What is the diagnosis and is it stable or unstable?

Hangman’s fracture, also known as traumatic spondylolisthesis of the axis (C2). This is considered an unstable cervical spine fracture [1].

•  Pearl: Unstable C spine fractures can be remembered by the mnemonic: Jefferson Bit Off A Hangman’s Thumb

                                                 i.     Jefferson fracture

                                                ii.     Bilateral Cervical Facet dislocation

                                               iii.     Odontoid fracture type II or III

                                               iv.     Atlanto- occipital dissociation

                                                v.     Hangman’s fracture

                                               vi.     Flexion teardrop fracture

What are the common mechanisms of injury?

Forced hyperextension mechanisms such as a passenger in a high-speed MVC, sporting injuries such as in diving, or falling forward onto a chin [2].

What type of imaging modality is needed?

Diagnosis can usually be made with a C-spine x-ray. CT scan has become the gold standard for initial evaluation. However, it does not adequately evaluate ligamentous injury and non-contrasted studies do not adequately assess vascular injury. 

• Pearl: Consider CT angiography in patients with blunt cervical injury to assess for vertebral artery injury. Among others, fractures of C1-3 are a risk factor for arterial injury.

What is your management in the ER?

Spine stabilization and immobilization, pain control, trauma evaluation, and spine service consultation.

What is your final disposition?

Admission and further management with your spine service

• Pearl: Definitive management will be guided by the Hangman’s fracture classification [3]. 

Table 1: From Management of Typical and Atypical Hangman’s Fractures3

• Pearl: Type I can usually be managed non-operatively with a cervical collar or halo, type II will vary depending on the ligamentous stability whether it is surgical or non-operative, and type III will likely need surgical stabilization [3].