Most of the Hangman’s fractures are treated conservatively. Surgical indication is only in type IIA and III fractures. There are many ways of fixing fractured spine either by anterior or posterior. Osteosynthesis of C2 pedicle by transpedicular screw in type IIA is a newer concept started by Judet by putting appropriate length of screws in C2 pedicle, so the fracture reduces and anatomical motion will remain intact. In fact it is a more physiological concept of fixing.

1. Osteosynthesis a physiological way of managing
Hangman’s fracture

2. Case Report
Osteosynthesis a physiological way of managing
Hangman’s fracture
Binod Kumar Singhania a,b,
*, Sapna Sirohia d
, Biswajit Sengupta a,c
a
Department of Neurosurgery, Apollo Gleneagles Hospitals, Kolkata 700054, India
b
Sr. Consultant Neurosurgeon, Flat No 10 C, Block 9, Silver Spring,
5 J. B. S. Halden Avenue, Kolkata 700105, India
c
Sr. Registrar, Flat No. C/3A, Sugam Sabuj, 125 N.S. Road, P. O. Narendrapur, Kolkata 700103, India
d
Department of Anaesthesia, Senior Consultant, 8 WE, Manikaran, 3 B, R. M. M. G. Lane, Kolkata 700010, India
a r t i c l e i n f o
Article history:
Received 29 July 2013
Accepted 7 August 2013
Available online 10 September 2013
Keywords:
Axis
C2
Hangman’s fracture
Osteosynthesis
Pedicle
a b s t r a c t
Most of the Hangman’s fractures are treated conservatively. Surgical indication is only in
type IIA and III fractures. There are many ways of fixing fractured spine either by anterior
or posterior. Osteosynthesis of C2 pedicle by transpedicular screw in type IIA is a newer
concept started by Judet by putting appropriate length of screws in C2 pedicle, so the
fracture reduces and anatomical motion will remain intact. In fact it is a more physio-
logical concept of fixing.1
I am doing by open method with exposure of C2 bilaterally and
putting appropriate screws in the fracture. It gives proper reduction, compression and
immediate stabilization of fracture.
Copyright ª 2013, Indraprastha Medical Corporation Ltd. All rights reserved.
1. Introduction
Hangman’s fracture is a colloquial terminology, first reported
by Wood-Jones in 1913 and then in 1965 Scheider et al had
reported eight cases of motor vehicular accident like Hang-
man’s fracture.2
It is a traumatic C2 spondylolisthesis due to
fracture of pars or pedicle (Fig. 1). C2 fracture is as common as
19% of all spinal injury and 55% of all cervical spine injury.3
Mechanism: The mechanism of Injury is either force full
fall in judicial hanging when noose has tightened below the
chin causing hyperextension of neck lead to fracture. Com-
monest cause is high impact motor vehicle accident where
unstrained passenger hit the head with steering, dashboard or
wind screen lead to hyperextension of neck or axial loading of
axis i.e. C2 with distraction of spine lead to fracture of pars or
pedicle.
Though the fracture is unstable in nature but sever
neurological deficit is unusual as C2 cavity opens due to
fracture. Most of the patient walks himself and very less
landed with sever neurological deficits unless C2 is severely
dislocated on C3 (Fig. 1). Unlike hangings where there are
cervico medullary as well vertebral artery injuries.
Clinically, presents with neck pain and no significant
neurological deficit.
X-ray cervical spine lateral view, which is showing fracture
line along pedicle and subluxation. C T scan with 3D recon
* Corresponding author. Flat No. 10 C, Block 9, Silver Spring, 5 J. B. S. Halden Avenue, Kolkata 700105, West Bengal, India. Tel.: þ91 (0) 33
22517004, 9830250606.
E-mail address: bsinghania@hotmail.com (B.K. Singhania).
Available online at www.sciencedirect.com
journal homepage: www.elsevier.com/locate/apme
a p o l l o m e d i c i n e 1 0 ( 2 0 1 3 ) 2 3 0 e2 3 2
0976-0016/$ e see front matter Copyright ª 2013, Indraprastha Medical Corporation Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.apme.2013.08.013

3. struction is the gold standard for seeing exact fracture pattern.
MRI should do to see disc injury, ligament integrity, cord injury
and vascular injury.
Hangman’s fracture was classified by Levine and Edward4
on the base of mechanism of injury.
Type I: Stable fracture with less than 3 mm translation, no
angulation. Disc and ligaments are intact.
Type IA: Little translation with no or minimal angulation.
Fracture line traversing foramen transversarium.
Type II: Most common type. More than 3 mm horizontal
displacement with less than 10
angulation. Disruption of
posterior longitudinal ligament and disc but intact ALL. Un-
stable fracture.
Type IIA: Slight translation but severe angulation seen in
flexion distraction injuries with tearing of posterior longitu-
dinal ligament and disc. Unstable fracture.
Type III: C2eC3 facet dislocation. Rare fracture results from
initial anterior facet dislocation of C2eC3 followed by exten-
sion injury fracturing the neural arch. Result in with unilateral
or bilateral facet dislocation of C2eC3.
2. Treatment
Treatment varies as per the severity of injury from non
operative to operative.
2.1. Non-operative
Type I with less than 3 mm subluxation needs rigid collar for
4e6 weeks. In type II injury when subluxation is more the
3 mm but less than 5 mm and angulation of less than 10 degree
can put in Halo vest for 12 weeks.5
Reduction can be achieved
by axial traction with extension in type II injury but in type IIA
no axial traction should be given, only manual reduction by
hyperextension.
2.2. Surgery
Surgery is indicated in Type IIA where subluxation is more
than 5 mm and angulation is of more than 10 degree and in
type III where there are facets dislocation.6
Fig. 1 e Diagrammatic representation of various type of C2 fracture.
Fig. 2 e a: X-ray cervical spine lateral view showing fracture line at C2 pedicle with C2-3 subluxation and angulation. b: Post
operative transpedicular screws with some reduction in subluxation.
a p o l l o m e d i c i n e 1 0 ( 2 0 1 3 ) 2 3 0 e2 3 2 231

4. 3. Approaches
Anterior cervical discectomy with fusion and fixation of C2-3
by bone graft and plate.7
Posterior C1 to C3 fixation with fusion by C1 transarticular
and C3 lateral mass screws with bony fusion.
Bilateral C2 pars screws osteosynthesis especially in type II
and IIA fracture. A proper length of screw has been put in C2
transpedicular or in pars.
4. Case reports
A 38 year old female was traveling in a motor van sitting on
the back seat facing rear side. The vehicle met an accident on
express way with a head on collision. She has been trans-
ported in our hospital with a Philadelphia collar on. She pre-
sented with severe neck pain, there was no neurological
deficit and was moderately obese.
X-ray C spine was showing C2-3 subluxation with a frac-
ture line near pedicle of C2 (Fig. 2a). A CT Scan was done to
confirm fracture which was showing pars fracture with frac-
ture line on left side was going along foramen transversarium.
MRI was showing no spinal cord injury with intact disc and
ALL. On measurement subluxation was more than 5 mm and
angulations of more than 10 degree falling in type IIA category.
I planned for surgical fixation rather than a Halo vest for 12
weeks and even after no surety of correction.
5. Technique
In prone position with head fixed in three point pins
Mayfield. C2 lamina and lateral mass has been exposed with
a small mid line incision. Medial portion of the pars was
identified by instrument. Entry point of the screw was
located at supero-medial quadrant of isthmus. First right
sided screw of 4 Â 24 mm size put in a direction of 20 degree
convergent and cephaloid, under C arm guidance avoiding
medial breach till anterior cortex reached. Due to displace-
ment of fracture some time standard entry point is not
possible and the trajectory has to be changed as per situa-
tion. On left side due to displaced fracture direction of tra-
jectory was changed and screw placed safely.
Post operatively patient was neurologically intact. On first
post operative day she was mobilized and Second post oper-
ative day was discharged. On first follow up, after two weeks
her X-ray cervical spine was showing screws in proper place
with less subluxation (Fig. 2b).
6. Discussion
Osteosynthesis is a more scientific way of fixing C2 fracture
with anatomical integrity, immediate stability and maintain-
ing normal physiological function. There are various ways of
placement of pedicular screws, by open method to more
minimally invasive i.e. Brain lab assisted and C T Scan guided.8
In C T guided, chance of infection is high as procedure is per-
forming in a C T suite then in an operating room. Whereas in
Brain lab navigation system which is giving more accuracy but
needs a gadget which is costly and not available in all centers.
It needs a longer time of surgery as hands on instrument have
to registered every time till accuracy. In open method skin
incision is bigger but needs only C arm and can maintain good
sterility. Scope of trajectory manipulation and less time
consuming then Brain lab. Two commonest fractures which
are preferably dealing with osteosynthesis are C2 odontoid
fracture and C2 Hangman’s fracture. There is few criticism of
this method that it is not dealing with injured C2-3 disc.
Conflicts of interest
All authors have none to declare.
r e f e r e n c e s
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Diagnosis and Management, Neurosurgery. 2nd ed. vol. 2.
1996:2886e2887.
3. Mulligan RP, Friedman JA, Mahabir RC. A nationwide review of
the associations among cervical spine injuries, head injuries,
and facial fractures. J Trauma. Mar 2010;68(3):587e592.
4. Levine AM, Edwards CC. The management of traumatic
spondylolisthesis of the axis. J Bone Joint Surg Am.
1985;67:217e226.
5. Vaccaro AR, Madigen L, Bauerle WB, Blescia A, Cotler JM. Early
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0301-620X.82B7.10408.
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