We present four patients who had sustained a traumatic dislocation of the atlanto-occipital joint. The diagnosis was initially missed in two patients. One patient, who was neurologically intact, was treated non-operatively. The remaining three recovered neurologically after an occipitocervical fusion. Early recognition of the injury, especially in multiply-injured patients with head injuries, and timely management may improve survival and neurological recovery.

Injuries at the occipitocervical junction are commonly due to high velocity trauma. Because of severe injury to the cervicomedullary junction and concomitant cerebral trauma, they are usually fatal. We describe our experience in the management of five patients who initially survived the injuries.

Between 1995 and 2000 we treated four men and one woman, ranging in age from 23 to 47 years, injured in motor vehicle accidents. All patients had head injuries, three with cranial nerve involvement, and four had polytrauma. Although initial radiographs of the skull included the occipitocervical junction, the traumatic disruption of the occipitocervical junction was not diagnosed for between two days and five weeks. One patient, who had no neurological deficit, developed periodic weakness of the lower limbs with rotation of the neck. In three patients the dislocation was posterior and in two it was anterior to Wackenheim’s line.

Three of four patients who required ventilatory support died before surgical stabilisation. The dislocation was reduced in only one of the remaining two, both of whom underwent a successful occipitocervical fusion (O-C2), with subsequent complete neurological recovery.

In patients with polytrauma, meticulous clinical evaluation and appropriate radiographic investigations of the occipitocervical junction are essential for early recognition and management of this potentially fatal injury.