Hangman’s fracture

Hangman’s fracture (from English hangman — executioner, hangman; the name is due to the biomechanical similarity with injury during judicial hanging) is a specific bilateral fracture of the pedicles of the second cervical vertebra.

The injury results in complete anatomical separation of the posterior arch from the vertebral body, leading to pronounced instability.

Etiology and pathophysiology

Historically, the mechanism of this injury was associated with execution by hanging. Sudden and forceful hyperextension of the head backwards in combination with stretching of the neck under the weight of a falling body led to an avulsion of the axis arches and fatal rupture of the spinal cord.

In contemporary civilian trauma, the vast majority of such fractures occur as a result of road traffic accidents. A typical scenario involves a strong impact to the face or chin against the steering wheel or windshield, causing explosive hyperextension of the neck and axial compression.

The fracture line strictly passes through the weakest zone of the second vertebra — the pars interarticularis. As a result, the anterior part of the vertebra (the body with the odontoid process) loses mechanical connection with the posterior stabilizing structures and slides forward, which in biomechanics is referred to as spondylolisthesis.

Clinical significance

This injury is classified as an unstable fracture. The severity is assessed using specific classifications that consider the degree of vertebral displacement and the presence of angular deformation.

Similar to a Jefferson fracture, patients with this injury may present to the hospital without severe neurological deficit. The avulsion and retention of the posterior arch functionally widens the spinal canal, providing additional space for the spinal cord.

However, instability of the segment poses a constant threat of delayed quadriplegia with even slight neck movement. Treatment is based on principles of rigid immobilization: ranging from the application of a Halo brace to anterior spinal fusion with metal plates.