• Sung-Kyu Kim, Dong-Gune Chang, Jong-Beom Park, Hyoung-Yeon Seo, and Yuna Kim.
• Department of Orthopaedic Surgery, Chonnam National University Medical School and Hospital, Gwangju.
• Medicine (Baltimore). 2021 Jan 22; 100 (3): e24396.

RationaleTraumatic atlantoaxial anteroinferior subluxation associated with a dens fracture and a Hangman fracture is a very rare and complex injury. Therefore, appropriate surgical strategy is not established.Patient ConcernsAn 85-year-old female presented with posterior neck pain and atypical neck position caused after rolling down a hill. Although neurological examinations for motor, sensory, gait, and reflex tests were normal, the patient complained of an abnormal neck posture.DiagnosesRadiological examinations revealed an atlantoaxial anteroinferior subluxation with kyphosis, a type IIA dens fracture (Anderson and D'Alonzo classification) with an anterolateral rotatory angulation of type IIA dens fracture fragment, and a type I Hangman fracture (Levine and Edwards classification). Nevertheless, the transverse atlantal ligament was intact.InterventionsWe considered that the intact transverse atlantal ligament and kinking of the type IIA dens fracture fragment into the left lateral mass of C1 prevented a spinal cord injury by blocking a further displacement of C1 to C2. Due to the patient's osteoporosis and the anterolateral rotatory angulated type IIA dens fracture fragment, a forceful reduction of the atlantoaxial anteroinferior subluxation with kyphosis could pose a high risk of fixation failure and spinal cord injury. Therefore, we performed in-situ posterior C1-2 fusion using a C1 lateral mass screw and C2 lamina screw fixations.OutcomesAt 1 year after surgery, the bone union of all fractures was achieved in the kyphosis state. Furthermore, the patient's clinical symptoms were improved with no neurological deficit.LessonsA thorough radiological examination and appropriate surgical strategy are important for successful diagnosis and treatment of a complex C1-2 injury.Copyright © 2021 the Author(s). Published by Wolters Kluwer Health, Inc.

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