Hangman's fracture

Hangman's fracture is the colloquial name given to a fracture of both pedicles or partes interarticulares of the axis vertebra (C2).

Hangman's fracture
Hangman's fracture
X-ray of the cervical spine with a Hangman's fracture. Left without, right with annotation. Clearly can be seen that C2 (red outline) is moved forward with respect to C3 (blue outline).


The injury mainly occurs from falls, usually in elderly adults, and motor accidents mainly due to impacts of high force causing extension of the neck and great axial load onto the C2 vertebra.[1] In a study based in Norway, 60% of reported cervical fractures came from falls and 21% from motor-related accidents.[2] 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%). There were 203 discharges from the age group 1-17; 1,843 from 18- to 44-year-olds; 2,147 from 45- to 64-year-olds, 4,890 from 65- to 84-year-olds, and 3440 from 85+-year-olds. Females accounted for 54.45% of occurrences while males accounted for the other 45.38%.[3]


Hangman's fracture
A demonstration of a common mechanism of a hangman's fracture in a car accident.

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.[4]

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 is 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 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.


Car crashes

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

Falling and colliding with other people in a contact sport can also cause this fracture. Falling causes the weight of the body to force hyperextension. In full-contact sports such as American football and Rugby, 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.


Non-surgical or surgical

Hangman's fractures treatments are both non-surgical and surgical [5][6].

Benefits of surgical hangman's fracture treatment

Sasso[7] also studied that people who underwent surgical treatment will not be affected by pin site infections, brain abscesses, facet joint stiffness, loss of spinal alignment, and skin breakdown. Another study concerns the surgical treatment of the ring of axis conducted by Barsa et al. (2006)[8] based on 30 cases within 41 patients treated by using anterior cervical fixation and fusion and 11 cases treated by a posterior CT.

Result of the surgical treatment

As a result, Barsa et al.[9] showed that the result of fracture fusion reduced after one year but only one patient died of other disease during the follow-up. Hakalo and Wronski (2008)[10] showed the benefits of 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.


Incidence According to Age Group in the USA during 2010
The pie chart shows the incidence of C2 fractures according to age groups. For the <17 age group, there were 203 incidents. For ages 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 C2 fracture accounts for nearly 19% of all spinal fractures[11] 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.[12]

Hospital costs in the USA

Trend of Hospital Charges and Number of Discharges
The graph shows the trend of hospital charges and number 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 percent increase. Mean health care costs went from $24,771 to $59,939.[3]

See also


  1. ^ 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.
  2. ^ 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.
  3. ^ a b "Healthcare Cost and Utilization Project". HCUP Home.
  4. ^ James R, Nasmyth-Jones R., "The occurrence of cervical fractures in victims of judicial hanging", Forensic Science International, 1992 Apr;54(1):81-91.
  5. ^ Sasso, Rick C. (2001). C2 Dens Fractures: Treatment Options. Journal of Spinal Disorders. 14(5): 455-463.
  6. ^ Li, Xin-Feng; Dai, Li-Yang; Lu, Hua; Chen, Xiao-Dong (19 October 2005). "A systematic review of the management of hangman's fractures" (PDF). European Spine Journal. 15 (3): 257–269. doi:10.1007/s00586-005-0918-2. Retrieved 27 August 2018.
  7. ^ Sasso, Rick C.(2001). C2 Dens Fractures: Treatment Options. Journal of Spinal Disorders. 14(5): 455-463.
  8. ^ 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.
  9. ^ 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.
  10. ^ 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.
  11. ^ 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.
  12. ^ 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.

External links

Albert Pierrepoint

Albert Pierrepoint (; 30 March 1905 – 10 July 1992) was an English hangman who executed between 435 and 600 people in a 25-year career that ended in 1956. His father, Henry, and uncle Thomas were official hangmen before him.

Pierrepoint was born in Clayton in the West Riding of Yorkshire. His family struggled financially because of his father's intermittent employment and heavy drinking. Pierrepoint knew from an early age that he wanted to become a hangman, and was taken on as an assistant executioner in September 1932, aged 27. His first execution was in December that year, alongside his uncle Tom. In October 1941 he undertook his first hanging as lead executioner.

During his tenure he hanged 200 people who had been convicted of war crimes in Germany and Austria, as well as several high-profile murderers—including Gordon Cummins (the Blackout Ripper), John Haigh (the Acid Bath Murderer) and John Christie (the Rillington Place Strangler). He undertook several contentious executions, including Timothy Evans, Derek Bentley and Ruth Ellis and executions for high treason—William Joyce (also known as Lord Haw-Haw) and John Amery—and treachery, with the hanging of Theodore Schurch.

In 1956 Pierrepoint was involved in a dispute with a sheriff over payment, leading to his retirement from hanging. He ran a pub in Lancashire from the mid-1940s until the 1960s. He wrote his memoirs in 1974 in which he concluded that capital punishment was not a deterrent, although he may have changed his position after that. He approached his task with gravity and said that the execution was "sacred to me". His life has been included in several works of fiction, such as the 2005 film Pierrepoint, in which he was portrayed by Timothy Spall.

Atlanto-occipital dislocation

Atlanto-occipital dislocation, orthopedic decapitation, or internal decapitation describes ligamentous separation of the spinal column from the skull base. It is possible for a human to survive such an injury; however, only 30% of cases do not result in immediate death. It should not be confused with atlanto-axial dislocation, which describes ligamentous separation between the first and second cervical vertebra.

Barton's fracture

A Barton's fracture is an intra-articular fracture of the distal radius with dislocation of the radiocarpal joint.

There exist two types of Barton's fracture – dorsal and palmar, the latter being more common. The Barton's fracture is caused by a fall on an extended and pronated wrist increasing carpal compression force on the dorsal rim. Intra-articular component distinguishes this fracture from a Smith's or a Colles' fracture.

Treatment of this fracture is usually done by open reduction and internal fixation with a plate and screws, but occasionally the fracture can be treated conservatively.

Bosworth fracture

The Bosworth fracture is a rare fracture of the distal fibula with an associated fixed posterior dislocation of the proximal fibular fragment which becomes trapped behind the posterior tibial tubercle. The injury is caused by severe external rotation of the ankle. The ankle remains externally rotated after the injury, making interpretation of X-rays difficult which can lead to misdiagnosis and incorrect treatment. The injury is most commonly treated by open reduction internal fixation as closed reduction is made difficult by the entrapment of the fibula behind the tibia.The entrapment of an intact fibula behind the tibia was described by Ashhurst and Bromer in 1922, who attributed the description of the mechanism of injury to Huguier's 1848 publication. The injury involving fibular fracture with posterior dislocation was described by David M. Bosworth in 1947.

Galeazzi fracture

The Galeazzi fracture is a fracture of the distal third of the radius with dislocation of the distal radioulnar joint. It classically involves an isolated fracture of the junction of the distal third and middle third of the radius with associated subluxation or dislocation of the distal radio-ulnar joint; the injury disrupts the forearm axis joint.

Gosselin fracture

The Gosselin fracture is a V-shaped fracture of the distal tibia which extends into the ankle joint and fractures the tibial plafond into anterior and posterior fragments.The fracture was described by Leon Athanese Gosselin, chief of surgery at the Hôpital de la Charité in Paris.


Hanging is the suspension of a person by a noose or ligature around the neck. The Oxford English Dictionary states that hanging in this sense is "specifically to put to death by suspension by the neck", though it formerly also referred to crucifixion and death by impalement in which the body would remain "hanging". Hanging has been a common method of capital punishment since medieval times, and is the primary execution method in numerous countries and regions. The first known account of execution by hanging was in Homer's Odyssey (Book XXII). In this specialised meaning of the common word hang, the past and past participle is hanged instead of hung.

Hanging is also a common method of suicide in which a person applies a ligature to the neck and brings about unconsciousness and then death by suspension. Partial suspension or partial weight-bearing on the ligature is sometimes used, particularly in prisons, mental hospitals or other institutions, where full suspension support is difficult to devise, because high ligature points (e.g., hooks or pipes) have been removed.

List of eponymous fractures

Eponymous fractures and fracture-dislocations are most commonly named after the doctor who first described them. They may also be named after an activity with which they are associated.

Pars interarticularis

The pars interarticularis, or pars for short, is the part of a vertebra located between the inferior and superior articular processes of the facet joint.In the transverse plane, it lies between the lamina and pedicle. In other words, in the axial view, it is the bony mass between the facets that is anterior to the lamina and posterior to the pedicle. It is abnormal in spondylolysis, either due to fracture or congenitally. Bilateral C2 pars fractures are known as a variant of the hangman's fracture.

On an anterior oblique radiograph of the lumbar spine, the pars is the neck of the imaginary Scottie dog; the Scottie dog's eye is the pedicle, its hindlegs the spinous process, its nose the transverse process, its ear the superior articular facet and its forelegs the inferior articular facet.Stress fractures of the pars interarticularis are known to be associated with playing sports such as volleyball, although the mechanism is somewhat unclear. Patients with spina bifida occulta have an increased risk for spondylolysis.

Rolando fracture

The Rolando fracture is a comminuted intra-articular fracture through the base of the first metacarpal bone (the first bone forming the thumb). It was first described in 1910 by Silvio Rolando. This is a fracture consisting of 3 distinct fragments; it is typically T- or Y-shaped.

Segond fracture

The Segond fracture is a type of avulsion fracture (soft tissue structures tearing off bits of their bony attachment) of the lateral tibial condyle of the knee, immediately beyond the surface which articulates with the femur.

Smith's fracture

A Smith's fracture, also sometimes known as a reverse Colles' fracture or Goyrand-Smith's, is a fracture of the distal radius. It is caused by a direct blow to the dorsal forearm or falling onto flexed wrists, as opposed to a Colles' fracture which occurs as a result of falling onto wrists in extension. Smith's fractures are less common than Colles' fractures.

The distal fracture fragment is displaced volarly (ventrally), as opposed to a Colles' fracture which the fragment is displaced dorsally. Depending on the severity of the impact, there may be one or many fragments and it may or may not involve the articular surface of the wrist joint.

Spinal fracture

A spinal fracture, also called a vertebral fracture or a broken back, is a fracture affecting the vertebrae of the spinal column. Most types of spinal fracture confer a significant risk of spinal cord injury. After the immediate trauma, there is a risk of spinal cord injury (or worsening of an already injured spine) if the fracture is unstable, that is, likely to change alignment without internal or external fixation.


Spondylolisthesis is the displacement of one vertebra compared to another. Medical dictionaries define spondylolisthesis specifically as the forward or anterior displacement of a vertebra over the vertebra inferior to it (or the sacrum). However, it is often defined in medical textbooks as displacement in any direction.

Tillaux fracture

A Tillaux fracture (or a Tillaux-Chaput avulsion fracture) is a Salter–Harris type III fracture through the anterolateral aspect of the distal tibial epiphysis. It occurs in older adolescents between the ages of 12 and 15 when the medial epiphysis had closed but before the lateral side has done so, due to an avulsion of the anterior tibiofibular ligament, at the opposite end to a Wagstaffe-Le Fort avulsion fracture

Tim Don

Timothy Philip "Tim" Don (born 14 January 1978 in Isleworth, London) is a triathlete from the United Kingdom.

Vancouver classification

The Vancouver classification is a grading system used in orthopaedics to determine management of post-operative periprosthetic femoral fractures following a hip arthroplasty. It is named for the city Vancouver, home province of the University of British Columbia where the authors of the 1995 paper worked.

Wagstaffe-Le Fort avulsion fracture

Le Fort's fracture of the ankle is a vertical fracture of the antero-medial part of the distal fibula with avulsion of the anterior tibiofibular ligament, opposite to a Tillaux-Chaput avulsion fracture

The injury was described by Léon Clément Le Fort in 1886.

Fractures and cartilage injuries (Sx2, 800–829)
Spinal fracture
Shoulder fracture
Arm fracture
Hand fracture
Pelvic fracture
Foot fracture

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