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. 

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.


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