Atlantoaxial Rotatory Fixation: Current Challenges and Advances in Diagnosis and Management.

» Atlantoaxial rotatory fixation (AARF), also known as atlantoaxial rotatory subluxation (AARS), is an uncommon cervical disorder that occurs predominantly in children and typically presents with painful torticollis in the characteristic "cock-robin" position. It is frequently associated with upper respiratory infections, minor trauma, or recent otolaryngologic procedures. » Computed tomography (CT) is the gold standard for diagnosing AARF because it provides accurate assessment of atlantoaxial alignment and rotational deformity. » Several classification systems have been proposed to characterize AARF, including the Fielding and Hawkins classification, the Pang-Li dynamic CT classification, and the PUTH classification, which incorporates reducibility to help guide treatment decisions. » Management strategies range from nonoperative treatments-such as cervical immobilization and traction-to more invasive nonoperative interventions, including manipulation under anesthesia or halo traction, depending on symptom duration and reducibility. » Surgical stabilization, most commonly posterior C1-C2 fusion using techniques such as the Goel-Harms construct, is generally reserved for irreducible deformities or cases that fail conservative management, highlighting the need for standardized diagnostic and treatment algorithms.