Pediatric emergency medicine trisk 905
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patient’s radiographs but should be considered if the head cannot be rotated past
midline. Rotary subluxation or displacement may be spontaneous or follow an
upper respiratory tract infection or traumatic event with variable severity. These
patients rarely present with abnormal neurologic findings. In these patients, their
chin will often point to the same side as the SCM spasm giving the child the
typical (cock robin) position. This presentation is logical considering that the
SCM muscle is attempting to reestablish normal neck position. Radiographs may
be useful to help distinguish between muscular torticollis and rotary subluxation,
although the radiographs may be normal in both cases ( Figs. 112.32 and 112.33 ).
Rotary subluxation should be suspected if, on an open-mouth radiograph, one of
the lateral masses of C1 appears forward and closer to the midline whereas the
opposite lateral mass appears narrow and away from the midline (lateral offset). A
CT scan is the most useful diagnostic tool in rotary subluxation ( Fig. 112.33 ).
Patients with mild rotary subluxation should be treated with a cervical collar and
analgesia for comfort, whereas those with moderate or resilient rotary
displacement may need immobilization, traction, or surgical intervention. If
anterior displacement of C2 on C1 is present, longer immobilization may be
needed to allow injured ligaments to heal.
FIGURE 112.32 Torticollis (wry neck). A: Lateral cervical radiograph with C2 cocked forward
on C3 and normal predental space (arrow ). B: Anteroposterior (AP) view demonstrating
spinous process of C2 (asterisk ) on the same side of the midline as the mandible points. C:
Difficult to interpret lateral cervical spine because of the rotation effect of torticollis. D: AP
view demonstrating spinous process of C2 (asterisk ) on the same side of the midline as the
mandible points. (Reprinted with permission from Swischuk L. Emergency Radiology of the
Acutely Ill or Injured Child . 2nd ed. Baltimore, MD: Williams & Wilkins; 1986:588.)
