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Updated: Jun 23 2021

Closed Cervical Traction

Images wells.jpg
  • Indications
    • Indications
      • subaxial cervical fractures with malalignment
      • unilateral and bilateral facet dislocations
      • displaced odontoid fractures
      • select hangman's fractures
      • C1-2 rotatory subluxation
    • Contraindications
      • patient who is not awake, alert, and cooperative
      • presence of a skull fracture may be a contraindication
  • Patient position
    • Preferred setting
      • emergency room, operating room, ICU for close observation and frequent fluoroscopy/radiographs
    • Patient position
      • supine with reverse trendelenburg or use of arm and leg weights can help prevent patient migration to the top of the bed with addition of weights.
    • Sedation
      • small doses of diazepam can be administered to aid in muscle relaxation
      • however patient must remain awake and able to converse
  • Pin Placement
    • Pin placement (Gardner-Wells pins)
      • pin placement is 1 cm above pinna, in line with external auditory meatus and below the equator of the skull.
        • if the pin is placed too anterior, the temporalis muscles and superficial temporal artery and vein are at risk
        • an anterior pin will apply an extension moment to the cervical spine
        • if the pin is placed too posterior, it can apply a flexion moment to the cervical spine.
        • a posterior pin with a flexion moment may facilitate reduction of a facet dislocation.
    • Pin tightness
      • On Gardner-Wells tongs, pins are tightened until spring loaded indicator protrudes 1 mm above surface
        • this is the equivalent of 139 newtons (31 lbs) of force
        • overtightening by 0.3 mm leads to 448 newtons (100 lbs)
        • failure of temporal bone occurs at 965 +/- 200 newtons (216 lbs)
        • note Mayfield pins are tightened to 60 lbs
      • overtightening of the pins can result in penetration of the inner table of the calvarium
        • this may cause cerebral hemorrhage or abscess
    • Pin strength
      • stainless steel pins have higher failure loads than titanium and MRI-compatible graphite and should be used with traction of > 50lbs.
  • Reduction with Serial Traction
    • Serial traction
      • an initial 10lbs is added.
      • weights are increased by 10lb increments every 20 minutes
      • serial exams and radiographs are taken after each weight is placed
      • maximal weight is controversial
        • some authors recommend weight limits of 70 lbs
        • recent studies report that up to 140 lbs is safe
    • Reduction maneuvers
      • reduction of a unilateral facet dislocation
        • reduction maneuver performed after facet is distracted to a perched position
        • maintain axial load and rotate head 30-40 degrees past midline, in the direction of the dislocation
        • stop once resistance is felt, and confirm with radiographs
      • reduction of bilateral facet dislocation
        • reduction maneuver performed after facet is distracted to a perched position
        • palpate the stepoff in the spinal process posteriorly and apply an anterior directed force caudal to the level of the dislocation
        • rotate the head 40 degrees beyond midline in one direction, and then rotate 40 degrees in the other direction while axial traction is maintained.
  • Complications
    • Failure to reduce
      • a bilateral, irreducible facet dislocation is unstable and should be treatment with urgent open reduction after an MRI is performed..
    • Change in neurologic exam
      • with any change in the neurologic exam the weights should be removed and an MRI should be obtained.
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