Isolated synchondrosis fracture of the atlas presenting as rotatory fixation of the neck: Case report and review of literature

BACKGROUND: Exclusive to the pediatric population, cartilaginous fractures of the atlas are singularly rare. Rarer still are those fractures that produce a fixed, rotational deficit of the neck. Here, the authors present the case of a 4-year-old boy with an isolated fracture of the anterior synchondrosis of C1 with a rotational component following a fall, as well as a review of the literature. Management with serial bedside manipulation, which is unique to our report, helped conservatively correct the rotation of the patient's neck, and, coupled with rigid bracing, demonstrated a comprehensive management strategy that resulted in fracture ossification at 3 months. CASE DESCRIPTION: Our patient is a 4-year-old boy who fell from a bunk bed and complained of severe neck pain. The patient was brought to the emergency room and was found to have an isolated anterior fracture of the right frontal synchondrosis of the atlas. After conservative management with a hard collar and cautious manual reductions at the bedside, rotation of our patient's neck spontaneously resolved on day 3. After 3 months of rigid immobilization, the patient remained at neurological baseline and his fracture was healed. Literature review demonstrated age range between 2 and 6 years, with a subset of patients demonstrating rotational components to their fractures. Complete resolution of nearly all patients treated with rigid immobilization after fracture was documented, yet several patients experienced delayed diagnosis. CONCLUSIONS: Knowledge of the radiographic appearance of the C1 ossification centers as well as the normal timeline and sequence of ossification is essential in differentiating a true synchondrosis fracture from normal, nonossified cervical cartilage. With early diagnosis, immobilization, pain control, and muscle relaxants, patients can recover well with conservative management, can successfully ossify fracture sites, and can recover without sequelae.