Atypical Hangman's Fracture Research Articles

Atypical Hangman's Fractures: An Institutional Study of 51 Patients With Atypical Traumatic Spondylolisthesis of C2.

Retrospective cohort study. Atypical hangman's fractures are associated with increased risk for neurologic injury due to involvement of the posterior cortex of the axis body. We present the largest single-center cohort of atypical hangman's fractures with the goal of guiding treatment decisions and outcomes based on fracture classification. We performed a retrospective analysis of all patients with atypical hangman's fractures treated at a single Level I trauma center between January 2010 and September 2023. 51 patients met inclusion criteria and demographic, treatment, and radiographic data were recorded and compared across the Type I and II fracture groups. Final treatment modalities varied significantly between the groups (P < 0.01), with hard cervical collar and invasive halo immobilization being the most prevalent treatments for fracture Types I and II respectively. One Type I fracture patient and four Type II fracture patients failed non-operative treatment, requiring surgery. Across both groups, posterior cervical fusion (73%) was the most common surgical approach. Median length of stay varied significantly between the two fracture groups (2.0 (1.0-7.0) vs 5.0 (3.0-8.0) days; P = 0.01). Irrespective of fracture type, longer hospital length of stay was associated with increased patient age (IRR = 1.02; P < 0.01), non-white race (IRR = 2.47; P = 0.01), injury caused by MVC (IRR = 1.93; P < 0.01), and the presence of non-spine orthopedic injuries (IRR = 1.72; P = 0.03). While atypical Type I hangman's fractures may be managed effectively non-operatively with a hard cervical collar, atypical Type II fractures managed with a hard cervical collar are at greater risk of requiring subsequent surgical intervention.

On İki Vakada Hangman Kırığının Cerrahi Tedavisi: Olgu Serisi

Objective: Hangman's fracture is a condition characterized by anterior displacement of C2 upon C3 with a fracture in the C2 where the neural arch attaches to the vertebral corpus as a result of axial loading of the head accompanying hyperextension. Material and Methods: From January 2015 to January 2022, analysis retrospectively included 12 patients operated by hangman's fracture. The lesions were considered to be a hangman's fracture after computed tomography findings. The clinical condition was classified on the basis of American Spinal Injury Association scale and visual analog scale. All patients underwent C2-3 posterior fusion. All patients had at 6 and 12 months follow-up cervical computed tomography, which were used to assess bony union, final displacement, and angulation. Results: 5 of the patients were males and 7 females with the age range of 22-82 (mean age 49). The cause of trauma was in vehicle accident in 4 patients, falling from a height in 6 patients, and falling after slipping in the bathroom in 2 patient. All patients complained of neck pain. Except for 2 patients with upper extremity paralysis and spastic tetraparesis, 10 patients had no neurological deficit. According to the Levine and Edwards typical hangman's fracture classification, 7 had Type II fractures, while one patient had Type III fractures. According to the Li-Wang atypical hangman's fracture classification, 4 were Type B. Conclusion: Radiological evaluation and subsequent classification are very important in management. Posterior C2-3 fusion is a very effective surgical way.

Presentation, management and outcomes of typical and atypical Hangman fractures - a case series

Presentation, management and outcomes of typical and atypical Hangman fractures - a case series

Failure of C2-3 Anterior Arthrodesis for the Treatment of Atypical Hangman's Fractures, a Case Series

Failure of C2-3 Anterior Arthrodesis for the Treatment of Atypical Hangman's Fractures, a Case Series

Surgical Outcomes for C2 Tear Drop Fractures: Clinical Relevance to Hangman's Fracture and C2-3 Discoligamentous Injury.

ObjectiveTo analyze characteristics of surgically managed tear drop (TD) fractures of the C2 axis associated with other injuries such as hangman's fracture and C2‐3 discoligamentous injury as well as treatment outcomes.MethodsA total of 14 patients (eight men and six women) with TD fractures of the C2, who were surgically treated at four national trauma centers of tertiary university hospitals from January 2000 to December 2017, were included in this retrospective study. The mean age of the patients was 45.5 years (ranging from 19 to 74 years). The characteristics, surgical treatment methods (anterior fusion vs posterior fusion), and results of 14 TD fractures of the C2 were analyzed retrospectively. And the clinical relevance between C2 TD fracture and hangman's fracture and C2‐3 discoligamentous injury was investigated through the co‐occurrence between injuries. The mean follow‐up time after surgery was 22.6 months (ranging from 12 to 60 months).ResultsAmong 14 patients with TD fracture of the C2, four patients (28.6%) had anterior TD fracture and 10 patients (71.4%) had posterior TD fracture. All 10 posterior TD fracture patients had anterior C2‐3 displacement. While two of four anterior TD fracture patients had posterior C2‐3 displacement, the remaining two did not. All 14 patients of TD fracture had at least two or more other associated C2 injuries as well as C2‐3 discoligamentous injuries. About 92.9% (13/14) of the patients had typical or atypical hangman's fracture; 100% (10/10) of the posterior TD fracture patients had hangman's fracture, but 75% (3/4) of the anterior TD fracture had hangman's fracture. At admission, 13 patients were neurologically intact. However, the remaining patient had spinal cord injury with American Spinal Injury Association (ASIA) impairment scale B with C2‐3 bilateral facet dislocation. All four anterior TD fracture patients underwent posterior C2‐3 fusion. While four of 10 posterior TD fracture patients underwent C2‐3 anterior fusion, the remaining six underwent posterior fusion. At last follow‐up, 100% (14/14) of the patients achieved solid fusion, and visual analog scale for neck pain was significantly improved (5.9 vs 2.2, P < 0.001). One patient with ASIA impairment scale B had significantly improved to scale D. No major complications occurred.ConclusionOur study showed that surgically managed TD fractures of the C2 showed a high incidence of other associated spine injuries including hangman's fracture and C2‐3 discoligamentous injury. Therefore, special attention and careful radiologic evaluation are needed to investigate the presence of other associated spine injuries including hangman's fracture and C2‐3 discoligamentous injury, which are likely to require surgery.

Atypical hangman’s fracture with concomitant subaxial fracture–dislocation treated with circumferential fusion of C2–C5—a case report

Atypical hangman's fractures are coronally-oriented vertical fractures of the posterior body of C2. Though these are not uncommon injuries, there is a paucity of data investigating the management of these fractures, especially when they occur in association with subaxial fracture dislocations. A 50-year-old male suffered a cervical extension injury when he dove into a shallow swimming pool while intoxicated. Initial examination demonstrated 2/5 strength in the right deltoid and biceps and 3/5 strength in the left deltoid and biceps with no motor or sensory function distal to the C5 level. Cervical CT scan revealed a C2 atypical hangman's fracture and a C4 right-sided facet fracture with traumatic spondylolisthesis at C4/5. We performed C2-C5 anterior cervical discectomy and fusion followed by a C3-C5 posterior instrumented fusion. At the patient's two year postoperative visit, the patient has had minimal improvement in neurologic function with 4/5 strength in bilateral deltoids and biceps and 2/5 strength in right wrist extension. Radiographs show a solid arthrodesis on flexion-extension radiographs. To our knowledge, this is the first case report discussing the operative management of an atypical hangman's fracture with a concomitant subaxial fracture-dislocation. This case report adds to our current knowledge by demonstrating a novel anterior-posterior approach for treating these complicated injuries.

Imageology classification and treatment option for atypical Hangman fractures

Objective The purpose of the retrospective study was to introduce a treatment option for atypical Hangman fractures (AHF) based on a new classification. Methods Sixty-seven patients with Hangman fractures were treated with a comprehensive treatment strategy. Firstly, Hangman fractures were classified as typical or atypical (AHF) lesions using computed tomography scans of the cervical spine. Secondly, AHF was divided into 1 of 4 types (type A1, A2, B1, and B2) devised by us to clarify the feature of injury. Thirdly, the injury status of disco-ligamentous complex (intact/indeterminate/ruptured) was evaluated using magnetic resonance imaging.If it was a stable lesion, conservative treatment was recommended.If not surgical treatment using anterior or/and posterior stabilization and fusion at C2-C3 level was used. Results Fifty-one patients were identified with AHF. According to our classification, thirty patients were classified as type A1, 14 cases as typeA2, 5 cases as type B1, and 2 cases as type B2 lesions. Thirteen AHF without C2-C3 instability (12 as type A1 and 1 as type B1) were treated with non-operative treatment, and 38 AHF with C2-C3 instability (18 as type A1, 14 as type A2, 4 as type B1, and 2 as type B2) were treated with operative treatment. Three patients (all with type A1 lesions) with slightly displacement of C2-3 underwent isolated direct screw osteosynthesis. The remaining 35 underwent posterior stabilization and fusion at C2-C3 level: 24 patients with posterior approach with C2 lag screws and C3 non-lag screws fixation and fusion (11 as type A1, 10 as type A2, 2 as type B1, and 1 as type B2); 3 patients with posterior approach with C1 and C3 screw-rod fixation and fusion (1 as type A1 and 1 as type B1); 7 with anterior approach by C2-3 discectomy and fusion (3 as type A1 and 4 as type A2); and 2 with anterior and posterior approach (1 as type B1 and 1 as type B2). The average follow-up period was 26 months (range, 12-86 months). Neck pain improved significantly at 3-month follow-up, and neurologic status improved at least 1 grade in 12 patients with neurologic deficits at final follow-up. Radiological evaluation showed bony fusion in all patients at 12-month follow-up. Radiological evaluation showed that all 13 AHF without C2-C3 instability treated with non-operative treatment gained fractures fusion at 3-6 month follow-up. Posterior approaches with C1 or C2 and C3 screw-rod fixation and fusion were found to obtain a better alignment of C2-C3 and satisfactory fusion of C2 pedicle factures than anterior approach. Conclusion The treatment option for AHF based on a new classification is helpful in managing such fractures, resulting in good clinical and radiological outcomes. C2 lag screws with or without C3 pedicle screws fixation via posterior approach may not only reduce fractures but also obtain alignment of C2-C3 effectively. Key words: Spinal fractures; Classification; Bone screws

Individual Surgical Strategy Using Posterior Lag Screw–Rod Technique for Unstable Atypical Hangman's Fracture Based on Different Fracture Patterns

The literature on surgical management of atypical hangman's fracture (AHF) is sparse. The aim of this study was to describe an individual surgical strategy using a lag screw-rod technique for treatment of unstable AHF based on different fracture patterns. A retrospective analysis of 23 patients with unstable AHF was performed. Fractures were classified into 3 patterns: A, 1 fracture line through 1 side of C2 body obliquely and another through pars interarticularis on the other side; B, 1 fracture line through 1 side of C2 body obliquely and another through contralateral lamina; C, bilateral oblique fracture lines through posterior cortex of C2 on different sides. Posterior C2-C3 pedicle screw fixation and fusion using a lag screw-rod technique with different surgical strategies for each fracture pattern was used for all patients. Complications, neck pain, neurologic status, reduction of anterior translation and angulation between C2 and C3, and fusion rate were evaluated. No technique-related complications (e.g., spinal cord or nerve injury caused by malposition of screws) occurred. Mean follow-up time was 37 months. Satisfactory reduction and bony union were demonstrated on postoperative radiographs. Neck pain and neurologic deficits caused by C2 injury improved significantly in all patients after operation. No graft or implant-related complications were observed in patients during the entire follow-up period. Using individual surgical strategies based on different fracture patterns, the posterior C2-C3 lag screw-rod technique may be an effective and reliable option for unstable AHF.

A novel classification for atypical Hangman fractures and its application: A retrospective observational study.

Atypical Hangman fractures (AHF) were first formally reported and considered to be more often associated with neurologic deficit in 1993. However, there is a paucity of literature focusing on these fractures. The purpose of the retrospective study was to introduce a new classification scheme for AHF and its application.Sixty-two patients with Hangman fractures were identified. There were 46 (74.2%, 46/62) AHF patients, including 29 type I, 9 type II, 5 type IIa, and 3 type III fractures (Levine–Edwards classification). Based on fracture patterns, incidence, and their impact on neurologic status, a primary classification for AHF was devised. The clinical features of AHF were observed, and a new classification was introduced. The appropriate treatment strategy of AHF was discussed.Of 46 AHF patients, 27 underwent surgical treatment (24 with posterior approach with screw-rod fixation and fusion, 1 with anterior approach by C2/3 discectomy and fusion, and 2 with anterior and posterior approach), and the remaining 19 patients underwent nonoperative treatment. No patient complained severe neck pain at final follow-up. Neurologic status improved 1 to 2 grade in 12 cases with neurologic deficit. All patients achieved bony fusion within the follow-up period.AHF should be recognized as a distinct fracture subtype. The new classification for AHF is based on the feature of fracture patterns, injury mechanism, incidence, and their impact on neurologic deficit. And the new classification is complementary to Levine–Edwards.

Management of Typical and Atypical Hangman's Fractures.

Study Design Retrospective study of a prospectively maintained database. Objective Our aim was to retrospectively review management and outcomes of patients with low-grade hangman's fractures, specifically looking at differences in outcomes between collars and halo immobilization. We also studied fracture patterns and their treatment outcomes. Methods Forty-one patients with hangman's fractures were identified from 105 patients with axis fractures between 2007 and 2013. Typical hangman's fractures were defined as traumatic spondylolisthesis of the axis causing a bilateral pars interarticularis fracture. Fractures involving the posterior cortex of C2 on one or both sides or an asymmetrical pattern were defined as atypical. Results There were 41 patients with a mean age of 59 years, with 13 (31.7%) typical and 28 (68.2%) atypical fractures. There were 22 (53.6%) type 1 fractures, 7 (41.4%) type 2 fractures, and 2 (4.9%) type 2a fractures in this series. Cervical collars were used to manage 11 patients (27% of all patients with hangman's fractures) and halo orthosis was used in 27 (65.8%). Three (7.3%) patients underwent surgical fixation of the fracture. Bony union was achieved in all patients on radiologic follow-up. Permanent neurologic deficit occurred in one patient due to associated injuries. Neck pain and stiffness were reported more commonly in the atypical group, but this finding was not statistically significant. Conclusions The majority of hangman type fractures can be treated nonoperatively. We found no difference in outcomes between a rigid collar or halo immobilization for treatment of low-grade fractures. Radiologic follow-up is essential to identify cases of nonunion.

Surgical Management of the Fractures of Axis Body: Indications and Surgical Strategy

Introduction The axis body fractures are relatively uncommon and have a variety of presentations. Surgical management to them has been only reported as case reports or included as a minor part of clinical management. The objective of this study is to summarize the indications for surgery and report the clinical outcome of surgical treatment based on different fracture patterns. Materials and Methods A retrospective analysis of 28 consecutive patients presenting with the axis body fractures was undertaken. The indications for surgical treatment were defined as follows: (1) fractures associated with instability of adjacent joints; (2) irreducible displaced superior articular facet fracture; (3) fractures resulting in spinal cord compression. The fractures were classified as sagittal, coronal, transverse and lateral mass fracture. One of the following surgical procedures was applied according to the fracture pattern: posterior C1-C2 pedicle screws fixation and fusion (I); posterior C1-C3 screws fixation and fusion (II); posterior osteosynthesis with C2 transpedicular half-thread lag screws (III). Results Thirteen patients were successfully managed operatively. Two transverse and two unilateral lateral mass fractures were treated with surgical procedure I, five sagittal fractures with II, four coronal fractures with III. Complications of malposition of screws and neurologic deficit did not occur during operation. Satisfactory reduction and bony union were demonstrated on postoperative radiographs. Conclusion The axis body fractures should be treated with individualized clinical management. Conservative remedies with external immobilization are still advocated as primary management for most cases. But for cases with adjacent joints instability or irreducible displaced superior articular facet fracture, surgical intervention is necessary. The optimal surgical choice should be based on the type of fracture pattern. Disclosure of Interest None declared References Starr JK, Eismont FJ. Atypical hangman's fractures. Spine 1993;18(14):1954–1957 Benzel EC, Hart BL, Ball PA, Baldwin NG, Orrison WW, Espinosa M. Fractures of the C-2 vertebral body. J Neurosurg 1994;81(2):206–212 Fujimura Y, Nishi Y, Kobayashi K. Classification and treatment of axis body fractures. J Orthop Trauma 1996;10(8):536–540 Korres DS, Papagelopoulos PJ, Mavrogenis AF, Benetos IS, Kyriazopoulos P, Psycharis I. Chance-type fractures of the axis. Spine 2005;30(17):E517-E520 German JW, Hart BL, Benzel EC. Nonoperative management of vertical C2 body fractures. Neurosurgery 2005;56(3):516-521, discussion 516–521 Koller H, Acosta F, Forstner R, et al. C2-fractures: part II. A morphometrical analysis of computerized atlantoaxial motion, anatomical alignment and related clinical outcomes. Eur Spine J 2009;18(8):1135–1153 Rainov NG, Heidecke V, Burkert W. Coronally oriented vertical fracture of the axis body: surgical treatment of a rare condition. Minim Invasive Neurosurg 1998;41(2):93–96 Bohay D, Gosselin RA, Contreras DM. The vertical axis fracture: a report on three cases. J Orthop Trauma 1992;6(4):416–419 Lozano-Requena JA, Pina-Medina A, Aracil-Silvestre J, Torro-Belenguer V, Baixauli-Castella F. Sagittal fracture of the second cervical vertebral body. Int Orthop 1994;18(2):114–115 Marotta TR, White L, TerBrugge KG, Spiegel SM, Stevens JK, Tator CM. An unusual type of hangman's fracture. Neurosurgery 1990;26(5):848-850, discussion 850–851 Jakim I, Sweet MB. Transverse fracture through the body of the axis. J Bone Joint Surg Br 1988;70(5):728–729 Maki NJ. A transverse fracture through the body of the axis. A case report. Spine 1985;10(9):857–859 Craig JB, Hodgson BF. Superior facet fractures of the axis vertebra. Spine 1991;16(8):875–877

Atypical hangman's fractures.

Nineteen cases of traumatic spondylolisthesis of the axis, including 13 standard hangman's fractures and 6 anterolistheses of the C2 vertebral body associated with Effendi's atypical hangman's fractures, were studied. Unlike the standard Effendi Type I or Type II fractures, atypical hangman's fractures, occurring through the posterior aspect of the vertebral body with unilateral or bilateral continuity of the posterior cortex or pedicle, routinely narrow the spinal canal because of the fracture pattern and degree of subluxation. These atypical C2 injuries were more frequent and more often accompanied by paralysis (33%) than was previously anticipated. Because of their greater potential for neurologic compromise, it is essential that these fractures be recognized as distinct from standard Types I and II C2 fractures. Larger series should clarify both the true incidence of paralysis and long-term results from these unique C2 injuries.

Familial lumbar stenosis. Case report of three siblings.

The craniocervical junction is a transitional segment from the cranium to the cervical spine with a unique architecture that accommodates a high degree of motion and requires considerable contributions from surrounding ligamentous structures for stability. The assessment, immobilization, and management of upper cervical spine injuries requires consideration of the complex architecture that exists and the movement that occurs in the craniocervical junction. Early diagnosis and stabilization of upper cervical spine injuries is crucial because devastating complications may occur in patients with an upper cervical spine injury. Several clinical and radiographic findings should elicit suspicion for occipitocervical dissociation, which is a highly unstable injury that requires surgical management via occipitocervical fusion. In general, the management of C1 fractures is based on the status of the transverse atlantal ligament. Isolated atlantoaxial dislocations are rare injuries and commonly are observed as translation injuries rather than rotation injuries in adults. The management of type II dens fractures is challenging and controversial, particularly in elderly patients; therefore, multiple factors must be considered in the management of type II dens fractures. Although many hangman fractures can be managed nonsurgically, atypical hangman fractures must be observed closely, and unstable or displaced hangman fractures are reduced and managed surgically.