Crushed Neck Injury With Laryngotracheal Transection and C2 Hangman’s Fracture

Authors: Joshua Rapp*¹, David Dillard¹, Ziad Obideen¹, Kenneth Walton¹, Colten Witte¹, Romeo Massoud MD², James K. Fortson MD, MBA, MPH, FACS²

Summary:

Cricotracheal transection combined with upper cervical spine fracture is exceedingly rare and often fatal. However, with efficient airway management, interdisciplinary collaboration and surgical techniques, effective outcomes can be achieved through damage control, ultimately improving quality-of-life.

This unique case conveys a 22-year-old male sustaining complete cricotracheal separation combined with unstable C2-3 subluxation who survived with no neurological sequelae. Intraoperatively, complete tracheal transection and a crushed larynx were identified, along with a fragmented cricoid ring and split thyroid cartilage. 2-0 Monocryl was used to reapproximate the cartilaginous edges, and the plates were bent for structural stability. An endotracheal tube was converted to an Abozulker-type stent and placed through the cords, which was reinforced with thrombin glue.

Survival without total neurological deficit following complete cricotracheal transection with unstable cervical fracture is exceptionally rare. In conclusion, meticulous anatomic reconstruction is critical for restoring normal airway continuity and cervical stability.

Background:

Cricotracheal transection with a Hangman’s fracture (C2) and concurrent C3 fracture is rare and usually fatal.^1,2,4 Very few cases in the literature present a full recovery of the patient.^3,5 The dramatic presentation of these patients can pose significant challenges and, if not diagnosed and treated promptly, may lead to a poor outcome. This is a case report of a 22-year-old male who sustained blunt trauma to the neck with combined cricotracheal separation and C2 fracture subluxation and who survived with no neurological sequelae. The purpose of this report is to describe a practical approach and detailed management of combined acute tracheal disruption and traumatic cervical spine injury.

Case Presentation:

A 22-year-old male was brought into the Emergency Department after falling from a ladder striking his anterior neck on a dumpster. The patient was found to be unresponsive and in respiratory arrest. Initial attempts to intubate the patient in the field were unsuccessful because of a difficult airway; therefore, a King airway was inserted successfully by paramedics. The absence of right breath sounds warranted needle decompression. The patient was maintained in the cervical spine at all times and transported to the hospital.

Upon presentation to the emergency department, the patient remained unresponsive and in noticeable respiratory distress, cyanotic with a blood pressure of 142/60, a heart rate of 89, a respiratory rate of 14, and a pulse oximeter reading in the 90–94% range. The physical examination revealed anterior neck superficial abrasions, ecchymosis, edema, significant subcutaneous emphysema, and crepitus extending from the face to the inguinal region. The King airway remained intact, although further auscultation examination revealed decreased breath sounds bilaterally. A chest X-ray was ordered revealing bilateral pneumothoraces (Figure 1). Subsequently, bilateral chest tubes were placed, resulting in re-expansion of both lungs (Figure 2).

The patient was mobilized quickly to the operating room. A transverse incision was made, and the dissection was performed through the anterior neck, revealing complete transection of the trachea and a crush injury to the larynx (Figure 3). The transected trachea was grabbed by Allis clamps, a window was created inferior to the injury via a Bovie, and a 6-French endotracheal (ET) tube was placed through the tracheotomy. At that point, the patient was stabilized, as the patient’s saturation improved to 98%. The larynx was completely crushed, and the cricoid ring was fragmented, with a notable segment attached to the straps and superiorly retracted. The larynx was retracted away from the trachea, and the thyroid cartilage was split longitudinally. The mucosa was removed from the cricoid ring, and the posterior portion of the larynx inferior to the cords was visualized after dissection. The skin incision was split in an inverted T fashion, extending vertically to obtain access to the superior aspects of the strap split. The anterior surfaces were cleared, and plating was attempted with 1 mm screws, but these screws were pulled through the noncalcified cartilage. The plates were subsequently bent to position. 2-0 Monocryl was used to reapproximate the cartilaginous edges, and the plate was used for a stable structure. An ET tube was fashioned into an Aboulker stent and placed through the cords (Figure 4). The damaged mucosa, transected trachea, cartilaginous junction of the trachea, and cricoid cartilage junction were reapproximated, and the straps were sealed down over the repair area of the larynx with thrombin glue. The ET tube was converted to a formal 8-French tracheostomy tube (Figure 5). The skin was closed, and direct laryngoscopy was performed to confirm that the Aboulker stent was in place. Given the significant degree of trauma to the patient’s neck, the patient was determined to benefit from an intraoperative gastrostomy tube (G-tube) placement. The patient’s abdomen was then prepped in the usual sterile fashion. The upper mid-epigastrium was incised, and an open G-tube was placed.

Following surgery, the patient was maintained with cervical spine precautions at all times with a collar. CT scans of the head, neck, chest, abdomen, and pelvis revealed an unstable C2–C3 fracture with subluxation and bilateral locked facets, bilateral hemopneumothoraces with chest tubes in place, extensive subcutaneous emphysema, and no intracranial hemorrhage or solid organ injury. Furthermore, there was a rupture of the posterior longitudinal ligament with posterior avulsion of the inferior end-plate of C2 from the disc’s annulus, along with general injury of the anterior longitudinal ligament and ligamentum flavum. A bilateral lateral mass fracture of C2 was also noted (Figure 8). On MRI, the spinal cord itself did not show any abnormalities, although there was significant spinal canal stenosis. An attempt at reduction was made with Gardner-Wells cervical traction but was not successful. Open reduction and internal fixation were performed with lateral mass screws at C2, C3, and C4 with C1-C2 wiring and posterior fusion at those levels (Figure 9).

Outcome and Follow-Up:

Postoperatively, the patient's neurological status improved. He was weaned off the ventilator to a tracheostomy collar without complications. The bilateral chest tubes were removed, and the patient tolerated the tube feeds without problems. Physical therapy, occupational therapy, and speech therapy were instituted. However, the patient remained catatonic with significant functional decline and required assistance with all aspects of mobility and activities of daily living (ADLs). Therefore, it was recommended that he be transferred to a rehabilitation center to continue his recovery. 

Initially, there was concern that his catatonic state may have been the result of anoxic encephalopathy. However, with aggressive therapy, the patient began to participate well with his entire assigned regimen and showed remarkable improvement. Prior to discharge, the patient still had his tracheostomy in place, ambulated independently, and tolerated a pureed diet but still required supplemental feeds through his G-tube.

Discussion:

Blunt neck trauma resulting in complete cricotracheal separation with a concurrent cervical spine fracture represents a highly catastrophic airway emergency in trauma care. ^1,2,4 Such injuries are extremely uncommon and often fatal, requiring immediate recognition, strict adherence to Advanced Trauma Life Support (ATLS) principles, and close coordination among multiple specialties. ^3,5 The survival of this patient illustrates how timely airway control and creative surgical decision-making can make a life-saving difference.

Early prehospital actions played a pivotal role. Clear reporting of the mechanism of injury and early suspicion for airway disruption guided the field team toward safer airway choices. When tracheal separation is a concern, endotracheal intubation can worsen the disruption, and attempts should be avoided. In this case, a supraglottic King airway provided adequate oxygenation until a controlled surgical airway could be created under direct surgical visualization.

On arrival, several clinical features can point toward an underlying laryngotracheal injury: apnea, aphonia, anterior neck bruising, and extensive subcutaneous emphysema. Once suspected, rapid tracheostomy and surgical exploration are essential, both to secure the airway and to assess adjacent structures such as the esophagus and cervical vasculature. Close collaboration among trauma surgery, otolaryngology, and neurosurgery teams is crucial to address airway continuity and spinal stabilization. This points towards the importance of interdisciplinary management and efficient leadership.

A key unique feature of this case was the use of an improvised airway stent during laryngeal reconstruction. While dedicated devices such as Montgomery stents are preferred, they are not always immediately available in emergency settings. Otolaryngology modified a standard endotracheal tube, opting to add longitudinal slits, securing Prolene sutures, and sealing the distal end with a needle cap, effectively creating a practical temporary stent. This approach is easily reproducible with materials commonly found in most operating settings and offers an alternative when time or resources are limited. Reconstruction was achieved by separately plating the thyroid and cricoid cartilages. In younger patients, cartilage is more flexible and less calcified, making screw fixation less reliable. For this reason, miniplates secured with absorbable sutures such as 3-0 or 4-0 Vicryl can provide sufficient stability.

Survival following complete cricotracheal transection in the setting of an unstable cervical spine fracture is rare but achievable. Early recognition, strict compliance with ATLS principles, and early surgical airway placement remain essential. When standard airway stents are unavailable, improvised alternatives can provide reliable airway support. Individualized reconstructive strategies and thoughtful postoperative management are critical in optimizing outcomes for this devastating pattern of injury.

LEARNING POINTS/TAKE HOME MESSAGES:

●      Combined cricotracheal disruption and cervical spine injury after blunt neck trauma is often fatal and therefore makes rapid ATLS-based airway and spine management essential. Patient outcomes are a direct result of interdisciplinary management and efficient surgical measures.

●      Field endotracheal intubation in suspected tracheal disruption is dangerous and can precipitate complete airway obstruction. Instead, emergency care teams should opt for alternative airway strategies, like a supraglottic airway King airway, to properly stabilize the patient until definitive care is reached.

●      Early recognition of key signs of major laryngotracheal injury should trigger immediate operative airway control and exploration while maintaining meticulous full cervical spine precautions.

Improvised stenting using universally available materials (e.g., modified endotracheal tube, Prolene suture, needle cap, dermal glue) can be safely, easily, and effectively used when commercial laryngeal stents are not readily accessible.

References:

1.     Chen FH, Fetzer D. Complete cricotracheal separation and third cervical spinal cord transection following blunt neck trauma: a case report of one survivor. J Trauma. 1993;35(1):140–2.

2.     Davies G, Leighton S, Hayward R, et al. Jet-ski injury: severe blunt neck trauma with survival. J R Soc Med. 2001;94(8):402–3.

3.     Hashima ARN, Marina MB, Sani A. Cricotracheal separation: a case of delayed diagnosis and treatment. Med J Malaysia. 2011;66(2):144–5.

4.     Hermon A, Segal K, Har-El G, et al. Complete cricotracheal separation following blunt trauma to the neck. J Trauma. 1987;27(12):1365–7.

Singh GB, Kummar R, Verma N, et al. A rare case of survival after complete traumatic cricotracheal separation. Case Rep Otolaryngol. 2012;2012:105763.

Authors’ information

Joshua Rapp https://orcid.org/0009-0002-1851-6470

David J. Dillard https://orcid.org/0009-0004-5075-7850

   Ziad H. Obideen https://orcid.org/0009-0004-1830-2143

Kenneth Walton https://orcid.org/0009-0006-7053-1669

   Colten L. Witte https://orcid.org/0009-0007-5736-5595

FIGURES: 

Figure 1. Chest X-Ray showing Bilateral Pneumothoraces. The pre-operative AP X-ray film demonstrates collapse of both lungs with visible bilateral air collections. 

Figure 2. Bilateral Chest Tubes in Place. Post-interventional chest X-ray showing bilateral chest tubes in place with lung re-expansion. 

Figure 3. Intraoperative Photograph of Transected Trachea and Larynx. Complete separation of the trachea and larynx is visualized during neck exploration.  

Figure 4. Intraoperative Photograph Showing Endotracheal Stent and Fixation Plate. An endotracheal (ET) tube serves as a stent while a titanium plate provides structural support during airway repair.  

Figure 5. Post-operative Photograph Showing Tracheostomy Tube in Place. The airway reconstruction site is intact with appropriate postoperative tracheostomy placement. 

Figure 6. Lateral Cervical Spine X-ray showing C2-3 Fracture. The image demonstrates misalignment 

Figure 7. Sagittal CT Scan Confirming C2-3 Fracture. The scan shows displaced fracture fragments and associated prevertebral swelling. 

Figure 8. MRI showing C2-C3 fracture. Imaging demonstrates C2-3 fracture with associated soft-tissue edema, along with spinal cord changes. 

Figure 9. Postoperative Lateral C-ray Following Open Reduction and Internal Fixation. Fixation hardware is visible with satisfactory alignment of C2-3 vertebrae.