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Hangmans Fracture

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Other Names

  • Traumatic spondylolisthesis of the axis
  • Traumatic spondylolisthesis of the C2
  • C2 Fracture
  • C2 pars interarticularis fracture
  • Hangman's Fracture


  • This page refers to traumatic pars interarticularis fracture of C2, often referred to as hangman's fracture


  • First described in the journal Lancet in 1913[1]
  • Coined "hangman's fracture" by Schneider due to similar fracture pattern seen in judicial hangings[2]


  • Represent 4-7% of all cervical fractures[3]
  • 11-22% of C2 fractures[4]


  • Best described as a bilateral fracture traversing the pars interarticularis of C2
    • There may be associated C2-C3 subluxation


  • Classically associated with hanged criminals
    • Due to fall and associated traumatic hyperextension
    • This injury is hardly seen with suicidal hangings[5]
  • In the modern era, most commonly seen in MVC, diving injuries or contact sports
    • Due to hyperextension and axial loading

Associated Injuries

  • C2-C3 subluxation

Risk Factors

  • Unknown

Differential Diagnosis

Clinical Features

  • General: Physical Exam Neck
  • History
    • Important to clarify trauma features
    • Discuss medical history including osteoporosis, cancer, vitamin D deficiency
  • Physical Exam
    • Posterior neck pain with palpation
    • May have evidence of radiculopathy, myelopathy or vertebral artery injury
    • Requires thorough neuromotor exam



  • Standard C-spine views
    • Includes Lateral, AP and odontoid views
  • Consider flexion-extension films


  • Best modality for evaluating fracture pattern


  • Evaluate for soft tissues including ligamentous construct, disc space, spinal cord, nerve roots


Levine-Edwards Classification System

  • Type I: <3mm anterolisthesis, no angulation[6]
  • Type II: >3mm anterolisthesis, angulation; disruption of posterior longitudinal ligament
  • Type IIa: Horizontal fracture line; angulation without anterolithesis
  • Type III: Type I with bilateral facet joint dislocation

Francis Grading System

  • Type 1: Less than 11 degrees of angulation and less than 3.5 mm of displacement[7]
  • 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
  • Type 5: Complete disc disruption



  • Short term
    • Hardware complications: pressure sores from collars, halo pin loosening, pressure sores
    • Surgical post-operative infection
  • Paucity of studies to guide decision making
    • Most recommendations based on expert opinion and case series
    • No class I or II evidence


  • Indications:
    • Needs to be updated
  • Initial: Apply rigid cervical collar
  • Long term: Collar or Halo-vest
  • Duration of 8-14 weeks


  • Indications
    • 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
  • Technique
    • Open reduction, internal fixation
  • Increases rate of osteosynthesis or fusion[8]
  • Technique: ACDF, a posterior fusion or a combined anterior–posterior fusion

Rehab and Return to Play


  • Needs to be updated

Return to Play

  • Needs to be updated


  • Non-union
    • Rare, less 10% rare (need citation)
  • Post op infection
  • Myelopathy
  • Radiculopathy

See Also


  1. Wood-Jones F. The ideal lesion produced by judicial hanging. Lancet 1913; 181: 53
  2. Schneider RC, Livingston KE, Cave AJ, et al. “HANGMAN'S fracture” of the cervical spine. J Neurosurg. 1965;22:141–154.
  3. Ge C, Hao D, He B, et al. Anterior cervical discectomy and fusion versus posterior fixation and fusion of C2–3 for unstable Hangman's fracture. J Spinal Disord Tech. 2015;28:E61–E66.
  4. 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. Adv Orthop. 2017;2017:6516893
  5. Radiopaedia. Hangman’s fracture 2015 [cited 2015 26th October], http://radiopaedia.org/articles/hangman-fracture
  6. Levine A, Edwards C, Maryland B. The management of traumatic spondylolisthesis of the axis. J Bone Joint Surg Am. 1985;67:217–226.
  7. Francis WR, Fielding JW, Hawkins RJ, Pepin J, Hensinger R. Traumatic spondylolisthesis of the axis. J Bone Joint Surg Br. 1981;63-B(3):313-8
  8. Murphy, Hamadi, et al. "Management of hangman's fractures: a systematic review." Journal of orthopaedic trauma 31 (2017): S90-S95.
Created by:
John Kiel on 4 July 2019 09:27:45
Last edited:
6 October 2022 23:15:26