During the past 30 years various treatment protocols for hangman's fractures have been attempted. In order to guide the management of hangman's fractures, different classifications have been introduced. However, opinions on operative or nonoperative treatment have not yet been solidified. To evaluate both conservative and operative management of hangman's fractures in the published literature and to provide appropriate guidelines for treatment of hangman's fractures, a systematic review of the literature regarding the management of hangman's fractures was performed. An English literature search from January 1966 to January 2004 was completed with reference to treatment of hangman's fractures. The classification for treatment guidance from the literature was also reviewed. Regarding a primary therapy for hangman's fractures, there were 20 papers (62.5%) that advocated for a conservative treatment and 11 of the remaining 12 papers suggested that conservative treatment was suitable for some stable fractures. The classification of Effendi et al. modified by Levine and Edwards was used widely. Most hangman's fractures could be managed successfully with traction and external immobilization, especially in Effendi Type I, Type II and Levine-Edwards Type II fractures. It is necessary for Levine-Edwards Type IIa and III fractures to be treated with rigid immobilization. Only for some stable Type I and Levine-Edwards Type II injuries, nonrigid external fixation alone was sufficient. Rigid immobilization alone was necessary for most cases. Surgical stabilization is recommended in unstable cases when there is the possibility of later instability, such as Levine-Edwards Type IIa and III fractures with significant dislocation. The classification system proposed by Effendi et al. and modified by Levine and Edwards provided a clinically reasonable guideline for successful management of hangman's fractures.

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