Osteosynthesis a physiological way of managing Hangman’s fracture

Case Report

Osteosynthesis a physiological way of managingHangman’s fracture

Binod Kumar Singhania a,b,*, Sapna Sirohia d, Biswajit Sengupta a,c

aDepartment of Neurosurgery, Apollo Gleneagles Hospitals, Kolkata 700054, Indiab Sr. Consultant Neurosurgeon, Flat No 10 C, Block 9, Silver Spring,

5 J. B. S. Halden Avenue, Kolkata 700105, IndiacSr. Registrar, Flat No. C/3A, Sugam Sabuj, 125 N.S. Road, P. O. Narendrapur, Kolkata 700103, IndiadDepartment of Anaesthesia, Senior Consultant, 8 WE, Manikaran, 3 B, R. M. M. G. Lane, Kolkata 700010, India

a r t i c l e i n f o

Article history:

Received 29 July 2013

Accepted 7 August 2013

Available online 10 September 2013

Keywords:

Axis

C2

Hangman’s fracture

Osteosynthesis

Pedicle

a b s t r a c t

Most of the Hangman’s fractures are treated conservatively. Surgical indication is only in

type IIA and III fractures. There are many ways of fixing fractured spine either by anterior

or posterior. Osteosynthesis of C2 pedicle by transpedicular screw in type IIA is a newer

concept started by Judet by putting appropriate length of screws in C2 pedicle, so the

fracture reduces and anatomical motion will remain intact. In fact it is a more physio-

logical concept of fixing.1 I am doing by open method with exposure of C2 bilaterally and

putting appropriate screws in the fracture. It gives proper reduction, compression and

immediate stabilization of fracture.

Copyright ª 2013, Indraprastha Medical Corporation Ltd. All rights reserved.

1. Introduction

Hangman’s fracture is a colloquial terminology, first reported

by Wood-Jones in 1913 and then in 1965 Scheider et al had

reported eight cases of motor vehicular accident like Hang-

man’s fracture.2 It is a traumatic C2 spondylolisthesis due to

fracture of pars or pedicle (Fig. 1). C2 fracture is as common as

19% of all spinal injury and 55% of all cervical spine injury.3

Mechanism: The mechanism of Injury is either force full

fall in judicial hanging when noose has tightened below the

chin causing hyperextension of neck lead to fracture. Com-

monest cause is high impact motor vehicle accident where

unstrained passenger hit the headwith steering, dashboard or

wind screen lead to hyperextension of neck or axial loading of

axis i.e. C2 with distraction of spine lead to fracture of pars or

pedicle.

Though the fracture is unstable in nature but sever

neurological deficit is unusual as C2 cavity opens due to

fracture. Most of the patient walks himself and very less

landed with sever neurological deficits unless C2 is severely

dislocated on C3 (Fig. 1). Unlike hangings where there are

cervico medullary as well vertebral artery injuries.

Clinically, presents with neck pain and no significant

neurological deficit.

X-ray cervical spine lateral view, which is showing fracture

line along pedicle and subluxation. C T scan with 3D recon

* Corresponding author. Flat No. 10 C, Block 9, Silver Spring, 5 J. B. S. Halden Avenue, Kolkata 700105, West Bengal, India. Tel.: þ91 (0) 3322517004, 9830250606.

E-mail address: bsinghania@hotmail.com (B.K. Singhania).

Available online at www.sciencedirect.com

journal homepage: www.elsevier .com/locate /apme

a p o l l o m e d i c i n e 1 0 ( 2 0 1 3 ) 2 3 0e2 3 2

0976-0016/$ e see front matter Copyright ª 2013, Indraprastha Medical Corporation Ltd. All rights reserved.http://dx.doi.org/10.1016/j.apme.2013.08.013

struction is the gold standard for seeing exact fracture pattern.

MRI should do to see disc injury, ligament integrity, cord injury

and vascular injury.

Hangman’s fracture was classified by Levine and Edward4

on the base of mechanism of injury.

Type I: Stable fracture with less than 3 mm translation, no

angulation. Disc and ligaments are intact.

Type IA: Little translation with no or minimal angulation.

Fracture line traversing foramen transversarium.

Type II: Most common type. More than 3 mm horizontal

displacement with less than 10� angulation. Disruption of

posterior longitudinal ligament and disc but intact ALL. Un-

stable fracture.

Type IIA: Slight translation but severe angulation seen in

flexion distraction injuries with tearing of posterior longitu-

dinal ligament and disc. Unstable fracture.

Type III: C2eC3 facet dislocation. Rare fracture results from

initial anterior facet dislocation of C2eC3 followed by exten-

sion injury fracturing the neural arch. Result in with unilateral

or bilateral facet dislocation of C2eC3.

2. Treatment

Treatment varies as per the severity of injury from non

operative to operative.

2.1. Non-operative

Type I with less than 3 mm subluxation needs rigid collar for

4e6 weeks. In type II injury when subluxation is more the

3mmbut less than 5mmand angulation of less than 10 degree

can put in Halo vest for 12 weeks.5 Reduction can be achieved

by axial traction with extension in type II injury but in type IIA

no axial traction should be given, only manual reduction by

hyperextension.

2.2. Surgery

Surgery is indicated in Type IIA where subluxation is more

than 5 mm and angulation is of more than 10 degree and in

type III where there are facets dislocation.6

Fig. 1 e Diagrammatic representation of various type of C2 fracture.

Fig. 2 e a: X-ray cervical spine lateral view showing fracture line at C2 pedicle with C2-3 subluxation and angulation. b: Post

operative transpedicular screws with some reduction in subluxation.

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3. Approaches

Anterior cervical discectomy with fusion and fixation of C2-3

by bone graft and plate.7

Posterior C1 to C3 fixation with fusion by C1 transarticular

and C3 lateral mass screws with bony fusion.

Bilateral C2 pars screws osteosynthesis especially in type II

and IIA fracture. A proper length of screw has been put in C2

transpedicular or in pars.

4. Case reports

A 38 year old female was traveling in a motor van sitting on

the back seat facing rear side. The vehicle met an accident on

express way with a head on collision. She has been trans-

ported in our hospital with a Philadelphia collar on. She pre-

sented with severe neck pain, there was no neurological

deficit and was moderately obese.

X-ray C spine was showing C2-3 subluxation with a frac-

ture line near pedicle of C2 (Fig. 2a). A CT Scan was done to

confirm fracture which was showing pars fracture with frac-

ture line on left side was going along foramen transversarium.

MRI was showing no spinal cord injury with intact disc and

ALL. On measurement subluxation was more than 5 mm and

angulations ofmore than 10 degree falling in type IIA category.

I planned for surgical fixation rather than a Halo vest for 12

weeks and even after no surety of correction.

5. Technique

In prone position with head fixed in three point pins

Mayfield. C2 lamina and lateral mass has been exposed with

a small mid line incision. Medial portion of the pars was

identified by instrument. Entry point of the screw was

located at supero-medial quadrant of isthmus. First right

sided screw of 4 � 24 mm size put in a direction of 20 degree

convergent and cephaloid, under C arm guidance avoiding

medial breach till anterior cortex reached. Due to displace-

ment of fracture some time standard entry point is not

possible and the trajectory has to be changed as per situa-

tion. On left side due to displaced fracture direction of tra-

jectory was changed and screw placed safely.

Post operatively patient was neurologically intact. On first

post operative day she was mobilized and Second post oper-

ative day was discharged. On first follow up, after two weeks

her X-ray cervical spine was showing screws in proper place

with less subluxation (Fig. 2b).

6. Discussion

Osteosynthesis is a more scientific way of fixing C2 fracture

with anatomical integrity, immediate stability and maintain-

ing normal physiological function. There are various ways of

placement of pedicular screws, by open method to more

minimally invasive i.e. Brain lab assisted and C T Scan guided.8

In C T guided, chance of infection is high as procedure is per-

forming in a C T suite then in an operating room. Whereas in

Brain lab navigation systemwhich is givingmore accuracy but

needs a gadget which is costly and not available in all centers.

It needs a longer time of surgery as hands on instrument have

to registered every time till accuracy. In open method skin

incision is bigger but needs only C arm and can maintain good

sterility. Scope of trajectory manipulation and less time

consuming then Brain lab. Two commonest fractures which

are preferably dealing with osteosynthesis are C2 odontoid

fracture and C2 Hangman’s fracture. There is few criticism of

this method that it is not dealing with injured C2-3 disc.

Conflicts of interest

All authors have none to declare.

r e f e r e n c e s

1. ElMiligui Y, Koptan W, Emran I. Transpedicular screw fixationfor type II Hangman’s fracture: a motion preserving procedure.Eur Spine J. 2012 August;9(8):1299e1305.

2. Stillerman CB, Roy RS, Weiss MH. In: Cervical Spine Injuries:Diagnosis and Management, Neurosurgery. 2nd ed. vol. 2.1996:2886e2887.

3. Mulligan RP, Friedman JA, Mahabir RC. A nationwide review ofthe associations among cervical spine injuries, head injuries,and facial fractures. J Trauma. Mar 2010;68(3):587e592.

4. Levine AM, Edwards CC. The management of traumaticspondylolisthesis of the axis. J Bone Joint Surg Am.1985;67:217e226.

5. Vaccaro AR, Madigen L, Bauerle WB, Blescia A, Cotler JM. Earlyhalo immobilization of displaced spondylolisthesis of the axis.Spine (PhilaPa 1996). 2002 Oct 15;27(20):2229e2233.

6. Samaha C, Lazennec JY, Laporte C, Saillant G. Hangman’sfracture: the relationship between asymmetry and instability. JBone Joint Surg Br. 2000;82:1046e1052. http://dx.doi.org/10.1302/0301-620X.82B7.10408.

7. Verheggen R, Jansen J. Hangman’s fracture: arguments in favorof surgical therapy for type II and III according to Edwards andLevine. Surg Neurol. 1998;49:253e262. http://dx.doi.org/10.1016/S0090-3019(97)00300-5.

8. Tallel S, Suchomel P, Lukas R, Beran J. CT-guided internalfixation of a Hangman’s fracture. Eur Spine J. 2000;9:393e397.

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