Unraveling Hyoid Fracture Patterns in Hanging: A Systematic Review of Demographic, Mechanical, and Autopsy Determinants

Hyoid bone fractures are a well-recognized but inconsistently reported finding in hanging deaths, reflecting the combined influence of demographic, biomechanical, and methodological factors. This systematic review, conducted in accordance with PRISMA 2020 guidelines, synthesizes evidence from 12 autopsy-based studies encompassing nearly 1750 cases of suicidal, judicial, and accidental hangings. The review assesses the prevalence, distribution, and morphology of hyoid fractures; associated laryngohyoid and cervical injuries; and modifiers such as age, sex, suspension completeness, ligature type, knot position, and drop mechanism. Across studies, fracture prevalence varied widely from <10% in methodologically limited series to nearly 50% in investigations employing comprehensive and standardized neck dissection – underscoring the decisive role of autopsy rigor in injury detection. Greater horn fractures predominated, while body and lesser horn fractures were uncommon. Age over 40 years, posterior or posterolateral knot positioning, complete suspension, and hard or narrow ligatures were repeatedly associated with increased fracture risk. Thyroid cartilage fractures and soft-tissue hemorrhage were frequent concomitant findings, whereas cervical spine trauma was largely confined to judicial long-drop hangings. Substantial heterogeneity in methodology, reporting quality, and case composition precluded quantitative meta-analysis; therefore, results are presented as a structured narrative synthesis. Overall, the findings reinforce the biomechanical and anatomical complexity of neck injuries in hanging and highlight the necessity for standardized, meticulous autopsy protocols to ensure accurate assessment of hyoid fractures and related injuries.