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, or ICU for close observation and frequent fluoroscopy or radiographs Patient position supine with reverse Trendelenburg, or the use of arm and leg weights, can help prevent patient migration to the top of the bed with the addition of weights Sedation small doses of diazepam may be administered to aid in muscle relaxation 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 the external auditory meatus, and below the equator of the skull if the pin is placed too anterior, the temporalis muscle, superficial temporal artery, and superficial temporal vein are at risk an anterior pin will apply an extension moment to the cervical spine if the pin is placed too posterior, a flexion moment may be applied 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 a spring-loaded indicator protrudes 1 mm above the surface this is the equivalent of 139 newtons (31 lbs) of force overtightening by 0.3 mm increases the force to 448 newtons (100 lbs) failure of the temporal bone occurs at 965 ± 200 newtons (216 lbs) in contrast, 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 those made of titanium or MRI-compatible graphite should be used with >50 lbs of traction Reduction with Serial Traction Serial traction an initial 10 lbs is applied weights are increased by 10-lb increments every 20 minutes serial exams and radiographs are obtained after each weight is applied maximal weight is controversial some authors recommend weight limits of 70 lbs recent studies report safety up to 140 lbs Reduction maneuvers reduction of a unilateral facet dislocation reduction maneuver is performed after facet is distracted to a perched position maintain axial load and rotate the head 30-40° past midline in the direction of the dislocation stop once resistance is felt confirm with radiographs reduction of bilateral facet dislocation reduction maneuver is performed after facet is distracted to a perched position palpate the stepoff in the spinous process posteriorly and apply an anteriorly directed force caudal to the level of the dislocation rotate the head 40° beyond midline in one direction, and then rotate 40° in the other direction while axial traction is maintained Complications Failure to reduce a bilateral irreducible facet dislocation is unstable and should be treated with urgent open reduction after MRI is performed Change in neurologic exam with any change in the neurological exam, the weights should be removed and MRI should be obtained