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AP fluoroscopy is useful to ensure that the K wire is in the midline, and a lateral view ensures the appropriate trajectory. The wound is closed in standard fashion. Although a specific pathoanatomical source cannot be routinely identified in the vast majority of patients with mechanical neck pain,1 a small number of patients may have a serious underlying medical condition that may be causing the neck pain, which would preclude physical therapy intervention.2–7, Fractures of the cervical spine are one example of a serious underlying medical condition that can cause neck pain. Neurosurgery. His physician prescribed Flexeril‡ and Naprosyn§ and referred him for physical therapy treatment of his neck pain. There are numerous treatment options available for hangman's fracture, from mild to severe. Fifteen patients with unstable hangman's fractures with age ranging from 17 years to 81 years were operated using CT-based navigation from September 2011 to march 2016. This decision, which is consistent with the recommendations of Li et al,17 was based on a normal neurological examination, a relatively low level of pain, and the results of radiographic flexion and extension views of the cervical spine, which revealed no evidence of instability. FIGURE 315-1 Type II odontoid fracture. Michael D Ross, John M Cheeks, Undetected Hangman's Fracture in a Patient Referred for Physical Therapy for the Treatment of Neck Pain Following Trauma, Physical Therapy, Volume 88, Issue 1, 1 January 2008, Pages 98–104, https://doi.org/10.2522/ptj.20070033. Written by recognized experts, this volume is a comprehensive reference on the use of advanced imaging techniques in the diagnosis and management of spinal trauma. , Weiss MA, Cotler JM, Call M. Stiell His cervical spine pain, especially the intermittent sharp pain, was aggravated by turning his head to look over either shoulder. Found inside – Page 260Other Nonodontoid, Nonhangman's C2 Body Fracture • Hyperextension teardrop, transverse, and vertical C2 body fractures ... with hangman's fractures Treatment • C2 body fractures often managed with conservative/nonoperative treatment ... These injuries may be missed clinically because of the lack of clinical signs except for neck pain. Hangman's fracture classification Levine/Effendi classification The system of Effendi et al as modified by Levine and others is widely used in grading adult HF (not applicable to peds). A concise, case-based clinical resource on the topic of imaging in spinal trauma, highly illustrated throughout. Approximately 9% to 20% of all cervical fractures are dens fractures, 2, 6 - 10 with most (65% to 74%) being type II fractures. 1) Images of a . Anterior subluxation of C2 on C3 greater than 3 mm serves as a marker for C2 to C3 intervertebral disc disruption. Found inside – Page 888Vertebral body and spinous process fractures are conservatively treated with external immobilization, ... However, the compression and hyperextension mechanism seen in the classic hangman's fracture contrasts with the distraction and ... Secondary Analysis of a Randomized Controlled Trial, International Classification of Functioning, Disability and Health (ICF), Coordination, Communication, and Documentation, Receive exclusive offers and updates from Oxford Academic, Copyright © 2021 American Physical Therapy Association. Even if the initial radiographs are negative for a fracture, additional diagnostic imaging may be necessary for a small number of patients, because they may have undetected injuries that would necessitate medical referral and preclude physical therapy intervention. If pain doesn't resolve with supportive care, referral to a spine surgeon for removal of fragments is indicated. It is important to remember that halo-vest orthosis is not very well tolerated in the elderly population, and therefore collar is recommended as first-line management.[8][9][10]. [].It is defined as fractures to the lamina, articular facets, pedicles, or pars of the axis vertebra. MP Hangman fracture is the second most frequent axis fracture, alter odontoid fracture. They determined that the important predictors of cervical spine fractures are: high-energy cause of injury (ie, high-speed motor vehicle accident >48 km/h or pedestrian struck by motor vehicle: odds ratio [OR]=11.6; 95% CI=5.4, 25). C2 fractures • Odontoid fracture • Hangman fracture • Miscellaneous fractures 6. There also was an ossific fragment in the posterior soft tissues, adjacent to the spinous process of C6. A screw is then inserted through the drill guide. Different surgical approaches, both anterior and posterior, have been described for treating Hangman's fracture [ 14 , 15 ]. He also denied any weight changes, bowel or bladder problems, chest pain, or shortness of breath. Indications for surgery include irreducible or unstable fracture for which reduction is impossible; significant neurological deficit; previous nonunion; prolonged delay in treatment; injuries that preclude halo placement, including skull fractures and chest or facial injuries; and patients at high risk for nonunion, including the elderly and debilitated.47–49. A typical hangman’s fracture allows for separation of the anterior elements from the posterior elements of the C2 vertebrae, therefore increase the available space for the spinal cord. , Mior S. Jensen In 1988, a new subtype of odontoid fracture (type IIA) was described that involves comminution at the base of the dens.14 Type III fractures traverse the body of the axis. We often place the patient in a collar for 4 to 6 weeks. The spine in the neck is usually called the cervical spine, which consists of two spine vertebrae, called C1 and C2. Cases in which nonunion was demonstrable on radiographs or CT scans within 6 to 12 months after trauma were attributed to increased age or greater dens displacement.24, Seybold and Bayley found a 65% overall fusion rate with halo immobilization and no significant difference in outcome in patients older than 60 years, in patients younger than 60 years, or by degree of displacement.41 Greene and colleagues reviewed 340 acute axis fractures and identified two categories of unstable type II fractures, which they recommended be treated by early surgical fusion. This case report describes a patient referred for physical therapy treatment of neck pain who had an underlying hangman's fracture that precluded physical therapy intervention. The complications and healing rates were analysed according to the fracture type and treatment used. JAMA. Hangman's fractures type 1 are a domain of nonsurgical treatment, while for types 2 and 3 fractures there is a consensus on surgical treatment depending on the degree of displacement [21, 39]. Hangman fracture, also known as traumatic spondylolisthesis of the axis, is a fracture which involves the pars interarticularis of C2 on both sides, and is a result of hyperextension and distraction. This most recent physician visit was at a different facility than his previous medical visits. The estimated annual incidence of spinal cord injury in the United States, not including those who die at the scene, is approximately 12,000 new cases each year. Type I fractures are rare and traditionally have been thought to be stable and thus managed nonoperatively. In contrast, unstable injuries do poorly if treate … The anatomy of the axis is unique in that it forms a connection with the mobile upper cervical spine and cranium and the lower cervical spine. Hangman's fracture treatment. Researchers studied fusion surgery performed via the posterior approach; this method demonstrated excellent results in 3-part fractures of the axis. Benefits of surgical hangman's fracture treatment . The bilateral fracture of the C2 vertebrae is the second most common type of C2 fracture. Found inside – Page iiiThis quick-reference guide is the first book written specifically for the many third- and fourth-year medical students rotating on an orthopedic surgery service. Written by leading orthopaedists and rehabilitation specialists, this volume presents sequential treatment and rehabilitation plans for fractures of the upper extremity, lower extremity, and spine. Fractures with anterior oblique orientation were more likely to be associated with fusion failure or fibrous union than were posterior oblique or horizontal fractures. Treatment and Prognosis. Angulation is measured as the angle between the inferior endplates of C2 and C3. Care must be taken to ensure proper radiographic imaging creates a picture from the occiput to the C7 through T1 disc space. Hangman = a person who performs judicial (judge-ordered) hangings Fracture = a break in a bone. IG Treatment. [2] coined the term hangman’s fracture in 1965. Eight weeks later, after seeking further medical care, the patient was referred for physical therapy intervention. Nonsurgical Management of Type II Fractures. In the human body, we have totally 33 bones or vertebrae in the spine. The physical therapist could not review initial conventional radiographs taken on the day of the motor vehicle accident because they were completed at another facility and found to be negative for a fracture. Found inside – Page 1352Twenty of 33 had no neurologic deficits, with no clear predilection for one fracture type. Nonoperative Treatment Indications. Most hangman's fractures can be treated nonopera- tively. Most type I injuries are effectively treated in a ... Several authors have described anterior C2 osteosynthesis in detail; for a more detailed description of the procedure, the reader is referred to other sources.24,25,63,65–68. Physical therapy may play a role in rehabilitative recovery in both surgical and non-surgical cases. This increased area for the spinal cord at this level allows for the relative lack of neurologic injury associated with a hangman’s fracture.[1]. We often approach the cervical spine from the left side to avoid injury to the recurrent laryngeal nerve, which has a more variable course on the right. 1988     [PubMed PMID: 3288418], Menger RP,Storey CM,Nixon MK,Haydel J,Nanda A,Sin A, Placement of C1 Pedicle Screws Using Minimal Exposure: Radiographic, Clinical, and Literature Validation. Treatment may be C-collar immobilization, halo immobilization, or surgical stabilization depending on displacement, angulation, and fracture stability . The radiologist's report also stated that the spinal cord was visualized and no definite cord compression was seen within the limits of the examination. Hangman's C2 Fracture . Because the patient had a history of significant neck trauma, constant low level neck pain that improved only slightly in the 8 weeks since the motor vehicle accident, and significant cervical spine motion limitations, however, the physical therapist ordered conventional radiographs of the cervical spine to rule out the possibility of an undetected fracture prior to manual treatment. [2, 6, 7] However, atypical HF (AHF) that includes fractures of the pedicle, lamina, and/or posterior . There were no signs of neurological deficits. OBJECTIVE: To investigate the mechanism of Hangman's fracture and its clinical manifestation and treatment. Cervical radiographs were ordered and revealed a grade 2 anterolisthesis of C2 on C3, with bilateral pars interarticularis fractures of C2, that appeared unchanged on flexion and extension radiographic views. Fractures of the spine are best managed by an interprofessional team that includes clinicians (including PAs and NPs), specialists (orthopedists, neurologists), orthopedic and neurology nurses, and therapists. XF In contrary to what everyone thinks, the dens of C2 always remains intact. Operative Treatment of Hangman's Fractures Christopher T. Martin Keith W. Michael John M. Rhee Radiologic Assessment—Key Factors to Consider on X-ray, MRI, CT The need for operative intervention is dependent upon fracture displacement and instability. He was neurologically normal but complained of neck pain. Based on the findings at his initial physical therapy visit, the physical therapist ordered conventional radiographs of the cervical spine to rule out the possibility of an undetected fracture. The anatomy of the axis is unique in that it forms a connection with the mobile upper cervical spine and cranium and the lower cervical spine. Mower FIGURE 315-3 A-E, Forty-four-year-old man seen after a fall. This case was presented as a platform presentation at PT 2007: Annual Conference and Exposition of the American Physical Therapy Association; June 30, 2007; Denver, Colo. Abbott Laboratories, Pharmaceutical Product Division, North Chicago, IL 60064. Based on the patient's history and the findings of the physical examination at his initial physical therapy visit, the physical therapist thought that the patient's symptoms were most likely caused by mechanical dysfunction in the cervical spine. Other noteworthy features of the C1-2 joint include the absence of a true intervertebral disk and relatively loose capsular ligaments,12 evolution of the ligamentum flavum into a weaker atlantoaxial membrane, a rich blood supply from branches of the vertebral and carotid arteries, and an increased spinal canal diameter.13 The odontoid process is held tightly to the anterior portion of the C1 ring by the strong transverse ligament, which prevents subluxation in the sagittal plane. Type I fractures are rare and traditionally have been thought to be stable and thus managed nonoperatively.15 The mechanism of the injury is considered to be avulsion of one of the alar ligaments.16 The fracture plane is often cephalad to the transverse ligament and therefore does not cause a violation of ligamentous continuity. [14], Spence KF Jr,Decker S,Sell KW, Bursting atlantal fracture associated with rupture of the transverse ligament. Advances in orthopedics. 1970 Apr     [PubMed PMID: 5425648], SCHNEIDER RC,LIVINGSTON KE,CAVE AJ,HAMILTON G,     [PubMed PMID: 14288425], Robinson AL,Olerud C,Robinson Y, Epidemiology of C2 Fractures in the 21st Century: A National Registry Cohort Study of 6,370 Patients from 1997 to 2014. Indications for surgery include irreducible or unstable fracture for which reduction is impossible; significant neurological deficit; previous nonunion; prolonged delay in treatment; injuries that preclude halo placement, including skull fractures and chest or facial injuries; and patients at high risk for nonunion, including the elderly and debilitated. In the acute setting, a rigid cervical collar should . 1992 May     [PubMed PMID: 1584391], Coric D,Wilson JA,Kelly DL Jr, Treatment of traumatic spondylolisthesis of the axis with nonrigid immobilization: a review of 64 cases. Found inside – Page 55Robot-Assisted. C2. Pedicle. Screw. Placement. for. the. Treatment. of. Hangman's. Fracture. Bo Liu, Jingye Wu, Huadong Wang, and Wei Tian W. Tian (ed.), Navigation Assisted Robotics in Spine and Trauma Surgery, ... The initial plan was to treat the patient with manual therapy and therapeutic exercise to address the patient's range-of-motion limitations and pain2 after conventional radiographs of the cervical spine were repeated. The Journal of bone and joint surgery. Os odontoideum and fractured calcified pannus may mimic acute C2 fractures. Based on the patient's history and the findings of the physical examination, the physical therapist (MDR) thought that the patient's symptoms were most likely caused by mechanical dysfunction in the cervical spine. This case involved a 61-year-old man who had a sudden onset of neck pain after a motor vehicle accident 8 weeks before his initial physical therapy visit. His emergency department physician prescribed Vicodin* for pain and recommended follow-up in the emergency department or with his primary care physician if his symptoms worsened. Palpate entire spine for tenderness / step off. Click to share on Twitter (Opens in new window), Click to share on Facebook (Opens in new window), Click to share on Google+ (Opens in new window), Presurgical Functional MappingAndrew C. Papanicolaou, Roozbeh Rezaie, Shalini Narayana, Marina Kilintari, Asim F. Choudhri, Frederick A. Boop, and James W. Wheless, the Child With SeizureDon K. Mathew and Lawrence D. Morton, and Pharmacologic Consequences of SeizuresShilpa D. Kadam and Michael V. Johnston, Self-Limited EpilepsiesDouglas R. Nordli, Jr., Colin D. Ferrie, and Chrysostomos P. Panayiotopoulos, in Epilepsy: A Network and Neurodevelopmental PerspectiveRaman Sankar and Edward C. Cooper, Hematology, Oncology and Palliative Medicine. Found inside – Page 49... of hangman's fracture is as follows: • Type I: Nondisplaced or minimal horizontal displacement (< 3 mm) • Mechanism: Hyperextension and axial loading • Disc: C2/3 disc intact • Stability: Fracture considered stable • Treatment: Halo ... In the lag screw technique, a drill bit is inserted into the anterior edge of C2, and a hole is drilled without the use of a K wire. In general, hangman's fractures, odontoid fractures (except type II), and most miscellaneous C2 fractures can be effectively managed with conservative treatment [5,6,9,11,23,24]. METHODS: Ten patients with Hangman's fracture treated at our hospital from 1988 to 2001 were analysed. Hangman's Fracture • Treatment • Type I and Ia: treat in cervical collar for 12 weeks • Type II: Halo for 12 weeks • Type IIa: ACDF C2/3 or posterior fixation • C2/3 acdf spares C1/2 motion segment • Posterior fixation • C1-C3 • Directly treat pars fracture with reduction and Lag technique • Type III: posterior reduction and . Found inside – Page 115Type I, Type II and Type IIA fractures may usually be treated non- operatively in the acute setting, while Type III fractures should be addressed surgically. Ultimately, treatment of Hangman's fractures varies from institution to ... Hangman's fracture treatment. Author information: (1)Department of Orthopaedics, First Affiliated Hospital of PLA General Hospital, Beijing; and. As surgical techniques became more refined, direct anterior screw fixation of C2 fractures has become more popular, and many clinicians now consider this procedure to be the treatment of choice for these injuries. Journal of neurosurgery. CT scan does not directly evaluate the spinal cord, soft tissue, or ligamentous construct. link. Treatment Options for Hangman's Fracture. Other noteworthy features of the C1-2 joint include the absence of a true intervertebral disk and relatively loose capsular ligaments. Even if plain films are negative and clinical suspicion is high, a CT scan is warranted. Li Z(1), Li F, Hou S, Zhao Y, Mao N, Hou T, Tang J. The purpose of this review is to provide an evidence-based analysis of the literature and clinical outcomes associated with the surgical and nonsurgical management of hangman's fractures. , Karoly P, Braver S. Hole This technique provides immediate stabilization; we have performed this procedure and often discharged the patient the next day. Found inside – Page 67Treatment of hangman's fractures varies from institution to institution. Types I, II, and IIa fractures may almost always be treated nonoperatively in the acute setting, while Type III fractures should always be addressed surgically. Type 1: Less than 3 mm subluxation of C2 on C3, due to axial loading, stable, rigid cervical collar treatment, Type 2: Disruption of the C2 to C3 disc, posterior longitudinal ligament, greater than 4 mm subluxation, greater than 11 degrees angulation, less than 5 mm requires a reduction in axial traction and halo fixation for 6 to 12 weeks while those greater than 5 mm can require surgery, Type 2a: Less displacement more angular deformity, flexion injury, unstable, not suitable for axial traction, treatment in halo, Type 3: C2 to C3 facet capsule disrupted, anterior longitudinal ligament disruption, unstable, may have a deficit, surgical candidates, Type 1: Less than 11 degrees of angulation and less than 3.5 mm of displacement, Type 2: Greater than 11 degrees of angulation and less than 3.5 mm of displacement, Type 3: Less than 11 degrees of angulation and greater than 3.5 mm displacement, Type 4: Greater than 11 degrees of angulation and greater than 3.5 mm of displacement, Severe angulation of C2 on C3 (Francis II and IV, Levine II), Disruption of the C2 to C3 disc space (Francis V, Levine II), Anterior displacement of C2 greater than 50% on C3, Inability to establish or maintain alignment with external immobilization, Nonunion after use of external immobilization, C1 lateral mass and C2 pars interarticularis screws, C1 to C2 wiring (also as an adjunct technique), Extension to C3 lateral mass if there is a disruption of the C2 to C3 intervertebral disc or facet joint capsules. 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