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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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