Hang ’em high

The film Hang ’Em High debuted in 1968 with Clint Eastwood starring as “Jed Cooper,” an innocent man who survives a lynching. Left for dead hanging from a tree, a stranger cuts him down and rescues him. The movie depicts a fictitious judge who mirrors the real-life legend Isaac Charles Parker, known as the “hanging judge” of the American Old West. Similar to Jed’s survival of a hanging, we also see survivors of hangman’s fractures that are typically a result of a motor vehicle crash.

Hanging was introduced as an execution technique during the invasion of the Roman Empire and has remained unchanged for the last 15 centuries.* Modifications were made to add a trap door, a standardized length of the drop, and positioning of the knot in a sub-mental location rather than a sub-aural location in an effort to make it a more humane and instantaneous process. Prior to these modifications, several unsuccessful hangings or protracted hangings that lasted until asphyxiation were reported, which explains why judges started sentencing prisoners “to be hanged from the neck until dead.”

The exact mechanism of those cases of instantaneous death was unknown until 1913, when anatomist and anthropologist Frederic Wood Jones published his work on the meticulous examinations of five cervical spines from judicial hangings, in which the knots all were placed in a sub-mental position.* The common finding was a fracture of the posterior arch of the axis caused by a violent jerk from the sub-mental knot throwing the victim’s head backwards (hyperextension) with longitudinal distraction, fracturing the axis and causing severe injury to the spinal cord, resulting in instantaneous death.

In 1965, neurosurgeon Richard C. Schneider, MD, and colleagues presented several cases of cervical fractures following car crashes.* The anatomist Gilbert Hamilton commented on the similarities between these traffic crashes and judicial hangings, and thus Dr. Schneider coined the term “hangman’s fracture.” His group extensively studied this type of fracture and noted that the third cervical vertebra forms a fixed point between the cranio-cervical junction and the lower cervical spine. Forces acting downward through the skull are distributed in three distinct vectors, and all three pass through the weakest point of the neural arch of the second cervical vertebra (axis). This occurrence leads to a fracture of the posterior elements of the second cervical vertebra, known as traumatic spondylolisthesis of the axis, or the hangman’s fracture. The injury occurs in some of the judicial hangings, as noted earlier, and when the chin of an unrestrained occupant in a motor vehicle crash strikes against the windshield or dashboard, causing a violent hyperextension and compression force. Without the longitudinal distraction of a judicial hanging, the hangman’s fractures sustained in a motor vehicle collision may not be lethal. Since the term was coined initially, there have been several classification schemes based upon anatomic pattern of injury. The latest and most widely used scheme describes five variants (I, Ia, II, IIa, III) of hangman’s fractures, which help to provide clinical guidelines for management.

To examine the occurrence of hangman’s fractures in the National Trauma Data Bank® (NTDB®) research dataset for 2012, admissions medical records were searched using the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM). Specifically searched was external cause of injury code (E-code) 805.02 (closed fracture of second cervical vertebra). A total of 11,514 records were found; 10,504 records contained a hospital discharge status, including 5,008 patients discharged to home, 2,784 to acute care/rehab, and 1,918 sent to skilled nursing facilities; 794 died. These patients were 50.8 percent male, on average 63.1 years of age, had an average hospital length of stay of 7.8 days, an intensive care unit length of stay of 6.3 days, an average injury severity score of 14, and were on the ventilator for an average of 8.5 days (see figure). Of the 5,360 tested for alcohol, almost one-third were positive.

Figure 1. Hospital discharge status

Advances in techniques for judicial hangings took place over the last 200 years, making it a more humane method of execution. England abolished judicial hanging in 1965, and the last hanging in the U.S. took place in Delaware in 1996. Hanging is still an option in only two states in the U.S.—New Hampshire and Washington.

Today, hangman’s fractures typically are encountered in patients involved in motor vehicle crashes. With the advent of the seat belt/shoulder harness, airbags, and headrests, automobiles now are engineered to try to prevent these injuries. However, failure to wear one’s seat belt/shoulder harness could result in a nonjudicial hanging.

Throughout the year, we will be highlighting data through brief reports in the Bulletin. The NTDB Annual Report 2012 is available on the ACS website as a PDF file and as a PowerPoint presentation at www.ntdb.org. In addition, information regarding how to obtain NTDB data for more detailed study is available on the website. If you are interested in submitting your trauma center’s data, contact Melanie L. Neal, Manager, NTDB, at mneal@facs.org.


Statistical support for this article has been provided by Chrystal Caden-Price, data analyst, NTDB.

*Rayes M, Mittal M, Rengachary SS, Sandeep M. Hangman’s fracture: A historical and biomechanical perspective. J Neurosurg Spine. 2011;14(2):198-208.

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