Dislocations of the first two cervical vertebrae are rare and very often fatal. We report a case of vertical atlantoaxial dislocation with no neurological signs and with a favourable outcome.A 62-year-old man was driving his car with his seat belt fastened when he had a violent head-on collision with a farming machine at the level of the plough. Axial traction responsible for hyperextension of the cervical spine and stretching of the left brachial plexus occurred. On arrival at the emergency unit, he had respiratory distress and blood aspiration due to a facial trauma. The Glasgow score was 3 and a CT scan of the brain showed mild intraventricular bleeding on the right.Plain radiographs of the cervical spine disclosed isolated C1-C2 dislocation, with a vertical C1-C2 gap exceeding 20 mm (Fig. 1). An emergency arteriogram of the aortic arch showed no abnormalities (Fig. 2).Immediate external reduction was carried out by applying firm pressure along the axis of the head under fluoroscopy (Fig. 3). Post-reduction stability was assessed during small flexion-extension motions.Tracheotomy and reconstructive maxillofacial surgery were immediately carried out, allowing secondary spinal stabilisation using a posterior approach in the prone position. Traumatic dura mater tears were identified and treated by biological glue. Posterior atlantoaxial fixation was performed using a combination of atlantoaxial grafting and wiring.Temporary fixation using an occipital-C4 plate (Howmedica) was performed (Fig. 4) to reduce the need for external immobilisation (cervical brace only). On day 9, an infection secondary to an occipital pressure sore was diagnosed. Microbiological studies of cerebrospinal fluid obtained by lumbar puncture were negative. On day 11, a revision was performed, but the fixation material was left in place.The patient was discharged from the intensive care unit after 3 months. He was still on antibiotic therapy, but had no tracheotomy or evidence of local infection. He had a persistent neurological deficit in the left upper limb, shown by electromyography to be secondary to the brachial plexus stretching. There was no evidence of spinal cord injury.One year later, the occipito-cervical plates were removed. Range of motion in all planes was excellent and the patient was fully pain free. The residual neurological deficit in the left upper limb was very mild (muscle score at 4+). DiscussionWe found no similar case of vertical atlantoaxial dislocation in the literature [2,10]. Furthermore, our clinical case calls for comments regarding three important points, namely:1. Interpretation of the lesion-inducing process 2. Patient status and absence of medulla oblongata or spinal cord neurological signs 3. Surgical strategy Abstract An unusual case of vertical atlantoaxial dislocation without medulla oblongata or spinal cord injury is reported. The pathogenic process suggested occipito-axial dislocation. The case was treated surgically with excellent results on mobility and pain.

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The sandwich operation in the surgical cure of the hallux valgus is an original technique. This evolution sprang from the limitations of the Petersen operation. It consists in a conservative arthroplasty of the 1st phalanx of the great toe combined with the Petersen technique. It allows three spatial modifications of the great toe deformity: a shortening, a rotation and a varisation.