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Hangman's Fracture (Traumatic Spondylolisthesis of C2)

Definition

• Grainger & Allison's Diagnostic Radiology

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Nomenclature and Mechanism

• Hyperextension + axial loading - the most common mechanism (motor vehicle collisions, diving)
• Flexion forces - responsible for some subtypes (especially Type IIa)
• Recent biomechanical evidence shows that different neck postures at time of impact produce distinct fracture patterns
• Rockwood and Green's Fractures in Adults, 10th ed. 2025; Campbell's Operative Orthopaedics, 15th ed. 2026

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Classification: Levine and Edwards (Modified from Effendi)

• Rockwood and Green's Fractures in Adults, 10th ed. 2025; Campbell's Operative Orthopaedics, 15th ed. 2026

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Diagnosis

• Plain radiographs: Lateral C-spine - anterior subluxation of C2 on C3; fracture line through pars
• CT scan: Gold standard - defines fracture morphology, identifies Starr-Eismont variant (posterior body involvement), and detects facet dislocation in Type III
• MRI: Essential if neurologic deficit present; evaluates disc, ligaments (PLL, ALL, ligamentum flavum), and cord injury

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Treatment

Non-operative (majority of cases - ~89% in large registry data)

• Coric et al.: cervical orthosis effective for fractures with < 6 mm displacement
• Vaccaro et al.: halo vest successful in 21/27 Type II and all Type IIa; failures (fracture angulation > 12°) required repeat traction

Operative (indications)

• Type III (facet dislocation - absolute indication)
• Neurologic deficit
• Failure to maintain reduction
• Starr-Eismont variant with instability
• Fractures requiring traction for reduction (traction cannot be maintained in a collar/halo vest)

Surgical options (three strategies):

1. Pedicle screw osteosynthesis at C2 - for fractures with minimal soft-tissue disruption; preserves motion; uncommon because most have soft-tissue injury
2. Anterior C2-C3 fusion - instrumentation at C2-C3 only; preserves C1-C2 rotation (~50% of cervical rotation)
3. Posterior C1-C2-C3 fusion - most stable construct; sacrifices C1-C2 motion

• Campbell's Operative Orthopaedics, 15th ed. 2026; Rockwood and Green's 10th ed. 2025

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Why Neurological Injury is Uncommon

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Quick Summary

Recent evidence note: A 2024 narrative review (PMID 39309549) on C2 fracture management highlights that multiple overlapping classification systems for C2 fractures can complicate treatment decisions - the Levine-Edwards system remains the standard for hangman's fractures specifically.

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HANGMAN'S FRACTURE (Traumatic Spondylolisthesis of C2)

BPT / MPT Final Year - Clinical, Evidence-Based Format

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✅ 1. DEFINITION AND CLASSIFICATION

The name is a misnomer - judicial hanging rarely produced this fracture. Modern causes are high-energy trauma (MVA, diving, falls). - Rockwood & Green's Fractures in Adults, 10th ed. 2025

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• Campbell's Operative Orthopaedics, 15th ed. 2026; Rockwood & Green's 10th ed. 2025

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✅ 2. DETAILED ANATOMY AND BIOMECHANICS

• C2 (Axis): Has a unique structure - odontoid process (dens), body, pedicles, pars interarticularis (isthmus), laminae, spinous process
• Pars interarticularis: The narrow bridge of bone between superior and inferior articular facets of C2 - the fracture site
• C1-C2 joint: Atlanto-axial joint - provides ~50% of total cervical rotation
• C2-C3 joint: Subaxial; stabilised by disc, PLL, ALL, ligamentum flavum, facet capsules
• Vertebral artery: Passes through foramen transversarium of C2 - at risk in displaced fractures
• Spinal cord at C2: Cord injury is RARE because anterior displacement of C2 body actually WIDENS the spinal canal (self-decompressing mechanism)

• Hyperextension + axial load → compressive force on pars interarticularis → bilateral pars fracture → C2 body subluxes anteriorly → posterior arch remains in normal position
• Flexion-distraction (Type IIa) → horizontal fracture line → marked kyphosis at C2-C3 → traction WORSENS deformity
• Type III: Flexion-compression → pars fracture + facet dislocation → most complex

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✅ 3. PATHOPHYSIOLOGY

1. High-energy trauma applies hyperextension + axial load to C2
2. Bilateral pars interarticularis fractures occur (weakest point of C2 arch)
3. C2 vertebral body with anterior arch separates from posterior elements
4. C2 body subluxes anteriorly on C3 → C2-C3 disc and ligament injury (in types II/IIa/III)
5. Canal decompression effect: Posterior arch stays posterior while body goes anterior → AP diameter of canal increases → neurological injury rare (except Starr-Eismont variant and Type III)
6. Starr-Eismont variant (Type Ia): Fracture extends into posterior body → posterior fragment displaces backward → canal compromise → higher neuro injury rate
7. Soft tissue injury: C2-C3 disc, PLL, ALL, ligamentum flavum, facet capsules are progressively disrupted from Type I → III
8. Vertebral artery injury possible in displaced fractures → vertebrobasilar ischaemia

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✅ 4. CLINICAL PRESENTATION

• High-energy MVA (most common), diving into shallow water, fall from height
• Patient reports severe neck pain, stiffness, inability to move neck
• May report upper limb tingling/weakness (if incomplete cord involvement)
• Loss of consciousness possible (associated head injury common)

• Severe neck pain at upper cervical region (C1-C2 level)
• Occipital headache (suboccipital pain)
• Neck stiffness / muscle spasm
• Pain radiating to shoulders (C3-C4 dermatome)
• Dysphagia (rare, retropharyngeal haematoma)
• Neurological symptoms: rare; if present → paresthesia, weakness in upper/lower limbs

• Tenderness over C2 spinous process
• Muscle guarding and spasm (upper cervical paraspinals, trapezius)
• Restricted all cervical ROM
• Neurological deficit: rare; if present - upper motor neuron signs (hyperreflexia, Babinski positive, clonus), sensory loss

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✅ 5. MUSCLE-WISE ASSESSMENT

• Rockwood & Green's Fractures in Adults, 10th ed. 2025

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✅ 6. EXPECTED POSITIVE FINDINGS

• Patient holding head with hands (protective posture)
• Forward head posture
• Restricted spontaneous cervical movement
• Ecchymosis over posterior neck (in high-energy trauma)
• Associated facial/head injuries

• Point tenderness over C2 spinous process (midline)
• Paraspinal muscle spasm (bilateral upper cervical region)
• Suboccipital tenderness

⚠️ Clinical Warning: Do NOT perform active cervical movements or provocative tests in acute/unstable hangman's fracture. Neurological and vascular assessment only.

• Dermatome testing: C2 (posterior scalp), C3 (posterior neck), C4 (shoulder top), C5-T1 (upper limbs)
• Deep tendon reflexes: Biceps (C5-C6), Triceps (C7), Brachioradialis (C6)
• Clonus, Babinski sign

• Complete inability to perform ADLs independently
• Unable to drive
• Dysphagia (if retropharyngeal haematoma)
• Gait disturbance if lower limb UMN signs
• Occupational limitations

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✅ 7. DIFFERENTIAL DIAGNOSIS

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✅ 8. INVESTIGATIONS

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✅ 9. PROBLEM LIST

1. Pain: severe upper cervical and suboccipital pain
2. Cervical instability (fracture-related)
3. Restricted cervical ROM (all planes)
4. Cervical muscle spasm (SCM, trapezius, suboccipitals)
5. Deep neck flexor weakness (inhibition by pain)
6. Neurological deficits (if SCI present): motor weakness, sensory loss, reflex changes
7. Vertebral artery compromise (if displaced)

1. Unable to perform cervical movements actively
2. Difficulty with ADLs (grooming, dressing, feeding)
3. Difficulty sleeping
4. Inability to drive

1. Unable to work / attend college
2. Reduced social participation
3. Sports and recreational activities restricted

1. Fear of movement (kinesiophobia)
2. Anxiety/depression post-trauma

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✅ 10. SMART GOALS

Short-Term Goals (0-6 weeks - Immobilisation Phase):

1. Patient will report pain reduction from 8/10 to 4/10 on NRS within 4 weeks of physiotherapy
2. Patient will demonstrate independent safe bed mobility with log-roll technique within 1 week
3. Upper limb ROM will be maintained at full range (shoulder, elbow, wrist) within 2 weeks
4. Patient will perform diaphragmatic breathing exercises independently within 3 days
5. Prevent DVT and pressure sores through positioning programme within 1 week

Long-Term Goals (3-6 months - Post-Immobilisation):

1. Patient will achieve pain-free full cervical ROM (flexion 45°, extension 60°, rotation 70°) within 3 months of orthosis removal
2. Patient will demonstrate MMT grade 5 for all cervical muscles within 4 months
3. Patient will return to full independent ADLs without pain within 3 months
4. Patient will return to work/study within 4-5 months
5. Patient will demonstrate correct posture and ergonomics for long-term spine health within 3 months

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✅ 11. PHASE-WISE PHYSIOTHERAPY MANAGEMENT

PHASE 1: Acute / Immobilisation Phase (0-6 weeks)

• Positioning: semi-Fowler's or supine with neutral cervical spine
• Log-roll technique for bed mobility - teach patient and family
• Deep breathing exercises (diaphragmatic) - prevent pulmonary complications
• Upper and lower limb passive/active-assisted ROM exercises (within spinal precautions)
• DVT prevention: ankle pumps, calf exercises
• Pressure area care: repositioning education
• Patient and caregiver education: collar/halo-vest care
• TENS / electrotherapy for pain control (over trapezius, paraspinals - NOT over fracture site)
• Orthosis management: rigid cervical collar (Type I) or halo vest (Type II/IIa)

⚠️ No active cervical exercises until fracture healing confirmed on imaging

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PHASE 2: Subacute / Post-Immobilisation Phase (6-12 weeks post-orthosis removal)

• Active cervical ROM exercises (see Section 13 below)
• Deep neck flexor (DNF) activation - Craniocervical flexion test (CCFT) protocol
• Postural re-education
• Scapular stabilisation exercises
• Thoracic mobility exercises
• Scar management (post-surgical cases)
• Electrotherapy: TENS, IFT for pain

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PHASE 3: Strengthening Phase (3-4 months)

• Progressive isometric → isotonic cervical strengthening
• Deep neck flexor endurance training
• Proprioceptive training (head repositioning accuracy)
• Shoulder girdle strengthening
• Core strengthening (spinal support)
• Functional activity training

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PHASE 4: Functional / Return to Activity Phase (4-6 months)

• Dynamic cervical stabilisation
• Sport-specific training (if applicable)
• Ergonomic training
• Work hardening programme

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✅ 12. MUSCLE-SPECIFIC EXERCISES

A. Deep Neck Flexor (DNF) Activation - Craniocervical Flexion

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B. Isometric Cervical Strengthening (Post-Healing)

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C. Active Cervical ROM Exercises

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D. Scapular Stabilisation - Retraction/Depression

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E. Upper Trapezius Stretch

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✅ 13. ELECTROTHERAPY

A. TENS (Transcutaneous Electrical Nerve Stimulation)

B. Interferential Therapy (IFT)

C. Ultrasound Therapy (Later Phase - Soft Tissue)

⚠️ Electrotherapy over the cervical spine requires extreme caution. Anterior neck (carotid sinus, vagus nerve) is strictly contraindicated. All parameters to be titrated to patient response.

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✅ 14. FUNCTIONAL AND GAIT TRAINING

• Bed mobility: log-roll technique (essential during immobilisation) - protects spinal alignment
• Sit-to-stand transfers: use of arms to push up; neutral spine maintained
• Walking with cervical orthosis: gait training on level ground → uneven surfaces
• Stair climbing: begin with one step at a time with railing support
• ADL training: grooming, feeding, dressing with adapted techniques
• Driving: NOT permitted with cervical orthosis; cleared only after medical review

• Spastic gait: scissoring pattern, foot drop → address with orthotics, gait retraining
• Ataxic gait (if cerebellar/dorsal column involved): wide-based gait → balance training
• Use of walking aids initially if balance affected

• Eyes-open to eyes-closed standing
• Single-leg stance (progressed)
• Head repositioning accuracy test
• Foam pad standing
• Vestibular rehabilitation if dizziness present

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✅ 15. HOME EXERCISE PROGRAMME (HEP)

1. DNF activation (chin tucks) - 3 sets × 10 reps × 10 sec hold; 2× daily
2. Active cervical ROM (flexion, extension, lateral flexion, rotation) - 10 reps each; 2× daily
3. Scapular retraction - 3 sets × 15 reps × 5 sec hold; daily
4. Upper trapezius stretch - 3 reps × 30 sec each side; 2-3× daily
5. Posture correction - chin tuck posture reminders every 30 minutes (especially during screen time)
6. Walking programme - 20-30 minutes brisk walking daily
7. Ergonomic advice:
   • Monitor at eye level
   • Avoid prolonged neck flexion (phone, reading)
   • Use pillow that maintains cervical lordosis
   • Sleep in supine or side-lying; avoid prone

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✅ 16. CRITERIA FOR RETURN TO ACTIVITY / SPORT

• Fracture healing confirmed on CT/X-ray
• Pain NRS ≤ 2/10
• Full pain-free cervical ROM
• Independent ADLs without assistance
• Cleared by treating orthopaedic/neurosurgeon

• Complete fracture healing (minimum 3-4 months)
• Full cervical ROM, pain-free
• Cervical muscle strength ≥ 90% of contralateral / normative values
• Cervical endurance normalised (DNF endurance test)
• No neurological deficits
• Physician clearance mandatory
• Contact sports (rugby, wrestling, American football): May require 6-12 months; special neck guard use considered

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✅ 17. COMPLICATIONS AND PROGNOSIS

• Type I: Excellent - heals with collar in 4-6 weeks
• Type II: Good with halo vest; ~10-15% fail conservative management
• Type IIa: Good if managed correctly (extension/compression, NO traction)
• Type III: Requires surgery; recovery depends on neurological status pre-operatively
• Only 11.2% of all hangman's fractures require surgery (National Trauma Data Bank)
• Neurological deficits: rare but, if present, prognosis depends on ASIA grade and completeness

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✅ 18. HIGH-YIELD VIVA AND UNIVERSITY EXAM POINTS

1. Define and classify Hangman's fracture with a diagram.
2. What is the mechanism of injury in each type of Hangman's fracture?
3. Why is neurological injury uncommon in Hangman's fracture?
4. What is the role of physiotherapy in managing Hangman's fracture?
5. Describe phase-wise physiotherapy management of a post-halo vest patient.
6. What is the Levine and Edwards classification?
7. Why is traction contraindicated in Type IIa?

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• Hangman's fracture = pars interarticularis of C2 (NOT dens, NOT C1)
• Canal widens → neuro injury rare, but NOT absent (Starr-Eismont Type Ia = high neuro risk)
• Type IIa = NEVER apply traction (accentuates kyphosis and deformity)
• Always clear cervical spine radiologically before starting active cervical exercises
• Deep neck flexors (Longus colli, Longus capitis) are the primary stabilisers - their activation is the cornerstone of cervical rehabilitation
• Halo vest complications: pin infection (most common), pulmonary restriction (must teach breathing exercises)

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1. "What precautions would you take before starting cervical exercises?" → Confirm fracture healing on imaging, physician clearance, ASIA assessment, no instability signs
2. "What is the difference between Type II and Type IIa?" → Type II: translation > 3 mm + angulation; Type IIa: minimal translation but MARKED angulation; horizontal fracture; flexion-distraction mechanism; NO TRACTION
3. "How do you assess deep neck flexors clinically?" → Craniocervical flexion test (CCFT) using pressure biofeedback unit; target 22-24 mmHg
4. "What is the significance of the Starr-Eismont variant?" → Fracture extends into posterior C2 body; posterior fragment displaces backward narrowing canal; higher neurological injury risk
5. "What electrical modality would you use and why?" → TENS for pain (gate control theory); IFT for deeper tissue; AVOID anterior neck and fracture site

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1. Applying active cervical exercises before radiological healing confirmed (dangerous)
2. Applying traction in Type IIa fracture (contraindicated - can cause paralysis)
3. Not checking ASIA classification in patients with trauma
4. Neglecting to teach log-roll technique to patient and caregivers
5. Placing TENS electrodes on anterior neck (over carotid sinus) - strictly contraindicated
6. Confusing Hangman's fracture (C2 pars) with Jefferson fracture (C1 burst) or odontoid fracture (C2 dens)
7. Starting aggressive ROM before adequate deep neck flexor activation

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✅ 19. REFERENCES

1. Rockwood and Green's Fractures in Adults, 10th Edition (2025) - Chapter on Upper Cervical Spine Injuries
2. Campbell's Operative Orthopaedics, 15th Edition (2026) - Chapter 48: Traumatic Spondylolisthesis of the Axis
3. Bailey and Love's Short Practice of Surgery, 28th Edition - Chapter 30: Spinal Injuries
4. Grainger & Allison's Diagnostic Radiology - Chapter 52: Cervical Spine Trauma
5. Miller's Review of Orthopaedics, 9th Edition - Upper Cervical Spine Injuries
6. Schwartz's Principles of Surgery, 11th Edition - Hangman's Fractures of C2
7. Adams and Victor's Principles of Neurology, 12th Edition - Mechanisms of Spinal Injury
8. Levine AM, Edwards CC. The management of traumatic spondylolisthesis of the axis. J Bone Joint Surg Am. 1985;67(2):217-226.
9. McDermott M, et al. Management of C2 fractures following multiple classifications, a narrative review. Brain Spine. 2024. PMID: 39309549
10. Journal of Clinical Medicine, 2025 - Management of Atypical Hangman's Fracture: Systematic Review - mdpi.com
11. StatPearls (NCBI) - Hangman's Fractures

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💡 Exam Tip: In theory exams, always draw the Levine-Edwards classification diagram. In viva, know the contraindication to traction in Type IIa cold. In practical, always start with spinal precautions and ASIA classification before any cervical assessment.