TRANSVERSE
LIGAMENT
RUPTURE
SUBLUXATION
YIZHAR
FLOMAN,
LEON
From
We report
four
children
treated
by posterior
fusion
IN
KAPLAN,
Hadassah
years
intervals
atlas-dens
at C1-C2
after
the failure
stabilisation
level
trauma
drosis
the
in children
usually
are
causes
etal
cases
have
even
more
a fracture
rare,
through
since
the
local
four
traumatic
ruptures
of
Two of
(Blatt
(Table
University
I). One
hit by vehicles
in an
accident.
child
when
All
The
had
head
injuries,
depressed
fracture
of the skull; two
and one had a supracondylar
fracture
one
with
had fractured
ribs,
ofthe humerus.
Floman,
MD, ProfessorofOrthopaedic
Surgery
Kaplan,
MD, Instructor
in Orthopaedic
Surgery
Elidan, MD, Senior Lecturer
in Otolarygology
Umansky,
MD, Senior Lecturer
in Neurosurgery
Hadassah
University
Correspondence
©
Hospital,
should
Jerusalem
of the
patients
were
before
the fusion.
treatment
is likely
to
a
91120,
and Joint
in the
diagnosis
six
diagnosis
three
of
of ligamentous
the children
and
a painful
and one
one
two
14 days,
Cl-C2
had had
long
when
the
was made,
conservative
for six to eight
this
had
tract
ligament
and
instability
a trial of
casts
Despite
one
some
of transverse
to
in Minerva
in traction.
torticollis,
had
treatment,
weeks,
the
atlanto-
axial
subluxation
persisted,
and the patients
were referred
spine centre.
Lateral radiographs
ofall four showed an intact dens
with increase
in the atlas-dens
interval
(ADI) of 6, 7, 8
to our
13 mm
and
respectively
views
decreased
In the
child
be fixed
near
forward
between
with
calcified
in three
an ADI
of 13 mm,
with cervical
the dens and
dystrophic
the
the
of the
Flexion-
in flexion
four
children.
of
the dens
anterior
atlas
(Fig.
Sc).
tissue
remnants
to block
3).
increased
appeared
to
part of the atlas and did not
extension
(Figs 4 and 5), the
the posterior
presumably
1, 2 and
that the ADI
in extension
with
move
space
(Figs
showed
the
being
This
ruptured
filled
tissue,
ligament,
movement.
TREATMENT
Israel.
All four
children
sublaminar
be sent to Dr Y. Floman.
1991 British
Editorial
Society ofBone
0301-620X/91/4152
$2.00
J Bone Joint Surg [Br]
1991 ; 73-B : 640-3.
640
all four
from
ranged
appeared
Y.
L.
J.
F.
delay
rupture
and
two to nine years, were seen at
Hospital
over an 11-year
period
had fallen
from a height,
two were
walking
and one was a car passenger
four
ligament
In one child with quadriparesis
All the children
had
signs of quadriparesis
extension
aged
children,
13 mm;
of the odontoid
was performed
level of suspicion.
Conservative
treatment,
with
1981).
Hadassah
of the transverse
treatment.
signs.
PATIENTS
The
tears
of 6, 7, 8 and
frank
synchon-
C1-C2
subluxation.
briefly reported
elsewhere
been
traumatic
is indicated.
of the dens.
We report
four children
transverse
ligament
and
the four
UMANSKY
rare in this age group since trauma
usually
causes
a
resulted
from falls or motor vehicle
accidents,
with
(ADI)
Trauma
to the cervical
spine in adults most commonly
involves
its lower part, but in children,
although
such
lesions are rare, they are mostly found in the region of Cl
and C2 (Fielding
1984). Ligament
injuries
at the atlantoaxial
FELIX
Jerusalem
ofconservative
and a fixed ADI of 13 mm, transoral
anterior
resection
Diagnosis
of this traumatic
lesion requires
a high
fail; surgical
ELIDAN,
Hospital,
with
This is extremely
injury. The injuries
ATLANTO-AXIAL
CHILDREN
JOSEF
University
two to nine
aged
atlas and atlanto-axial
subluxation.
skeletal
rather than a ligamentous
considerable
delay in diagnosis.
Flexion
radiographs
showed
AND
Surgery
grafts.
halo-cast
surgery.
had
wires,
Three
which
a posterior
using
were
was
In one child
THE
performed
retained
a ‘rigid’
JOURNAL
C1-C2
autogenous
after
fusion,
iliac
immobilisation
for six to eight
collar
OF BONE
two with
crest
AND
in a
weeks
was used.
JOINT
bone
The
after
child
SURGERY
TRANSVERSE
Table
I. Clinical
details
LIGAMENT
of four
RUPTURE
children
treated
by C1-C2
fusion
Age
(yr)
Sex
Injury
Other Injury
Delay In
diagnosis
1
9
M
Fall
Concussion
12 days
2
5
M
RTAt
Pedestrian
Concussion
Fracture
of
and
3
2
F
RTA
Car passenger
Concussion
4
4
F
RTA
Pedestrian
Depressed
of skull
Fractured
*ADI,
atlas-dens
tRTA,
fusion
road traffic accident
preceded
by transoral
Fig.
flexion.
ATLANTO-AXIAL
Case
humerus
Case
AND
3. Figure
Figure
1
2
-
ligament
rupture
Conservative
ADI
(mm)
Neurology
management
Operation
7
Normal
Traction
3 weeks
Fusion
12 days
8
Hyper-reflexia
Halo-cast
6 weeks
Fusion
14 days
6
Normal
Minerva
6 weeks
fracture
6 days
13
Quadriparesis
Minerva
halo-cast
3 months
ribs
resection
Fig.
of a two-year-old
confirming
Fig.
73-B,
No. 4, JULY
1991
Gallie
fusion
Gallie
fusion
of the dens
the increased
girl injured
atlas-dens
2
Fig.
in a motor-vehicle
interval.
Figure
3
accident,
-
After
Cl-C2
showing
posterior
an atlas-dens
fusion
Case 4. Figure
4 - Lateral
radiograph
of a four-year-old
girl
knocked
down
by a car. There
is extreme
displacement
of
the dens,
with an ADI of 13 mm. Figure
Sa - Initially,
a CT
scan in a Minerva
cast shows
that the AD! is only moderately
increased.
Figure Sb - Another
section
at a later date shows
flecks of bone avulsed
from the atlas.
Figure
Sc - The space
between
atlas and dens contains
calcified
dystrophic
tissue.
VOL.
plaster
interval
radiograph
CT scan
for transverse
641
IN CHILDREN
ribs
1
Lateral
-
SUBLUXATION
Sa
Fig.5b
Fig.
4
Fig.
Sc
with
3
interval
sublaminar
of 6 mm in forward
wires.
642
Y. FLOMAN,
with fixed atlanto-axial
dislocation
resection
of the odontoid
process
fusion (Fig. 6).
L. KAPLAN,
had anterior
before
the
J. ELIDAN,
transoral
posterior
and
ranging
from
children
had a satisfactory
pain and torticollis.
Two
a 4 mm
interval.
neurological
to 10 years,
fusion with
had a normal
There
signs
was
in both
complete
relief of
ADI and one had
resolution
affected
all the
of the
abnormal
children.
and
Chung
1978).
that
an ADI
pathological
Locke,
that
widest
most
the
were
of 4 mm
in children.
Gardner
ADI
3 mm or less.
or
more
Cattell
should
be
and Filtzer
an ADI of 3 mm or more in 20% of
the age of seven years, but consider
that
displacement
by over 5 mm in flexion
indicates
ligament
rupture,
especially
with a history
of trauma.
Filipe,
Demay
and Zakine
(1989) believe that anterior
displace-
endanger
1968).
the age of seven
fractures
(Sherk,
Traumatic
rupture
in
They
(1965) reported
children
under
must
Cervical
spine injuries
are rare under
years, and 75% of these are odontoid
while
children,
ment
of over
10 to 12 mm signifies
a tear of the
ligamentous
complex.
In such a case, the displaced
DISCUSSION
Nicholson
was 3.5 mm,
consider
considered
six months
of 200 normal
(1966)
found
In a review
Van
Epps
flexion
RESULTS
At follow-up,
F. UMANSKY
Such
possibility
1957).
the
spinal
excessive
ofobstruction
entire
dens
cord in the ‘safe zone’ (Steel
displacement
also raises
the
of the vertebral
arteries
(Werne
of the
transverse
ligament
is extremely
rare in children,
since
the synchondrosis
of the dens is usually weaker
than the
ligaments.
In their classic paper on this ligament
injury,
Fielding
et al (1974) reported
11 patients,
only one being
under six years of age, while the others were young adults
or teenagers.
Pennecot
et al(1984)reported
three children
with traumatic
atlanto-axial
instability,
ofwhich
one was
shown
at post-mortem
to have a transverse
ligament
rupture.
Birney and Hanley (1989) surveyed
84 paediatric
and adolescent
cervical
spine injuries
finding
only two
cases of transverse
ligament
rupture.
We have seen four
paediatric
cases in 1 1 years.
Ligament
insufficiency
or rupture
secondary
to
inflammatory
or rheumatoid
disease may be seen (Werne
1957 ; Fielding
to trauma
The
1984)
is found
transverse
and
transverseligament
in adults
(Levine
rupture
and
Edwards
due
Fig. 6
1986).
ligament
is a tight band between
the
tubercles
on the medial
side of the lateral masses
of the
atlas, passing
behind
the dens and holding
it against
the
articular
notches
on the posterior
surface
of the anterior
arch of the atlas. It provides
primary
stability
and is
supplemented
by the alar, apical cruciate,
accessory
and
capsular
ligaments.
et al (1974) found
two
In a biomechanical
modes
of failure
Atlanto-axialligament
leading,
in our own
study,
Fielding
of the transverse
ligament
: usually the body of the ligament
ruptured,
but
occasionally
a fleck of bone was avulsed
from the lateral
masses of the atlas (see Fig. Sb).
Mechanisms
ofinjury
to the ligament
include forced
forward
flexion
and
axial
loading
of the
atlas,
opening
the ring and causing
secondary
rupture
of the transverse
ligament,
as in a Jefferson
fracture
with atlanto-axial
subluxation.
In cadaveric
specimens,
Spence,
Decker
and Sell (1970) showed
that a 6 to 9 mm displacement
of
the lateral masses of the atlas will rupture
the transverse
ligament.
The
diagnosis
radiological.
will maintain,
flexion
anteriorly
or extension.
and
of
transverse
ligament
An intact atlanto-axialligamentous
in adults,
an ADI of 3 mm
Injury
increases
allows
the ADI.
the atlas
rupture
complex
or less during
to be displaced
Case
4. CT scan
after
transoral
resection
of the dens,
showing
the defect
in the anterior
arch of the atlas and
absence
ofthe
odontoid.
Some calcified
remnants
are still
visible
at the site of the dens.
is
diagnosis
and
previously
is important,
cases
injuries may easily be missed,
to several
days delay
in
up to five years
(Pennecot
since
in those
et al 1984).
neurological
few cases
A high level
compromise
published
of suspicion
or deterio-
ration
may occur.
The atlanto-axial
subluxation
may
become
fixed, as in one of our patients
(Fig. 5).
Fielding
et al, in 1974, stated
that treatment
for
transverse
ligament
rupture
should
be surgical,
but in
1984
Fielding
suggested
that conservative
measures
should be tried. We consider
that conservative
treatment
is unlikely
to succeed
or to provide
a stable
atlanto-axial
articulation.
Conservative
treatment
failed to produce
a
stable reduction
in our series : we consider
that a posterior
fusion,
method,
and
in the reduced
is the treatment
Hawkins
odontoid
process
1978).
position,
preferably
by the Gallie
of choice
(Hensinger,
Fielding
Where
in the ‘safe
THE
JOURNAL
there
zone’
OF BONE
is
fixation
of Steel,
AND
of
the
a transoral
JOINT
SURGERY
TRANSVERSE
approach
should
decompress
be used
the spinal
LIGAMENT
RUPTURE
to resect
the
displaced
(Fang
and
Ong
cord
AND
dens
ATLANTO-AXIAL
and
Filipe
1962 ; P#{225}sztor
1985).
We wish to thank
Doctors
3 and 4 to our care.
No benefits
in any
from a commercial
party
this
A. Hannani
and
E. Frish
for referring
cases
form
have
been
related
directly
received
or
or indirectly
will be received
to the subject
of
Hensinger
Levine
and
Locke
Blatt
Catteil
Fang
TJ, Hanley
adolscence.
EN Jr. Traumatic
cervicalspine
Spine
1989; 14:1277-82.
JM,
Shiloni
E, Robin
GC,
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