The median atlantoaxial joint between the anterior arch of the atlas and the odontoid process is the principal rotation joint of the cervical spine. The dens pivots within the ring formed by the anterior atlas arch anteriorly and the transverse ligament posteriorly. This joint accounts for nearly half of all head rotation, making it the most mobile single joint in the cervical spine and the one most vulnerable to destabilisation from trauma or inflammatory arthritis.
Down syndrome, rheumatoid arthritis, and high-energy cervical trauma all produce atlantoaxial instability at the median joint. The atlanto-dens interval (ADI) on lateral cervical radiographs normally less than 3 mm in adults (5 mm in children) increases in instability. ADI greater than 5 mm in adults requires surgical stabilisation.
Locked rotatory subluxation of C1 on C2 producing the torticollis posture that fails to reduce spontaneously, managed with traction and immobilisation in acute cases.
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