Imaging observation of possible mechanism and stability of type B Hangman’s fracture_Chinese Journal of Reparative and Reconstructive Surgery

Authors：

LI Hanming ¹ ,  WANG Qing ¹ ,  LI Guangzhou ² , WANG Gaoju ¹ , YANG Jin ¹ , ZHANG Hao ² , ZHANG Jian ¹ , CHEN Zhike ¹

1. Department of Orthopedics, Affiliated Hospital of Southwest Medical University, Luzhou Sichuan, 646000, P. R. China;
2. Department of Orthopedics, Suining Central Hospital, Suining Sichuan, 629018, P. R. China;

Corresponding author：

WANG Qing, Email: wqspine2004@163.com; LI Guangzhou, Email: guangzhouli08@163.com

Keywords：

Hangman’s fracture; imaging features; damage mechanism; stability

DOI：

10.7507/1002-1892.202503086

Video：

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Objective To investigate the possible mechanism and fracture stability of subtypes of type B Hangman’s fracture by using imaging observation. Methods Patients with type B Hangman’s fractures admitted to multiple centers between January 2008 and October 2023 were selected as the research objects. The clinical data and imaging data of patients who met the selection criteria were extracted. The patient’s age, gender, cause of fracture, disease duration, visual analogue scale (VAS) score of neck pain, neck disability index (NDI), and American Spinal Injury Association (ASIA) classification of spinal cord function were collected. Based on the imaging data, the anatomical structure of the contralateral superior articular process fracture, the relationship between the superior articular process fracture line and the position of the odontoid process, the associated posterior vertebral wall fracture and its classification, the incidence of vertebral arch floating and C_{2, 3} instability were observed. The superior articular fracture angle (SAFA), superior articular fracture displacement distance (SAFD), and C₂ vertebral body rotation (VBRA) were measured. According to the anatomical structure of the contralateral superior articular process fracture, the patients were divided into a pedicle fracture group (POA group), a inferior articular process fracture group (IAP group), and a laminar fracture group (CSL group). The baseline data and imaging indexes were analyzed between groups, and the imaging anatomical characteristics of each subtype of fracture were observed to explore its possible mechanism and fracture stability. Results A total of 86 cases of type B Hangman’s fractures were collected. There were 67 males and 19 females. The mean age was 51.0 years old (range, 21-78 years). There were 48 cases of pedicle fracture (POA group), 25 cases of inferior articular process fracture (IAP group), and 13 cases of laminar fracture (CSL group). There was no significant difference in age, gender, cause of fracture, course of disease, VAS score of neck pain, and NDI between groups (P>0.05). However, the incidence of spinal cord injury in POA group was the highest (P<0.05). The incidences of superior articular process fracture line posterior to the odontoid process and posterior vertebral wall fracture in POA group were the highest (P<0.05). The incidences of vertebral arch floating and C_{2, 3} instability in IAP group were the highest (P<0.05). There were significant differences in SAFA and VBRA between groups (P<0.05). There was no significant difference in SAFD between groups (P>0.05). The differences in the incidences of fracture displacement>3 mm and VBRA>5° between groups were significant (P<0.05). There were 78 cases of unstable Hangman’s fracture, including 2 cases of simple C_2、3 instability, 22 cases of simple axis rotation and displacement instability, 8 cases of simple vertebral arch floating instability, and the rest of the patients had two or more types of instability. Conclusion The mechanism of different subtypes of type B Hangman’s fracture may be that the lateral mass of the rotation of the atlas applied the overextension compression force to the unilateral superior articular process of the axis vertebra, and the contralateral pedicle, inferior articular process and lamina fractures were caused by direct violence or/and rotational violence to different degrees. The decomposition of this type of fracture into C_{2, 3} intervertebral, axis vertebra body displacement and rotation and vertebral arch floating instability is beneficial to the treatment and surgical approach selection.

1.	Yunde A, Furuya T, Orita S, et al. Hangman’s fracture in geriatric population: a nationwide multicenter study in Japan. Global Spine J, 2025, 15(2): 921-929.
2.	Scholz M, Kandziora F, Kobbe P, et al. Treatment of axis ring fractures: recommendations of the spine section of the German Society for Orthopaedics and Trauma (DGOU). Global Spine J, 2018, 8(2 Suppl): 18S-24S.
3.	李广州, 欧阳建元, 王清, 等. 枢椎环骨折损伤机制的三维有限元分析. 中国脊柱脊髓杂志, 2022, 32(2): 160-168.
4.	Levine AM, Edwards CC. The management of traumatic spondylolisthesis of the axis. J Bone Joint Surg (Am), 1985, 67(2): 217-226.
5.	Müller EJ, Wick M, Muhr G. Traumatic spondylolisthesis of the axis: treatment rationale based on the stability of the different fracture types. Eur Spine J, 2000, 9(2): 123-128.
6.	Coric D, Wilson J A, Kelly D L, Jr. Treatment of traumatic spondylolisthesis of the axis with nonrigid immobilization: a review of 64 cases. J Neurosurg, 1996, 85(4): 550-554.
7.	Goel A, Hawaldar A, Shah A, et al. Hangman’s fracture: a clinical review based on surgical treatment of 15 cases. Neurosurg Rev, 2022, 45(1): 595-606.
8.	Mudumba VS, Pavan S, Alugolu R. Saradhi’s single stage, anterior sequential reduction utilizing C3 for type Ⅲ hangman’s fracture: A novel technique. J Craniovertebr Junction Spine, 2022, 13(1): 80-84.
9.	Bhushan A, Beland A, Poelstra C, et al. Immobilization protocols for the treatment of cervical spine fracture: a scoping review. Spine J, 2024, 24(9): 1571-1594.
10.	Li G, Wang Q. Detailed observation of anatomical location and pattern in Hangman’s fracture based on computed tomography three-dimensional reconstruction. J Orthop Surg Res, 2023, 18(1): 136. doi: 10.1186/s13018-023-03622-x.
11.	何思羽, 王清, 李广州, 等. 枢椎环骨折部位及损伤机制的三维CT分型研究. 中华骨科杂志, 2020, 40(20): 1387-1396.
12.	戴亦心, 张帅, 欧阳建元, 等. 影响单纯枢椎环骨折稳定性的各解剖结构骨折三维CT分型研究及临床意义. 中国脊柱脊髓杂志, 2020, 30(2): 142-150.
13.	侯黎升, 贾连顺, 谭军, 等. 枢椎各结构的解剖学部位研究. 中国临床解剖学杂志, 2005, 23(1): 44-48.
14.	Panjabi MM. The stabilizing system of the spine. Part Ⅰ. Function, dysfunction, adaptation, and enhancement. J Spinal Disord, 1992, 5(4): 383-397.
15.	White AA, Panjabi MM. The basic kinematics of the human spine. A review of past and current knowledge. Spine (Phila Pa 1976), 1978, 3(1): 12-20.
16.	Starr JK, Eismont FJ. Atypical hangman’s fractures. Spine (Phila Pa 1976), 1993, 18(14): 1954-1957.
17.	Al-Mahfoudh R, Beagrie C, Woolley E, et al. Management of typical and atypical Hangman’s fractures. Global Spine J, 2016, 6(3): 248-256.
18.	王清, 党耕町, 李广州, 等. 不典型Hangman骨折影像学分型与治疗选择. 中华骨科杂志, 2018, 38(19): 1177-1185.
19.	Menon VK. Mechanically relevant anatomy of the axis vertebra and its relation to Hangman’s fracture: an illustrated essay. Neurospine, 2019, 16(2): 223-230.
20.	Zhang J, Li G, Wang Q. Is it feasible to treat unstable traumatic spondylolisthesis of the axis via posterior fixation without fusion? BMC Musculoskelet Disord, 2023, 24(1): 122. doi: 10.1186/s12891-023-06233-z.
21.	Kurucan E, Sulovari A, Thirukumaran C, et al. Volume-outcome relationship in halo vest utilization for C₂ fractures. Spine J, 2020, 20(10): 1676-1684.
22.	Isidro S, Molinari R, Ikpeze T, et al. Outcomes of halo immobilization for cervical spine fractures. Global Spine J, 2019, 9(5): 521-526.
23.	Murphy H, Schroeder GD, Shi WJ, et al. Management of Hangman’s fractures: a systematic review. J Orthop Trauma, 2017, 31 Suppl 4: S90-S95.
24.	Arand M, Neller S, Kinzl L, et al. The traumatic spondylolisthesis of the axis. A biomechanical in vitro evaluation of an instability model and clinical relevant constructs for stabilization. Clin Biomech (Bristol), 2002, 17(6): 432-438.
25.	勾瑞恩, 母心灵, 崔京福, 等. 颈前路间盘切除植骨融合治疗不稳定Hangman骨折. 中国矫形外科杂志, 2021, 29(14): 1269-1272.
26.	ElMiligui Y, Koptan W, Emran I. Transpedicular screw fixation for type Ⅱ Hangman’s fracture: a motion preserving procedure. Eur Spine J, 2010, 19(8): 1299-1305.
27.	Chowdhury FH, Haque MR. C₁-C₃ lateral mass screw-rod fixation and fusion for C₂ pathologies and Hangman’s fractures. Asian Spine J, 2014, 8(6): 735-746.
28.	Liu Y, Li X, Chen T, et al. Minimally invasive percutaneous new designed transpedicular lag-screw fixation for the management of Hangman fracture using O-arm-based navigation: a clinical study. BMC Musculoskelet Disord, 2023, 24(1): 494. doi: 10.1186/s12891-023-06614-4.
29.	Li G, Wang Q, Liu H, et al. Individual surgical strategy using posterior lag screw-rod technique for unstable atypical Hangman’s fracture based on different fracture patterns. World Neurosurg, 2018, 119: e848-e854.
30.	Beucler N. Open reduction and C1C3 posterior Harms-Goel fixation for unstable Hangman’s fracture: technical note. Neurosurg Rev, 2024, 47(1): 558. doi: 10.1007/s10143-024-02807-0.
31.	Wang G, Jiang D, Wang Q, et al. A novel technique using a pedicle screw and bucking bar for the treatment of hangman’s fracture. Orthop Traumatol Surg Res, 2019, 105(4): 709-711.
32.	马向阳, 邹小宝, 王宾宾, 等. 后路钉棒固定非融合治疗新鲜Ⅱ型和ⅡA型Hangman骨折. 中国矫形外科杂志, 2019, 27(22): 2080-2083.
33.	欧阳建元, 高云, 李广州, 等. 应用有限元模型分析椎弓根拉力螺钉固定枢椎环骨折的稳定性. 中国脊柱脊髓杂志, 2020, 30(1): 62-71.
34.	Zhao J, Liu Y, Zhang Q, et al. Robot-assisted percutaneous pars-pedicle screw fixation for treating Hangman’s fracture. J Orthop Surg Res, 2023, 18(1): 271. doi: 10.1186/s13018-023-03765-x.

1. Yunde A, Furuya T, Orita S, et al. Hangman’s fracture in geriatric population: a nationwide multicenter study in Japan. Global Spine J, 2025, 15(2): 921-929.
2. Scholz M, Kandziora F, Kobbe P, et al. Treatment of axis ring fractures: recommendations of the spine section of the German Society for Orthopaedics and Trauma (DGOU). Global Spine J, 2018, 8(2 Suppl): 18S-24S.
3. 李广州, 欧阳建元, 王清, 等. 枢椎环骨折损伤机制的三维有限元分析. 中国脊柱脊髓杂志, 2022, 32(2): 160-168.
4. Levine AM, Edwards CC. The management of traumatic spondylolisthesis of the axis. J Bone Joint Surg (Am), 1985, 67(2): 217-226.
5. Müller EJ, Wick M, Muhr G. Traumatic spondylolisthesis of the axis: treatment rationale based on the stability of the different fracture types. Eur Spine J, 2000, 9(2): 123-128.
6. Coric D, Wilson J A, Kelly D L, Jr. Treatment of traumatic spondylolisthesis of the axis with nonrigid immobilization: a review of 64 cases. J Neurosurg, 1996, 85(4): 550-554.
7. Goel A, Hawaldar A, Shah A, et al. Hangman’s fracture: a clinical review based on surgical treatment of 15 cases. Neurosurg Rev, 2022, 45(1): 595-606.
8. Mudumba VS, Pavan S, Alugolu R. Saradhi’s single stage, anterior sequential reduction utilizing C3 for type Ⅲ hangman’s fracture: A novel technique. J Craniovertebr Junction Spine, 2022, 13(1): 80-84.
9. Bhushan A, Beland A, Poelstra C, et al. Immobilization protocols for the treatment of cervical spine fracture: a scoping review. Spine J, 2024, 24(9): 1571-1594.
10. Li G, Wang Q. Detailed observation of anatomical location and pattern in Hangman’s fracture based on computed tomography three-dimensional reconstruction. J Orthop Surg Res, 2023, 18(1): 136. doi: 10.1186/s13018-023-03622-x.
11. 何思羽, 王清, 李广州, 等. 枢椎环骨折部位及损伤机制的三维CT分型研究. 中华骨科杂志, 2020, 40(20): 1387-1396.
12. 戴亦心, 张帅, 欧阳建元, 等. 影响单纯枢椎环骨折稳定性的各解剖结构骨折三维CT分型研究及临床意义. 中国脊柱脊髓杂志, 2020, 30(2): 142-150.
13. 侯黎升, 贾连顺, 谭军, 等. 枢椎各结构的解剖学部位研究. 中国临床解剖学杂志, 2005, 23(1): 44-48.
14. Panjabi MM. The stabilizing system of the spine. Part Ⅰ. Function, dysfunction, adaptation, and enhancement. J Spinal Disord, 1992, 5(4): 383-397.
15. White AA, Panjabi MM. The basic kinematics of the human spine. A review of past and current knowledge. Spine (Phila Pa 1976), 1978, 3(1): 12-20.
16. Starr JK, Eismont FJ. Atypical hangman’s fractures. Spine (Phila Pa 1976), 1993, 18(14): 1954-1957.
17. Al-Mahfoudh R, Beagrie C, Woolley E, et al. Management of typical and atypical Hangman’s fractures. Global Spine J, 2016, 6(3): 248-256.
18. 王清, 党耕町, 李广州, 等. 不典型Hangman骨折影像学分型与治疗选择. 中华骨科杂志, 2018, 38(19): 1177-1185.
19. Menon VK. Mechanically relevant anatomy of the axis vertebra and its relation to Hangman’s fracture: an illustrated essay. Neurospine, 2019, 16(2): 223-230.
20. Zhang J, Li G, Wang Q. Is it feasible to treat unstable traumatic spondylolisthesis of the axis via posterior fixation without fusion? BMC Musculoskelet Disord, 2023, 24(1): 122. doi: 10.1186/s12891-023-06233-z.
21. Kurucan E, Sulovari A, Thirukumaran C, et al. Volume-outcome relationship in halo vest utilization for C₂ fractures. Spine J, 2020, 20(10): 1676-1684.
22. Isidro S, Molinari R, Ikpeze T, et al. Outcomes of halo immobilization for cervical spine fractures. Global Spine J, 2019, 9(5): 521-526.
23. Murphy H, Schroeder GD, Shi WJ, et al. Management of Hangman’s fractures: a systematic review. J Orthop Trauma, 2017, 31 Suppl 4: S90-S95.
24. Arand M, Neller S, Kinzl L, et al. The traumatic spondylolisthesis of the axis. A biomechanical in vitro evaluation of an instability model and clinical relevant constructs for stabilization. Clin Biomech (Bristol), 2002, 17(6): 432-438.
25. 勾瑞恩, 母心灵, 崔京福, 等. 颈前路间盘切除植骨融合治疗不稳定Hangman骨折. 中国矫形外科杂志, 2021, 29(14): 1269-1272.
26. ElMiligui Y, Koptan W, Emran I. Transpedicular screw fixation for type Ⅱ Hangman’s fracture: a motion preserving procedure. Eur Spine J, 2010, 19(8): 1299-1305.
27. Chowdhury FH, Haque MR. C₁-C₃ lateral mass screw-rod fixation and fusion for C₂ pathologies and Hangman’s fractures. Asian Spine J, 2014, 8(6): 735-746.
28. Liu Y, Li X, Chen T, et al. Minimally invasive percutaneous new designed transpedicular lag-screw fixation for the management of Hangman fracture using O-arm-based navigation: a clinical study. BMC Musculoskelet Disord, 2023, 24(1): 494. doi: 10.1186/s12891-023-06614-4.
29. Li G, Wang Q, Liu H, et al. Individual surgical strategy using posterior lag screw-rod technique for unstable atypical Hangman’s fracture based on different fracture patterns. World Neurosurg, 2018, 119: e848-e854.
30. Beucler N. Open reduction and C1C3 posterior Harms-Goel fixation for unstable Hangman’s fracture: technical note. Neurosurg Rev, 2024, 47(1): 558. doi: 10.1007/s10143-024-02807-0.
31. Wang G, Jiang D, Wang Q, et al. A novel technique using a pedicle screw and bucking bar for the treatment of hangman’s fracture. Orthop Traumatol Surg Res, 2019, 105(4): 709-711.
32. 马向阳, 邹小宝, 王宾宾, 等. 后路钉棒固定非融合治疗新鲜Ⅱ型和ⅡA型Hangman骨折. 中国矫形外科杂志, 2019, 27(22): 2080-2083.
33. 欧阳建元, 高云, 李广州, 等. 应用有限元模型分析椎弓根拉力螺钉固定枢椎环骨折的稳定性. 中国脊柱脊髓杂志, 2020, 30(1): 62-71.
34. Zhao J, Liu Y, Zhang Q, et al. Robot-assisted percutaneous pars-pedicle screw fixation for treating Hangman’s fracture. J Orthop Surg Res, 2023, 18(1): 271. doi: 10.1186/s13018-023-03765-x.

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