Hangman's / C2 Fracture

 

Hangman CTHangmans

 

Definition

 

Bilateral pars fracture of C2

Traumatic spondylolisthesis of C2

 

Mechanism

 

Motor vehicle accident

Fall from height

 

Neurological injury

 

Neurological injury thought to be uncommon as fragments separate and decompress

 

Different to judicial hanging where spinal cord is severed

 

Gangzhou et al J Orthop Res 2017

- 97 patients with hangman's fracture

- 23/97 with neurological injury

- all partial spinal cord injuries

- associated with increased displacement / angulation (type II, IIa, III)

 

Levine & Irving Classification

 

Hang IHang IIHang IIaHang III

Type Characteristics Mechanism Management
Type I

Vertical fracture line

< 3 mm anterior displacement

C2/3 disc normal

Axial compression and hyperextension Collar 6 weeks
Type II

Vertical fracture line

> 3 mm anterior displacement

C2/3 disc disrupted

Unstable

Axial compression and hyperextension

Traction and halo-vest

Consider surgery

Type IIa

Horizontal fracture line

Significant angulation

 

Flexion-distraction

Avoid traction

Hyperextension and halo-vest

Consider surgery

Type III Type I with C2/3 facet dislocation   Surgery

 

Murphy et al J Orthop Trauma 2017

- 548 fractures mean age 38

- Type I: 46/548 (8.4%)

- Type II: 228/548 (41.6%)

- Type IIa 89/548 (16.2%)

- Type III: 35/548 (6.4%)

 

Xray

 

Hangmans XrayHangmans xray 2

 

HangmansHangman 2

 

CT scan

 

Hangmans CT Undisplaced0001Hangmans CT Undisplaced0003

 

Hang CT 1Hang CT 2Hang CT 3

 

Management

 

Instability

 

Disruption of C2/3 disc and posterior longitudinal ligament (PLL)

- significant anterior displacement (Type II)

- significant angulation (Type IIa)

- Type III

 

Nonoperative management

 

Indication

 

Type I

- collar 8 weeks

- flexion extension views to assess stability

 

Results

 

Murphy et al J Orthop Trauma 2017

- systematic review of operative versus nonoperative care

- union rate of 131 fractures treated nonoperatively was 94%

- union rate of 417 fractures treated operatively was 99%

 

Li et al Eur Spine J 2006

- systematic review

- union rates with nonoperative management

- Type I: 100%

- Type II: 60%

- Type III: < 40%

 

Hang CTHangmans Halo

Hangman's fracture reduced and held in halo-vest

 

Hangmans flexionHangmans extension

Post halo flexion and extension views demonstrating fracture stability

 

Operative Management

 

Indications

 

Significant displacement / angulation with disc and PLL damage

- Type II

- Type IIa

- Type III

 

Options

 

Anterior fixation / fusion

Posterior fixation / fusion

Combined

 

Anterior

 

Anterior cervical discectomy and fusion ACDF

 

ACDF C2/3

- preserves C1 motion

- lower risk of vertebral artery injury

 

Zhonghai et al J Neurosurg Spine 2015

- 38 patients with unstable hangman's fracture

- treated with ACDF or C3 corpectomy and fusion

- fusion in 36/38 (95%)

 

Posterior

 

Hangmans fracture fixation

 

1.  Posterior C1 - C3 fusion

 

Significant loss of motion

 

2.  C2 trans-pedicle screw fixation + C3 fixation +/- fusion

 

Short segment fixation +/- fusion

- preserves ROM

 

Ma et al Spine 2011

- 35 unstable C2 hangman's fractures

- C2 / C3 posterior short segment fixation and fusion

- 100% fusion at 6 months in all cases

 

3.  C2 trans-pedicle lag screw fixation

 

Liu et al J Orthop Surg Res 2020

- 25 patients with unstable C2 hangman's fractures

- reduced with tongs

- fixed with transpedicle screws

- 100% osseous union and full range of motion