A pictorial review of atlanto-axial rotatory fixation: Key points for the radiologist

Atlanto-axial rotatory fixation (AARF) is a rare condition which occurs more commonly in children than in adults. The terminology can be confusing and the condition is also known as 'atlanto-axial rotatory subluxation' and 'atlanto-axial rotary dislocation'. Rotatory fixation is the preferred term, however, as in most cases the fixation occurs within the normal range of rotation of the joint. By definition, therefore, the joint is neither subluxed nor dislocated. AARF is a cause of acquired torticollis. Diagnosis can be difficult and is often delayed. The radiologist plays a key role in confirming the diagnosis. The classification system proposed by Fielding in 1977 is most frequently used and will be discussed in detail. Given that this classification system was devised in the days before computed tomography (CT), as well as the fact that combined atlanto-axial and atlanto-occipital rotatory subluxation (AORF) is omitted from the classification, we propose a modification to the classification of this rare but significant disorder. The radiological findings in six cases of AARF will be illustrated, including a case with associated atlanto-occipital subluxation. The pertinent literature is reviewed and a more comprehensive classification system proposed. The imaging approach to diagnosis and the orthopaedic approach to management will be discussed.