====== Hangman’s fracture treatment ====== [[Hangman´s fracture]]s classified as [[Effendi type 1]], and [[Levine and Edwards type 1]] and [[Levine and Edwards type 2]] were successfully treated non-operatively, with no modifiers identified for non-union or instability. For Levine-Edwards type IIA and III, surgery was generally recommended, but these should be classified as [[AO Spine Upper Cervical Injury Classification System]] type B and C, respectively, without a need for modifiers. For [[odontoid fracture]]s, fractures in the dens base, with displacement, or in elderly patients were associated with non-union (M1), and patients' specific factors (surgical condition) seem to affect the decision of treatment (M3) for considering surgery. They identified from the literature some axis injury characteristics that seem to affect the treatment decision in historical series. Knowledge of these modifiers may further enhance the system's clinical utility ((Joaquim AF, Bigdon SF, Camino-Willhuber G, Öner CF, Schnake KJ, Bransford R, Chhabra HS, El-Skarkawi M, Vaccaro AR, Schroeder GD; AO Spine Knowledge Forum Trauma & Infection. The [[AO Spine Upper Cervical Injury Classification System]] (AO UCIC) - An [[Umbrella Review]] of Traumatic Axis Injuries Factors that May Affect Treatment Decision. Global Spine J. 2025 Mar 29:21925682251333300. doi: 10.1177/21925682251333300. Epub ahead of print. PMID: 40156313.)). ===== General information ===== Nonsurgical management produces an adequate reduction in 97–100% and results in a fusion rate of 93–100% if the external immobilization is adequately maintained for 8–14 weeks (average time for healing is ≈ 11.5 weeks). Specific treatment depends on the reliability of the patient and the degree of stability as described below. Most cases do well with non-halo immobilization. Level III ● hangman’s fractures may initially be managed with external immobilization in most cases (halo or collar) ● surgical stabilization should be considered in cases of: a) severe angulation of C2 on C3 (Levine II, Francis II & IV) b) disruption of the C2–3 disc space (Levine II, Francis V) c) or inability to establish or maintain alignment with external immobilization Stable fractures (Levine Types I or IA, or Francis Grades I or II) Treat with immobilization (Aspen or Philadelphia collar) or cervicothoracic orthosis (CTO) (e.g. SOMI) is usually adequate) × 3 months. Halo-vest may be needed in unreliable patients or for combination C1–2 fractures. Schneider reported 50 cases of Type I fracture treated with non-halo fixation, only 1 was taken to surgery and was found to already be fused. Unstable fractures ===== Levine Type II ===== [[Levine Type II Hangman’s fracture treatment]]. ===== Levine Type III ===== ✖ Reduction with traction may be dangerous with locked facets. ORIF is recommended.27 MRI prior to surgery is recommended to assess the C2–3 disc. Can follow ORIF with halo-vest for the fracture, or can fuse at the same time as ORIF. ===== Surgical treatment ===== ==== Indications ==== Few patients have indications for surgical treatment of HF, and include those with: 1. inability to reduce the fracture (includes most Levine Type III & some Type II) 2. failure of external immobilization to prevent movement at fracture site 3. traumatic C2–3 disc herniation with the compromise of the spinal cord 4. established non-union: evidenced by movement on flexion-extension film; all failures of nonoperative treatment had displacement > 4 mm Hangman’s fractures likely to need surgery: 1. Levine Type II or III 2. or Francis grade II, IV, or V 3. or if either: a) anterior displacement of C2 VB> 50 % of the AP diameter of the C3 VB b) or if angulation produces widening of either the anterior or posterior borders of the C2–3 disc space > the height of the normal C3–4 disc below Surgical options For the infrequent patient who needs surgery for a hangman’s fracture. The fracture is either transfixed (osteosynthesis) or fusion across the fracture must be done as outlined here: 1. fusion techniques: a) posterior approach: ● C1–2 posterior wiring and fusion (e.g. using interspinous fusion technique of Dickman and Sonntag is an option only if all the following are intact: C2–3 disc, C2–3 joint capsules and posterior arch of C1. Rationale: This procedure unites C1 to the posterior fracture fragment of C2 which is still linked to C3 by the facet joints (posterior to the fracture), while the portion of C2 anterior to the fracture is still linked to C3 through the C2–3 disc. This technique preserves motion between C2 & C3. ● C1–3 fusion using C1 lateral mass screws (p. 1568) & C3 lateral mass screws connected with rods (skipping C2) ● occiput-C3 fusion: may be used if C1 is also damaged (skipping C1 & C2) b) anteriorC2–3 discectomy with fusion. Optional anterior plating or zero-profile graft/plate. Performed via a transverse anterior cervical incision midway between the angle of the jaw and the thyroid cartilage ● preserves more motion by excluding C1 ● this approach is also recommended for established nonunion ● not optimal for Levine Type III requiring ORIF for locked facets ● also used when at least a partial reduction cannot be achieved ● technique: for special considerations for approach to the C2–3 junction (cannot be performed in some short & thick necks) 2. osteosynthesis: screw placement from posterior approach through the C2 pedicle across the frac- ture fragment. Not recommended for established nonunion. The fracture must be reduced before the screw holes are drilled (the fracture may be reduced by patient positioning, and can be assisted by pulling posteriorly on the ring or C1 e.g. using a cable looped through C1). Screw entry point and trajectory are similar to the technique for C2 pedicle screws. The posterior fracture fragment may be over drilled with a 3.5 mm drill. A “top hat” or washer is placed in the hole and a 2.7 mm drill is used to drill the VB. Screw length: 30–35 mm for average adults. An alternative to over drilling is to use a lag screw with 20 mm unthreaded portion (e.g. Depuy ASIF orthopedic screws are available in 4.5 mm diameter at 30 mm length with 16 mm unthreaded portion, which is close). ==== Treatment endpoint ==== Plain X-rays should show trabeculation across the fracture site or interbody fusion of C2 to C3. Flexion-extension lateral radiographs should show no movement at the fracture site. ---- Treatment of the hangman's fracture is dependent on the stability of the injury. Surgical treatment leads to an increase in the rate of osteosynthesis/fusion without significantly increasing the rate of complication. Both an anterior and a posterior approach result in a high rate of fusion, and neither approach seems to be superior ((Murphy H, Schroeder GD, Shi WJ, Kepler CK, Kurd MF, Fleischman AN, Kandziora F, Chapman JR, Benneker LM, Vaccaro AR. Management of Hangman's Fractures: A Systematic Review. J Orthop Trauma. 2017 Sep;31 Suppl 4:S90-S95. doi: 10.1097/BOT.0000000000000952. PubMed PMID: 28816880. )). Hur et al. carefully suggest that primary ACDF with plating via the standard anterior retropharyngeal approach may be a feasible treatment option. It provides immediate stability and allows for early ambulation while promoting a stable bone union with minimal morbidity ((Hur H, Lee JK, Jang JW, Kim TS, Kim SH. Is it feasible to treat unstable hangman's fracture via the primary standard anterior retropharyngeal approach? Eur Spine J. 2014 Aug;23(8):1641-7. doi: 10.1007/s00586-014-3311-1. Epub 2014 Apr 23. PubMed PMID: 24756893. )).