Management of Atypical Hangman’s Fracture (C2 Axis): Systematic Review of Classification, Treatment Strategies, and Clinical Outcomes

Background and Objectives: To provide a systematic narrative review of published literature on atypical hangman’s 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’s 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’s 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.