Hangman's fracture

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Hangman's fracture
Classification and external resources
Gray87.png
Second cervical vertebra, or epistropheus, from above.
ICD-10 S12.1
ICD-9 805.02

A hangman's fracture is the colloquial name given to a fracture of both pedicles or pars interarticularis of the axis vertebra (C2) (or, Epistropheus).

Epidemiology[edit]

The C2 fracture accounts for nearly 19% of all spinal fractures[1] and 55% of cervical fractures. Within C2 fractures, the hangman’s fracture accounts for 23% of occurrences while the odontoid or dens fracture accounts for 55% of them.[2]

Common Causes and High Risk Groups[edit]

The pie chart shows the incidence of C2 fractures according to age groups. For the <17 age group, there were 203 incidents. For Age 18-44 there were 1843. For 45-64 there were 2147. For 65-84 there were 4890 and for 85+ there were 3440 incidents. A total of 12,532 discharges in America were reported in 2010.

The injury mainly occurs from falls usually in older adults and motor accidents mainly due to impacts of high force causing extension of the neck and great axial load onto the C2 vertebrae.[3] In a study based in Norway, 60% of reported cervical fractures came from falls and 21% from motor related accidents.[4] According to the Agency for Healthcare Research and Quality (AHRQ), the group under the highest risk of C2 fractures are elderly people within the age group of 65-84(39.02%) at risks of falls (61%) or motor accidents (21%) in metropolitan areas (94%). 203 discharges were from the age group 1-17; 1843 from 18-44 year olds; 2147 from 45-64 year olds, 4890 from 65-84 year olds, and 3440 from 85+ year olds. Females accounted for 54.45% of occurrences while males accounted for the other 45.38%.[5]

Hospital Costs[edit]

The graph shows the trend of hospital charges and # of discharges over the span of 12 years in the U.S.A. In 1998, hospital costs were $24,423 with 4,991 discharged. In 2010 hospital charges increased to 59,939 with 12,532 discharged.

Statistics from the AHRQ show that there were 12,532 hospital discharges from C2 fractures in the US during 2010. The mean healthcare costs were $17,015 and the “national bill” or the aggregate charges were $749,553,403. Only 460 in-hospital deaths related to the C2 fracture occurred. From 2000 to 2010, the number of discharges has increased from 4,875 to 12,532, almost a 250% increase. Mean health care costs went from $24,771 to $59,939.[6]

Mechanisms[edit]

The mechanism of the injury is forcible hyperextension of the head, usually with distraction of the neck. Traditionally this would occur during judicial hanging, when the noose was placed below the condemned subject's chin. When the subject was dropped, the head would be forced into hyperextension by the full weight of the body, a sufficient force to cause the fracture. However, despite its long association with judicial hangings, one study of a series of such hangings showed that only a small minority of hangings produced a hangman's fracture.[7]

Apart from hangings, the mechanism of injury - a sudden forceful hyperextension centered just under the chin - occurs mainly with deceleration injuries in which the victim's face or chin strike an unyielding object with the neck in extension. The most common scenario would be a frontal motor vehicle accident with an unrestrained passenger or driver, with the person striking the dashboard or windshield with their face or chin. Other scenarios would include falls, diving injuries, and collisions between players in contact sports.

Although a hangman's fracture is unstable, survival from this fracture is relatively common, as the fracture itself tends to expand the spinal canal at the C2 level. It is not unusual for patients to walk in for treatment and have such a fracture discovered on X-rays. Only if the force of the injury is severe enough that the vertebral body of C2 is severely subluxed from C3 does the spinal cord become crushed, usually between the vertebral body of C3 and the posterior elements of C1 and C2.

Hangman’s Fracture Preventions[edit]

Car Crashes[edit]

Hangman's fracture

Most commonly this can occur during a car accident. A person involved in a car crash, especially with no seat belt, can slam their chin against the steering wheel, dashboard or windshield causing the hyperextension to occur.

Contact Sports[edit]

Falling and collisions with other people in a contact sport can also cause this fracture. Falling causes the weight of the body to force hyperextension. Collision with other players in a contact sport can be very dangerous as well: in football, diving for the ball can lead a player to land on his head, forcing the neck into hyperextension; the further piling of players on top of an injured player adds more weight and can lead to further occurrences of this fracture.

Treatment[edit]

Non-surgical or Surgical[edit]

Hangman's fractures treatments are both non-surgical and surgical according to Sasso,[8] from the department of Orthopaedic Surgery at Indiana University School of Medicine.

Benefits of Surgical Hangman's fracture treatment[edit]

Sasso[9] also studied that people who went on the surgical treatment will not be affected by pin site infections,brain abscesses, facet joint stiffness, loss of spinal alignment, and skin break-down. Another studies about the surgical treatment of is the ring of axis that Barsa P et al. (2006))[10] conducted a 30 cases within 41 patients to treat by using anterior cervical fixation and fusion and 11 cases treated by a posterior CT.

Result of the surgical treatment[edit]

As a result, Barsa P et al.[11] showed that the result of fracture fusion reduced after one year but only one patient died of other disease during the follow-up. Besides, Hakalo J., Wronski J. (2008)[12] both showed that operative treatment such as using transoral C2-C3 discectomy with plate-cage stabilization or posterior direct pars screw repair for the reducing and healing process.

In deliberate or suicidal hanging, asphyxia is much more likely to be the cause of death due to associated prevertebral swelling.

A common sign is a constricted pupil (Horner's syndrome) on the ipsilateral side due to loss of sympathetic innervation to the eye, caused by damage to the sympathetic trunk in the neck.

See also[edit]

References[edit]

  1. ^ Mulligan, RP.; Friedman, JA.; Mahabir, RC. (Mar 2010). "A nationwide review of the associations among cervical spine injuries, head injuries, and facial fractures.". J Trauma 68 (3): 587–92. doi:10.1097/TA.0b013e3181b16bc5. PMID 19996802. 
  2. ^ Ryan, MD.; Henderson, JJ. (1992). "The epidemiology of fractures and fracture-dislocations of the cervical spine.". Injury 23 (1): 38–40. doi:10.1016/0020-1383(92)90123-a. PMID 1541497. 
  3. ^ Ryan, MD.; Henderson, JJ. (1992). "The epidemiology of fractures and fracture-dislocations of the cervical spine.". Injury 23 (1): 38–40. doi:10.1016/0020-1383(92)90123-a. PMID 1541497. 
  4. ^ Pratt, H.; Davies, E.; King, L. "Traumatic injuries of the c1/c2 complex: computed tomographic imaging appearances.". Curr Probl Diagn Radiol 37 (1): 26–38. doi:10.1067/j.cpradiol.2007.07.001. PMID 18054664. 
  5. ^ http://www.hcup-us.ahrq.gov/
  6. ^ http://www.hcup-us.ahrq.gov/
  7. ^ James R, Nasmyth-Jones R., The occurrence of cervical fractures in victims of judicial hanging, Forensic Science International, 1992 Apr;54(1):81-91.
  8. ^ Sasso, Rick C. (2001). C2 Dens Fractures: Treatment Options. Journal of Spinal Disorders. 14(5): 455-463.
  9. ^ Sasso, Rick C.(2001). C2 Dens Fractures: Treatment Options. Journal of Spinal Disorders. 14(5): 455-463.
  10. ^ Barsa P; Buchvald P; Frohlich R; Hradil J; Lukas R; Suchomel P; & Taller S.(2006). Surgical treatment of fracture of the ring of axis - "hangman's fracture". 73(5): 321-8.
  11. ^ Barsa P; Buchvald P; Frohlich R; Hradil J; Lukas R; Suchomel P; & Taller S.(2006). Surgical treatment of fracture of the ring of axis - "hangman's fracture". 73(5): 321-8.
  12. ^ Hakalo J; Wronski J.(2008). Operative treatment of hangman's fractures of C2. Posterior direct pars screw repair or anterior plate-cage stabilization? 42(1): 28-36.