Updated: 4/17/2017

Halo Orthosis Immobilization

Topic
Review Topic
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Questions
10
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Evidence
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https://upload.orthobullets.com/topic/2019/images/safe zones showing nerves_moved.jpg
https://upload.orthobullets.com/topic/2019/images/osteology 3_moved.jpg
https://upload.orthobullets.com/topic/2019/images/abducens.jpg
https://upload.orthobullets.com/topic/2019/images/abducens_clinical.jpg
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 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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Questions (10)

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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? Review Topic

QID: 4931
FIGURES:
1

Surgical intervention is usually required.

1%

(14/2560)

2

It is caused by direct trauma to the supraorbital nerve.

14%

(365/2560)

3

It is caused by direct trauma to the supratrochlear nerve.

7%

(169/2560)

4

It is related to injury to cranial nerve VI.

76%

(1945/2560)

5

It is related to injury to cranial nerve VII.

2%

(53/2560)

L 2

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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? Review Topic

QID: 3754
FIGURES:
1

Supratrochlear nerve and optic nerve

6%

(185/3314)

2

Supraorbital nerve and optic nerve

16%

(533/3314)

3

Supratrochlear nerve and cranial nerve VI

4%

(144/3314)

4

Supraorbital nerve and cranial nerve VI

15%

(510/3314)

5

Supraorbital nerve and supratrochlear nerve

58%

(1926/3314)

L 4

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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? Review Topic

QID: 3461
FIGURES:
1

Weakness in biting and chewing strength

8%

(409/5213)

2

Deficit in medial and downward eye movement

10%

(501/5213)

3

Deficit in lateral eye movement

59%

(3063/5213)

4

Inability to close eyes against resistance

21%

(1071/5213)

5

Tongue deviation toward the affected side

3%

(138/5213)

L 4

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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? Review Topic

QID: 3193
FIGURES:
1

Region A

1%

(36/3841)

2

Region B

18%

(698/3841)

3

Region C

2%

(86/3841)

4

Region D

76%

(2909/3841)

5

Region E

2%

(87/3841)

L 2

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

QID: 2923
1

Rotation at the atlantoaxial joint

67%

(1784/2672)

2

Flexion and extension in the subaxial cervical spine

20%

(529/2672)

3

Rotation in the subaxial cervical spine

5%

(143/2672)

4

Lateral bend in the subaxial cervical spine

6%

(147/2672)

5

Flexion and extension at the cervicothoracic junction

2%

(61/2672)

L 3

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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? Review Topic

QID: 885
1

Facial nerve

3%

(34/1342)

2

Supraorbital nerve

84%

(1130/1342)

3

Abducens nerve

8%

(104/1342)

4

Zygomaticotemporal nerve

3%

(42/1342)

5

Zygomaticofacial nerve

2%

(28/1342)

L 2

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