Introduction Hangman’s fracture, defined as a bilateral pars interarticularis fracture of C2, is a common cervical spine injury treated either conservatively or surgically depending on fracture stability and displacement. Conservative immobilization often provides satisfactory fusion in stable patterns, whereas operative fixation is increasingly used in unstable injuries. Despite widespread use of both approaches, evidence comparing long-term outcomes and complication profiles remains inconsistent. This study aimed to compare surgical versus conservative management of Hangman’s fractures with respect to union and treatment-related complications through a meta-analysis of comparative studies. Methods A systematic review was conducted in accordance with PRISMA and Cochrane Collaboration standards. PubMed, Scopus, Cochrane Library, and Google Scholar were searched through November 2025. Comparative clinical studies evaluating adult patients with traumatic Hangman’s fractures treated operatively or nonoperatively were included. Methodological quality and risk of bias were assessed using the ROBINS-I tool. Six retrospective studies comprising 197 adults (11–62 per study) met eligibility criteria. Results All included studies had an overall moderate risk of bias. Surgical and conservative management did not differ significantly in rates of nonunion (RR = 4.33; p = 0.09), treatment failure including conversion or revision (RR = 2.19; p = 0.18), posttreatment stiffness (RR = 0.98; p = 0.95), infection (RR = 0.42; p = 0.21), neurologic complications (RR = 1.03; p = 0.97), or one-year mortality (RR = 1.64; p = 0.65). Conservative management demonstrated significantly fewer miscellaneous complications such as delirium, DVT, and dysphagia (RR = 0.46; p = 0.002). Conclusion Based on observational evidence, nonoperative treatment of Hangman’s fractures achieves outcomes comparable to surgical fixation regarding union, neurological preservation, and functional recovery, with fewer treatment-related complications in appropriately selected, stable patients, whereas surgical stabilization remains necessary for unstable fractures or in patients for whom prolonged immobilization is unsuitable. Additional prospective randomized studies are needed to refine patient selection and enhance individualized management strategies.

Surgical versus conservative management of Hangman’s fractures: a meta-analysis

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发表日期：

2026年3月7日

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Marc Boutros,
Guy Awad,
Christèle Asmar,
Jad Lawand,
Antoine Mouawad,
Jad Bou Monsef

摘要

Introduction

Hangman’s fracture, defined as a bilateral pars interarticularis fracture of C2, is a common cervical spine injury treated either conservatively or surgically depending on fracture stability and displacement. Conservative immobilization often provides satisfactory fusion in stable patterns, whereas operative fixation is increasingly used in unstable injuries. Despite widespread use of both approaches, evidence comparing long-term outcomes and complication profiles remains inconsistent. This study aimed to compare surgical versus conservative management of Hangman’s fractures with respect to union and treatment-related complications through a meta-analysis of comparative studies.

Methods

A systematic review was conducted in accordance with PRISMA and Cochrane Collaboration standards. PubMed, Scopus, Cochrane Library, and Google Scholar were searched through November 2025. Comparative clinical studies evaluating adult patients with traumatic Hangman’s fractures treated operatively or nonoperatively were included. Methodological quality and risk of bias were assessed using the ROBINS-I tool. Six retrospective studies comprising 197 adults (11–62 per study) met eligibility criteria.

Results

All included studies had an overall moderate risk of bias. Surgical and conservative management did not differ significantly in rates of nonunion (RR = 4.33; p = 0.09), treatment failure including conversion or revision (RR = 2.19; p = 0.18), posttreatment stiffness (RR = 0.98; p = 0.95), infection (RR = 0.42; p = 0.21), neurologic complications (RR = 1.03; p = 0.97), or one-year mortality (RR = 1.64; p = 0.65). Conservative management demonstrated significantly fewer miscellaneous complications such as delirium, DVT, and dysphagia (RR = 0.46; p = 0.002).

Conclusion

Based on observational evidence, nonoperative treatment of Hangman’s fractures achieves outcomes comparable to surgical fixation regarding union, neurological preservation, and functional recovery, with fewer treatment-related complications in appropriately selected, stable patients, whereas surgical stabilization remains necessary for unstable fractures or in patients for whom prolonged immobilization is unsuitable. Additional prospective randomized studies are needed to refine patient selection and enhance individualized management strategies.