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Hangman’s frx / Traumatic Spondylolisthesis of the Axis

- See:
      - Axis:
      - Hyperextension Injury

- Discussion:
    - frx of pars interarticularis of C2 & disruption of C2-C3 junction
    - type of traumatic spondylolisthesis - "Hangman's frx"
    - term "hangman's fracture" is not accurate for the majority of cases, because mechanism of injury for clinically encountered frxs often 
           lacks large traction force present in judicial hangings;
    - in cases in which there is neurologic injury, there will usually be significant horizontal translation w/ accompanying damage to the 
           posterior longitudinal ligament w/ or w/o damage of the C2-C3 interspace;
    - mechanism of injury in adults:
           - judical lesion: hyperextension and distraction;
           - hyperextension w/ vertical compression of posterior column, & translation of C2 and C3;
           - forceful extension of already extended neck is most commonly described mech of injury, but other causes include flexion of flexed 
                  neck & compression of an extended neck;
           - a blow on the forehead forcing the neck into extension is a classic mechanism of injury producing fractures thru the pedicles of C2 
                  known as traumatic spondyloslisthesis of C2;
    - children:
           - injury involves a combination of flexion and distraction;
           - injury is rare in children less than 8 years of age, since most fractures will occur thru the odontoid synchondrosis which does not 
                  fuse until age 6-7 yrs (see development of dens and pediatric dens frx);

- Radiographs:
    - Cross Table Lateral (injury is readily seen on x-ray)

- Levine Classification: (does not apply to children);
    - Type I:
           - < 3 mm translation, no angulation;
           - bilateral pars frx, prevertbral soft tissue swelling, w/ normal disc space & normal alignment;
           - C2-3 disk and ligamentous structures remain intact;
           - may be treated with a cervicothoracic brace (SOMI) which limitis flexion
           - 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);
    - Type II:
           - most common fracture subtype;
           - greater than 3 mm translation, and greater than than 10 deg angulation;
           - these frx are apparently caused by hyperflexion and are unstable;
           - frx is manifested by pars frx, anterior displacement of C2 body, & disruption & asymmetric widening of C2-3 disc 
                  space as well as soft tissue swelling;
                  - C2-3 disk and posterior longitudinal ligament are disrupted;
                  - anterior longitudinal ligament usually remains intact;
           - type II is typically rx'ed w/ halo vest for 3 months;
           - type II injuries may be difficult to manage;
                  - following reduction, halovest trial is reasonable, but this device may not maintain alignment.
           - type IIa:
                  - flexion/distraction variant, unstable;
                  - fracture line is more oblique than vertical and there is more angulation vs translation;
                  - posterior C2-3 disc space widening (more w/ traction);
                  - type IIA, in addition to frx of type II, has widening of posterior part of C2-3 disk w/ traction, & should be rx'ed in halovest;
                  - this is also rx'ed w/ halo vest, but avoid overdistraction;
                  - halo traction may cause overdistraction of this frx;
                  - traction may cause further fracture displacement and is avoided;
    - Type III:
           - includes all characteristics of type II frx as well as bilateral interfacetal dislocation;
           - may require open reduction of facet dislocation halo immobilization for the pedicle injury;
           - type III has angulation, translation, and also unilateral or bilateral facet dislocation at C2-3.

- Non Operative Rx:
    - halovest
    - pts w/ Hangman's fx should not be placed in cervical traction if mechanism of injury involves extension or distraction;
    - children:
           - traction should generally be avoided;
           - reduction is obtained w/ gentle extension;
           - some residual displacement may be accepted;
           - need to immobilize in halo for 6-8 weeks;

- Surgical Treatment:
    - ORIF may be necessary to obtain and maintain reduction;
    - internal fixation techniques include posterior oblique wiring, which resists rotational forces, & screw fixation of C-2 posterior elements 
         to the C-2 body.
         - this latter technique depends on integrity of C-2 & C-3 capsules and ligaments, which is usually the case.

Injuries of the atlas and axis. A follow-up study of 85 axis and 10 atlas fractures.

Fractures of the neural arch of the axis. A report of twenty-nine cases.

Caspar plate fixation for the treatment of complex hangman's fractures.

Unstable hangman's fractures.

Traumatic spondylolisthesis of the axis.

The management of traumatic spondylolisthesis of the axis.

Axis fractures: a comprehensive review of management and treatment in 107 cases.

Hangman's fracture: radiologic assessment in 27 cases.