) for the presenting position, neutral position, and corrected positions, as well as the percentage of correction in divergence angle for types II and III, the type according to Pang and Li, the radiologist’s interpretation (Yes, No, Non-diagnostic) and the radiologist who evaluated each study (1-7). For the radiologists interpretation; Yes: AARF; No: Normal or muscular torticollis; ND: No clear diagnosis established; NA: Not applicable.

Table 2 Associated conditions

Associations	Pang class and associations
Minor trauma (7)	I	Minor trauma (2)
ENT or craniofacial procedures (10)	II	Craniofacial procedures (3)
		ENT procedures (3)
		Grisels (1)
		Unknown (2)
Grisels (7)	III	Minor trauma (1)
Unknown (8)	IV	Unknown (6)
		ENT procedures (3)
		Grisels (3)
		Minor trauma (3)
		Occipital condyle fracture (1)
Occipital condyle fracture (1)	V	Grisels (3)
		ENT procedures (2)
Down syndrome (1)		Minor trauma (2)
		Unknown (1)
Congenital muscular torticollis (1)		Down syndrome (1)

The conditions associated with the painful torticollis are illustrated on the left side, and on the right side these associations are grouped according to the Pang and Li type.

Table 3 Clinical findings

Pt #	Pang	Age	Gen	History	Delay to initial presentation	Prior treatment	1° Rx.	Dur (d)	Results	2° Rx.	Dur (d)	Results	3° Rx.	Dur (wk)	Outcome	Immobilization	FU (wk)	Final results
1	1, 1	8	F	Fell backwards while walking	3 wk initial, referred after 6 mo	3, 5	5	14	3	6		1				PH × 6 wk, SC × 1 wk	108	1
2	1, 3	8	F	Shaking water from ear	4 wk	3, PT	4	7	3	4	10	3	5	3	1	PH × 3 mo	150	1
3	2, 4	7	M	Goldenhar syndrome, ear reconstruction	7 d	None	4	8	1	-	-	-	-	-	-	PH × 4 wk	NR	1
4	2	6	F	Crouzon syndrome, midfacial advancement	None	None	4	10	1	-	-	-	-	-	-	PH × 4 wk	2	1
5	2	10	F	Pharyngitis	7 d	None	4	14	1	-	-	-	-	-	-	PH × 2 mo	6	1
6	2	7	M	Awakened with stiff neck	10 d	None	4	3	2	4	4	2	-	-	-	None	2	1
7	2, 4	13	F	ADN	7 d	None	4	7	1	-	-	-	-	-	-	HC × 6 wk	2	1
8	2, 5	7	M	Tonsillectomy/ADN, Klippel-Feil	5 d	None	4	7	1	-	-	-	-	-	-	SC	2	1
9	2	8	F	Tonsillectomy/ADN	4 d	None	1	10	2		NR	2	NR	NR	NR	SC	1.5	1
10	5, 2	5	M	Golderhar Syndrome, Hemifacial microsomia. 2 episodes S/P mandibular reconstruction and zygoma and mandible reconstruction	4 d	None	4, 4	4, 5	1	-	-	-	-	-	-	PH × 4 wk, HC × 3 wk		1
11	5, 5, 2	9	M	Neck pain	Unknown	None	4	5	3	-	-	-	-	-	-	PH × 3 wk	18	3
12	4	6	M	Unknown	Unknown	None	1	-	-	-	-	-	-	-	-	-	-	No Ortho
13	4	5	M	Unknown	4-5 mo	None	Outpatient consult	-	-	-	-	-	-	-	-	None	NA	1
14	4	6	F	Scarlet fever	6 wk	6 wk of oral antibiotics	Outpatient consult	-	-	-	-	-	-	-	-	-	NA	1
15	4	6	M	Unknown	ER	None	1	-	-	-	-	-	-	-	-	-	-	No Ortho
16	4	8	M	Unknown	ER	None	3	-	-	-	-	-	-	-	-	PH × 8 wk	-	No Ortho
17	4	9	M	All terrain vehicle injury, occipital condyle fracture	None	None		1	-	-	-	-	-	-	-	-	20	1
18	4	6	F	Cervical lymphadenitis	None	2	4	-	-	-	-	-	-	-	-	HC × 1 wk	1	1
19	4	5	F	Congenital muscular torticolis	1 mo	Torticolis sx at 1.5 yr of age	Bipolar Release	-	1	-	-	-	-	-	-	-	-	-
20	4, 4	12	F	Retropharyngeal abscess	3-4 d	None	4	10	1	-	-	-	-	-	-	SC × 2 wk	3	1
21	4	6	M	Throwing ball	2 wk	4	4	14	2	-	7	2			2	Persistent	1	1
22	4	9	F	Unknown	None	None	PT	-03/ 17/ 003	-		-	-	PT			Recurrence	18	-
23	4	7	F	Choanal Atresia repair, ADN	2 d	2	1	2	2	4	-	-	-	-	-	CTO × 6 wk	9	1
24	4	8		Wrestling	None	None	3		-	-	-	-	-	-	-	HC	-	No FU
25	4	10	M	ADN	None	None	3	.	-	-	-	-	-	-	-	-	-
26	4, 4	8	F	Minor trauma doing handstand	None	None	4	5	1	-	-	-	-	-	-	-	18	1
27	4, 4	4	F	None	NA	None	3 PT	2	1	-	-	-	-	-	-	SC × 2 wk	2	1
28	5	12	F	Turning head during sleep	1 d	None	3	-	-	-	-	-	-	-	-	-	-	No FU
29	5	14	F	Down syndrome	None	None	4	10	2	-	-	-	-	-	-	PH × 6 wk/SC, PT	8	1
30	5	6	F	ADN	3-4 d	None	4	2	1	-	-	-	-	-	-	SC × 3 wk, PT	8	1
31	5	5	F	Pharyngitis	3-4 d	None	3	-	1	-	-	-	-	-	-	SC × 2 wk	8	1
32	5	7	M	Lymphadenitis	4 wk	PT	4	7	1	-	-	-	-	-	-	HC × 6 wk	20	1
33	5	6		ADN	None	None	4	3	1	-	-	-	-	-	-	HC × 6 wk, PT	6	1
34	5	6	F	Serving tennis	4 wk	None	3	10	1	-	-	-	-	-	-	-	1.5	No FU
35	5	9	M	URI	2 d	None	4	7	3	4	3	1	-	-	-	PH × 8 wk	10	1

All patients had neck pain, torticollis, and a normal neurologic examination. Clinical information includes age, gender, historical features, delay to presentation, previous treatment, treatment course and duration, immobilization, results and follow-up. Delay: Time from symptoms to evaluation in days; HC: Hard cervical collar; SC: Soft cervical collar; CTO: Cervicothoracic orthosis; PT: Physical therapy; AND: Adenoidectomy; URI: Upper respiratory infection; Treatment: 1: Analgesic with or without an antibiotic; 2: Analgesic, muscle relaxant, with or without an antibiotic; 3: Soft or hard collar; analgesic, muscle relaxant with or without an antibiotic; 4: Admission, skin traction, analgesics, muscle relaxant; 5: Skeletal traction; 6: C1-C2 arthrodesis; Results of treatment: 1: Resolved; 2: Persistent; 3: Relapse; Final results: 1: Asymptomatic, normal activities; 2: Persistent tilt, no pain, no other symptoms; 3: Persistent torticollis, pain and/or other symptoms.