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Table of Contents    
Year : 2016  |  Volume : 64  |  Issue : 4  |  Page : 811-814

Traumatic bilateral atlantoaxial rotatory subluxation with hangman fracture in an adult

Department of Spine Surgery, First Affiliated Hospital, Sun Yat-Sen University, Guangdong, China

Date of Web Publication5-Jul-2016

Correspondence Address:
Shao-Yu Liu
Department of Spine Surgery, First Affiliated Hospital, Sun Yat-Sen University, Guangdong
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0028-3886.185412

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How to cite this article:
Han K, Cui SB, Wang L, Wei FX, Liu SY. Traumatic bilateral atlantoaxial rotatory subluxation with hangman fracture in an adult. Neurol India 2016;64:811-4

How to cite this URL:
Han K, Cui SB, Wang L, Wei FX, Liu SY. Traumatic bilateral atlantoaxial rotatory subluxation with hangman fracture in an adult. Neurol India [serial online] 2016 [cited 2020 Jun 6];64:811-4. Available from:


Traumatic atlantoaxial rotatory subluxation in adults is very rare, with only 11 reported cases in the English literature.[1],[2] Meanwhile, traumatic C2 spondylolisthesis, also known as Hangman fracture, is a relatively common disease, which may lead to a serious outcome. Herein, we report an extremely rare combination of a Hangman fracture associated with traumatic atlantoaxial subluxation, which, to the authors' knowledge, has been described only once.[2]

A 19-year-old woman was transferred to our department after a road traffic accident. She complained of bilateral neck pain and weakness of the left shoulder and upper arm. On physical examination, the strength of extensor and flexor muscle groups of the arm were IV/V but the power in rest of the muscle goups was V/V. The neurological examination showed hyperesthesia on the left side of the neck and hypoesthesia in the limbs and rest of the body, mainly below the level of manubrium sterni. Computed tomography (CT) scan revealed bilateral atlantoaxial rotatory subluxation along with type III Hangman fracture [Figure 1].
Figure 1: CT scan done immediately after the accident. (Left) Axial CT scan of C1–C2 vertebrae with head in neutral position demonstrating the odontoid asymmetry in relation to the lateral masses of C1 as well as the anterior shift of C1 with the  Atlas More Details-dens interval >5 mm (Fielding type III); (middle and right) CT scans showed the type III Hangman fracture with C2 body fracture

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A skull traction was applied for providing an immediate immobilization and to prevent deterioration of the sagittal alignment. However, there was no improvement in either the symptoms nor in the bony aligment (as seen on lateral radiographs of the cervical spine) even after 2 weeks. After this, a bidirectional cervical traction was used [Figure 2]. The bidirectional traction system is a combination of skull traction and occipital-jaw belt traction. Occipital-jaw belt traction has two traction lines, and the traction weight on each side is equal to half of the skull traction weight. The traction weight should be adjusted according to the patient's reaction. For example, if severe neck pain or vomiting occurs, the traction weight should be reduced. In our patient, after 3 weeks, the symptoms had improved, and the lateral cervical spine radiograph showed reduction of the C2 spondylolisthesis [Figure 3]. A halo crown and vest was used thereafter for approximately 2 months. The CT scan showed reduction of the atlanto-axial subluxation and C2 spondylolisthesis, and the union of C2 vertebral fracture was observed on a 3-month follow-up radiological imaging [Figure 4]. The cervical range of motion (ROM) was 45° in flexion, 30° in extension, 15° on left and right lateral bending, and 40° on the left and right rotatory activity. The cervical rotatory activity of the patient is depicted in [Figure 5]. Alignment remained satisfactory and no surgery was needed.
Figure 2: Bidirectional cervical traction system. Blue line shows the skull traction, and the red line shows the occipital-jaw belt traction system

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Figure 3: Lateral cervical spine radiograph after the application of bidirectional cervical traction for 3 weeks. It showed reduction of C2 spondylolisthesis

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Figure 4: CT scans at a 3-month follow-up. (Left) Reduction of subluxation; (middle) union of C2 vertebral fracture; (right) reduction of C2 spondylolisthesis

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Figure 5: Radiographs in hyperextension and hyperflexion at a 3-month follow-up showed a normal cervical range of motion

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Bilateral traumatic atlantoaxial rotatory subluxation with Hangman fracture in adults is a very rare combination. It may result from traffic collisions, falls, or sports injuries. Sudden violent force acting on the cervical spine in the axial plane causing excessive flexion is the main mechanism of injury. A CT scan is very helpful in guiding the operative management, as it can provide information regarding the severity of the atlantoaxial subluxation and C2 spondylolisthesis, and also help in ascertaining the location of the site of pars fracture. Management of the simultaneous occurrence of both traumatic atlantoaxial subluxation and type III Hangman fracture is controversial. Institution of an early skull traction is a widely accepted form of conservative treatment that was widely prevalent until recently.[3],[4],[5] However, this form of skull traction has not been found to be very effective in many cases, and therefore, a bidirectional cervical traction was invented as a modified traction system by Doctor Jingfa Liu. It is composed of a skull traction in the axial direction and a cervical traction in the vertical direction. This special traction system is much better than the application of only a skull traction, as it can provide persistent axial and vertical force to obtain a closed reduction of both the C2 spondylolisthesis and C1-2 subluxation. In this report, the patient had a rare complex injury of pars and vertebral fracture, C2 spondylolisthesis, and atlantoaxial rotatory subluxation. She was an appropriate patient for a bidirectional cervical traction. Following the application of traction, reduction was achieved at approximately 3 weeks after the initial cervical traction, and the cervical alignment was maintained and remained normal until the last follow-up after three months. However, for patients with an unstable Hangman fracture (where skull traction is contraindicated), or in those patients who do not achieve closed reduction of their malaligned vertebrae, surgical intervention should be the appropriate option. This extremely rare fracture complex, traumatic bilateral atlantoaxial subluxation with Hangman fracture, has only been reported once prior to this study. None of currently prevelant management guidelines can be applied to this special category of fracture complex. Ultimately, reduction of the subluxation and spondylolisthesis are the most important therapeutic goals. The bidirectional cervical traction is recommended as the initial mode of management, but surgical intervention may occasionally be needed. The latter may be needed only if no improvement is observed after 3 to 4 weeks of bidirectional traction, or due to the recurrence of redislocation after a total reduction of the fracture-dislocation had initially been achieved.


The authors wish to thank the patient for supporting our work.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Venkatesan M, Bhatt R, Newey ML. Traumatic atlantoaxial rotatory subluxation (TAARS) in adults: A report of two cases and literature review. Injury 2012;43:1212-5.  Back to cited text no. 1
Chaudhary SB, Martinez M, Shah NP, Vives MJ. Traumatic atlantoaxial dislocation with hangman fracture. Spine J 2015;15:e15-8.  Back to cited text no. 2
Vaccaro AR, Madigan L, Bauerle WB, Blescia A, Cotler JM. Early halo immobilization of displaced traumatic spondylolisthesis of the axis. Spine (Phila Pa 1976) 2002;27:2229-33.  Back to cited text no. 3
Jones RN. Rotatory dislocation of both atlanto-axial joints. J Bone Joint Surg Br 1984;66:6-7.  Back to cited text no. 4
Wise JJ, Cheney R, Fischgrund J. Traumatic bilateral rotatory dislocation of the atlanto-axial joints: A case report and review of the literature. J Spinal Disord 1997;10:451-3.  Back to cited text no. 5


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]


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