“Hangman's Fracture” of the Cervical Spine

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Traffic accidents occasionally produce a distinctive variety of fracture (or fracture-dislocation) of the upper cervical spine, characterized by a bilateral avulsion-fracture through the neural arch of the axis without injury to the odontoid process and with or without fracture-dislocation of the 2nd cervical vertebral body upon the 3rd. The similarity of this lesion to that effected by the modern technique of judicial hanging justifies its description as “hangman's fracture” of the cervical spine.

Some years ago one of us (R.C.S.5) published a radiograph of a lesion sustained in a traffic accident which revealed just such an

Article Information

Section of Neurosurgery, Department of Surgery, University of Michigan Medical School and Hospital, and St. Joseph Mercy Hospital, Ann Arbor, Michigan.

Pahlavi University, Shiraz, Iran. Formerly Department of Neurosurgery, Providence Hospital, and University of Oregon Medical School, Portland, Oregon.

Department of Anatomy, St. Bartholomew's Hospital Medical College, University of London, England.

Department of Anatomy, Marischal College, Aberdeen, Scotland.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Roentgenogram showing fracture-dislocation of C2 vertebral body anteriorly on C3 with complete avulsion of neural arch of the axis from the body. (Reprinted through the courtesy of Charles C Thomas and Kahn et al.5)

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    Cases 1, 2 and 3. All three roentgenograms revealed an avulsion fracture of the neural arch of the axis bilaterally and some degree of dislocation of C2 vertebral body on C3 vertebra.

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    Case 4. (A) Typical injury was demonstrated initially on May 12, 1962. (B) Cervical roentgenogram on July 25, 1962 demonstrating further dislocation of C2 vertebral body on C3 after failure to wear a prescribed support. (C) Anterior cervical spinal fusion of C2 and C3 vertebral bodies had been performed by Dr. Robert Bailey 9 weeks prior to this roentgenogram. Solid bony union was achieved, preventing further dislocation.

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    Case 5. (A) Bilateral fracture of neural arch of axis with minimal dislocation of C2 on C3 vertebral body was demonstrated initially on Jan. 16, 1959. (B) Laminagrams made at this time showed further definition of the extent of the fracture. (C) A follow-up roentgenogram 3 months later revealed good alignment with solid bony union.

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    Case 6. (A) Initial roentgenogram revealed the fractures through the neural arch of the axis (arrow) but only minimal dislocation of C2 and C3 vertebral body. (B) Patient refused to stay in traction or wear a collar and within 5 days had a more severe degree of dislocation (arrow). (C) After accepting immobilization in a collar, cervical roentgenogram 14 weeks after injury shows almost complete obliteration of C2–C3 intervertebral space.

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    Case 7. (A) Initial roentgenogram of cervical spine disclosing typical fracture-dislocation. (B) In spite of skeletal traction for 4 weeks and hyperextension, reduction of the fracture-dislocation of C2 on C3 vertebral body could not be accomplished. Bony union was occurring without neurologic deficit. The roentgenogram was made through a Minerva jacket 3½ weeks after injury.

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    Case 8. (A) Roentgenogram of cervical spine exhibiting the typical initial injury Nov. 24, 1962. (B) Laminagram (retouched) demonstrating good realignment of fracture-dislocation after 5 weeks of skeletal traction. (C) Plain lateral view of cervical spine taken at same time as laminagram showing added advantages of latter procedure.

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    Case 8. Anterior-posterior view of laminagram is presented to indicate the odontoid process is intact. The fractures of the neural arch of the axis are not evident in this plane (arrows).

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    “The lesion present in the Nubian series of hangings and in the skull of Dr. Pritchard. Fractured base of the skull; effect of a subaural knot.” (Reprinted from article by F. Wood-Jones15)

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    A padded leather chin trough “which could be rapidly fixed on the ascending rope after the noose had been adjusted, and immediately outside the eye of that noose”. (Reprinted from article by J. J. Marshall8)

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    “The lesion present in Captain C. F. Fraser's series of judicial hangings. Separation of the arch of the axis from the body; effect of a submental knot”. (Reprinted from article by F. Wood-Jones15)

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    (1) “Body and neural arch of the vertebra”. (2) “Portions of vertebra viewed from the right side”. (3) “Portions of vertebra viewed from the left side”. (Reprinted from article by W. Vermooten13)

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    Anterior and lateral aspects of craniocervical region to illustrate the lines of transmission of cranial weight through the atlanto-axial complex to the spinal column proper and the consequent mechanical vulnerability of the neural arch of the axis (A. J. E. Cave)

References

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KahnE. A.BassettR. C.SchneiderR. C.CrosbyE. C. Correlative neurosurgery. Springfield, Ill.: Charles C Thomas1955xv413 pp.KahnBassettSchneiderCrosby

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KalleE. Beobachtungen über den Tod bei Hinrichtungen mit dem Strang. Dtsch. Z. ges. gerichtl. Med.193222: 192203.KalleDtsch. Z. ges. gerichtl. Med.22: 192–203.

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LindC. E.Jr. Personal communication.LindJr. Personal communication.

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MarshallJ. J. de Z. Judicial hanging. Lancet19131: 193194.Marshallde Z. Judicial hanging. Lancet1: 193–194.

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PatersonA. M. [Fracture of cervical vertebrae.]189024: ix.Paterson24: ix.

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RobertsonW. G. A. Recovery after judicial hanging. Brit. med. J.19351: 121122.RobertsonBrit. med. J.1: 121–122.

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SchneiderR. C.KahnE. A. Chronic neurological sequelae of acute trauma to the spine and spinal cord. I. The significance of the acuteflexion or “tear-drop” fracture-dislocation of the cervical spine. J. Bone Jt. Surg.195638-A: 985997.SchneiderKahnJ. Bone Jt. Surg.38-A: 985–997.

13.

VermootenW. A study of the fracture of the epistropheus due to hanging with a note on the possible causes of death. Anat. Rec.192120: 305311.VermootenAnat. Rec.20: 305–311.

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WolffR. Injury to the cervical vertebrae as a result of judicial hanging. J. med. Ass. S. Afr.19282: 460462.WolffJ. med. Ass. S. Afr.2: 460–462.

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Wood-JonesF. The ideal lesion produced by judicial hanging. Lancet19131: 53.Wood-JonesLancet1: 53.

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