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Hangman’s Fracture

Hangman’s fracture or traumatic spondylolisthesis of C2 is characterized by bilateral fractures of the pars interarticularis with varying degrees of intervertebral disc disruption. It is the second most common fracture of the C2 vertebrae following a fracture of the odontoid process.

The mechanism of injury includes motor vehicle accidents and falls with flexion, extension and axial loads. Hanging mechanisms involve hyperextension and distraction injury, in which the patient may experience bilateral pedicle fractures and complete disruption of the disc and ligaments between C2 and C3.

Hangman’s Fracture Diagnosis

Spinal cord injury in patients who survive the initial trauma is relatively uncommon, so the patient may complain of little more than local pain and stiffness. There is, however, tenderness over the spinous process of C2.

See Also: Odontoid Process

Lateral, anteroposterior (AP), and open-mouth odontoid views are necessary. The retropharyngeal space may be widened on the lateral view. There is a 30% incidence of concomitant cervical spine fractures.

CT scan is the most important modality for determining fracture etiology and ruling out an injury regarding a C2 fracture. A CT scan is warranted even if plain films are negative and clinical suspicion is high.

Evaluation with MRI is essential for analyzing the ligamentous construct, disc space, spinal cord, nerve roots, and other soft tissue injuries. MRI is also useful for determining the acute nature of the fracture when this is otherwise unknown. This is done via non-contrasted imaging. 

Vascular imaging may be indicated. The vertebral artery’s second segment (V2) runs through the transverse foramen of C2 to C6, while V3 runs extradurally, exiting the C2 foramen across the sulcus arteriosus.  This can place it at risk for injury.

See Also: Atlas Fracture
traumatic spondylolisthesis of C2

Hangman’s Fracture Classification

The commonly used classification scheme is Levine and Edwards’ modification of the Effendi and Francis classification.

  • Type I, non-displaced fracture of the pars interarticularis.
  • Type II, displaced fracture of the pars interarticularis.
  • Type IIa, displaced fracture of the pars interarticularis with disruption of the C2–3 disco-ligamentous complex.
  • Type III, dislocation of C2–3 facet joints with fractured pars interarticularis.
See Also: Occipital Condyle Fractures
Hangman's Fracture Classification

Hangman’s Fracture Treatment

Type I injuries are stable and heal with 12 weeks of immobilization in a rigid cervical orthosis.

Type II injuries usually require skull traction with slight extension of the neck over a rolled up towel for 3–6 weeks to maintain anatomical reduction. Serial radiographic confirmation of maintenance of reduction is required. The patient can be mobilized in a halo vest for the rest of the 3 month period.

In type IIA injuries, traction may exacerbate the condition; therefore, a halo vest with slight compression is applied under image intensification to achieve and maintain anatomical reduction for 12 weeks until union occurs. Anterior interbody fusion and plating of the C2–3 interspace for a type IIA injury may be performed as an alternative to halo immobilization. Bilateral C2 pars screw osteosynthesis is an option to stabilize type II injuries after reduction.

For type III injuries, surgery is required because of the inability to obtain or maintain reduction of the C2–3 facet dislocation. Initial halo traction is followed by open reduction and fusion. Surgical options include an anterior C2–3 interbody fusion or a posterior C1–3 fusion.

Hangman's Fracture Treatment

References & More

  1. Mercer’s Textbook of Orthopaedics and Trauma, Tenth edition.
  2. LeFever D, Whipple SG, Munakomi S, et al. Hangman’s Fractures. [Updated 2023 Aug 13]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK519496/
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