C2 Hangman’s Fracture

FACTS

Definition: bilateral C2 pars fracture w/ traumatic C2-C3 subluxation
Recall the C2 Axis fracture Types
1. Odontoid/Dens
2. Hangman's (traumatic spondylolisthesis)
3. Miscellaneous Fx
C2 Hangman's Fx
  • mechanism: axial loading + hyperextension >> hyperflexion or rotation
  • population: usually younger patients with
  • usually stable fractures (detailed below)

HPI

 

PHYSICAL EXAM

routine spine exam
evaluate for parasthesias
evaluate for external signs of injury associated w/ hyperextension/axial force
evaluate for stroke sx (BCVI)

IMAGING

CT cervical spine without
CTA head and neck - evaluate for BCVI and stroke
MRI C-spine without contrast - evalute for abnormal hyperintensity on T2/FLAIR
XR Cervical flexion-extension
A/P
Collar/halo x 3 months for most patients, OR for some patients (detailed below)
 

Francis and Levine Classifications

Based on two measurements (1) displacement and (2) angulation [angle between inferior endplates of C2/C3] defined as follows:
1745183173930-395.png

Francis

1745183153487-248.png

Levine (Modified Effendi) Classification

Type 1
Type 1A
Type 2
Type 2A
Type 3
Mechanism
axial load + extension
hyperextension + lateral bending
axial load + extension w/ rebound flexion
flexion-distraction
flexion-dislocation
Describe
fx just posterior to VB
fx lines not parallel "atypical"
vertical fx through pars
oblique fx
oblique fx + facet dislocation
Definition
d: < 3mm
θ: 0˚
-
d: >3mm
θ: <11˚
d: minimal (≤ 3mm)θ: severe (can be >15˚)
Displacement/angulation: significant+ C2-3 facet dislocation
C2-3 disk
intact
-
disrupted
disrupted
Ligaments
PLL intact
-
PLL disrupted
PLL disrupted
ALL may be disrupted
Deficits
rare
33% paralyzed
rare
rare (<10%)
may occur, may be fatal
Stability
stable
stable
unstable
unstable
unstable
Management
Immobilization (Aspen C-collar) or CTO x 3 months. Rarely: Halo-vest (unreliable patients)
ㅤ
d ≤ 5mm AND θ < 10˚
1. reduce w/ gentle gentle traction
2. halo immediately
3. mobilize within 24h
4. obtain upright lateral C-spine to confirm adequate
5. Monitor outpatient w/ serial XR, OR if fx moves
d > 5mm OR θ > 10˚
1. reduce w/ gentle traction
2. fusion
• reduce w/ Halo immediately x 3 mos (95% union)
• NO traction
• Consider OR
• Consider OR
• NO TRACTION (if facets locked)
Operative Options:
  • Type 2/Type 3, consider C2-3 ACDF or C1-3 PSF
  • traumatic C2–3 disc herniation w/ spinal cord compression is always an indication for operating, regardless of
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