Daily Radiology Case

Explanation

Hangman fractures are traumatic spondylolistheses of C2 resulting from hyperextension and axial loading forces — classically associated with high-impact mechanisms including motor vehicle collisions and falls. The injury produces bilateral fractures through the pars interarticularis of C2, with the degree of C2–C3 anterolisthesis and disc disruption determining stability. Despite the dramatic radiographic appearance, neurological deficits are often absent because the fracture effectively decompresses the spinal canal at this level. Management ranges from external immobilization with a halo brace for stable patterns to posterior surgical fixation for unstable injuries with significant translation, as in this case. Vertebral artery injury must be actively sought given the proximity of the transverse foramina to the fracture lines, and Biffl grading guides anticoagulation versus conservative management decisions.

Source: Hacking C, Hangman fracture and bilateral vertebral blunt cervebrovascular injury - Biffl grade 1 and 4. Case study, Radiopaedia.org (Accessed on 12 Mar 2026) https://doi.org/10.53347/rID-223696

Hints

• A 55-year-old male is brought in by ambulance following a fall down a flight of stairs while intoxicated, with neck pain and inability to move his head without significant discomfort.
• He has no focal neurological deficits on initial assessment, though midline cervical tenderness is elicited on palpation at the level of the upper cervical spine. CT cervical spine with CTA is urgently obtained.
• CT reveals a comminuted fracture of C2 through the bilateral pars interarticularis, with extension into the left transverse process and posterior arch bilaterally. The odontoid process and C2 vertebral body are intact.
• There is moderate anterolisthesis of C2 on C3 measuring 6 mm with subluxation of the left C2/3 facet joint. Hyperattenuating epidural material extending from C1–C3 with a maximum thickness of 10 mm causes moderate spinal canal stenosis at C2/3, consistent with an anterior epidural hematoma.
• CTA reveals complete loss of opacification of the right vertebral artery at C4 with only thready retrograde filling above this level, consistent with a Biffl grade 4 injury. An additional filling defect of the left vertebral artery at C3 cannot exclude a focal intimal injury.
• This is an unstable upper cervical injury pattern caused by hyperextension and axial loading, producing distraction through a predictable bilateral osseous landmark at C2. The associated vertebral artery injuries were managed conservatively, though subsequent MRI confirmed right cerebellar infarcts from the vascular compromise.