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Updated: Jun 23 2021

Traumatic Spondylolisthesis of Axis (Hangman's Fracture)

  • summary
    • Traumatic Spondylolisthesis of Axis, also known as a Hangman's Fracture, is a traumatic fracture of the bilateral pars interarticularis of C2.
    • Diagnosis is made with CT of the cervical spine.
    • Treatment may be C-collar immobilization, halo immobilization, or surgical stabilization depending on displacement, angulation, and fracture stability. 
  • Etiology
    • Mechanism 
      • hyperextension
        • leads to fracture of pars
      • secondary flexion
        • tears PLL and disc allowing subluxation
    • Associated injuries
      • 30% have concomitant c-spine fx
  • Presentation
    • Symptoms
      • neck pain
    • Physical exam
      • patients are usually neurologically intact
  • Imaging
    • Radiographs
      • flexion and extension radiographs show subluxation
    • CT
      • study of choice to delineate fracture pattern
    • MRA
      • consider if suspicious of a vascular injury to the vertebral artery
  • Classification 
      • Levine and Edwards Classification
      • (based on mechanism of injury)
      • Mechanism
      • Characteristics
      • Treatment
      • Type I
      • Axial compression and hyperextension
      • < 3mm horizontal displacement C2/3
      •  No angulation
      •  C2/3 disc remains intact
      • Stable fx pattern
      • Rigid collar x 4-6 weeks
      • Type II
      • Hyperextension and axial load followed by rebound flexion
      • > 3mm of horizontal displacement
      •  Significant angulation
      •  Vertical fracture line
      •  C2/3 disc and PLL are disrupted
      • Unstable fracture pattern
      • If < 5 mm displacement, reduction with traction then halo immobilization x 6-12 weeks
      •  If > 5mm displacement,  displacement, surgery or prolonged traction
      •  Usually heal despite displacement (autofuse C2 on C3)
      • Type IIA
      • Flexion-distraction
      • No horizontal displacement
      •  Horizontal fracture line
      •  Significant angulation
      • Avoid traction in Type IIA.
      •  Reduction with gentle axial load + hyperextension, then compression halo immobilization for 6-12 weeks.
      • Type III
      • Flexion-distraction followed by hyperextension
      • Type I fracture with associated bilateral C2-3 facet dislocation
      • Rare injury pattern
      • Surgical reduction of facet dislocation followed by stabilization required.
  • Treatment
    • Nonoperative
      • rigid cervical collar x 4-6 weeks
        • indications
          • Type I fractures (< 3mm horizontal displacement)
      • closed reduction followed by halo immobilization for 8-12 weeks
        • indications
          • Type II with 3-5 mm displacement
          • Type IIA
        • reduction technique
          • Type II use axial traction combined + extension
          • Type IIA use hyperextension (avoid axial traction in Type IIA)
    • Operative
      • reduction with surgical stabilization
        • indications
          • Type II with > 5 mm displacement and severe angulation
          • Type III (facet dislocations)
        • technique
          • anterior C2-3 interbody fusion
          • posterior C1-3 fusion
          • bilateral C2 pars screw osteosynthesis
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