What is Hangman’s Fracture?

Patient Presentation
A 15-year-old male came to the emergency room after attempting to commit suicide by hanging. He had had an argument with friends earlier in the day and then another with his parents in the evening. He was found unconscious but breathing by his parents. The pertinent physical exam showed an irregular breathing pattern at 38, heart rate of 62 and blood pressure of 150/94 with a Glascow Coma Scale of 4 with no eye opening or verbal utterances with abnormal flexion and inconsistent withdrawal to pain. Neurological examination showed pupils that were 1-2 mm and sluggish, and a positive gag. A cervical collar was in place.

The radiologic evaluation of computer tomography of the brain and cervical spine showed fractures in C2. The diagnosis of hangman’s fracture of the C2cervical vertebra with anoxic brain injury. He was intubated, hyperventilated, and had fluids monitored closely. Mannitol, phenobarbital and appropriate sedation and analgesia were given. A stiff cervical collar was put into place. On day 3 he was extubated and slowly recovered. He was transferred to the general floor and received appropriate psychiatric intervention. He was discharged home wearing the collar until his neurosurgical followup appointment. Neuropsychiatric testing and psychiatric treatment were also followed up as an outpatient.

Case Image
Figure 95 -Contiguous axial images from a CT scan of the cervical spine through the level of the C2 vertebral body demonstrating the Hangman’s fracture. The image on the left shows the fracture extending through the left C2 facet. The image on the right shows the fracture extending through the right transverse process and involving the right transverse foramen which raised concern for possible right vertebral artery injury which was ruled out on a subsequent CT angiogram of the neck.
 
Case Image
Figure 96 – Sagittal two dimensional reconstructions from a CT scan from the left, center and right of the cervical spine show the fractures through the left C2 facet (left image), right transverse process (right image) and anterior inferior aspect of the C2 vertebral body (center image). Thus all 3 columns of the cervical spine are fractured. 

Discussion
In the United States in 2005, for children and teens ages 5-19 years, 14% of deaths were from suicides. It was the third most common cause of death for both 10-14 year olds (1. unintentional injury, 2. malignant neoplasms) and 15-19 year olds (1. unintentional injuries, 2. homicide) and the actual number of deaths is significantly higher in the 15-19 years old (N=1613) than the 10-14 year olds (N=270). Age adjusted death rates show consistent trends over the past 10 years for children and teens

Data from Europe shows suicide is still the second leading cause of death in 15-29 year olds, but has declined in absolute numbers over the past 2 decades. A study of Swiss children and teens from 1998-2007 found that there were 0 suicides in 0-12 year olds and 333 in 13-19 year old out of a total of 12,226 suicides. Hanging was the second most common cause of suicide for males (1. firearms) and third for females (1. railway injuries, 2. jumping from height.).

Suicide ideation, plans and even attempts are fairly common in children and adults. While adults appear to have more mental illness as one aspect of their suicidal behavior, children and adolescents appears to have impulsiveness combined with short term triggers such as relationship conflicts to be part of the underlying cause. “Many young suicide attempters report that they spent only minutes between the decision and the actual attempt indicating a high degree of impulsiveness.” Therefore restricting access to more violent methods such as firearms and jumping are important.

Learning Point
The term “hangman’s fracture” was first coined in 1965. Hangman’s fracture occurs in hanging, motor vehicle accidents (i.e. improper seat belt placement) and diving accidents. Since 1981, classification systems have developed which describe the relationship between C2 and C-3, basically fracture(s) of C-2 with or without anterior or posterior displacement relative to C-3. Treatment is usually successful external immobilization and traction.

The earliest account of execution by hanging was between 800-600 BCE in Homer’s epic poem the Odyssey. Hanging became a popular execution method in Europe, after German tribes invaded extensive parts of Europe. Judicial hanging has been used for men, women and children as capital punishment for crimes including treason, murder, piracy and robbery. Today, judicial hanging is only sanctioned in a few countries in the world including the United States, where it is an option in two states (i.e. New Hampshire, Washington)

In hanging, death itself is caused by one or more reasons including asphyxia, hemorrhage of the head and neck vascular structures and fracture of the cervical vertebral column. The biomechanics are affected by the form and placement of the noose material and the force such as the victim’s weight and length of the drop.

Questions for Further Discussion
1. What is the Werther effect?
2. List some suicide prevention techniques?
3. What is Cushing’s Triad?
4. What are the current standards for acute head injury treatment? To Learn More see http://www.pediatriceducation.org/2007/11/05/what-are-the-current-recommendations-for-treatment-of-acute-traumatic-head-injury/

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for these topics: Coma and Suicide.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

Li XF, Dai LY, Lu H, Chen XD. A systematic review of the management of hangman’s fractures. Eur Spine J. 2006 Mar;15(3):257-69.

Division of Adolescent School Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control. Available from the Internet at http://www.cdc.gov/HealthyYouth/injury/pdf/facts.pdf (rev. 11/2008, cited 1/30/2012).

Rayes M, Mittal M, Rengachary SS, Mittal S. Hangman’s fracture: a historical and biomechanical perspective. J Neurosurg Spine. 2011 Feb;14(2):198-208.

Hepp U, Stulz N, Unger-Koppel J, Ajdacic-Gross V. Methods of suicide used by children and adolescents. Eur Child Adolesc Psychiatry. 2011 Dec 1.

Adolescent Health. Centers for Disease Control. Available from the Internet at http://www.cdc.gov/nchs/fastats/adolescent_health.htm (rev. 1/27/2012, cited 1/30/2012).

ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    7. All medical and invasive procedures considered essential for the area of practice are competently performed.
    8. Health care services aimed at preventing health problems or maintaining health are provided.
    9. Patient-focused care is provided by working with health care professionals, including those from other disciplines.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Practice Based Learning and Improvement
    13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.

  • Systems Based Practice
    25. Quality patient care and assisting patients in dealing with system complexities is advocated.

    Author

    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa Children’s Hospital

  • What Does Bart's Hemoglobin on a Neonatal Screening Test Mean?

    Patient Presentation
    A 2-week-old female came to clinic for well-child care. She was a full-term infant who was breastfeeding and had regained her birth weight. She had no jaundice and appeared to have no problems with hearing or vision. Her parents had family support and were doing well other than being tired. Her neonatal screen had been positive for a Bart’s hemoglobin and she had a complete blood count (CBC) done at 1 week was normal for her age and a confirmatory hemoglobin electrophoresis was sent. The past medical history showed no pre- or post-natal problems. The family history was positive for Hepatitis B in the father. There was mild anemia in the family but more information was not available. The family was from Southeast Asia. The review of systems was negative.

    The pertinent physical exam showed an alert infant with weight of 3834 g (50-75%, up 76g from birth weight), head circumference of 35.5 cm (50-75%) and length of 53 cm (75%). Her examination was negative. The diagnosis of a normal infant with probable alpha thalassemia was made. The state neonatal screening program had contacted the family and she already had an appointment with a hematologist. Some basic information about alpha thalassemia had been given to the family and they felt comfortable at this time with this information, especially since her CBC had been normal.

    Discussion
    Hemoglobin is important as it is the major oxygen carrier to tissues. It is comprised of a protoporphyrin unit, elemental iron and 4 globin chains together. The globin chains are alpha (chromosome 16), beta, gamma or delta proteins (all on chromosome 11) The predominant hemoglobin is Hemoglobin A (adult) with 2 alpha and 2 beta globin chains. Minor hemoglobins are Hemoglobin F (fetal) with 2 alpha and 2 gamma globin chain and Hemoglobin A2 with 2 alpha and 2 delta globin chain. The beta gene produces 2 proteins and there can be variations of the beta gene include sickle cell, C and E.

    There is a very tightly controlled ratio of production of the chains where alpha chains are matched basically 1 for 1 to the other chains. When this ratio is disrupted then disease can occurs. Thalassemia is one of the most common single-gene disorders, and often occurs in populations in the malaria belt of the world as thalassemias provides some genetic protection against this infectious disease. It is possible for two genetic mutations to occur simultaneously and to have abnormalities of both alpha and beta globin chains such as an alpha thalassemia trait and sickle cell disease.

    It is estimated that alpha thalassemia is carried in more than 270 million individuals. About 300,000-400,000 severely affected infants are born every year, mainly in Asia, India, or the Middle East.

    Healthy individuals have 4 alpha-globin genes (α α/ α α)
    Alpha thalassemia happens when there is an absent or reduced amount of the alpha globin chains produced. Up to 4 genes can be missing and result in different disease patterns.

    • 1 gene missing (- α / α α)
      • Silent carrier
      • Can make Hemoglobin A normally therefore individuals usually have no clinical problems and their complete blood count is usually normal or has mild decreases in the RBC mean corpuscular volume (MCV) and mean corpuscular hemoglobin (MCH) can be seen.
      • Prognosis is excellent.

    • 2 gene missing (- α / – α) or (- – / α α)
      • Alpha thalassemia trait
      • (- α / – α) – this is the trans isomer and is common in African Americans. A trans isomer combined with another trans isomer can only produce a patient with alpha thalassemia trait. (- α) + (- α) = (- α / – α)
      • (- – / α α) is the cis isomer is more common in people of Southeast Asian, Southern Chinese, Mediterranean and Middle Eastern descent. The cis isomer is of more concern because it can lead to a 3 or 4 gene deletion if combined with another trans or cis deletion which causes severe disease or death (see below). (- -) + (- α) = (- – / – α) or (- -) + (- -) = (- – / – -)
      • Can make Hemoglobin A to a great extent therefore affected individuals usually have no clinical problems but often will have changes in their complete blood count including mild anemia, decreased RBC, MCV and MCH.
      • Prognosis is excellent.

    • 3 gene missing (- – / – α)
      • Hemoglobin H disease
      • Cannot make as much Hemoglobin A, therefore there is an increase in tetramers of beta hemoglobin (also known as Hemoglobin H). Hemoglobin H has a high binding capacity for oxygen, so although it can release oxygen, it doesn’t release it efficiently to the tissues. Patients have moderate to severe anemia, low MCH and MCH and high reticulocyte counts.
      • Prognosis depends on the type of hemoglobin made which varies in different populations. Complications can occur including marrow hyperplasia, aplastic or hypoplastic crises, hepatosplenomegaly, skeletal abnormalities, osteopenia, fractures, malignancies and transfusion related problems.
      • Close followup is needed.

    • 4 gene missing (- – / – -)
      • Alpha Thalassemia Major
      • Cannot make any Hemoglobin A and produces Bart’s hemoglobin or tetramers of gamma hemoglobin chains
      • Causes hydrops fetalis and is incompatible with life because of inability to carry oxygen to tissues leading to high output congestive heart failure, hepatosplenomegaly, and end organ failure. Demise occurs in utero or short after birth usually.

    Learning Point
    Bart’s hemoglobin (tetramers of gamma hemoglobin chains) are produced in the neonatal period.
    It can occur in silent carriers (1-2% of total hemoglobin), trait (5-15% of total hemoglobin) or Hemoglobin H (20-40% of total hemoglobin). Neonatal screening with elevated Bart’s hemoglobin can indicate probable alpha thalassemia but is not perfect. Confirmatory hemoglobin electrophoresis testing is necessary. Prenatal testing is available for at risk families usually by polymerase chain reaction testing.

    Questions for Further Discussion
    1. What is Cooley’s anemia?
    2. What is the current role of bone marrow transplantation for thalassemia and sickle cell anemia?

    Related Cases

    To Learn More
    To view pediatric review articles on this topic from the past year check PubMed.

    Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

    Information prescriptions for patients can be found at MedlinePlus for these topics: Thalassemia and Newborn Screening.

    To view current news articles on this topic check Google News.

    To view images related to this topic check Google Images.

    Kaye CI. Newborn Screening Fact Sheets. Pediatrics 2006;118;e934.

    Cheerva AC, Bleibel SA, Jones-Crawford JL. Alpha Thalassemia. Medscape.
    Available from the Internet at http://emedicine.medscape.com/article/955496-overview (rev. 10/5/2011, cited 1/17/12).

    Alpha Thalassemia Trait. St. Jude Children’s Research Hospital.
    Available from the Internet at http://www.stjude.org/stjude/v/index.jsp?vgnextoid=d966885309c6f110VgnVCM1000001e0215acRCRD&vgnextchannel=17bfdb6324d6f110VgnVCM1000001e0215acRCRD
    (rev. 2012, cited 1/17/2012).

    ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    5. Patients and their families are counseled and educated.
    7. All medical and invasive procedures considered essential for the area of practice are competently performed.
    8. Health care services aimed at preventing health problems or maintaining health are provided.
    9. Patient-focused care is provided by working with health care professionals, including those from other disciplines.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Practice Based Learning and Improvement
    13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.

  • Systems Based Practice
    23. Differing types of medical practice and delivery systems including methods of controlling health care costs and allocating resources are known.
    25. Quality patient care and assisting patients in dealing with system complexities is advocated.
    26. Partnering with health care managers and health care providers to assess, coordinate, and improve health care and how these activities can affect system performance are known.

    Author

    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa Children’s Hospital

  • What Causes Jaw Pain?

    Patient Presentation
    A 15-year-old female came to clinic with a 4 day history of increasing jaw pain and trismus. She described it as a dull pain around the temporomandibular joint (TMJ) that would awaken her from sleep occasionally and was more painful in the morning when awakening. The pain improved with ibuprofen use. She denied mouth lesions, tooth pain, tooth sensitivity, ear pain, difficulty swallowing, fever, or upper respiratory problems. She denied trauma and any clicking in the jaw. The past medical history was non-contributory.

    The pertinent physical exam showed a healthy female with normal vital signs and growth parameters. HEENT showed some decreased range of motion in the TMJ. She had no obvious oral lesions or masses. She denied pain when tapping on individual teeth nor had obvious caries. Palpation of the major salivary glands was negative. She had shoddy adenopathy at the base of the mandible and her ears were normal. The diagnosis of new onset TMJ pain secondary to an unknown cause was made. The patient was referred to her own dentist who made a panoramic radiograph which found no abnormalities, but did find some increased dental wear. An interocclusal splint was fabricated, which the patient was to wear nightly. It was also recommended that patient take naproxen at regular intervals to decrease joint inflammation and pain. At followup 1 month later, she stated that her acute pain resolved within about 1 week.

    Discussion
    Although temporomandibular joint dysfunction is not a common complaint in children and adolescents it does occur and is an important part of the larger differential diagnosis of jaw, face, head, ear and neck pain. Medical physicians can easily forget that this is a joint like all other joints in the body and is subject to general joint problems including overuse and arthritis. Trauma after an accident is easy to identify but other problems in specific populations needs to be considered such as hemarthrosis in a patient with a bleeding disorder. Any patient who is being evaluated for possible juvenile arthritis or similar rheumatologic problems should also have the TMJ evaluated.

    While TMJ problems are often managed by dental professionals and otolaryngologists the physical examination of the dental structures is important for all health care providers to remember. The physical examination should include evaluation of the TMJ by placing fingertips anterior to the tragus and palpating the joint as the patient opens and closes. Swelling, tenderness, decreased range of motion, clicking, popping and deviations should be noticed. Sounds from the joint may also be heard. The gums and soft tissues should be noted for swelling, bleeding, retraction, and discoloration. The teeth should be noted if they are missing, loose, discolored, or carious. Tapping on individual teeth and/or areas of the gums and other soft structures may help to pinpoint the affected area. Palpation of the major salivary glands and notation of any fluid that can be milked from Stetson’s duct should be noted.

    Learning Point
    Jaw pain like TMJ pain has a large differential diagnosis. The differential diagnosis of jaw pain includes:

    • Muscular (most common cause of TMJ pain)
      • Parafunctional habits
        • Daytime including gum chewing, resting telephones between shoulder and
          ear

        • Nighttime including bruxism, clenching
    • Odontogenic
      • Abscess
      • Caries
      • Orthodontic appliances
      • Temporomandibular (TMJ) joint abnormalities including TMJ syndrome, inflammatory or infectious arthritis
      • Salivary dysfunction/stone
    • Infectious
      • Clostridium botulinum
      • Mumps
      • Osteomyelitis
      • West Nile virus
    • Neurological
      • Otalgia
      • Trigeminal nerve abnormalities
    • Tumor
      • Bone – carcinoma, fibrous dysplasia, Langerhans cell histiocytosis, osteoblastoma, osteoid osteoma, sarcoma, , metastatic disease,
      • Other – arteriovenous malformation, lymphoma, rhabdomyosarcoma
    • Other
      • Drug reaction – sumitriptan, zolmitriptan, epopostenol, nicotine, vinoelbine
      • Lymphadenopathy
      • Trauma

    A table with a differential diagnosis of jaw lesions by their radiographic appearance can be found in To Learn More below.

    Questions for Further Discussion
    1. What are indications for referral for jaw pain to a dentist?
    2. What is the role of a primary care provider in dental health?

    Related Cases

      Symptom/Presentation: Pain

    To Learn More
    To view pediatric review articles on this topic from the past year check PubMed.

    Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

    Information prescriptions for patients can be found at MedlinePlus for these topics: Temporomandibular Joint Dysfunction and Jaw Injuries and Disorders.

    To view current news articles on this topic check Google News.

    To view images related to this topic check Google Images.

    Gupta M, Kaste SC, Hopkins KP. Radiologic appearance of primary jaw lesions in children. Pediatr Radiol. 2002 Mar;32(3):153-68.

    West Nile Virus Activity – United States, July 31 – August 7, 2002, and Louisiana, January 1 -August 7, 2002. MMWR. 51:31;August 9, 2002 .

    Sommer OJ, Aigner F, Rudisch A, et. al.. Cross-sectional and functional imaging of the temporomandibular joint: radiology, pathology, and basic biomechanics of the jaw. Radiographics. 2003 Nov-Dec;23(6):e14. Epub 2003 Aug 14.

    Toscano P, Defabianis P. Clinical evaluation of temporomandibular disorders in children and adolescents: a review of the literature. Eur J Paediatr Dent. 2009 Dec;10(4):188-92.

    ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    7. All medical and invasive procedures considered essential for the area of practice are competently performed.
    8. Health care services aimed at preventing health problems or maintaining health are provided.
    9. Patient-focused care is provided by working with health care professionals, including those from other disciplines.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Practice Based Learning and Improvement
    13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.

  • Systems Based Practice
    23. Differing types of medical practice and delivery systems including methods of controlling health care costs and allocating resources are known.
    24. Cost-effective health care and resource allocation that does not compromise quality of care is practiced.

    Author

    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa Children’s Hospital
    Sarah Swenson, DDS
    Pediatric Dental Resident, University of Iowa College of Dentistry