This document discusses fractures of the axis vertebra (C2). It begins by describing the embryology and anatomy of C2. It then covers the different types of C2 fractures including odontoid fractures (Type I-III), Hangman's fractures (Levine classification Type I-III), and miscellaneous C2 fractures (Benzel classification). For each type of fracture, the mechanisms of injury, evaluation, management options (surgical vs nonsurgical), specific treatment approaches, complications, and considerations in elderly patients are described in detail.

1. Odontoid and Hangman fracture
Dr Dikpal

2. Embryology
• Gastrulation begins in 3rd week
• The mesoderm thickens bilaterally and segments
into paired cuboidal structures called somites at
around 20 days’ gestation.
• They form along a rostrocaudal axis. A total of 42
to 44 pairs of somites form, 4 occipital, 8 cervical,
12 thoracic, 5 lumbar, 5 sacral and 8 to 10
coccygeal.
• regression of the first occipital somite and the
last five to seven coccygeal somites, leaving a
total of 38.

3. • The ventral portions of the somites are the
sclerotomes that eventually become the
skeletal system, including the vertebral bodies,
the cartilaginous tissue, the disks, and the
cells of the spinal meninges.

6. Anatomy of axis vertebra
Features :
• Odontoid process: 1-1.5 cm long and 1 cm
wide
• Articulating facets : The superior facets do not
form an articular pillar with the inferior facets,
but are anterior to the latter
• Thick lamina, stout pedicle and large spinous
process

11. C2 fractures
• Odontoid fracture
• Hangman fracture
• Miscellaneous fractures

13. Odontoid fracture
• M/C
• 50-60% of axis fractures
• Anderson D`Alonzo classification

14. Type percent
1 1-3%
2 54-74%
3 39-42%

15. Grauer`s modification

16. Prof Goel`s additional parameter
• Type A: vertical or compression
fracture
• Type B : facets of atlas and axis are
malaligned
• Type C : fracture line traverses
through facet of axis

17. Type I odontoid fracture
• MOI : avulsion of alar ligament
• Evaluation : thin CT / MRI
• Management : NONSURGICAL Vs
surgical
• Collar vs halo vest

19. Problems with halo vest
• Pressure sore
• Pin site infection
• Pin loosening
• Breathing issues
• Pneumonia

20. Type II odontoid fracture
• Due to lateral bending and extension
forces
• Considered unstable
• Surgery vs nonsurgical
• Collar (53-57%)
• Halo vest (70-73%)

21. Nonsurgical usually fails
• Watershed zone with poor blood supply
(apex by ICA branches- cleft perforating
vs , Base by VA branches- ant and post vs)
• Neck is area of enormous load
transmission

23. Type III odontoid #
• Due to pure extension
• Conservative
• 87-100% healing rate on conservative
management
• Shallow type III = Type II >>> surgical mx

24. Surgical
Posterior
• Gallie (midline graft with a single wire),
• Brooks (bilateral sublaminar wires),
• Sonntag (interspinous) methods
• Magerl transarticular C1-C2 fixation
• Prof Goel`s technique
• Harm`s technique

28. Surgical
Anterior
• less morbidity
• Less loss of motion compared to post fixation
• Fracture < 6 months
• Intact transverse ligament
• One screw = two screw (biomechanically)
• c/I : severe osteopenia, ant oblique sloping
fracture
• Complication : screw fall out / pullout

29. Anterior odontoid screw fixation
• If unstable fibre optic intubation
• Supine with shoulder roll
• Tong traction
• Fluoroscopy for proper reduction and alignment
• Skin incision at C5-6 disc space
• Left side prefered
• Trachea and esophagus medially and carotid
laterally

30. • Soft tissue opened cephalad to C2 region
• Two tech
• Cannulated screw tech
• Lag screw tech

33. Magerl technique
• Transarticular screw placement
• Indication :
poor bone quality, such as in elderly
patients, fractures older than 6 months, and
transverse ligament injuries

34. • Prone position
• Occiput to c3 incision
• Subperiosteal dissection to expose C2 pars
upward to C1-C2 joint
• The screw entry point is 2 mm lateral from the
medial edge of the facet and 3 mm superior to
the caudal edge
• The desired trajectory goes through the C1-2
joint and enters the lateral mass of C1,
pointed at the anterior tubercle. Bicortical
purchase is desired
• Posterior wiring and bony fusion

37. Drawback
• Technically demanding
• Posterior wiring

38. Posterior lateral mass fixation
• Exposure similar to transarticular
• C1 entry point middle of lateral mass
• Trajectory : slightly medially and parallel to C1
arch
• C2 entry : The entry point is halfway between
the upper and lower articular surfaces of C2
• Trajectory : 25 degrees cephalad and 20 to 25
degrees medially.

40. Complication of C2 #
• VAI
• Pseudarthrosis, wound infection, nerve root
injury, persistent numbness or neuropathic
pain, and screw breakage

41. C2 # in elderly
• >70yrs
• Common in spine trauma
• Surgery with anterior or posterior better than
immobilisation
• Collar better than halo vest for conservative
management

43. Traumatic spondylolisthesis -
"Hangman's fracture"
• Fracture of pars interarticularis of C2 &
disruption of C2-C3 junction
• term "hangman's fracture" is not accurate for
the majority of cases: lacks large traction force
present in judicial hangings
• In cases in which there is neurologic injury,
:significant horizontal translation w/
accompanying damage to the posterior
longitudinal ligament w/ or w/o damage of
the C2-C3 interspace

44. mechanism of injury in adults:
• Judical lesion: hyperextension and distraction;
• Blow on the forehead forcing the neck into
extension is a classic mechanism of injury
producing fractures through the pedicles
of C2 known as traumatic spondyloslisthesis
of C2;

47. Levine Classification
• Type I
• < 3 mm translation, no angulation;
• bilateral pars frx, prevertebral soft tissue swelling,
w/ normal disc space & normal alignment;
• C2-3 disk and ligamentous structures remain
intact;
• type I A: minimal translation and little or no
angulation;
- CT demonstrates extension of fracture
through the foramen transversum (which may
injure the vertebral artery)

49. TYPE II
• more than 3 mm of displacement of C2 on C3
with or without angulation and disruption of
the C2-3 disk and posterior longitudinal
ligament
• Type IIa fractures have angulation (can be >15
degrees) and minimal subluxation (<3 mm),
with the same associated disk and
ligamentous injury

51. Type III
• fractures have type II features with
associated unilateral or bilateral
facet dislocation, along with injury to
anterior and posterior longitudinal
ligaments
• Type IIa and III fractures are rare and
are generally considered unstable

53. Management
• Nonsurgical : fusion rate 93-100 % - 12-14
weeks
• Levine type I or Ia fractures can be treated
with collar immobilization for 3 months
• Type II fractures usually reduce with gentle
cervical traction. Patients with these fractures
should be placed in a halo vest for 3 months

54. • For fractures with more than 5 mm of
subluxation or at least 30 degrees of
angulation, surgical fixation should be strongly
considered
• Levine type IIa fractures should be reduced
immediately in a halo vest with extension and
compression applied. Halo vest immobilization
for 3 months results in a 95% union rate.
Traction in these fractures can accentuate the
deformity.

55. • Levine type III fractures require surgery for
stabilization and reduction
Surgery
• Posterior : can narrow the spinal canal as
angulation not addressed
• Anterior : exposure difficult
• Because most patients are neurologically
intact, it is often unnecessary to completely
resect the entire disk and the posterior
longitudinal ligament

56. MISCELLANEOUS C2 FRACTURES
• grouped into four basic types: vertebral body,
lamina, spinous process, and lateral mass
fractures
Benzel classification
• Type I fractures are vertically and coronally
oriented.
• Type II fractures are vertically and sagittally
oriented.
• Type III fractures are transverse (horizontally)
oriented

57. • Fractures through the foramen transversarium
>> CT angiography for VAI.
• Treatment of asymptomatic VAI remains
controversial because there is no level I
evidence. Studies have shown improved
outcomes in patients receiving anticoagulation
or antiplatelet agents.
• In symptomatic VAI patients, treatment is
necessary, but the choice of treatment
remains controversial>>>> Endovascular
recommended