Monday, August 15, 2005

Our local EMS has a policy that leads to almost all MVC patients being placed in full spinal package. We try to see them as soon as possible to get them off the boards. Our nurses reflexively order C-spine x-rays, although, with most of these, we can cancel the x-rays after clearing the patient clinically.

I am an advocate of doing something all the way or not doing it. When a patient presents to triage with a complaint of neck pain and an appropriate mechanism, such as a fall or MVC and you suspect a c-spine injury, you should fully protect the patient. I have worked in ER's where the triage nurse would just put on a soft collar. Even just placing a hard collar is dangerous. I believe that you are admitting that you suspected a c-spine injury without adequately protecting the patient from the injury. If you don't do anything, at least you could argue later that you felt the likelihood of a significant injury was so low that no protection was required.

Anyway, John, a 56 year-old man, presented about 1700 on a Saturday afternoon. He was complaining of a sore neck and a headache. He had wrecked his truck about 12 hours earlier and walked home, a distance of approximately 2 miles. His father reported that he had taken a "hydro" when he got home and then slept until just prior to presentation.

Our triage nurse alertly called for a collar and spine board. My colleague evaluated him and found a completely normal appearing man, neurologically intact. John was complaining of a sore neck with a good mechanism of injury, so my colleague ordered c-spine films. Here is what we saw:



Up close:



A classic "Hangman's Fracture." Of course, it isn't classic that this man was up and about for 12 hours with this fracture. I commend an alert triage nurse for recognizing this and not blowing this off because of the 12 hour delay in presentation.

We transferred this guy to our local referral Level 1 trauma center and he has done well. He was incredibly lucky.

Why, you ask, is it called a "Hangman's fracture?" Well, I can tell you.

Hanging has been a method of execution for centuries. Initially, the executioner would simply tie a rope around the victims neck and raise them off the ground, resulting in strangulation. The use of the hangman's noose, with it's characteristic knot



will actually break the neck, resulting in a much quicker execution, to the relief of those required to witness. The resulting fracture is a C2 pedicle fracture, as this patient had.