A hangman’s fracture is better described as bilateral fracture traversing the pars interarticularis of C2 with an associated traumatic subluxation of C2 on C3. It is the second most common fracture of the C2 vertebrae following a fracture of the odontoid process and is almost always stable without the need for surgical intervention. Steele’s rule of thirds states that the cross-sectional area at the level of the atlas may be divided into three equally represented parts: the dens, space, and the spinal cord. This increased area for the spinal cord at this level is what allows for the relative lack of neurologic injury associated with a hangman’s fracture.

Schneider et al. coined the term hangman’s fracture in 1965. Despite the term implying a hyperextension and distraction injury; such as in the case of a judicial hanging, the more common mechanism of action is hyperextension and axial loading. These injuries are most commonly seen in motor-vehicle accidents, diving injuries, or contact sports.

History and Physical

It is important to recognize that outside of the obvious motor vehicle collisions, and high-impact falls, low-energy and blunt trauma, especially in the elderly population, can induce significant unstable injury. History should also entertain risk factors for fracture such as osteoporosis, metastatic burden, or vitamin D deficiencies. Physical exam findings include pain with palpation in the posterior portion of the neck, radiculopathy, myelopathy, and possible posterior fossa findings secondary to vertebral artery injury. A strict neurologic exam including cranial nerves, sensory, motor, and rectal tone is mandatory.

Evaluation

Laboratory tests should be ordered as an adjunct in overall medical status. Normalized hemoglobin, hematocrit, PT/PTT, INR, and platelet counts will be needed for operative intervention.

X-ray

Evaluation of with x-rays will provide limited but important information. Care must be taken to ensure proper radiographic imaging creates a picture from the occiput to the C7 through T1 disc space. This is essential in reviewing cervical spine trauma. Lateral, anteroposterior (AP), and open-mouth odontoid views are necessary. Approximately, 93% of cervical spine injuries are apparent with combined, lateral, AP, and odontoid view radiographs. X-rays are an excellent modality for determining alignment during the immediate injury, post-operative period, as well as long-term, follow up.

CT Scan

CT scan is the most important modality for determining fracture etiology and ruling out injury with regards to a C2 fracture. Even if plain films are negative and clinical suspicion is high a CT scan is warranted. CT scan does not directly evaluate the spinal cord, soft tissue, or ligamentous construct. It is important to recognize the importance that complete imaging will require dedicated thin-cut CT reconstructions. Non-contrast CT scan is adequate for evaluation of the bony anatomy for fracture. This can be coupled with a CT angiogram (see below) for evaluation of the vascular anatomy.

MRI

Evaluation with MRI is important for the analysis of 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. T2 signal hyperintensities and STIR changes within the dens, ligaments, or soft tissue can illustrate an acute component. MRI is less dangerous than flexion-extension cervical injury. Furthermore, MRI evaluation is mandatory in the evaluation of the transverse ligament for the surgical decision matrix of non-displaced type II odontoid fractures. An intact transverse ligament is needed for the anterior placement of an odontoid screw.

Vascular 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. Indeed, in one series 15% of patients with C1 to C2 fractures had a vertebral artery injury. Of which, type-III odontoid fractures posed the greatest risk. It is important to note that an untreated vertebral artery injury has a 24% stroke rate. CT angiography can be coupled to CT imaging upon fracture evaluation with consideration of kidney function. Level-III evidence suggests that patients with C1 to C3 fractures can be screened with multi-slice multi-detector CT angiography. At this time MR angiography cannot be listed as the sole imaging modality for the evaluation of vertebral artery injury. First-line investigation with percutaneous angiography is overly aggressive.

A rigid cervical collar should be immediately placed in the emergency room setting.

The majority of Hangman’s fractures may be successfully treated with external orthosis alone.

Vascular imaging should be performed in all C1 to C3 fractures.

Enhancing Healthcare Team Outcomes

Fractures of the spine are best managed by an interprofessional team that includes orthopedic and neurology nurses, and therapists. Clinicians should be aware that imaging is critical for the diagnosis of hangman's fracture. CT scan is the most important modality for determining fracture etiology and ruling out injury with regards to a C2 fracture. Even if plain films are negative and clinical suspicion is high a CT scan is warranted. CT scan does not directly evaluate the spinal cord, soft tissue, or ligamentous construct. It is important to recognize the importance that complete imaging will require dedicated thin-cut CT reconstructions. Non-contrast CT scan is adequate for evaluation of the bony anatomy for fracture. This can be coupled with a CT angiogram for evaluation of the vascular anatomy. A missed injury can prove to fatal.

Most patients can be managed with external support and with time full recovery is possible.