Surgical Management of Adult Traumatic Atlantoaxial Rotatory Fixation with Hangman Fracture: Case Report and Literature Review

Document Type : CASE REPORT


1 Department of Neurosurgery, Shiraz University of Medical Sciences, Shiraz, Iran

2 Department of Surgery, Rafsanjan University of Medical Sciences, Rafsanjan, Iran


Atlantoaxial rotatory fixation (AARF) is a rare type of adult cervical spine injury. The classic symptoms 
are painful torticollis and limited neck range of motion. To avoid catastrophic consequences, early 
diagnosis is necessary. The present study presents the successful treatment of a scarce case of adult 
AARF with a Hangman fracture and a comprehensive literature review. A 25 -year-old man presented to 
the trauma bay with left-sided torticollis after a motor vehicle accident. Cervical computed tomography 
scans revealed type I AARF. Torticollis resolved after cervical traction with partial reduction, and 
posterior C1-C2 fusion was performed as part of the therapy. Recognition of AARF after trauma requires 
a high index of suspicion, and early diagnosis is critical for the achievement of the best possible patient 
outcomes. Since the combination of a Hangman fracture and C1-C2 rotatory fixation is complex and 
unique, it must be tailored to the associated injuries.
 Level of evidence: IV


Main Subjects

1. Greenberg MR, Forgeon JL, Kurth LM, Barraco RD, Parikh PM.
Atlantoaxial rotatory subluxation presenting as acute
torticollis after mild trauma. Radiol Case Rep. 2020;
15(11):2112-2115. doi: 10.1016/j.radcr.2020.08.028.
2. Singh V, Singh P, Balakrishnan S, Leitao J. Traumatic bilateral
atlantoaxial rotatory subluxation mimicking as torticollis in
an adult female. J Clin Neurosci. 2009; 16(5):721-722. doi:
3. Stenson D. Diagnosis of acute atlanto-axial rotatory fixation in
adults. Radiography. 2011; 17(2):165-170.
4. Chaudhary SB, Martinez M, Shah NP, Vives MJ. Traumatic
atlantoaxial dislocation with Hangman fracture. Spine J. 2015;
15(4):e15-8. doi:10.1016/j.spinee.2014.12.150
5. Eghbal K, Rakhsha A, Saffarrian A, Rahmanian A,
Abdollahpour HR, Ghaffarpasand F. Surgical Management of
Adult Traumatic Atlantoaxial Rotatory Subluxation with
Unilateral Locked Facet; Case Report and Literature Review.
Bull Emerg Trauma. 2018; 6(4):367-371. doi:10.29252/beat060416
6. Eghbal K, Derakhshan N, Haghighat A. Ocular Manifestation of
a Cervical Spine Injury: An Adult Case of Traumatic
Atlantoaxial Rotatory Subluxation Manifesting with
Nystagmus. World Neurosurg. 2017; 101:817.e1-817.e3.
doi:10.1016/j.wneu.2017.02.064 7. Levine AM, Edwards CC. The management of traumatic spondylolisthesis of the axis. Bone Joint Surg Am. 1985;
8. Spinnato P, Zarantonello P, Guerri S, et al. Atlantoaxial
rotatory subluxation/fixation and Grisel’s syndrome in
children: clinical and radiological prognostic factors. Eur J
Pediatr. 2021; 180(2):441-447. doi: 10.1007/s00431-020-
9. Vaccaro AR, Madigan L, Bauerle WB, Blescia A, Cotler JM.
Early halo immobilization of displaced traumatic
spondylolisthesis of the axis. Spine. 2002; 27(20):2229-33.
10. Goel A. Torticollis and rotatory atlantoaxial dislocation: A
clinical review. J Craniovertebr Junction Spine. 2019;
10(2):77-87. doi:10.4103/jcvjs.JCVJS_40_19
11. Fielding JW, Stillwell WT, Chynn KY, Spyropoulos EC. Use of
computed tomography for the diagnosis of atlanto-axial
rotatory fixation. A case report. J Bone Joint Surg Am. 1978;
12. Rahimizadeh A, Williamson W, Rahimizadeh S. Traumatic
Chronic Irreducible Atlantoaxial Rotatory Fixation in Adults:
Review of the Literature, With Two New Examples. Int J Spine
Surg. 2019; 13(4):350-360. doi:10.14444/6048
13. Rahimizadeh A, Williamson W, Rahimizadeh S. Traumatic
chronic irreducible atlantoaxial rotatory fixation in adults:
review of the literature, with two new examples. Int J Spine
Surg. 2019; 13(4):350-360. doi: 10.14444/6048.
14. Eghbal K, Derakhshan N, Haghighat A. Ocular manifestation of
a cervical spine injury: an adult case of traumatic atlantoaxial
rotatory subluxation manifesting with nystagmus. World
Neurosurg. 2017; 101:817.e1-817.e3. doi: