Traumatic Spondylolisthesis of Axis (Hangman's Fracture)

Topic updated on 12/04/15 10:39pm
Introduction pagebreak
  • Traumatic anterior spondylolithesis of the axis due to bilateral fracture of pars interarticularis
    • MVA is most common cause
  • Mechanism is
    • hyperextension
      • leads to fracture of pars
    • secondary flexion
      • tears PLL and disc allowing subluxation
  • Associated injuries
    • 30% have concomitant c-spine fx
  • Symptoms
    • neck pain
  • Physical exam
    • patients are usually neurologically intact
  • 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 & Treatment

Levine and Edwards Classification (based on mechanism of injury)
Type I
  • < 3mm horizontal displacementC2/3 
  • No angulation
  • C2/3 disc remains intact
  • stable fx pattern 
  • Rigid cervical collar 4-6 weeks
Type II
  • > 3mm of horizontal displacement
  • Significant angulation
  • Vertical fracture line
  • C2/3 disc and PLL are disrupted
  • unstable fracture pattern
  • If < 5mm displacement than reduction with traction then halo immobilization for 6-12 weeks.
  • If > 5mm displacement consider surgery or prolonged traction.
  • Usually heal despite displacement (autofuse C2 on C3).
Type IIA
  • No horizontal displacement
  • Horizontal fracture line
  • Significant angulation
  • Avoid Traction in Type IIA.
  • Reduction with hyperextension then halo immobilization for 6-12 weeks.
Type III
  • Type I fracture with associated bilateral C2-3 facet dislocation
  • Rare injury pattern
  • Surgical reduction of facet dislocation followed by stabilization required.

  • Nonoperative
    • rigid cervical collar 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
          • cervical axial traction combined with extension
        • Type IIA
          • 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


Please Rate Educational Value!
Average 3.0 of 52 Ratings

Qbank (1 Questions)

Sorry, this question is available to Virtual Curriculum members only.

Click HERE to learn more and purchase the Virtual Curriculum today!

HPI - Pt fell from tree about 30 feet while intoxicated. After day in hospital went in...
149 responses fx.jpg
HPI - 30 yo Somali man from Nairobi now living in Juba fell off a big truck onto his u...
poll How would you treat this patient?
426 responses
See More Cases



Topic Comments