Imaging findings of flexion type of hangman's fracture; an attempt for a more objective evaluation with newly introduced scoring system

Detailed observation of anatomical location and pattern in Hangman's fracture based on computed tomography three-dimensional reconstruction

OBJECTIVE

To observe the precise anatomical location and pattern of the fracture lines in Hangman's fracture.

METHODS

Three-dimensional computed CT images of 210 patients with Hangman's fracture were collected. According to the involvement of anatomical structures, the injuries were classified into facet joint injury and pure bony injury. The C2 ring was also divided into: anterior, middle, and posterior elements. The anatomical structures involvement and fracture patterns were observed.

RESULT

Total 520 anatomical structures injuries were involved in 210 patients Hangman's fractures, including 298 facet joints injuries (57.3%) and 222 bony injuries (42.7%). The most common facet joints injury was superior articular facet injury of C2, and the most common pure bony injury was pediculoisthmic component fracture. The injuries of anterior element (60.6%) were more common than that of middle (20.4%) or posterior (19.0%) element. One injury in anterior element on one side and another injury located in the anterior, middle or posterior element other side was the most common fracture pattern. Injury of middle element on one side with another injury located in the middle or posterior element could be also observed.

CONCLUSION

In Hangman's fractures, fracture lines could occur in any part of C2 ring. Facet joints injuries were more common than pure bony injuries, and the injuries of anterior element were also more common than that of middle or posterior element. The high prevalence of facet joints injuries means that most of Hangman's fractures may be involved with intra-articular injuries.

Mechanically Relevant Anatomy of the Axis Vertebra and Its Relation to Hangman's Fracture: An Illustrated Essay

To describe the biomechanically relevant anatomy of the Axis vertebra and the load transfer patterns within the bone, and on that basis, to postulate its mechanism of injury, a literature review was conducted of the anatomy and biomechanics of Axis fractures. Two hypotheses have been presented: the internal gear hypothesis and the leaf spring hypothesis. Both are based on the trabecular anatomy of the vertebra and its load transmission patterns. The relationship of the Axis with Hangman’s injury is also discussed. According to the leaf spring hypothesis, the C2 pedicle corresponds to the shackle in the assembly and constitutes the weak link. The trabecular architecture of the Axis is such that the primary compression of the trabeculae is directed from the superior facet to the C2–3 endplate, with few trabeculae directed to the inferior facet. Along with the trabecular void in this area, this renders the isthmus vulnerable to trauma. The isthmus of the Axis is biomechanically susceptible to injury due to its unique anatomy in relation to the whole cervical spine and the internal load transmission patterns of the bone. The author suggests that in the flexion type of Hangman’s injury, the C1–2 posterior ligaments are disrupted and need to be addressed.