What is the prognosis and treatment for a subluxation (partial dislocation) of the neck in a 4-year-old child?

Management and Prognosis of Neck Subluxation in a 4-Year-Old Child

Prompt medical evaluation and appropriate treatment of neck subluxation in a 4-year-old child is essential, with most cases responding well to conservative management if diagnosed early.

Types of Neck Subluxation in Children

• Atlantoaxial rotatory subluxation (AARS) is the most common form of neck subluxation in children, characterized by abnormal rotation and fixation of the atlas (C1) on the axis (C2) 1, 2
• Traumatic subluxation can occur following minor trauma, falls, or ENT procedures 1, 3
• Grisel's syndrome refers specifically to non-traumatic atlantoaxial subluxation typically following ENT surgery or head/neck infections 1

Clinical Presentation

• Typical presentation includes painful torticollis ("cock-robin" position), with the head tilted to one side and rotated to the opposite side 2, 3
• Neck pain and reduced range of motion are common symptoms 3, 4
• Children may present with delayed onset of symptoms, often more than 24 hours after the initial injury event 3
• Young children (mean age 7.7 years) are more commonly affected than older children 3

Diagnostic Approach

• Prompt imaging is essential for accurate diagnosis and treatment planning 5
• CT scan with 3D reconstruction is the gold standard for diagnosis of atlantoaxial subluxation, allowing classification according to the Fielding-Hawkins system 1
• Dynamic CT studies may be needed to verify the subluxation in some cases 2
• MRI is appropriate when there is concern for spinal cord involvement or ligamentous injury 5
• Radiographs may show persistent asymmetry of the odontoid in relation to the atlas but have limitations in young children due to normal variants that can mimic pathology 5

Treatment Options

Treatment should be based on the severity, duration, and stability of the subluxation:

Conservative Management (First-Line)

• For minor and acute cases: soft cervical collar, rest, and analgesics 2, 4
• For moderate cases: cervical immobilization and physical therapy 4
• Most cases (96%) can be managed conservatively 1

Advanced Interventions

• For more severe cases: head halter traction 2
• For persistent or high-grade instability: halo traction (16% of cases) 3
• Surgical intervention (internal fixation) is reserved for irreducible or recurrent subluxation (approximately 4% of cases) 3, 4

Prognosis

• Early diagnosis and appropriate treatment lead to excellent outcomes in most cases 1, 4
• Conservative treatment is successful in the majority of cases when diagnosed early 4
• Approximately 8.8% of conservatively treated cases may recur, requiring surgical intervention 1
• Only 3.6% of patients develop long-term sequelae, with minor limitation of neck movement being the most common 1
• Delayed diagnosis (beyond 4 weeks) is associated with poorer outcomes and may necessitate surgical intervention 1, 4

Important Considerations and Pitfalls

• Cervical spine injuries in children differ from those in adults due to anatomical differences and greater ligamentous laxity 5
• Normal variants in young children under 8 years (such as pseudosubluxation of C2-C3) can complicate radiographic interpretation 5
• The risks of sedation for imaging should be balanced against the benefits, particularly when radiographs are normal 5
• Child abuse should be considered as a possible etiology in any child younger than 5 years with trauma affecting the neck 5
• Failure to identify an unstable spine injury can lead to increased patient morbidity, while unnecessary immobilization can result in skin breakdown 5

Follow-up Recommendations

• Regular follow-up is essential to monitor for potential complications such as recurrence or neurological changes 1
• Physical therapy may be beneficial during recovery to restore normal range of motion 4
• Parents should be educated about potential warning signs that would necessitate immediate medical attention 1