Levine and Edwards classification

Last revised by Joshua Yap on 28 Sep 2022

The Levine and Edwards classification is the most widely used classification system of hangman fractures of the C2 vertebra 3. The injury, also known as traumatic spondylolisthesis of the axis, and the amount and direction of displacement determines stability and guides treatment. The classification system is a modified version of the original scheme described by Effendi 4


  • type I: minimally displaced fracture with ≤3 mm antero-posterior translation
    • no angulation
    • C2/3 disc intact therefore no disc space widening
    • due to a hyperextension and axial loading mechanism
    • associated with atlas fractures, specifically Jefferson, odontoid process and posterior arch fractures
    • stable injury
    • treatment is collar immobilization
  • type II: displaced fracture with >3 mm antero-posterior translation
    • angulation of ≤10o
    • vertical fracture line
    • the C2/3 disc and posterior longitudinal ligament are disrupted
    • due to a distractive flexion or compressive hyperextension mechanism
    • associated with C3 anterosuperior compression fractures and C2 endplate avulsion fractures
    • unstable injury
    • treatment depends on the degree of displacement and is either with halo immobilization or surgery
  • type IIa: type II fracture with minimal or no translation but marked angulation
    • angulation of >10o
    • horizontal/oblique fracture line
    • significant angular deviation without anterior translation
    • anterior longitudinal ligament is intact
    • due to a similar mechanism as type II injuries
    • unstable injury
    • treatment is with a compression halo but traction needs to be avoided (as it increases fracture angulation)
  • type III: type II fracture with bilateral facet joint dislocation
    • rare
    • due to a distractive flexion mechanism
    • treatment is surgery

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