Snapshot A 27-year old male is involved in a motor vehicle accident. He was unrestrained. On arrival in the emergency room he is alert and oriented, airway is stable, and has a normal blood pressure and heart rate. Physical exam shows a laceration over his forehead with periorbital echymosis. He has 5/5 strength in his upper and lower extremities with normal sensory and reflexes. A radiograph is shown. (Hangman's fracture) Introduction Any injury to the skull should raise suspicion for cervical spine injury Specific subtypes Hangman's fracture traumatic anterior spondylolithesis of the axis due to bilateral fracture of pars interarticularis motor vehicle accident (MVA) is most common cause mechanism hyperextension with secondary flexion Syringomyelia spinal cord injury secondary to whiplash Presentation Symptoms neck pain Physical exam patients are usually neurologically intact Evaluation C-spine xray CT study of choice to delineate fracture pattern MRI best at showing soft tissues (ligaments, spinal cord) Treatment Stabilization of the cervical spine If apneic, airway preservation with minimal neck movement orotrachial intubation with rapid induction Medical give steroids for suspected spinal cord injuries Surgical repair of spine if indicated