Plain radiographs have low sensitivity in detecting Occipito-Cervical (OC) injury and/or instability. The diagnosis can be most easily made using a sagittal CT scan of the cervical spine. Acquired OC instability is distinct from traumatic OC dislocation—a rare injury associated with high-velocity trauma, a high incidence of associated neurological and vascular injury. It is identified in 19% of fatal cervical injuries but has become more commonly seen clinically due to improved techniques in resuscitation and imaging. The patient should have a detailed neurological examination and the cervical spine should be immobilised in a cervical collar if there is any history of trauma. In the presence of lowor high-energy trauma, other cervical fractures should be carefully excluded. Fixation can be achieved via a rigid OC screw-rod or plate construct. Traction has been reported to worsen neurological compromise and so should not be attempted.