C2 Hangman's Fx

Last modified by Hussein Abdallah on 2025/04/20 23:34

CONTENTS

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

routine spine exam

evaluate for parasthesias

evaluate for external signs of injury associated w/ hyperextension/axial force

evaluate for stroke sx (BCVI)

[ ] 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

[ ] Collar/halo x 3 months for most patients, OR for some patients (detailed below)

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

	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)		d ≤ 5mm AND θ < 10˚ reduce w/ gentle gentle traction halo immediately mobilize within 24h obtain upright lateral C-spine to confirm adequate Monitor outpatient w/ serial XR, OR if fx moves d > 5mm OR θ > 10˚ reduce w/ gentle traction 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

Type 1	Type 1A	Type 2

Type 2a	Type 2a	Type 3 - Type 2+ bilateral C2-3 facet dislocation

Figure 1: mechanism of Hangmann's fracture following a submantal knot

Figure 2 - Notice unique anatomy of C2 shows that pars and pedicle border is ambiguous (Adopted Greenburg 61.2)