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Traumatic rupture of transverse colon, small bowel injury and Hangman's fracture

Case contributed by Dr Heather Pascoe


Passenger in MVA

Patient Data

Age: 85
Gender: Female


  • No acute pathology


  • Mildly displaced, coronally oriented C2 fracture (Hangman’s fracture) extends through the vertebral body to the pars interarticularis, with extension  into the transverse foramina bilaterally.
  • Minimally displaced fracture through C6 anterior tubercle.


  • Ulcerated thoracic aortic plaque is more likely than focal aortic injury involving the junction of the aortic arch and descending aorta, with a focal area of intramural contrast. No evidence of extravasation. No mediastinal hematoma.
  • Small amount of free gas is present within the anterior mediastinum, most likely tracking superiorly from the pneumoperitoneum.
  • Oblique fracture involves the medial aspect of the right clavicle with associated fat stranding and hematoma overlying the adjacent right sternocleidomastoid muscle.
  • Displaced fracture through the proximal diaphysis of the left humerus. Moderate glenohumeral degenerative changes, with two calcified intraarticular bodies.


  • Haemopneumoperitoneum with gross active bleeding probably from avulsion of 1st jejunal vein from SMV.
  • Proximal jejunal injury (with rupture and/or vascular devitilisation suspected).
  • Proximal ileal injury adjacent to where the transverse colon is ruptured.
  • Traumatic rupture of transverse colon with pneumoperitoneum and fecal content within the adjacent peritoneal cavity.
  • Subcutaneous fat stranding noted within the seatbelt distribution.
  • Severe hypovolemia with collapsed IVC and pre shock bowel.

Incidental findings:

  • Small hiatus hernia.

Case Discussion

A Hangman's fracture occurs following direct upward impact to the face or chin causing hyperextension and loading the posterior aspect of the axis. This results in bilateral vertically oriented fractures through the pars interarticularis. Always check if the fracture lines extend through the transverse foramina as if they do, there is a risk of vertebral artery injury.

Free intraperitoneal gas is not always identified in patients with bowel perforation. If there is free air may be found adjacent to the site of perforation or remotely in the upper abdomen. Significant bowel injury however can be present even if no free gas is identified. In this situation other changes such as bowel wall thickening, free fluid and fluid in the mesentery may suggest the diagnosis.

CT findings of severe hypotension and are seen not only in trauma cases but also in other conditions which cause marked hypotension eg sepsis. They are due to sympathetic stimulation in severe hypotension which results in shunting of blood away from “non-essential” organs. The signs are potentially reversible with aggressive fluid resuscitation and treatment of the underlying cause. It is thus important to distinguish these changes from those requiring surgery.

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Case information

rID: 32899
Published: 9th Feb 2018
Last edited: 29th Jul 2020
Inclusion in quiz mode: Included

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