Updated: 5/4/2022

Halo Orthosis Immobilization

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  • Introduction
    • 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
  • Indications
    • 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
  • Contraindications
    • 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%)
  • Imaging
    • 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
  • Complications
    • Higher complications in children (70%) than adults (35%)
    • 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 (Cranial Nerve VI) 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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Flashcards (7)
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Questions (11)
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(SBQ13PE.6) A 6-year-old girl with severe scoliosis has been treated with halo traction for 2 weeks, after which she presented with the physical exam findings found in Figures A and B. Which of the following statements are true regarding this complication?

QID: 4931
FIGURES:

Surgical intervention is usually required.

1%

(23/4229)

It is caused by direct trauma to the supraorbital nerve.

13%

(549/4229)

It is caused by direct trauma to the supratrochlear nerve.

6%

(259/4229)

It is related to injury to cranial nerve VI.

78%

(3286/4229)

It is related to injury to cranial nerve VII.

2%

(82/4229)

L 1 B

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(SBQ12SP.56) Figure A is an illustration of a skull with three colored zones. Placing a pin for a halo vest orthosis in the red zone places what structures at risk?

QID: 3754
FIGURES:

Supratrochlear nerve and optic nerve

5%

(201/4313)

Supraorbital nerve and optic nerve

13%

(563/4313)

Supratrochlear nerve and cranial nerve VI

5%

(208/4313)

Supraorbital nerve and cranial nerve VI

16%

(674/4313)

Supraorbital nerve and supratrochlear nerve

61%

(2642/4313)

L 1 C

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(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?

QID: 3461
FIGURES:

Weakness in biting and chewing strength

8%

(471/6068)

Deficit in medial and downward eye movement

10%

(595/6068)

Deficit in lateral eye movement

59%

(3602/6068)

Inability to close eyes against resistance

20%

(1208/6068)

Tongue deviation toward the affected side

3%

(158/6068)

L 4 C

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(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?

QID: 3193
FIGURES:

Region A

1%

(44/5069)

Region B

18%

(928/5069)

Region C

3%

(130/5069)

Region D

75%

(3818/5069)

Region E

2%

(120/5069)

L 1 C

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

QID: 2923

Rotation at the atlantoaxial joint

66%

(2125/3231)

Flexion and extension in the subaxial cervical spine

20%

(655/3231)

Rotation in the subaxial cervical spine

6%

(188/3231)

Lateral bend in the subaxial cervical spine

5%

(173/3231)

Flexion and extension at the cervicothoracic junction

3%

(81/3231)

L 3 D

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(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?

QID: 885

Facial nerve

3%

(50/1952)

Supraorbital nerve

84%

(1630/1952)

Abducens nerve

8%

(163/1952)

Zygomaticotemporal nerve

3%

(52/1952)

Zygomaticofacial nerve

2%

(47/1952)

L 1 D

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Evidence (18)
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