HANGMAN’S FRACTURE

T. G. WILLIAMS, SOUTHAMPTON, ENGLAND

From the Royal South Hants Hospital, Southampton

of four hangman’s fractures of the axis, three occurred in road accidents and were stable, undisplaced

and free of neurological signs, with full recovery after six to twelve weeks in a cervical collar. The fourth

fracture occurred in a fall with profound tefraparesis from haemorrhage into the spinal cord, and the patient

died a week later. There are two types of hangman’s fracture : that of the axis pedicle, which results frommore common than usually supposed because of the

82 THE JOURNAL OF BONE AND JOINT SURGERY

extension and compression of the cervical column, is

slight symptoms it causes.

Originally described in the victims ofjudicial hanging

(Wood Jones 19 13), hangman’s fracture is sometimes seen

in orthopaedic practice after road accidents or simple

falls. A review of the literature, with four case reports,

suggests that this injury may be more common than

hitherto supposed.

Grogono (1954) noted the similarity between the

“ideal” lesion produced by hanging and the radiological

appearance of a bilateral axis pedicle fracture in a woman

with transient tetraplegia after a car accident ; he thought

cord injury a likely sequel of such fractures, but subse-

quent reports have proved otherwise. Garber (1964) pre-

sented eight cases with traumatic spondylolisthesis of the

axis and very slight neurological signs after road accidents,

and considered the lesion a distinct clinical entity which

Schneider, Livingstone, Cave and Hamilton (1965) termed

hangman’s fracture when they reported eight cases after

road accidents and gave a detailed review of the possible

judicial lesions. DeLorme (1967) analysed forty cases of

axis pedicle fracture and suggested that some were flexion

injuries. In a review of fourteen cases, ten of which were

treated operatively by dowel fusion, Cornish (1968) sug-

gested that the axis pedicle fracture in the civilian may

follow extension and compression of the upper cervical

spine. In a larger series of cervical injuries, Norrell and

Wilson (1970) treated five cases of unstable hangman’s

fracture by dowel fusion, a further seven cases being

managed conservatively. Saldeen (1967) presented a case

of hangman’s fracture with decapitation by a loose

diagonal safety belt, and Edgar, Fisher, McSweeney and

Park (1972) described a motor-cyclist who recovered from

profound tetraparesis caused by a distracted hangman’s

fracture sustained when he was caught under the jaw by

a rope across the road. Apart from these specific reports,

isolated cases have been included in larger series of

cervical injuries, such as those of Rogers (1957) and

Norton (1962).

The term hangman’s fracture has thus been used in

the literature to describe both the judicial lesion and its

exact civilian counterpart on the one hand, and the axis

pedicle fracture following road accidents or falls on the

other (Table I). The two types differ markedly in mechan-

ism, clinical features and prognosis, and the aim of this

paper is to examine these differences in the published

literature and in four new cases.

MECHANISM

Hangman’s fracture results from hyperextension of the

upper cervical spine. The axis breaks symmetrically

across its pedicles or lateral masses, and the fracture may

extend across the posterior part of the body. Contrary

to popular belief, the dens always remains intact and

never contributes to cord injury or death in this condition.

The pedicles are the thinnest part of the bony ring of the

axis, weakened by the foramen transversarium on each

side (Figs. 1 to 4). The lateral masses, bearing the

superior articular facets, each straddle the vertebral body

and the inferior facet in the lateral view (Fig. 2), and

therefore they too take the brunt of forces transmitted

through the modified upper two cervical vertebrae to the

cervical spine below (Schneider et a!. 1965). The pedicles

and lateral masses are thus at the point of greatest

leverage between the extending “cervico-cranium” (the

skull, atlas, dens and body of the axis) and the relatively

fixed lower cervical spine, to which the neural arch of

the axis is anchored by its inferior facets, stout bifid

spinous process and strong nuchal muscles (Fig. 5).

Although the true hangman’s fracture and the axis

pedicle fracture sustained in road accidents share the

same radiological appearance, the clinical features re-

viewed in Table I and summarised in Table II differ so

markedly that there must be some fundamental difference

in mechanism. Cornish (1968) suggested that the axis

pedicle fracture from road accidents, which permits

spondylolisthesis of the axis if the anterior ligament is

disrupted, is the result of extension and compression of

the upper cervical spine in contrast to the extension and

distraction which follows hanging (Figs. 6 and 7).

Fracture caused by extension and compression-Extension

of the upper cervical spine with compression may be

produced by a simple forward fall with the chin, forehead

T. G. Williams, B.A., F.R.C.S., Surgical Registrar, Ipswich Hospital, Anglesea Road, Ipswich, Suffolk, England.

Schneider et a!. (1965):“Hangman’s fracture” ; 8 cases

Outcome

Edgar et a!. (1972):1 hangman’s fracture

Cornish (1968): traumaticspondylolisthesis of the axis;14 cases

Local injury toneck and face

Motor-cyclistcaught under jawby rope

Profoundtetraparesis

Skull tractionfor 7 weeks

Slight left-sidedweakness

Vehicle passenger Sound fusion

VOL. 57-B, No. I, FEBRUARY 1975

HANGMAN’S FRACTURE 83

TABLE IREPORTED CASES OF HANGMAN’S FRACTURE

Author and his description Additional injury Cause Neurological signs Treatment

Wood Jones (191 3): The ideallesion in judicial hanging

Grogono (1954): Axis fractureresembles judicial lesion

Garber (1964): traumaticspondylolisthesis ; 8 cases

- Judicial hanging - - Death

- Head jolted in car Transient Skull traction Residual weaknessaccident tetraplegia for 6 weeks of right arm

- Road accidents None or slight Rest and traction Successful

Retropharyngeal Driver, thrown Areflexic Skull traction; Left hemiparesis

swelling marked out of car Minerva jacket

- Thrown from car Minimal Minerva jacket Symptom-free

Laryngeal injury Struck chin on - Skull traction; Symptom-freesteering wheel ; cervical brace other thanwore seat belt laryngeal problems

Fractured pelvis Driver, head-on - Delayed anterior Fusion stable

and ribs accident fusion

Multiple injuries Car accident - Halter traction Solid healing

- Driver, car - Cervical traction Symptom-free

overturned then collar

- Back-seat car - Skeletal traction; Early bony union

passenger Minerva jacketNeck and tongue Front-seat car - Skeletal traction; Not stated.

lacerated passenger cervical brace Good reduction

Saldeen (1967) - Loose seat belt (Decapitation) Death

Norrell and Wilson (1970):12 hangman’s fractures

7 cases; nil.5 cases; nil

Not stated.Not stated

Notstated(?absent)Notstated(?present)

Skull traction;dowel fusion

Successful.Sound fusion

Unstable C.5 on Domestic fall - Dowel fusion Not statedC.6 subluxation

- Bicyclist struck by Incomplete Dowel fusion Considerablecar quadriplegia recovery

Fractured spinous Fall on rocks - Dowel fusion Symptom-freeprocess of C.3

- Thrown from car - Dowel fusion Not stated

- Car passenger - Bed rest Symptom-free

- Thrown out of - Dowel fusion Osteoarthritis of

vehicle C.l on C.2

- Fall from cart - Dowel fusion Neck stiffness

Severe head injury Car driver Flaccid paresis Died from head injury 4 days later

- Car passenger - Dowel fusion Symptom-free

Fractures C.3 and Driver of - Dowel fusion Sound fusionC.6 spinous overturned carprocesses

Locked facet C.7 Road traffic Right-sided Splintage Sound fusionon T.1 accident weakness and

paraesthesiaefrom C.7 only

- Passenger, car - Dowel fusion Not statedoverturned

Fracture posterior Driver of - Dowel fusion Some stiffness (hasarch of atlas overturned car rheumatoid arthritis)

- Splint

FIG. 1 FIG. 2

Cervico-cranium

Skull

Atlas

Odontoid pegBody of axis

Neural archof axis

Remainingcervical spine

FIG. 5 FIG. 6 FIG. 7

84 T. G. WILLIAM5

THE JOURNAL OF BONE AND JOINT SURGERY

FIG. 3 1I�

Three drawings (Figs. 1 to 3) and one oblique radiograph (Fig. 4) of the isolated axis, showingthe narrow pedicles, the stout spinous process, the wide circular spinal canal, and the way inwhich the superior articular facet straddles the vertebral body and inferior facet on each side.

Diagram showing the axis pedicles as the point of leverage of the extending “cervico-craniuni” (hatched) against the relatively fixed lowercervical spine (Fig. 5). Hangman’s fracture resulting from extension and compression (Fig. 6) and extension and distraction of the upper

cervical spine (Fig. 7).

TABLE IITHE Two TYPES OF HANGMAN’S FRACTURE

True hangman’s fracture Axis pedicle fracture

Mechanism

Typical cause

Radiological

appearance

Cord injury

Neurologicalsigns

Symptoms

Presentation

Prognosis

Treatment Gentle supervised skulltraction (less than 2 kg)with frequent checkradiographs.Proceed to fusion ifdistraction or neuro-logical signs increase

Supportive collar if thereare no cord signs and thefracture isstable.Skull traction for 6weeks, or operative dowelfusion, if symptomssevere or neurologicalsigns develop

(I,’

HANGMAN’S FRACTURE 85

VOL. 57-B, No. 1, FEBRUARY 1975

Extension and distrac-tion of the uppercervical spine

Extension and compres-sion of the upper cervicalspine

Judicial hanging. Blow on the forehead orLoose safety belt vertex with the upper

neck extended

Severe distraction of the Fracture of both pediclestwo fragments of theaxis, broken throughthe pedicles or lateral

of the axis, occasionallyinvolving the body of theaxis. Dens intact.

masses. There may be:-No other cervical bony -spondylolisthesis of theinjury. axisDens intact -one or more fractures

of the upper cervicalspinous processes

-bony injury of themiddle or lowercervical spine

Severe; due to traction Rare; from bleeding inthe cord

Flaccid tetraparesis Rare

Local and neurological Occipital neuralgia ; localcervical discomfort andstiffness

Immediate May be delayed severaldays

Poor; death usually �instant from cord injury

Good; symptoms usuallyslight and resolvecompletely

or vertex striking an obstacle while the body continues

to topple; a similar situation occurs when the unrestrained

car occupant is either projected forward in a head-on

accident and strikes his head on the inside of the vehicle,

or is ejected out and hits his head on the road. Afterwards

the patient usually holds his head slightly flexed, in which

position the fracture is stable although the anterior liga-

ment and the disc below the axis may be disrupted.

Neurological injury is rare, presumably because the spinal

canal is sufficiently wide at this level (Figs. 1 to 4) to

accommodate some movement of the fragments, which

in any case tend to separate and widen the canal; the

rarity of direct cord injury confirms that distraction does

not occur in this type of hangman’s fracture. Cornish

(1968) considered the occasional avulsion fracture of the

tip of the body of the axis inferiorly to be evidence of

extension. Associated mid-cervical injuries and fractures

of the spinous processes are also sometimes seen and

suggest that compression has occurred. Forsyth (1964)

proposed an almost identical mechanism of extension

with compression to explain fracture-dislocations of the

middle of the cervical spine, which were previously con-

sidered flexion injuries; it is therefore interesting that

there were other cervical injuries in some of Cornish’s

patients (Table I). Perhaps the axis snaps if the blow to

the head is received with the upper cervical spine already

extended; Cornish (1968) suggested that the vulnerable

position is with the head “ducked” (Fig. 8). By contrast,

if the neck is in the neutral position when the head is

struck, the soft tissues can take up some of the slack and

the whole cervical spine then extends evenly under tension

until either the anterior ligament gives way at the summit

of the arc or the facets collapse posteriorly (Fig. 9).

Fracture caused by extension and distraction-Distraction

ofthe upper cervical spine follows violent extension when

the rapidly moving body is suddenly restrained under the

chin or across the front of the neck. This is the aim of

judicial hanging by a submental knot and “long drop”

(which varies inversely with the victim’s weight and is

usually about six feet). The subaural knot, recommended

by Lord Aberdare’s Committee in 1886 and still appar-

ently in use in 1947 (British Medicalfournal), is unreliable

and may fracture the base ofthe skull (Wood Jones 1913).

Too short a drop may not break the neck, presumably

leaving the victim to die ofvascular occlusion and cerebral

ischaemia, as often happens in suicidal hanging (Good-

body 1973). If the drop is too long the victim’s head

FIG. 8 FIG. 9

Extension and compression of the upper cervical spine following a blow to the head, producing (Fig. 8) a hangman’s fracture, as suggestedby Cornish (1968); and (Fig. 9) middle cervical injury, as depicted by Forsyth (1964), with anterior ligament disruption anteriorly or

facet disintegration posteriorly.

FIG. I 1�” . 11 II .. 12Case 2-Cervical radiographs showing in Figure 10 a fracture of the hyoid; the axis pedicle fracture was just visible in this view. InFigure 1 1 the axis pedicle fracture is seen in a 20-degree oblique view, and in Figure 12 the mild separation of the fragments on forward

flexion.

86 T. G. WILLIAMS

THE JOURNAL OF BONE AND JOINT SURGERY

may be avulsed completely (Haughton 1866). Similarly,

a loose diagonal seat belt may permit a car occupant to

slide under the belt in a head-on accident, catching his

neck and distracting the axis from the third cervical

vertebra sometimes to the point of decapitation (Saldeen

1967). Distraction is thus a more violent injury than

compression and is usually accompanied by severe ex-

ternal evidence of injury to the neck with pronounced

local symptoms and a greater likelihood of neurological

sequelae from direct injury to the spinal cord.

CLINICAL FEATURES

The diagnosis of the compression type of hangman’s

fracture may not be made for several days after injury.

Presentation may be late, especially if the fracture fol-

lowed a simple fall with no other injury. Three patients

reported by Cornish (1968) presented to his orthopaedic

unit three or more days after injury, although he did not

account for the delay. Initial symptoms are often slight

and the patient usually experiences occipital neuralgia

with some local discomfort and stiffness of the upper

cervical spine. Indeed, the symptoms and signs may

resemble meningism.

CASE REPORT

Case 1-A thirty-four-year-old man attended hospital com-plaining of increasing stiffness and discomfort in his neck fortwenty-four hours, following a car accident he could notclearly recall. Radiographs showed an undisplaced, stablefracture through the body and neural arch of the axis. Therewere no neurological signs and he was discharged fromhospital a week later wearing a soft supportive collar. Localdiscomfort resolved within three months, and neck movementswere full and pain-free two months later.

Two years after the accident the patient was referred backto the orthopaedic department with occipital neuralgia andneck stiffness resembling his original symptoms. He was found

to have viral meningitis.

The doctor may not suspect bony injury in the

absence of local symptoms, or his attention may be

directed towards more obvious injuries sustained by the

patient. Even when bony injury is suspected, lateral and

antero-posterior radiographs may not reveal the fracture

because it is sometimes best seen in oblique views.

Furthermore, the clinician may think that the radiological

appearance suggests an old fracture or even a congenital

anomaly if the symptoms are slight, especially if there is

little prevertebral swelling.

CASE REPORTS

Case 2-A twenty-three-year-old car driver was admitted to

hospital immediately after a violent accident he could notremember. There were abrasions on the right side of hisforehead and left side of his neck, no neurological signs, andapparently pain-free cervical movements. Six hours later the

right side of his neck began to swell, embarrassing swallowingand speech. Cervical radiographs (Fig. 10) showed a hyoidfracture. Oblique views (Fig. 1 1) revealed a fracture acrosseach axis pedicle with mild but stable separation of thefragments on forward flexion (Fig. 12).

Thirty-six hours after admission the patient took his own

discharge against medical advice. He wore a soft supportivecollar for twelve weeks. Six months after injury his onlysymptoms were discomfort and stiffness on extending his neckor turning his head to the right.

Case 3-A seventy-eight-year-old woman sustained a trochan-teric fracture of her right femur in a car accident in which shelost consciousness briefly. On admission she was found tohave some mid-cervical tenderness, and the radiographs (Figs.13 and 14) were thought to show a congenital anomaly orunusual degenerative lesion of the axis. The femoral fracturewas fixed internally and she was discharged to a hospital in herdistant home town wearing a soft supportive collar.

Review of the radiographs confirmed that she had brokenboth pedicles of the axis.

Lateral radiographs in flexion and extension should

be taken, with oblique views if necessary, to confirm the

presence and stability ofcompression hangman’s fracture.

The difficulties already discussed often obscure the correct

diagnosis and it is possible that cases are being overlooked

because of a failure to appreciate that upper cervical bony

injury may be accompanied by slight or delayed symptoms

axis pec..Je fractures thought initially to be a congenital anomaly.

Fio. 16

. . .

‘ 4� �,4.

- #{163}3. 17Case 4. Figure 15-Lateral cervical radiograph showing an oblique fracture through theposterior half of the body and lateral masses of the axis and through the neural arch of theatlas. Figure 16 is a necropsy photograph of the fracture through the right lateral mass of theaxis. It has been superimposed on a diagrammatic sketch of the rest of the vertebra. Thefracture line runs through the base of the odontoid peg. Figure 17 shows the necropsyphotograph of the upper cervical spine bisected slightly to the right of the midline. Theintervertebral discs and the anterior and posterior ligaments are intact ; the spinal cord has not

been injured from without although there has been bleeding into its substance.

HANGMAN’S FRACTURE 87

VOL. 57-B, No. I, FEBRUARY 1975

and no neurological deficit, with equivocal radiological such patients are recorded as surviving tetraparesis

signs. (Cornish 1968 ; Edgar et a!. 1972). The further case

Patients with more severe cord injuries after a hang- presented below is unusual in that the neurological find-

man’s fracture with distraction of the axis fragments ings followed a cervical injury apparently caused by

presumably die without reaching a clinician, and only two extension and compression.

88 T. G. WILLIAMS

THE JOURNAL OF BONE AND JOINT SURGERY

CASE REPORT

Case 4-A forty-year-old mental defective fell forwards duringa grand ma! seizure and banged his head on a doorway. Onrecovering consciousness fifteen minutes later he was unable

to move his limbs. On admission to hospital he was found tohave a flaccid tetraparesis. He had a small laceration abovehis left eye and another on top of his head. Cervical radio-

graphs (Fig. 15) showed a fracture through the neural arch ofthe atlas extending through both lateral masses of the axis,which was subluxated forward on the third cervical vertebra.There was no radiological evidence of prevertebral swelling.

Skulltraction was applied with 6 pounds (2722 kilograms)weight, and ventilation was assisted through an endotrachealtube. Five days later he was breathing on his own and couldmake slight leg movements. He died two days later from theaspiration of vomit.

At necropsy the axis fracture was seen to run obliquelythrough the body and across the lateral masses (Figs. 16 and17). The anterior and posterior ligaments and intervertebraldiscs were intact, though blood had tracked beside them.There was no evidence of compression of the intact spinalcord, but some bleeding had occurred into its substance atthe level of the axis. The vertebral vessels were uninjured.

Perhaps this patient went into opisthotonos during hisepileptic seizure, forcibly extending his neck, which was then

subjected to compression when the top of his head struck the

doorway.

It is interesting that when Grogono (1954) presented

his original case, he suggested that cord injury was a

likely sequel of any axis pedicle fracture, although, as in

the report above, the lesion he discussed had probably

followed extension and compression of the upper cervical

spine.

TREATMENT

Treatment of the undisplaced stable hangman’s fracture

is symptomatic and a supportive collar usually suffices

until symptoms subside over six to twelve weeks. Al-

though some earlier cases were subjected to fusion, this

is now reserved for patients with severe local symptoms

or obvious neurological involvement. Schneider et a!.

(1965) felt that skull traction permitted early bony union

of the fracture-dislocation, though there is a danger of

over-distraction of the obviously unstable injury if trac-

tion exceeds two kilograms or check radiographs are not

sufficiently frequent (Edgar et a!. 1972). Cornish (1968)

condemned traction outright, preferring fusion between

the axis and third cervical vertebra. He approached this

site through a left submental skin crease incision, passing

anterior to the sternomastoid and posterior to the great

vessels, and checked the level radiologically before cutting

a circular bed coronally across the disc space with a tube

saw three-eighths of an inch in diameter. The anaesthetist

stretches the neck whilst the surgeon inserts a bone dowel

seven-sixteenths of an inch in diameter, taken from the

iliac crest. The patient is mobilised with a cervical splint

seven days after operation ; the splint is discarded after

six to ten weeks when radiological union has occurred.

Norrell and Wilson (1970) successfully treated five cases

of unstable hangman’s fracture by bone dowel fusion,

discharging their patients home on average only ten days

after operation.

I thank Professor J. S. Ellis, Mr M. S. Brett and Mr A. C. Warr for permission to report their cases, and Dr R. A. Goodbody for hisdissection and photographs of the post-mortem specimen of the upper cervical spine. I am grateful to Mr T. Earl and the Departmentof Medical Illustration at Southampton University, and to the Department of Medical Photography at Ipswich Hospital, for the diagrams.I thank Dr P. B. Guyer and Dr S. W. Heap for the use of radiographs taken by their Department.

REFERENCES

British Medical Journal (1947) Any Questions : Judicial hanging. British Medical Journal, 2, 160.Cornish, B. L. (1968) Traumatic spondylolisthesis of the axis. Journal ofBone and Joint Surgery, 50-B, 31-43.

DeLorme, T. L. (1967) Axis-pedicle fractures. Journal ofBone andJoint Surgery, 49-A, 1472.

Edgar, M. A., Fisher, T. R., McSweeney, T., and Park, W. M. (1972) Tetraplegia from hangman’s fracture: report of a case with recovery.Injury, 3, 199-202.

Forsyth, H. F. (1964) Extension injuries of the cervical spine. Journal ofBone andJoint Surgery, 46-A, 1792-1796.

Garber, J. N. (1964) Abnormalities of the atlas and axis vertebrae-congenital and traumatic. Journal of Bone and Joint Surgery, 46-A,1782-1791.

Goodbody, R. A. (1973) Personal communication.

Grogono, B. J. S. (1954) Injuries of the atlas and axis. Journal of Bone and Joint Surgery, 36-B, 397-410.

Haughton, S. (1866) On hanging, considered from a mechanical and physiological point of view. London, Edinburgh and Dublin:Philosophical Magazine and Journal of Science, 4th series, 32, 23-34.

Norrell, H., and Wilson, C. B. (1970) Early anterior fusion for injuries ofthe cervical portion of the spine. Journal ofthe American MedicalAssociation, 214, 525-530.

Norton, W. L. (1962) Fractures and dislocations of the cervical spine. Journal ofBone and Joint Surgery, 44-A, 115-139.

Rogers, W. A. (1957) Fractures and dislocations of the cervical spine. Journal ofBone andJoint Surgery, 39-A, 341-376.Saldeen, T. (1967) Fatal neck injuries caused by use of diagonal safety belts. Journal of Trauma, 7, 856-862.

Schneider, R. C., Livingston, K. E., Cave, A. J. E., and Hamilton, G. (1965) “Hangman’s fracture” of the cervical spine. Journal ofNeurosurgery, 22, 141-154.

Wood Jones, F. (1913) The ideal lesion produced by judicial hanging. Lancet, I, 53.