Hot Seat #262: A “collarly” debate
Posted on: September 12, 2026, by : Brittany Fitzpatrick
Case by Kate Ritter, CNH PEM Fellow
You get a call about a trauma transfer from OSH.
Patient is a 22-month-old male who was sitting in the front seat of a non-electric bike going 20 mph on a gravel trail (dad was pedaling), patient’s foot got caught in the front wheel and both patient and dad flew off bike. Patient has a “non-displaced mandibular fracture” and “widening of the right lateral dental ligament” “c/f ligamentous injury of the neck.” Patient was helmeted. Abdominal CT looks normal. Outside hospital was unable to get labs or place an IV due to pt age and cooperation. Foot XR no fracture. No LOC reported. Awaiting final reads on pan-scans.
VS from pre arrival HR 127, RR 24, sat 97%, T 36.5.
Patient arrives (by air, as he’s from 2.5h away). On arrival, he is sitting calmly and happily, looking around, moving his neck all around. He does not arrive in a collar. By doorway exam, A/B/C grossly intact and GCS 15. He has abrasions and bruising to his R cheek and mandible with a contusion to his R lip with apparent soft tissue swelling. When giving report, transport tells you that the final read CT neck was negative and OSH cleared the C-collar. He also has abrasions to his RLE. He has no IV.
Primary survey is negative and secondary survey reveals a posteriorly displaced R mandibular lateral incisor. Secondary survey otherwise negative.
Once patient is settled in a room and you’ve handed off the discs for upload, you review his packet from OSH. There are no final reads in the papers he came with, but the pre-arrival was subsequently updated with the final reads.
Pre arrival updated with final CT reads:
CT neck: No acute fracture of the cervical spine. Asymmetric widening of the right lateral atlantodental interval, questionably from positioning versus ligamentous injury. Suggest further evaluation with MRI.
CT facial bones: Nondisplaced fracture of the right parasymphysis of the mandible extending to the mandibular symphysis.
CT head: No CT evidence of acute intracranial abnormality.
CT A/P: No acute traumatic findings in the chest abdomen or pelvis.
Second reads completed.
CT C-spine: Minimal apparent widening of the right atlantodental interval. This is likely secondary to patient rotation during imaging, however underlying mild ligamentous injury is not entirely excluded. Given measurement is below 5 mm, atlantoaxial instability is highly unlikely. Recommend clinical correlation and consider cervical spine MRI if clinically indicated.
CT A/P: Bilateral inguinal testes, otherwise normal CT of chest/abdomen/pelvis
CT head: Negative
CT max face: Nondisplaced fracture of the right anterior mandible with the fracture extends through the right central and lateral incisors, with associated soft tissue swelling of the chin. Small areas of increased attenuation along the anterior medial and anterolateral right orbital globe, as described above. Etiology unclear, might be related to prior surgery. However, sclerochoroidal calcification could be underlying possibility.
XR RLE: Negative
Ortho resident on for spine and sees the patients and reviews images. Based on their exam low suspicion for ligamentous injury but recommends discharging in a collar and following up in clinic in 1 week. OMFS sees patient and recommends soft diet and non-operative management for mandibular fracture and follow up in 2 weeks. Dental reviews images of teeth and no acute dental intervention. Optho does not know what to make of the incidental findings but does not think it requires intervention. Tertiary survey is negative, patient continues to have full painless ROM of neck.
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If the child is fully rotating their neck without any discomfort, by definition there is no C1-C2 ligamentous injury. This is your “clinical correlation” as requested in the final CT neck reading by Radiology. In my opinion, there is no need for any collar during our ED visit or post-discharge.