Background Traumatic occipitocervical dislocations (OCDs) are rare and potentially devastating injuries, and delayed diagnosis and management is a well-known risk factor for poor outcomes in high energy trauma. Early surgical stabilization has been shown to improve outcomes and neurologic recovery in these patients. We present a case of incongruent atlanto-occipital (O-C1) joints found on post-operative computed tomography (CT) imaging following C1-C2 fusion. This patient was treated non-operatively in a cervical collar (C-collar) after traction testing revealed no dynamic instability. Case Description A 19-year-old male with history of obesity was involved in a high-speed motor vehicle collision (MVC). On arrival, he had elevated troponins but otherwise normal laboratory workup and electrocardiogram (EKG). He remained hypotensive throughout his initial presentation. A reliable neurologic exam could not be obtained due to the patient’s intubated and sedated status, however, bulbocavernosus reflex was intact, reflexes were normal and the patient did not demonstrate evidence of spinal or neurogenic shock. CT of the full spine revealed distraction of the C1-C2 articulation without associated fracture, and without clear disruption or distraction of the O-C1 joint. He was taken to the operating room for C1-C2 posterior instrumentation and fusion. Post-operative cervical spine CT revealed further distraction and subluxation of the occipitocervical junction bilaterally, with condyle to C1 interval (CCI) of 4-mm bilaterally, a basion-dens interval (BDI) of 10 mm, and a Power’s Ratio of 1.1. The patient was brought back urgently to the operating room for traction testing to rule out OCD. There was no distraction noted on dynamic traction testing, and the patient was treated non-operatively in a C-collar. At 12 weeks post-injury, the patient experienced no neck pain, and flexion/extension radiographs showed no evidence of subluxation or distraction at the O-C1 joints. Conclusions Incongruity of the O-C1 joint may not be synonymous with instability as previously thought, and in cases of O-C1 incongruity with stable traction testing, non-operative treatment with external immobilization can be considered as a viable treatment option even in the polytraumatized patient.

Introduction:Conversion of provisional external fixation to intramedullary nail (IMN) in femur fractures has been reported to be safe within 14 days of initial surgery. However, there is no current literature guiding this practice in tibial fractures. The purpose of this study was to identify the time period when conversion of external fixation to nail in tibial fractures is safe.Methods:After obtaining IRB approval, tibial fractures (OTA 41A, 42, 43A) that received provisional ex-fix and were converted to IMN from 2009 to 2019 were retrospectively reviewed. Skeletally mature patients with minimum 6 months of follow-up were included. The primary outcome was deep infection. External fixation days were categorized as less than 7, 8 to 14, and 15+ days. Risk ratios of infection were estimated using generalized linear regression with a Poisson distribution. A separate regression model evaluated risk factors for infection using both the external fixation and non–external fixation tibial cohorts.Results:Twenty-eight patients (32%) were treated for deep infection. The infection rate for closed fractures was 28% (11 of 39 patients) and for open fractures was 35% (17 of 49 patients) (P = 0.56). Examining both tibial cohorts, external fixation (odds ratio [OR] = 2.39, P = 0.017), open fracture (OR = 3.13, P = 0.002), and compartment syndrome (OR = 2.58, P = 0.01) were all associated with infection in regression modeling. Median external fixation days for patients with deep infection was 8 days (Inter‐quartile range, 3 to 18 days) as compared with 4 days (IQR, 2 to 9 days) in patients without infection (P = 0.06). While controlling for open fractures, the 8- to 14-day group had RR = 1.81 (P = 0.2), and the 15+-day group had RR = 2.67 (P = 0.003) as compared with the <7-day group.Discussion:Infection rates of tibial fracture patients treated with external fixation and converted to IMN were high. Surgeons should strongly consider the necessity of external fixation for these fractures. Earlier conversion of external fixation to definitive fixation reduced infection rates.Level of Evidence:Level IV—case series