The patient was admitted to Arabic Center 26-October-2010 after falling down in the early morning. He progressed small ICH hematomas both cerebral hemispheres and severe fracture of the C3 and C4 bodies with dislocation of the upper part of the cervical column from the the caudal part with severe extension disruption. He got also several minor injuries. He is a known patient with Ankylosing spondylitis and Alzheimer  disease.

MRI and CT-scan performed confirming the presence of the above mentioned fractures of the cervical spine.

The patient was sent to Shmaisani hospital and upon examination with the Philadelphia collar, he was moving all limbs and he was not responding to verbal commands due to advanced Alzheimer disease.

Using anterior approach with weight 15 Kg applied to the Hallo traction was unable to perform any reduction of the dislocation. Skeletonization of C2, C3-4-5 revealed that the C3 and 4 were completely crushed. Traction was increase to 18 Kg and various positions with neural and overflexion was used to perform open reduction. It was possible to perform the reduction after removing several bony obstacles, locking the dislocation with the patient in overflexion setting.

Using 3 level Trinica plate, the screws were inserted to the C2 body and part of the deformed C3 in the left side. It was impossible to use the C4 because it was friable, for fixation. Three screws were used to fuse C5  at different locations. Overdistraction with weights over 18 KG were avoided  so as to avoid traction injury to the spinal cord. Trying to put the patient in stress extension, showed that the lower screws slipped out from their places and the dislocation regained the initial position. The patient was put back in flexion traction and longer 18 mm screws with wider diameter 4.6  were reinserted to different directions. The traction was removed and another check for the screws was performed. The construct is stable . 12 ml Novabone was inserted to fill the bony gaps were there was no bone at C3 and C4 bodies. The reduction was not perfectly reduced and it was acceptable.

Routine closure of the wound and the patient was awakened and he start to move the four limbs. He was put in ventilator to 2 days to pass the period of retropharyngeal swelling.

The patient has an ugly dislocation with complete destruction of C3 and C4. This type of fracture is unstable and can trigger a fatal sequels if not fused and stabilized.

The ankylosing spondylitis  made the fracture strangely looking, that the fracture was involved the bones and calcified tissues. The later caused difficulty in performing even open reduction.

Over distraction was avoided to prevent vertebral arteries injury or spinal cord distraction, for what the acceptable reduction was sufficient to achieve.