Hangman Pdf

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ObjectivesExplain the causes of a hangman's fracture.Describe the presentation of a patient with a hangman's fracture.Summarize the treatment options available for hangman's fractures.Review interprofessional team strategies for enhancing coordination and communication to improve the management of hangman's fractures and optimize patient outcomes.Access free multiple choice questions on this topic.

It is vitally important to keep in mind the unique anatomy of the atlas-axis complex when treating their associated injuries. Unlike the subaxial cervical spine, the C1 to C2 complex does not contain an intervertebral disc; there are unique ligaments that allow for support of the cranium and provide the majority of cervical rotation. There is also a close relationship between the transverse foramen, which carries the vertebral artery through the cervical spine, with the C2 pedicle/pars interarticularis, which may slightly weaken this area allowing for a fracture to occur.

Angulation in this system is measured as the angle between the inferior endplate of C2 and C3. Anterior subluxation of C2 on C3 greater than 3 mm is a marker for C2 to C3 intervertebral disc disruption. It is important to recognize that this grading system does not apply to the pediatric population.[8]

Two factors are considered for the Francis Grading system: angulation and displacement. Angulation is measured by the degree of anterior angulation off the posterior vertebral line drawn straight from the C3 vertebral body. The magnitude of anterolisthesis that measures displacement is graded as either greater than or less than 3.5 mm.[9]

It is important to recognize that outside of the obvious motor vehicle collisions and high-impact falls, low-energy and blunt trauma, especially in the elderly population, can induce significant unstable injury. History should also entertain fracture risk factors such as osteoporosis, metastatic burden, or vitamin D deficiencies. Physical exam findings include pain with palpation in the posterior portion of the neck, radiculopathy, myelopathy, and possible posterior fossa findings secondary to vertebral artery injury. A strict neurologic exam including cranial nerves, sensory, motor, and rectal tone is mandatory.

Evaluation with X-rays will provide limited but important information. Care must be taken to ensure proper radiographic imaging creates a picture from the occiput to the C7 through the T1 disc space. This is essential in reviewing cervical spine trauma. Lateral, anteroposterior (AP), and open-mouth odontoid views are necessary. Approximately 93% of cervical spine injuries appear with combined, lateral, AP, and odontoid view radiographs. X-rays are an excellent modality for determining alignment during the immediate injury, post-operative period, as well as long-term follow-up.

Computed tomography is the mainstay of radio imaging.[10] CT scan is the most important modality for determining fracture etiology and ruling out an injury regarding a C2 fracture. A CT scan is warranted even if plain films are negative and clinical suspicion is high. CT scan does not directly evaluate the spinal cord, soft tissue, or ligamentous construct. It is important to recognize the importance that complete imaging will require dedicated thin-cut CT reconstructions. Non-contrast CT scan is adequate for evaluating the bony anatomy for fracture. This can be coupled with a CT angiogram (see below) for evaluation of the vascular anatomy.

Evaluation with MRI is essential for analyzing the ligamentous construct, disc space, spinal cord, nerve roots, and other soft tissue injuries. MRI is also useful for determining the acute nature of the fracture when this is otherwise unknown. This is done via non-contrasted imaging. T2 signal hyperintensities and STIR changes within the dens, ligaments, or soft tissue can illustrate a critical component. MRI is less dangerous than flexion-extension cervical injury.

The Effendi, Levine, and Francis classifications are solely based on static radiographs.[1] The management algorithm however is also dependent upon the integrity of the C2/3 disc, the anterior and the posterior longitudinal ligaments.[10] The MRI is an important armamentarium to connote concurrent instability which is determined by:

Non-operative treatment is advocated for extension type Levine-Edwards type I and type II hangman's fracture whereas flexion type Levine type IIa and type III fractures invariably require surgical intervention.[2][4][10][21]

A systematic review has shown that conservative treatment failed sequentially for Levine-Edward's type I (fusion rate of almost 100%) to III fractures (fusion rate of only 30%).[1] This approach is also time-consuming and harbingers high-risk risks of nonunion. In one study comprising 625 patients who were managed with halo-vest immobilization (HVI), cohorts aged>80 had higher risks of complications, mortality, and readmissions. [22] Another similar study comprising 189 patients with 71.1% sustaining C2 fractures and managed with halos showed a mortality of 8.3%, a failure rate of 10.7%, and a complication rate of 46.3%.[23]

C2 to C3 anterior cervical discectomy and fusion may be used with anterior plating to stabilize the C2 to C3 vertebral bodies. The main benefit of the anterior approach is preserving the C1 motion, which drastically decreases the morbidity compared to posterior fixation.[9]

Successful repair of the fractured bone(s) can lead to excellent recoveries with a good long-term prognosis. Some cases require fusion of the C2 and C3 vertebrae. Researchers studied fusion surgery performed via the posterior approach; this method demonstrated excellent results in 3-part fractures of the axis.[41]

Patients need to understand that most cases will not require surgery. They may need to wear a neck collar to limit movement to promote healing and prevent further injury. More commonly, they will require halo immobilization.

Less commonly, the patient will require surgery. All aspects of the procedure need to be explained to the patient, and they should receive reassurance regarding the high degree of successful recovery following surgery, as cited above. They should also be given realistic expectations regarding recovery time, lasting as long as a year.

Fractures of the spine are best managed by an interprofessional team that includes clinicians (including PAs and NPs), specialists (orthopedists, neurologists), orthopedic and neurology nurses, and therapists. Physical therapy may play a role in rehabilitative recovery in surgical and non-surgical cases. This interprofessional approach will result in improved patient outcomes. [Level 5]

Clinicians should be aware that imaging is critical for the diagnosis of a hangman's fracture. CT scan is the most important modality for determining fracture etiology and ruling out an injury regarding a C2 fracture. Even if plain films are negative and clinical suspicion is high, a CT scan is warranted. CT scan does not directly evaluate the spinal cord, soft tissue, or ligamentous construct. It is important to recognize the importance that complete imaging will require dedicated thin-cut CT reconstructions. Non-contrast CT scan is adequate for evaluating the bony anatomy for fracture. This can be coupled with a CT angiogram for evaluation of the vascular anatomy. A missed injury can prove fatal.

Thank you very much, I should have asked a loooong time ago, it would have saved me a lot of time. Yes, it would be great to understand how she put it together as for my task I have about 10 words which I have to build into a hangman game....

Jean Cololre, a drummer in the colonial troops at Qubec, was imprisoned for duelling in 1751. In the cell next to his was Franoise Laurent, who had been sentenced to hang for stealing. Except for letters of pardon, the only way at the time for someone under sentence of death to escape hanging was, for a man, to become a hangman, or, for a woman, to marry one. Franoise persuaded Cololre to apply for the vacant (and undesirable) post of executioner, and also to marry her.

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Background: Hangman's fractures account for 15% to 20% of all cervical spine fractures. The grading system developed by Effendi and modified by Levine and Edwards is generally used as the basis for management decisions. Nonetheless, the optimal management remains controversial. The objective of this study was to describe the treatments used in France in patients with hangman's fractures. The complications and healing rates were analysed according to the fracture type and treatment used.

Material and methods: A prospective, multi-centre, observational study was conducted under the aegis of the French Society for Spine Surgery (SocitFranaisedeChirurgieRachidienne, SFCR). Patients were included if they had computed tomography (CT) evidence of hangman's fracture. Follow-up data were collected prospectively. Fracture healing was assessed on CT scans obtained 3 and 12 months after the injury. The type of treatment and complications were recorded routinely.

Conclusion: Hangman's fracture is associated with low rates of mortality and neurological complications. Non-operative treatment is appropriate in Type I hangman's fracture, with a 100% healing rate in our study. Types II and III are characterised by damage to the ligaments and discs requiring either anterior C2-C3 fusion or posterior C1-C3 screw fixation.

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