Study design: A case is reported in which late displacement of a "hangman's fracture" was managed by transoral C2-C3 fusion by using bicortical iliac crest graft and a titanium cervical locking plate.
Objectives: To review the management of unstable fractures of the axis and to study other reports of transoral instrumentation of the cervical spine.
Summary of background data: Undisplaced fractures of the axis are considered to be stable injuries. Although late displacement is unusual, it can lead to fracture nonunion with persisting instability and spinal cord dysfunction. In this situation, an anterior fusion of the second and third cervical vertebrae is preferred to a posterior fusion from the atlas to the third cervical vertebra, which would abolish lateral rotation between C1 and C2.
Methods: The literature on hangman's fractures was reviewed. Clinical and radiographic details of a case of C2 instability were recorded, and the particular problems posed by late displacement were considered.
Results: There are no other reports of transoral instrumentation of the cervical spine. A sound fusion of C2-C3 was obtained without infection or other complications. Good neck movement returned by 6 months after surgery.
Conclusion: Undisplaced fractures of the axis are not always stable. The transoral route allows good access for stabilization of displaced hangman's fractures. In special circumstances, a locking plate may prove useful in securing the bone graft. The cervical spine locking plate can be inserted transorally with no complications and by using standard instrumentation.