HANGMAN'S FRACTURE - C2 TRAUMATIC SPONDYLOLISTHESIS
Bilateral Pars Fracture | Levine-Edwards Classification | Type IIA - No Traction
Levine-Edwards Classification
Critical Must-Knows
- Type IIA: Traction is CONTRAINDICATED - flexion-distraction injury
- Auto-decompression explains low neurological injury rate (canal expands)
- Measure translation AND angulation on lateral radiograph
- Type IIA: angulation out of proportion to translation (greater than 11 degrees, less than 3mm)
- Most treated non-operatively (collar or halo) - surgery for Type III or failed conservative
Examiner's Pearls
- "Type IIA recognition: angulation greater than translation (greater than 11 degrees, less than 3mm)
- "All types can have severe injury but neurological deficit rare (canal expands)
- "Associated head/facial trauma common (forehead impact mechanism)
Clinical Imaging
Imaging Gallery
Exam Warning
Orthopaedic examiners test the Levine-Edwards classification and specific management for each type. The most commonly tested pitfall is Type IIA - recognizing that traction is CONTRAINDICATED because it will worsen the flexion-distraction injury. Type IIA has minimal translation but marked angulation.
At a Glance Table
Hangman's Fracture Quick Reference
| Feature | Type I | Type II | Type IIA | Type III |
|---|---|---|---|---|
| Translation | Less than 3mm | Greater than 3mm | Less than 3mm | Variable |
| Angulation | Minimal | Significant | Severe (greater than 11°) | Variable |
| Mechanism | Extension + axial load | Extension then flexion | Flexion-distraction | Flexion-compression |
| C2-C3 Disc | Intact | Disrupted | Posterior disruption | Complete disruption |
| Stability | Stable | Unstable | Unstable | Very unstable |
| Treatment | Rigid collar 8-12 weeks | Halo vest 8-12 weeks | Halo in EXTENSION (NO traction) | Surgery - fusion |
| Union Rate | Near 100% | 90-95% | High with correct treatment | Variable post-surgery |
| Key Pearl | Most common type | May use traction initially | TRACTION CONTRAINDICATED | Facet dislocation present |
HANGMAN
Memory Hook:HANGMAN helps remember Hangman's fracture assessment and the critical Type IIA warning
TYPES
Memory Hook:TYPES helps remember Levine-Edwards management - especially that Type IIA prohibits traction
ASSESS
Memory Hook:ASSESS the Hangman's fracture patient systematically
COLLAR
Memory Hook:COLLAR or halo - management depends on type, with special rules for IIA and III
Overview and Clinical Significance
The C2 Pars Fracture
Hangman's fracture (traumatic spondylolisthesis of C2) is a bilateral fracture through the pars interarticularis of the axis. The term derives from the similar fracture pattern caused by judicial hanging, though modern cases are typically from motor vehicle accidents.
Epidemiology
- 4-7% of all cervical fractures
- Most common C2 fracture (excluding odontoid)
- Peak: young adults (MVA), elderly (falls)
- Male predominance
- Neurological injury only 6%
Mechanism
- Hyperextension + axial load (most common)
- Motor vehicle accident (forehead strike)
- Falls from height
- Diving accidents
- Type IIA: flexion-distraction
Why Cord is Spared
- Bilateral pars fracture creates "auto-decompression"
- Posterior ring separates from anterior elements
- Canal diameter increases with injury
- Contrast with burst fractures that narrow canal
- "Jefferson expands, Hangman's translates but opens"
Historical Context
Sir Geoffrey Jefferson first described the mechanism in 1927, relating it to judicial hanging. In judicial hanging:
- Drop causes hyperextension and distraction
- Bilateral pars fractures occur
- Spinal cord transection at C2 level
- Death from respiratory arrest (phrenic nerve C3-5)
Modern Hangman's fractures differ - lower energy, variable mechanisms, rarely cause death.
Exam Pearl
The low neurological injury rate (approximately 6%) in Hangman's fractures is explained by the "auto-decompression" effect - the bilateral pars fractures allow the spinal canal to expand rather than compress. This is in contrast to burst fractures where bone retropulses into the canal.
Pathophysiology and Mechanisms
C2 Vertebral Anatomy
The axis (C2) has unique anatomy:
C2 Structural Features
| Feature | Description | Clinical Relevance |
|---|---|---|
| Odontoid process (dens) | Superior projection articulating with C1 | Fractures classified separately (Anderson-D'Alonzo) |
| Pars interarticularis | Connects superior and inferior articular processes | Site of Hangman's fracture - thin isthmus |
| Superior articular facets | Large, flat, face superolateral | Articulate with C1 lateral masses |
| Inferior articular facets | Face anteroinferior | Articulate with C3 - can dislocate in Type III |
| Vertebral artery groove | Courses through transverse foramen | At risk with displaced fractures |
| Body | Large, bears weight from above | Translates forward with bilateral pars fracture |
Biomechanics of Injury
Classic Mechanism (Types I, II, III) - Hyperextension + Axial Load:
- Forehead strikes dashboard or object
- Neck forced into hyperextension
- Axial load transmitted through cervical spine
- Pars interarticularis fractures bilaterally (weakest point)
- Variable translation of C2 body on C3
Type IIA Mechanism - Flexion-Distraction:
- Different mechanism - flexion injury
- Distraction forces rather than compression
- Minimal translation but severe angulation
- Disc disruption between C2-C3
- CRITICAL: Traction contraindicated
Classification Systems
Levine-Edwards Classification
The most widely used classification system, based on mechanism and radiographic parameters:
Levine-Edwards Classification of Hangman's Fractures
| Type | Translation | Angulation | Mechanism | C2-C3 Disc |
|---|---|---|---|---|
| Type I | Less than 3mm | Minimal | Axial load + extension | Intact |
| Type II | Greater than 3mm | Significant | Axial load + extension then flexion | Disrupted |
| Type IIA | Minimal (less than 3mm) | Severe (greater than 11 degrees) | Flexion-distraction | Disrupted |
| Type III | Variable | Variable | Flexion-compression | Disrupted + facet dislocation |
Characteristics
- Less than 3mm translation
- Minimal angulation
- C2-C3 disc intact
- Stable fracture pattern
- Posterior longitudinal ligament intact
Management
- Rigid cervical collar (Philadelphia, Miami J)
- 8-12 weeks immobilization
- Near 100% union rate
- Excellent prognosis
- No need for halo
Exam Pearl
Type IIA recognition: Look for "angulation out of proportion to translation" - if you see greater than 11 degrees angulation with less than 3mm translation, this is Type IIA. The mechanism is flexion-distraction, and traction will make it worse by further opening the posterior disc.
Radiographic Examples
Clinical Assessment
History
Key mechanism features:
- MVA: Dashboard injury, forehead strike
- Fall: Onto head or face (hyperextension)
- Diving: Impact with head
- Sports: Contact sports, gymnastics
- Type IIA clue: Flexion mechanism history
Associated symptoms:
- Neck pain (posterior, radiating to occiput)
- Limited range of motion
- Headache
- Neurological symptoms (rare - 6%)
Physical Examination
Maintain cervical spine immobilization until cleared. High association with other cervical and head injuries in MVA patients. Complete ATLS primary survey before focused spine examination.
Examination findings:
- Inspection: Cervical collar in place, facial/forehead trauma
- Palpation: Posterior midline tenderness at C2 level
- Neurological: Full motor/sensory exam (usually normal)
- Associated injuries: Head trauma, facial fractures common
Red Flags for Neurological Injury
Though rare, neurological injury can occur:
- Complete cord injury from judicial hanging mechanism
- Type III with cord compression
- Associated injuries (disc herniation, facet locking)
- Vertebral artery injury
Imaging
Plain Radiographs
Lateral Cervical Radiograph:
- Critical view for Hangman's fracture diagnosis
- Measure translation of C2 on C3
- Measure angulation at C2-C3
- Assess prevertebral soft tissue swelling
- Look for associated injuries
Key Measurements:
- Translation: measure C2 body posterior margin to C3
- Angulation: angle between C2 inferior endplate and C3 superior endplate
- Type I: less than 3mm translation, minimal angulation
- Type II: greater than 3mm translation, variable angulation
- Type IIA: less than 3mm translation, greater than 11 degrees angulation
CT Imaging
CT Findings
- Bilateral pars fractures
- Fracture pattern and comminution
- Translation measurement (more accurate)
- Facet alignment (Type III)
- Associated fractures (C1, C3)
CT Advantages
- Superior fracture detail
- Multiplanar reconstructions
- 3D reconstructions helpful for planning
- Detects subtle fractures missed on radiograph
- Assess vertebral artery foramina
MRI Assessment
Indications for MRI:
- Neurological deficit
- Type II, IIA, III fractures
- Planning for surgical management
- Assessing disc and ligament integrity
- Cord evaluation
MRI Findings by Type
| Type | C2-C3 Disc | Ligaments | Cord |
|---|---|---|---|
| Type I | Intact | PLL intact | Normal |
| Type II | Disrupted | PLL torn | Usually normal |
| Type IIA | Posterior disruption | Posterior ligaments torn | Usually normal |
| Type III | Complete disruption | All ligaments torn | May be compressed |
Imaging Pitfalls
Exam Warning
Beware of "pseudo-Hangman's" appearance in children - synchondroses at C2 can mimic fracture lines. Synchondroses have smooth, corticated edges and are bilateral and symmetric. True fractures have irregular, non-corticated edges.
Management Algorithm
Rigid Cervical Collar:
- Philadelphia, Miami J, or Aspen collar
- Duration: 8-12 weeks
- Follow-up radiographs at 2, 6, 12 weeks
- Flexion-extension views at 12 weeks to confirm stability
- Near 100% union rate
Prognosis: Excellent outcomes with full return to function expected and minimal long-term sequelae.
Special Considerations
Elderly Patients:
- Higher fall mechanism
- May have osteoporosis
- Halo complications higher (pin loosening, infection)
- Consider collar for stable patterns
- Lower threshold for surgery if unstable
Associated Injuries:
- Head trauma common (forehead impact)
- Facial fractures
- Other cervical fractures (C1 Jefferson, C3)
- Assess entire cervical spine with CT
Surgical Technique
Indication: Type III, failed non-operative management, irreducible Type II
Technique:
- Patient supine, slight neck extension
- Standard Smith-Robinson right-sided approach
- Identify C2-C3 level with fluoroscopy
- Complete discectomy and endplate preparation
- Interbody graft or cage placement (PEEK or allograft)
- Anterior plate fixation with screws into C2 and C3 bodies
- Avoid extending plate above C2-C3 (adjacent segment issues)
- Intraoperative fluoroscopy confirmation
Key Points: Direct access to disrupted disc, anterior column support, high fusion rates (greater than 90%), may need posterior supplementation for severe instability.
Exam Pearl
Anterior C2-C3 ACDF is the most common surgical approach for Hangman's fracture requiring surgery. It provides direct access to the disrupted disc, allows anterior column support, and achieves high fusion rates. Posterior fixation may be added for severe instability or Type III injuries.
Complications
Overview
Hangman's fractures have relatively low complication rates compared to other cervical spine injuries, primarily due to the "auto-decompression" effect. However, specific complications can occur based on fracture type and treatment method.
Hangman's Fracture Complications
| Complication | Incidence | Risk Factors | Management |
|---|---|---|---|
| Non-union | 5-10% | Type II/III, inadequate immobilization | Extended immobilization or surgery |
| Malunion | Variable | Type IIA in flexion, poor reduction | May be asymptomatic or require surgery |
| Vertebral artery injury | Rare (less than 5%) | Displaced fracture through foramen | CTA screening, observation |
| Neurological deterioration | Very rare (less than 2%) | Type III, cord compression | Urgent surgical decompression |
| Halo complications | 10-30% | Elderly, osteoporosis, poor compliance | Pin care, early removal, convert to collar |
Non-union
Incidence: 5-10% overall (higher in Type II/III, rare in Type I)
Risk Factors:
- Inadequate immobilization duration
- Poor patient compliance
- Smoking and diabetes
- Severe initial displacement
Management:
- Asymptomatic: observation
- Symptomatic: C2-C3 fusion (anterior or posterior)
Malunion
Patterns: Kyphotic deformity, residual translation, Type IIA treated in flexion
Management:
- Conservative if asymptomatic
- Corrective osteotomy and fusion if severe
Vertebral Artery Injury
Incidence: Rare (less than 5%), usually asymptomatic
Diagnosis: CTA cervical spine for high-energy injuries
Management: Observation, antiplatelet therapy, rarely endovascular intervention
Neurological Complications
Incidence: Overall 6%, highest in Type III (10-15%)
Pattern: Usually present at time of injury, delayed deterioration very rare
Management: Maintain alignment, surgical decompression if indicated
Halo Vest Complications
Incidence: 10-30%, higher in elderly
Types:
- Pin site infections (10-20%)
- Pin loosening (5-15%)
- Respiratory complications
- Skin breakdown
- Dysphagia
Management: Pin care, early recognition, may require early halo removal
Postoperative Care
Immediate Postoperative Period
Day 0-3:
- ICU or high-dependency monitoring if neurologically intact
- Cervical collar or halo vest immobilization
- Neurological checks every 2-4 hours
- Pain management (multimodal analgesia)
- DVT prophylaxis (mechanical and chemical)
- Early mobilization when stable
Immobilization Protocol
After Fusion Surgery:
- Hard cervical collar for 6-8 weeks (anterior fusion alone)
- Halo vest for 8-12 weeks (posterior fusion or combined)
- Serial radiographs at 2, 6, 12 weeks
- CT at 12 weeks to assess fusion
After Non-operative Treatment:
- Collar: 8-12 weeks for Type I
- Halo: 8-12 weeks for Type II/IIA
- Flexion-extension radiographs at 12 weeks
Follow-up Schedule
Follow-up Protocol
| Time | Assessment | Imaging | Activity |
|---|---|---|---|
| 2 weeks | Wound check, neurology | Lateral radiograph | Collar/halo wear |
| 6 weeks | Pain, ROM assessment | AP + Lateral radiographs | Light activities only |
| 12 weeks | Fusion assessment | CT + flexion-extension | Wean immobilization |
| 6 months | Final fusion check | CT if non-union concern | Return to full activity |
| 12 months | Discharge if healed | Only if symptomatic | No restrictions |
Rehabilitation
Phase 1 (0-6 weeks):
- Maintain immobilization
- Upper extremity exercises (shoulder, elbow)
- Core strengthening (no neck movement)
- Gait training with collar/halo
Phase 2 (6-12 weeks):
- Gradual collar/halo weaning
- Gentle active ROM exercises
- Progressive strengthening
- Proprioceptive training
Phase 3 (3-6 months):
- Full ROM restoration
- Advanced strengthening
- Sport-specific training (if appropriate)
- Return to work assessment
Return to Activity Guidelines
Return to Activity Timeline
| Activity | Type I | Type II/IIA | Type III (Surgical) |
|---|---|---|---|
| Light desk work | When comfortable in collar | When comfortable in halo | 6-8 weeks post-surgery |
| Driving | After collar weaned, full ROM | After halo removed, ROM restored | 3 months post-surgery minimum |
| Heavy manual work | 3 months, confirmed union | 4-6 months, confirmed union | 6 months post-fusion |
| Contact sports | 6 months if union confirmed | Case-by-case, often restricted | Generally not recommended |
| High-risk activities | Patient decision after counseling | Counsel on risk | Not recommended |
Outcomes and Prognosis
Overall Outcomes
Hangman's fractures have generally excellent outcomes when appropriately treated:
Type I:
- Near 100% union rate with collar
- Full return to function expected
- Minimal long-term neck pain (less than 10%)
- Excellent prognosis
Type II:
- 90-95% union rate with halo
- Good functional outcomes
- Some patients have mild chronic neck pain (20-30%)
- Non-union rate 5-10% (may require late surgery)
Type IIA:
- Good outcomes if recognized and treated correctly
- Key is avoiding traction
- Union rates similar to Type II with correct management
- May have more neck stiffness than Type I
Type III:
- Variable outcomes
- Highest rate of neurological injury (10-15%)
- Surgery usually achieves stable fusion (greater than 85%)
- Loss of C2-C3 motion segment
- May have persistent neck pain (30-40%)
Functional Outcomes
Long-term Functional Outcomes
| Outcome Measure | Type I | Type II/IIA | Type III |
|---|---|---|---|
| Union rate | Greater than 95% | 90-95% | 85-90% (surgical) |
| Return to work | 95% full duty | 85% full duty | 70% full duty |
| Chronic neck pain | Less than 10% | 20-30% | 30-40% |
| C2-C3 ROM loss | Minimal | 10-20 degrees | Complete (if fused) |
| Patient satisfaction | Excellent (90%) | Good (80%) | Fair-Good (70%) |
Predictors of Poor Outcomes
Factors associated with worse long-term outcomes:
- Type III injuries (highest complication rate)
- Elderly patients (greater than 65 years)
- Neurological injury at presentation
- Delayed diagnosis or treatment
- Non-compliance with immobilization protocol
- High-energy mechanism
- Smoking and comorbidities
Evidence and Guidelines
Levine-Edwards Classification
- Classification of traumatic spondylolisthesis of C2 based on mechanism and radiographic parameters. Identified Type IIA as distinct flexion-distraction pattern requiring different treatment (no traction).
Non-operative Management Outcomes
- High union rates (greater than 90%) with external immobilization for Type I and II Hangman's fractures. Neurological injury rare (approximately 6%).
Type IIA Recognition
- Type IIA fractures represent flexion-distraction injuries with severe angulation (greater than 11 degrees) but minimal translation. Traction worsens displacement and should be avoided.
Surgical vs Non-operative Treatment
- Surgical treatment may achieve faster fusion and return to activity compared to halo vest for Type II fractures. However, most heal with non-operative management.
Elderly Patient Considerations
- Halo vest complications higher in elderly patients including pin site infections, pin loosening, and respiratory complications. Consider collar for stable patterns or early surgery for unstable.
Viva Scenarios
Exam Viva Scenarios
Practice these scenarios to excel in your viva examination
Type II Classification and Management
"A 35-year-old male is in an MVA. Lateral cervical radiograph shows a bilateral C2 pars fracture with 5mm translation and 8 degrees angulation. What is your classification and management?"
Classification:
- This is a Type II Hangman's fracture
- Translation greater than 3mm (5mm present)
- Angulation 8 degrees (significant)
- C2-C3 disc is disrupted
- Unstable pattern
Initial Management:
- Maintain cervical immobilization
- ATLS survey - MVA mechanism means multiple injury potential
- Full neurological examination (expect intact - 94% have no deficit)
- CT cervical spine - assess fracture pattern, associated injuries
- Consider MRI - evaluate C2-C3 disc, cord
Definitive Treatment:
- Halo vest immobilization for 8-12 weeks
- May apply gentle traction initially to reduce translation
- Convert to halo vest once reduced
- Serial radiographs to monitor alignment
- Flexion-extension views at 12 weeks to confirm stability
Surgical Indications:
- Unable to achieve or maintain reduction
- Patient cannot tolerate halo
- Non-union after halo treatment
- Options: anterior C2-C3 fusion or posterior fixation
Type IIA Recognition
"A Hangman's fracture is identified with 2mm translation but 15 degrees of angulation. What type is this and how would you manage it differently?"
Classification - Type IIA:
- Minimal translation (2mm - less than 3mm)
- Severe angulation (15 degrees - greater than 11 degrees)
- Angulation out of proportion to translation = Type IIA
- This is a FLEXION-DISTRACTION injury
- Different mechanism from Types I, II, III
Critical Management Difference:
- TRACTION IS CONTRAINDICATED!
- Traction will worsen the injury by distracting the posterior elements
- The posterior disc and ligaments are disrupted
- Applying traction opens this gap further
Correct Management:
- Halo vest applied in slight EXTENSION
- Extension closes the posterior disc gap
- Compressive force reduces the angulation
- Duration: 8-12 weeks
- Close radiographic monitoring for reduction maintenance
Why This Matters:
- Applying standard traction (as for Type II) would worsen injury
- Could convert to more unstable pattern
- May cause neurological injury if cord compressed
- Recognition is key to appropriate management
Neurological Sparing
"Explain why neurological injury is rare in Hangman's fractures despite the unstable nature of the injury."
The "Auto-Decompression" Concept:
- Bilateral pars fractures disconnect posterior from anterior ring
- When C2 translates forward on C3, the posterior elements stay behind
- This INCREASES the space available for the spinal cord
- Canal diameter enlarges rather than decreases
- Compare to burst fractures where bone retropulses into canal
Anatomical Factors:
- Spinal canal is widest at craniocervical junction
- Steel's Rule of Thirds: 1/3 cord, 1/3 space at C1
- Similar generous canal at C2 level
- Room for cord even with some translation
Mechanism Factors:
- Hyperextension mechanism separates elements apart
- No compression of neural elements
- Cord "rides through" the widening canal
- Contrast with judicial hanging - distraction causes cord transection
When Neurological Injury Does Occur:
- Type III with facet dislocation (cord compression)
- Associated disc herniation
- Massive energy judicial hanging mechanism
- Pre-existing canal stenosis
- Combined injuries with other fractures
MCQ Practice Points
High-Yield Facts for MCQs
Classification:
- Type I: less than 3mm translation, minimal angulation, collar treatment
- Type II: greater than 3mm translation, significant angulation, halo treatment
- Type IIA: minimal translation (less than 3mm) but severe angulation (greater than 11 degrees), NO TRACTION
- Type III: facet dislocation, surgical treatment
Exam Pearl
Q: How are Type I, II, and IIA distinguished by measurement? A: The Levine-Edwards classification uses 3mm translation and 11 degrees angulation thresholds. Type I is less than 3mm translation. Type II is greater than 3mm translation. Type IIA is less than 3mm translation but greater than 11 degrees angulation.
Key Measurements:
- 3mm: threshold between Type I and Type II translation
- 11 degrees: threshold for Type IIA angulation
- 8-12 weeks: typical immobilization duration
Exam Pearl
Q: What is the classic exam trap regarding Type IIA fractures? A: Type IIA is a FLEXION-DISTRACTION injury (unlike others). Traction is CONTRAINDICATED as it worsens displacement. Treatment is halo in extension.
Mechanism:
- Type I, II, III: hyperextension with axial loading
- Type IIA: flexion-distraction (opposite mechanism)
- Judicial hanging: hyperextension + distraction (usually fatal)
Neurological Injury:
- Overall rate: approximately 6%
- Explained by "auto-decompression" - canal expands
- Type III has highest risk
- Bilateral pars fractures allow posterior elements to separate
Exam Pearl
Q: Why is neurological injury rare (6%) in Hangman's fractures? A: "Auto-decompression" - the bilateral pars fractures allow the posterior elements to separate from the anterior body, expanding the spinal canal diameter rather than narrowing it.
Type IIA Critical Points:
- TRACTION IS CONTRAINDICATED
- Halo applied in EXTENSION position
- Flexion-distraction mechanism
- Angulation out of proportion to translation
- Most commonly tested pitfall in exams
Surgical Indications:
- Type III (facet dislocation)
- Failed non-operative management
- Irreducible Type II
- Patient unable to tolerate halo
- Non-union after appropriate immobilization
Exam Pearl
Q: Which Hangman's fracture requires surgical stabilization? A: Type III (with facet dislocation). It is highly unstable. Type I and II are usually managed with collar or halo respectively.
Imaging:
- Lateral cervical radiograph: key view
- Measure both translation AND angulation
- CT: fracture pattern, facet alignment
- MRI: disc disruption, cord, ligaments
Exam Pearl
Q: What specific measurements must be taken on lateral X-ray? A: Both translation AND angulation. Measuring only translation will miss Type IIA (minimal translation, severe angulation).
Common Exam Traps
- Type IIA traction: Most common mistake - traction worsens injury
- Neurological injury rate: Not high despite "unstable" fracture
- Measurement confusion: Must measure BOTH translation and angulation
- Mechanism confusion: Type IIA is flexion, not extension
- Surgical timing: Type III needs surgery, not all Hangman's fractures
- Collar vs halo: Type I gets collar, Type II gets halo
- Union rates: Generally excellent with appropriate treatment
MCQ Stems to Expect
- "A patient has C2 pars fracture with 2mm translation and 15-degree angulation. What is the classification and management?"
- "What explains the low neurological injury rate in Hangman's fractures?"
- "What is contraindicated in Type IIA Hangman's fracture?"
- "A Type III Hangman's fracture is characterized by..."
- "What is the most appropriate initial immobilization for a Type II Hangman's fracture?"
Australian Context
Epidemiology:
- Hangman's fractures represent 4-7% of cervical spine fractures in Australian trauma registries
- Predominantly motor vehicle accidents in younger adults, falls in elderly population
- Higher incidence in rural and regional areas due to MVA mechanism
Trauma System Management:
- Managed within established trauma network protocols
- Spinal immobilization by paramedics for all MVA patients
- Transfer to Level 1 trauma centre for major trauma
- Early spine surgery consultation at receiving hospitals
Non-operative Management:
- Rigid cervical collar fitting by orthotist (Miami J, Philadelphia, Aspen)
- Halo vest application by spine surgeon in operating theatre
- 8-12 week immobilization duration typical
- Outpatient follow-up in specialized spine clinics
- Serial imaging covered by Medicare
Surgical Access:
- Spinal surgery available at major metropolitan and regional centres
- Multidisciplinary spine teams (orthopaedic and neurosurgery collaboration)
- May require inter-hospital transfer from smaller regional facilities
- Access to modern instrumentation and fusion materials
Rehabilitation:
- Inpatient rehabilitation for surgical cases or neurological deficit
- Outpatient physiotherapy widely accessible
- Return to work programs through rehabilitation providers
- WorkCover involvement for work-related injuries
Return to Work/Activity:
- Light desk work: When comfortable in immobilization device
- Driving: After collar/halo weaned with full ROM restored
- Heavy manual work: 3-6 months depending on fracture type
- Contact sports: Case-by-case assessment, often restricted
- High-risk activities: Individual counseling on risks
Exam Cheat Sheet
HANGMAN'S FRACTURE
High-Yield Exam Summary
Classification
- •Type I: less than 3mm translation, minimal angulation = COLLAR
- •Type II: greater than 3mm translation, angulation = HALO
- •Type IIA: less than 3mm translation BUT greater than 11 degrees angulation = HALO IN EXTENSION, NO TRACTION!
- •Type III: facet dislocation → SURGERY
Key Concepts
- •Bilateral C2 pars fracture (traumatic spondylolisthesis)
- •Neurological injury rare (6%) - canal expands (auto-decompression)
- •Type IIA is flexion-distraction - traction worsens injury
- •Measure translation AND angulation on lateral cervical radiograph
Critical Pitfalls
- •Applying traction to Type IIA (CONTRAINDICATED)
- •Missing Type IIA - look for angulation > translation
- •Treating Type III non-operatively (needs surgery)
- •Missing associated C1 or C3 fractures
Exam Tips
- •Type IIA recognition is the classic exam trap
- •minimal translation + severe angulation = Type IIA
- •Explain auto-decompression for why cord spared
- •Know surgical options for Type III