Halo Orthosis Immobilization

Topic updated on 04/19/15 2:42pm
  • Fixes skull relative to torso 
    • provides most rigid form of cervical spine external immobilization
    • ideal for upper C-spine injury
  • Allows intercalated paradoxical motion in the subaxial cervical spine
    • therefore not ideal for lower cervical spine injuries (lateral bending least controlled) 
      • "snaking phenomenon"
        • recumbent lateral radiograph shows focal kyphosis in midcervical spine 
        • yet, upright lateral radiograph shows maintained lordosis in midcervical spine
  • Adult
    • definitive treatment of cervical spine trauma including
      • occipital condyle fx
      • occipitocervical dislocation
      • stable Type II atlas fx (stable Jefferson fx)
      • type II odontoid fractures in young patients 
      • type II and IIA hangman’s fractures
    • adjunctive postoperative stabilization following cervical spine surgery
  • Pediatric
    • definitive treatment for
      • atlanto-occipital dissociation
      • Jefferson fractures (burst fracture of C1)
      • atlas fractures
      • unstable odontoid fractures
      • persistent atlanto-axial rotatory subluxation 
      • C1-C2 dissociations
      • subaxial cervical spine trauma
    • preoperative reduction in the patients with spinal deformity
  • Absolute
    • cranial fractures
    • infection
    • severe soft-tissue injury
      • especially near proposed pin sites
  • Relative
    • polytrauma
    • severe chest trauma
    • barrel-shaped chest
    • obesity
    • advanced age
      • recent evidence demonstrates an unacceptably high mortality rate in patients aged 79 years and older (21%)
  • CT scan prior to halo application
    • indications
      • clinical suspicion for cranial fracture
      • children younger than 10 to determine thickness of bone
Adult Technique
  • Adults
    • torque
      • tighten to 8 inch-pounds of torque
    • location
      • total of 4 pins
      • 2 anterior pins 
        • safe zone is a 1 cm region just above the lateral one third of the orbit (eyebrow) at or below the equator of the skull  
          • this is anterior and medial to temporalis fossa/temporalis muscle
          • this is lateral to supraorbital nerve 
      • 2 posterior pins
        • placed on opposite side of ring from anterior pins
    • followup care
      • can have patient return on day 2 to tighten again
      • proper pin and halo care can be done to minimize chance of infection
Pediatric Technique
  • Pediatrics 
    • torque
      • best construct involves more pins with less torque 
        • total of 6-8 pins
        • lower torque (2-4 in-lbs or "finger-tight") 
    • pin locations
      • place anterior pins lateral enough to avoid injury to the frontal sinus, supratrochlear and supraorbital nerves 
      • place pins anterior enough to avoid the temporalis muscle
      • place pins posteriorly opposite from anterior pins
    • brace/vest
      • custom fitted vest for children > 2 years
      • children <2 yrs should use Minerva cast
    • CT scans may help in pin placement
      • can help facilitate avoiding cranial sutures
      • can  help facilitate avoiding thin regions of skull
      • help limit risk of complications 
  • Loosening (36%)
    • can be treated with retightening
    • if continues to loosen, should be treated with pin exchange
  • Infection (20%)
    • can especially occur with posterior pin in temporalis fossa because
      • pins hidden in hairline
      • bone is thin
      • temporalis muscle moves with chewing
    • can be treated with oral antibiotics if pin not loose
      • if pin infection and loose then pin should be removed
  • Discomfort (18%)
    • treated by loosening skin around pin
  • Dural puncture (1%)
  • Abducens nerve palsy 
    • epidemiology
      • is most commonly injured cranial nerve with halo
    • pathophysiology
      • thought to be a traction injury to cranial nerve 6, which affects abducens nerve (innervate lateral rectus muscles) 
    • symptoms
      • diplopia
    • physical exam
      • loss of lateral gaze on affected side 
    • treatment
      • observation as most resolve spontaneously
  • Supraorbital nerve palsy  
    • injured by medially placed anterior pins
  • Supratrochlear nerve palsy  
    • injured by medially placed anterior pins
  • Medical complications
    • pneumonia
    • ARDS
    • arrhythmia


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Qbank (8 Questions)

(OBQ11.38) A 27-year-old male is an unrestrained passenger in a motor vehicle accident. He was medically stabilized in the emergency room. His initial injury CT scans are seen in Figures A and B. He is neurologically intact and placed in a halo fixator prior to surgical treatment. What is the most common neurologic complication with halo traction? Topic Review Topic
FIGURES: A   B        

1. Weakness in biting and chewing strength
2. Deficit in medial and downward eye movement
3. Deficit in lateral eye movement
4. Inability to close eyes against resistance
5. Tongue deviation toward the affected side

(OBQ10.99) With halo immobilization the anterior pin should be placed in which of the following regions in Figure A to avoid injury to the supraorbital nerve and optimize stability? Topic Review Topic
FIGURES: A          

1. Region A
2. Region B
3. Region C
4. Region D
5. Region E

(OBQ09.110) The halo vest is most effective at controlling which of the following spinal motions? Topic Review Topic

1. Rotation at the atlantoaxial joint
2. Flexion and extension in the subaxial cervical spine
3. Rotation in the subaxial cervical spine
4. Lateral bend in the subaxial cervical spine
5. Flexion and extension at the cervicothoracic junction

(OBQ07.224) A 20-year-old man presents with a type III odontoid fracture and undergoes halo application. What nerve structure is in danger if the anterior pins are placed too medially? Topic Review Topic

1. Facial nerve
2. Supraorbital nerve
3. Abducens nerve
4. Zygomaticotemporal nerve
5. Zygomaticofacial nerve

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