A 48-year-old woman complains of neck pain after a car crash. She was a restrained driver who was rear-ended at a moderate rate of speed.
She denies loss of consciousness, headache, vision changes, focal weakness, or sensory deficits. She is not on blood-thinning medications.
She was placed in a cervical spine collar, and placed on a backboard by EMS. The photograph shows her x-ray.
What is the diagnosis and the management of this condition?
Quick Consult: Diagnosis: Hangman's Fracture
A Hangman's fracture is a traumatic spondylolisthesis (vertebral displacement anterior or posterior in relation to inferior vertebra) fracture of the axis vertebra (C2) through both pedicles or the pars interarticularis, and disruption of the C2-C3 junction. This fracture typically results from a hyperextension and distraction mechanism. Common mechanisms are forcible extension of the head with the natural distraction of the neck, forced flexion of the neck, or compression of an extended neck.
This is best known as a Hangman's fracture because it can be the consequence of a judicial hanging, in which the noose is placed below the chin so the condemned's weight forcibly flexes the head when he is dropped, causing C2 fracture and dislocation and resulting in cord compression and death.
One post-mortem study of hanging victims, however, found that only a small fraction of hangings actually produce a Hangman's fracture. (Forensic Sci Int 1992;54:81.) The most likely cause of death in most cases is prevertebral swelling, carotid and vertebral artery compression, or rupture resulting in secondary cerebral ischemia. (Med Sci Law 2009;49:18.)
Today the most common injury mechanism of a Hangman's fracture is associated with deceleration injuries from a sudden forceful strike of the victim's face or chin on a hard object while the neck is in extension or hyperextension, such as the forehead striking the dashboard in a motor vehicle crash. It is less commonly associated with diving accidents, contact sports injuries, or falls on the head. (Orthop Clin North Am 1978;9:1011.)
The Hangman's fracture is fairly common, with one-third of all cervical spine injuries occurring at C2. Traumatic spondylolisthesis of the axis is uncommon in children, however, because the odontoid synchondrosis (cartilaginous joint) does not fuse until age 6 or 7. (Wheeless' Textbook of Orthopaedics; www.wheelessonline.com.)
A significant force is required to generate this injury, and as many as 30 percent of patients with this injury will also have another C-spine injury. Up to 10 percent will have another noncervical traumatic injury. Evaluation of a suspected cervical spine fracture secondary to trauma should follow standard trauma evaluation and resuscitation protocols. The C2 nerve root provides sensory innervation to the anterolateral neck, inferior ear, and posterior scalp, and controls the motor function of sternocleidomastoid and trapezius. This is an unstable high cervical spine fracture because the fracture pattern creates a pathologic increase in the cervical canal space, and it is common for patients to have neck pain but no neurological deficits on presentation.
Radiographs or multi-spiral CTs are necessary to diagnose a Hangman's fracture. (Zhongguo Gu Shang 2009;22:349.) The findings are best seen on lateral views of cervical spine radiographs, and may include prevertebral swelling in the upper cervical region, avulsion of the anteriorinferior corner of C2 from rupture of anterior longitudinal ligament, anterior dislocation of C2 vertebral body, and bilateral C2 pars interarticularis fractures.
The Levine classification for adults can be used to describe these C2 fractures. Type I (65%) covers bilateral pedicle fractures with less than 3 mm of anterior C2 body displacement and no angulation (stable). Type II (28%) has significant displacement and angulation and anterosuperior C3 wedge compression fracture (unstable), and Type III (7%) has severe displacement and severe angulation (unstable). (www.wheelessonline.com.)
Patients with a C2 fracture require spine specialist consultation. Most patients are treated successfully with stabilization of the spine using a halo vest traction device. Surgical stabilization and fusion is typically reserved for patients with nonunion or disruption of the C2-C3 disk. (Zentralbl Chir 1998;123:907.)
This patient was found to have a C2 fracture and placed in a C-spine collar. The spine specialist said she had improved pain on follow-up, and radiographs did not show any evidence of listhesis. She will continue C-spine immobilization until healing occurs.
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Dr. Wileris an assistant professor of emergency medicine and the medical director of reimbursement at the University of Colorado Denver School of Medicine and an adjunct assistant professor of emergency medicine at the Washington University School of Medicine in St. Louis.
In Brief: ABEM Elects New Members
The American Board of Emergency Medicine recently elected three new members to its board of directors, Jill M. Baren, MD; Mary Nan S. Mallory, MD; and Robert P. Wahl, MD.
Dr. Baren is a professor of emergency medicine and pediatrics at the Perelman School of Medicine at the University of Pennsylvania. She is the chair of emergency medicine and chief of emergency services of the University of Pennsylvania Health System. She has served as past president of the Society for Academic Emergency Medicine.
Dr. Mallory is a professor of emergency medicine and the program director for the emergency medicine residency at the University of Louisville School of Medicine, where she also serves as the vice chief of staff for the University of Louisville Hospital.
Dr. Wahl is an assistant professor and the residency director in emergency medicine at Wayne State University School of Medicine. He also serves as emergency medicine faculty at Detroit Receiving Hospital.Copyright © 2012 Wolters Kluwer Health, Inc. All rights reserved.