Controversies in management of floating lateral mass fractures of subaxial cervical spine: a narrative review.

This narrative review examines floating lateral mass (F3) fractures of the subaxial cervical spine, uncommon but clinically relevant injuries that are frequently under-recognized. A comprehensive literature search was conducted in PubMed, Embase, LILACS, and the Cochrane Library to identify studies published between 1990 and May 2025. These fractures result from combined pedicle and lamina disruption, separating the articular processes and creating a "floating" lateral mass. Despite advances in imaging, assessment of mechanical instability remains controversial, particularly in minimally displaced injuries. Magnetic resonance imaging is essential for identifying associated intervertebral disc and posterior ligamentous complex injuries, which are strongly associated with failure of non-operative treatment. Surgical management is commonly indicated when instability or neurological compromise is present, with anterior cervical discectomy and fusion being the most frequently reported approach. However, the optimal strategy, including anterior, posterior, or combined fixation and the number of stabilized levels, remains debated and is guided by fracture morphology, reducibility, and disco-ligamentous involvement. Dynamic radiographs and computed tomography angiography may provide complementary information in selected cases. Overall, these fractures should be considered potentially unstable. Surgical stabilization is appropriate in most patients, whereas conservative management may succeed in carefully selected stable cases with close clinical and radiographic follow-up.