' Hangman's Fracture" of the Cervical Spine*

RICHARD C. SCHNEIDER,M.D., t KENNETHE. LIVINGSTON,M.D.,$

A. J. E. CAVE, M.D., D.Sc.,w AND GILBERT HAMILTON,M.D., Crr.B.][

RAFFIC accidents occasionally produce

T a distinctive v a r i e t y of fracture (or

fracture-dislocation) of the u p p e r cer-
vical spine, characterized b y a bilateral
avulsion-fracture t h r o u g h the neural arch of
the axis without injury to the odontoid pro-
cess and with or without fracture-dislocation
of the s cervical vertebral b o d y upon the
8rd. T h e similarity of this lesion to t h a t ef-
fected b y the m o d e r n technique of judicial
hanging justifies its description as " h a n g -
m a n ' s f r a c t u r e " of the cervical spine.
Some years ago one of us (R.C.S. 5) pub-
lished a radiograph of a lesion sustained in a
traffic accident which revealed just such an
avulsion-fracture of the l a m i n a r portion of
the neural arch of the axis with a c c o m p a n y -
ing m a r k e d dislocation of the axis u p o n the
3rd v e r t e b r a (Fig. 1). T h o u g h the detailed
case history had been lost the a u t h o r recalled
t h e surprising survival of the p a t i e n t without
neurologic defect; the mechanics of the in-
j u r y remained unknown. S u b s e q u e n t l y two
of us (R.C.S., K.E.L.) collected a series of 8
patients involved in traff• accidents in
w h o m this same t y p e of cervical lesion was
manifest and for w h o m b o t h clinical m a -
terial and the evidence of follow-up exami-
nations were available for consideration. This
clinical information has been correlated with
an assessment of the mechanics of m o d e r n
judicial hanging a n d this a n a t o m i c o p a t h o -
Fio. 1. Roentgenogram showing fracture-dislocation
Received for publication March 9, 1964. of C~ vertebral body anteriorly on C3 with complete
* The substance of an address presented at the 17th avulsion of neural arch of the axis from the body.
annual meeting of the Neurosurgical Society of America, (Reprinted through the courtesy of Charles C Thomas
Phoenix, Arizona, January ~ , 1964. and Kahn et al. 5}
t Section of Neurosurgery, Department of Surgery,
University of Michigan Medical School and Hospital,
and St. Joseph Mercy Hospital, Ann Arbor, Michigan. logical correlation has afforded a plausible
:~Pahlavi University, Shiraz, Iran. Formerly Depart-
ment of Neurosurgery, Providence Hospital, and Uni- concept of the m e c h a n i s m involved in such
versity of Oregon Medical School, Portland, Oregon. fracture-dislocations. T h e victims of judicial
wDepartment of Anatomy, St. Bartholomew's Hos- hanging are n a t u r a l l y not available for
pital Medical College,University of London, England.
]l Department of Anatomy, Marischal College, Aber- study, b u t traffic victims with " h a n g m a n ' s
deen, Scotland. fracture" m a y survive a n d thus permit the
141
 14~ Schneider, Livingston, Cave and Hamilton
FIGS. ~ (left), 8 (middle) and 4 (right). Cases 1, ~ and 3. All three roentgenograms revealed an avulsion fracture of
the neural arch of the axis bilaterally and some degree of dislocation of C~ vertebral body on C3 vertebra.
e v a l u a t i o n of c l i n i c a l s t a t u s , of t h e u l t i m a t e
f a t e of t r a u m a t i z e d spine, a n d of t h e p o s s i b l e
m e a n s of p r e v e n t i o n a n d t r e a t m e n t of s u c h
injuries.
Case Reports
Case l. A.J., a 84-year-old mill worker, was
admitted to Providence Hospital, Portland, Ore.
on March 24, 1962, having been injured several
hours previously when he was thrown from his car
as it struck a pole. He sustained abrasions of the
head and right side of the body.
Although comatose he responded to painful
stimuli with slight movement of his left extremi-
ties. The pupils were equal and there was bilateral
internal strabismus and a continuous rotatory
nystagmus. H e was arefiexic. Roentgenograms of
the cervical spine showed bilateral avulsion of the
pedicles of the 2nd cervical vertebra with sub-
luxation of the ~nd vertebral body on the 3rd.
Slight compression fracture of the 3rd cervical
vertebra was noted and there was marked retro-
pharyngeal swelling (Fig. 2). Crutchfield skeletal
traction was applied ~4 hours later, replacing the
halter traction. The patient became more alert
but he had difficulty moving his tongue and
swallowing so t h a t his condition required a
tracheostomy on March 26. Since the traction
m a r k e d l y increased the distraction of the spinal
alignment at the site of the fracture-dislocation,
the weight was decreased, skeletal traction was
removed, and the fracture was treated by im-
mobilization in slight cervical hyperextension in a
M i n e r v a jacket.
A t the time of the patient's discharge from the
hospital on April 14, 1962 he was able to eat and
swallow and no longer required a tracheostomy
tube, b u t he still had a residual left hemiparesis.
The Minerva jacket was replaced with a cervical
brace, which the patient removed intermittently
against advice. When last seen on M a y 24, 196~
he had regained strength in the left leg but still
had a painful and paretic left arm.
Case 2. A.B., a 40-year-old registered nurse, was
a d m i t t e d to Providence Hospital on April 17,
1962, 48 hours after having been thrown from her
car when it skidded from the road. T h e patient
h a d not been unconscious. She complained only of
tingling of the left arm and hand b u t these symp-
toms disappeared within a few days.
T h e neurologic findings were normal except for
a bilateral diminution of the biceps reflex and a
transient left extensor p l a n t a r reflex. Roentgeno-
grams of the cervical spine demonstrated a bi-
lateral avulsion of the pedicles from the body of
the 2nd cervical vertebra (Fig. 8).