A 60 year old male is brought in by ambulance following a head on collision at moderate speed in a car. He reports severe midline cervical neck pain and does not tolerate a hard cervical spine collar.
He has no other significant injuries and no neurological deficit on exam.
The patient is sent for an CT cervical spine in addition to other trauma scans
Describe and interpret the CT scan
There is an acute undisplaced fracture involving pars interarticularis of C2 bilaterally extending into the bilateral transverse foramina
Clinical Pearls
This CT demonstrates a hangman fracture – a fracture of the pars interarticularis of C2.
The most common cause of this type of fracture is high velocity hyperextension of the neck. The fracture got its name from the pattern of injury observed during judicial hangings where the knot of the noose was placed under the victim’s chin, forcing hyperextension after a drop (and sudden stop) from significant height.
Hangman fractures are classified as typical is there is bilateral pars interarticularis fractures of C2, and atypical if one or both sides of C2 has a vertical fracture through the posterior vertebral body instead of the pars interarticularis (2).
These fractures make up 4-7% of all cervical spine fractures (1), and neurological impairment is only seen in about 25% of cases; atypical fractures have higher rate of neurological compromise than typical injuries.
This type of cervical spine fracture should be further investigated with a CT angiogram of the neck to exclude vertebral artery injury, in case there is extension of the fracture through the transverse foramen (3).
Treatment may be conservative (collar or halo) or require surgical fixation – consultation with neurosurgical teams always advised.
This patient was managed conservatively with an Aspen collar, with review arranged with a neurosurgeon as an outpatient 6 weeks following the injury.
References
- Murphy H, Schroeder GD, Shi WJ, Kepler CK, Kurd MF, Fleischman AN, Kandziora F, Chapman JR, Benneker LM, Vaccaro AR. Management of Hangman’s Fractures: A Systematic Review. J Orthop Trauma. 2017 Sep;31 Suppl 4:S90-S95.
- Burke JT, Harris JH Jr. Acute injuries of the axis vertebra. Skeletal Radiol. 1989;18(5):335-46
- Lebl DR, Bono CM, Velmahos G, Metkar U, Nguyen J, Harris MB. Vertebral artery injury associated with blunt cervical spine trauma: a multivariate regression analysis. Spine (Phila Pa 1976). 2013 Jul 15;38(16):1352-61.
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Dr Leon Lam FRANZCR MBBS BSci(Med). Clinical Radiologist and Senior Staff Specialist at Liverpool Hospital, Sydney
FACEM, MBBS (Hon), B. Pharm. Emergency Medicine Education Fellow at Liverpool Hospital, Australia. Special interests in clinical education, ECG interpretation and diagnostic ultrasound. Proud father and husband, sadly a golf tragic
Sydney-based Emergency Physician (MBBS, FACEM) working at Liverpool Hospital. Passionate about education, trainees and travel. Special interests include radiology, orthopaedics and trauma. Creator of the Sydney Emergency XRay interpretation day (SEXI).