{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,3,27]],"date-time":"2026-03-27T16:08:43Z","timestamp":1774627723800,"version":"3.50.1"},"reference-count":33,"publisher":"MDPI AG","issue":"4","license":[{"start":{"date-parts":[[2026,3,27]],"date-time":"2026-03-27T00:00:00Z","timestamp":1774569600000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Medicina"],"abstract":"<jats:p>Background and Objectives: To provide a systematic narrative review of published literature on atypical hangman\u2019s fractures focusing on pathophysiology, treatment options and clinical outcomes. Materials and Methods: A systematic review was performed according to PRISMA guidelines. MEDLINE (PubMed), EMBASE, Scopus, and Cochrane Library were searched until March 2025. Studies reporting outcomes of atypical hangman\u2019s fractures treated conservatively or surgically were included. Data on demographics, mechanism of injury, treatment modality, outcomes, and complications were extracted and analyzed. Results: Thirteen studies with a total of 275 patients were included. The average age was 54.36 years. High-energy trauma was the predominant mechanism of injury. Conservative treatment was performed in 210 patients, with 204 (97.14%) achieving fusion and 6 (2.86%) converted to surgical treatment. Surgical fixation was performed in 71 patients, most commonly via a posterior approach. Failure of surgical treatment occurred in 5 patients, all treated with isolated anterior fusion. Neurologic injury was reported in 21 patients (7.63%), with full recovery in 14 (66%). Conclusions: Atypical hangman\u2019s fractures represent a distinct subgroup of C2 fractures with diverse morphology and stability. Most fractures are stable and may be managed conservatively. Surgical fixation should be reserved for unstable patterns. If surgery is pursued, posterior fixation is recommended. Outcomes are generally favorable for both conservative and surgical treatment.<\/jats:p>","DOI":"10.3390\/medicina62040637","type":"journal-article","created":{"date-parts":[[2026,3,27]],"date-time":"2026-03-27T14:33:33Z","timestamp":1774622013000},"page":"637","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Management of Atypical Hangman\u2019s Fracture (C2 Axis): Systematic Review of Classification, Treatment Strategies, and Clinical Outcomes"],"prefix":"10.3390","volume":"62","author":[{"ORCID":"https:\/\/orcid.org\/0009-0007-3682-617X","authenticated-orcid":false,"given":"Stjepan","family":"Ivandi\u0107","sequence":"first","affiliation":[{"name":"Spinal Surgery Division, Department of Traumatology, University Hospital Centre Sestre Milosrdnice, 10000 Zagreb, Croatia"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-7143-4354","authenticated-orcid":false,"given":"Sathish","family":"Muthu","sequence":"additional","affiliation":[{"name":"Orthopaedic Research Group, Department of Spine Surgery, Coimbatore 641045, India"},{"name":"Central Research Laboratory, Aarupadai Veedu Medical College and Hospital, Vinayaka Mission\u2019s Research Foundation (Deemed to be University), Puducherry 607403, India"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Lora","family":"Grbanovi\u0107","sequence":"additional","affiliation":[{"name":"Department of Radiology, University Hospital Center, 10000 Zagreb, Croatia"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Jay","family":"Toor","sequence":"additional","affiliation":[{"name":"Section of Orthopedics, Department of Surgery, University of Manitoba, Winnipeg, MB R3T 2N2, Canada"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Jure","family":"Pave\u0161i\u0107","sequence":"additional","affiliation":[{"name":"Spinal Surgery Division, Department of Traumatology, University Hospital Centre Sestre Milosrdnice, 10000 Zagreb, Croatia"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Mi\u0161o","family":"Krsti\u010devi\u0107","sequence":"additional","affiliation":[{"name":"Spinal Surgery Division, Department of Traumatology, University Hospital Centre Sestre Milosrdnice, 10000 Zagreb, Croatia"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-6123-5589","authenticated-orcid":false,"given":"Mirza","family":"Pojski\u0107","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, University of Marburg, 35037 Marburg, Germany"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Stipe","family":"\u0106orluka","sequence":"additional","affiliation":[{"name":"Spinal Surgery Division, Department of Traumatology, University Hospital Centre Sestre Milosrdnice, 10000 Zagreb, Croatia"},{"name":"St. Catherine Specialty Hospital, 10000 Zagreb, Croatia"},{"name":"Department of Anatomy and Physiology, University of Applied Health Sciences, 10000 Zagreb, Croatia"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"1968","published-online":{"date-parts":[[2026,3,27]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"346","DOI":"10.1055\/s-0035-1550343","article-title":"Traumatic Spondylolisthesis of the Axis Vertebra in Adults","volume":"5","author":"Schleicher","year":"2015","journal-title":"Glob. Spine J."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"319","DOI":"10.1302\/0301-620X.63B3.7263741","article-title":"Fractures of the ring of the axis. A classification based on the analysis of 131 cases","volume":"63","author":"Effendi","year":"1981","journal-title":"J. Bone Joint Surg. Br."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"217","DOI":"10.2106\/00004623-198567020-00007","article-title":"The management of traumatic spondylolisthesis of the axis","volume":"67","author":"Levine","year":"1985","journal-title":"J. Bone Joint Surg. Am."},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"175","DOI":"10.1177\/21925682241284559","article-title":"Atypical Hangman\u2019s Fractures: An Institutional Study of 51 Patients with Atypical Traumatic Spondylolisthesis of C2","volume":"15","author":"Botros","year":"2025","journal-title":"Glob. Spine J."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"1954","DOI":"10.1097\/00007632-199310001-00005","article-title":"Atypical hangman\u2019s fractures","volume":"18","author":"Starr","year":"1993","journal-title":"Spine"},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"345","DOI":"10.1097\/BSD.0000000000001093","article-title":"Hangman\u2019s Fracture","volume":"33","author":"Turtle","year":"2020","journal-title":"Clin. Spine Surg. Spine Publ."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"18S","DOI":"10.1177\/2192568217745061","article-title":"Treatment of Axis Ring Fractures: Recommendations of the Spine Section of the German Society for Orthopaedics and Trauma (DGOU)","volume":"8","author":"Scholz","year":"2018","journal-title":"Glob. Spine J."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"8321680","DOI":"10.1155\/2017\/8321680","article-title":"C2 Fracture Subtypes, Incidence, and Treatment Allocation Change with Age: A Retrospective Cohort Study of 233 Consecutive Cases","volume":"2017","author":"Robinson","year":"2017","journal-title":"BioMed Res. Int."},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"E286","DOI":"10.1097\/BSD.0000000000000641","article-title":"Conservative Treatment of Hangman Variant Fractures","volume":"31","author":"Niemeier","year":"2018","journal-title":"Clin. Spine Surg. Spine Publ."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"e7492","DOI":"10.1097\/MD.0000000000007492","article-title":"A novel classification for atypical Hangman fractures and its application: A retrospective observational study","volume":"96","author":"Li","year":"2017","journal-title":"Medicine"},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"1046","DOI":"10.1302\/0301-620X.82B7.0821046","article-title":"Hangman\u2019s fracture: The relationship between asymmetry and instability","volume":"82","author":"Samaha","year":"2000","journal-title":"J. Bone Joint Surg. Br."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"S90","DOI":"10.1097\/BOT.0000000000000952","article-title":"Management of Hangman\u2019s Fractures: A Systematic Review","volume":"31","author":"Murphy","year":"2017","journal-title":"J. Orthop. Trauma"},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"248","DOI":"10.1055\/s-0035-1563404","article-title":"Management of Typical and Atypical Hangman\u2019s Fractures","volume":"6","author":"Beagrie","year":"2016","journal-title":"Glob. Spine J."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"257","DOI":"10.1007\/s00586-005-0918-2","article-title":"A systematic review of the management of hangman\u2019s fractures","volume":"15","author":"Li","year":"2006","journal-title":"Eur. Spine J."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"454","DOI":"10.14444\/8445","article-title":"Surgical Management of Hangman\u2019s Fracture: A Systematic Review","volume":"17","author":"Mahmoud","year":"2023","journal-title":"Int. J. Spine Surg."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"52","DOI":"10.25259\/SNI_49_2020","article-title":"Failure of C2-3 anterior arthrodesis for the treatment of atypical Hangman\u2019s fractures: A three case series","volume":"11","author":"Aljuboori","year":"2020","journal-title":"Surg. Neurol. Int."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"e848","DOI":"10.1016\/j.wneu.2018.07.285","article-title":"Individual Surgical Strategy Using Posterior Lag Screw\u2013Rod Technique for Unstable Atypical Hangman\u2019s Fracture Based on Different Fracture Patterns","volume":"119","author":"Li","year":"2018","journal-title":"World Neurosurg."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"80","DOI":"10.13105\/wjma.v5.i4.80","article-title":"Assessing the quality of studies in meta-analyses: Advantages and limitations of the Newcastle Ottawa Scale","volume":"5","author":"Luchini","year":"2017","journal-title":"World J. Meta-Anal."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"2363","DOI":"10.1111\/os.13163","article-title":"Surgical Outcomes for C2 Tear Drop Fractures: Clinical Relevance to Hangman\u2019s Fracture and C2-3 Discoligamentous Injury","volume":"13","author":"Kim","year":"2021","journal-title":"Orthop. Surg."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"133","DOI":"10.1016\/j.clineuro.2018.03.024","article-title":"Multiplanar realignment for unstable Hangman\u2019s fracture with Posterior C2-3 fusion: A prospective series","volume":"169","author":"Salunke","year":"2018","journal-title":"Clin. Neurol. Neurosurg."},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"146","DOI":"10.1016\/j.jocn.2019.08.046","article-title":"Direct trans-pedicular screw fixation for atypical hangman\u2019s fracture: A minimally invasive technique using the tubular retractor system","volume":"70","author":"Youngseok","year":"2019","journal-title":"J. Clin. Neurosci."},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"715","DOI":"10.1007\/s10140-022-02041-5","article-title":"Traumatic spondylolisthesis of axis: Clinical and imaging experience at a level one trauma center","volume":"29","author":"Cai","year":"2022","journal-title":"Emerg. Radiol."},{"key":"ref_23","first-page":"8","article-title":"Surgical Management of the Hangman\u2019s Fracture in the Twelve Cases: Case Series","volume":"43","year":"2023","journal-title":"Turk. Klin. J. Med. Sci."},{"key":"ref_24","first-page":"516","article-title":"Nonoperative management of vertical C2 body fractures","volume":"56","author":"German","year":"2005","journal-title":"Neurosurgery"},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"206","DOI":"10.3171\/jns.1994.81.2.0206","article-title":"Fractures of the C-2 vertebral body","volume":"81","author":"Benzel","year":"1994","journal-title":"J. Neurosurg."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"335","DOI":"10.1007\/BF00361422","article-title":"Acute injuries of the axis vertebra","volume":"18","author":"Burke","year":"1989","journal-title":"Skelet. Radiol."},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"2229","DOI":"10.1097\/00007632-200210150-00009","article-title":"Early Halo Immobilization of Displaced Traumatic Spondylolisthesis of the Axis","volume":"27","author":"Vaccaro","year":"2002","journal-title":"Spine"},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"703","DOI":"10.1016\/j.otsr.2019.03.009","article-title":"Hangman\u2019s fracture: Management strategy and healing rate in a prospective multi-centre observational study of 34 patients","volume":"105","author":"Prost","year":"2019","journal-title":"Orthop. Traumatol. Surg. Res."},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"667","DOI":"10.3892\/etm.2013.898","article-title":"One-stage posterior C2 and C3 pedicle screw fixation or combined anterior C2-C3 fusion for the treatment of unstable hangman\u2019s fracture","volume":"5","author":"Liu","year":"2013","journal-title":"Exp. Ther. Med."},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"182","DOI":"10.1097\/01.brs.0000251917.83529.0b","article-title":"Hangman\u2019s Fracture: A Biomechanical Comparison of Stabilization Techniques","volume":"32","author":"Duggal","year":"2007","journal-title":"Spine"},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"529","DOI":"10.1097\/BRS.0b013e3181d60067","article-title":"Posterior short-segment fixation and fusion in unstable Hangman\u2019s fractures","volume":"36","author":"Ma","year":"2011","journal-title":"Spine"},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"432","DOI":"10.1016\/S0268-0033(02)00037-2","article-title":"The traumatic spondylolisthesis of the axis A biomechanical in vitro evaluation of an instability model and clinical relevant constructs for stabilization","volume":"17","author":"Arand","year":"2002","journal-title":"Clin. Biomech."},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"5S","DOI":"10.1177\/21925682231189928","article-title":"AO Spine\/Praxis Clinical Practice Guidelines for the Management of Acute Spinal Cord Injury: An Introduction to a Focus Issue","volume":"14","author":"Kwon","year":"2024","journal-title":"Glob. Spine J."}],"container-title":["Medicina"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/1648-9144\/62\/4\/637\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,3,27]],"date-time":"2026-03-27T15:12:26Z","timestamp":1774624346000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/1648-9144\/62\/4\/637"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,3,27]]},"references-count":33,"journal-issue":{"issue":"4","published-online":{"date-parts":[[2026,4]]}},"alternative-id":["medicina62040637"],"URL":"https:\/\/doi.org\/10.3390\/medicina62040637","relation":{},"ISSN":["1648-9144"],"issn-type":[{"value":"1648-9144","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,3,27]]}}}