64.7 Skeletal traction

This is the best treatment for an unstable fracture of a patient’s cervical spine. Surgeons differ in the method they like. Some like Hoen’s traction, in which wires are passed through burr holes, while others prefer Gardner Wells tongs or a halo. The trouble with a halo is that it is difficult to align and may slip off, which is why Hoen’s traction is gaining in popularity. This allows a patient to move his head freely, and you can leave it in position for months if necessary. It takes slightly longer than applying tongs, but is much more reliable. You will have to learn to make burr holes for head injuries anyway (63.4), so this is an additional use for them.

Traction is the surest way of stabilizing an unstable fracture or fracture dislocation, or occasionally of releasing locked facets. Be prepared to apply it yourself because: (1) patients with injured cervical spines travel badly, especially over bumpy roads, (2) the equipment is simple, (3) it may be the only way to prevent severe disability, (4) it can be used effectively. But it is not easy to apply and it requires expert nursing, so the indications we give for it differ from those of the experts. They always apply traction if a patient has a normal cord, because it is the best way of preserving it. But, if you are not expert and your nursing is less than perfect, a patient may be safer in a cuirasse. There is little point in anyone applying cervical traction if a patient is already quadriplegic.

If a patient has a fracture dislocation, traction will draw the fragments of his spine apart, restore the diameter of his cervical canal, and reduce the danger of pressure on his cord. When you apply traction, aim to draw the fragments apart with steadily increasing traction over a few hours, then maintain traction with a smaller weight for several weeks. Finally, protect the patient’s neck with a cast or collar, so that his spine can heal and become stable in about 8 weeks. To be on the safe side it is desirable to protect it for 6 months.

If a patient has bilateral locked facets of his cervical spine (rare), they are usually associated with complete permanent quadriplegia. If so, traction is pointless. In the unlikely event that he has no neurological lesion, immobilization in a cuirasse or an efficient collar is a possible alternative to trying to unlock them, which is difficult.

When you apply traction to a fracture dislocation, apply only just enough weight to reduce it. If you apply too much too suddenly, you may increase the patient’s soft tissue injury, and harm his cord. Adjust the traction to his build and don’t exceed what is advised below.

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Figure 64.11: CERVICAL TRACTION WITH GARDNER WELLS TONGS. When you apply traction to a fracture dislocation, apply only just enough weight to reduce it. If you apply too much too suddenly, you may increase the patient’s soft tissue injury, and harm his cord. Adapted from de Palma with kind permission.

SKELETAL TRACTION FOR THE CERVICAL SPINE

INDICATIONS (1) Unstable fractures or fracture dislocations of a patient’s cervical spine, with partial quadriplegia, or early (within a few days) complete quadriplegia, in whom there is still some hope of improvement. (3) Rupture of the posterior ligaments. (4) As a temporary splint for cervical fractures while a patient is being treated for his other injuries.

In more expert hands the most important indication for traction is an unstable fracture with no neurological signs. if you are less expert, he may be safer in a cuirasse.

CONTRAINDICATIONS (1) Complete permanent quadriplegia in which traction is almost pointless. (2) Unstable fractures in which there have been neurological signs, but in which these have now gone (fit a cuirasse). (3) Stable fractures in which traction is unnecessary (fit a collar). (4) Signs of instability which are only present in flexion and extension views (fit a cuirasse). (5) Locked facets, unilateral or bilateral, with or without neurological signs. Experts would apply traction. if you cannot refer the patient, fit a cuirasse.

CAUTION! You must be able to take bedside X–rays. if you cannot do this, don’t try to apply traction—fit him with a collar or cuirasse.

HALTER Fit the patient with a halter temporarily while you are organizing the traction device.

THE BED Apply traction on a bed with fracture boards (or a door) covered with at least 10 cm of foam rubber, and large castors. You should be able to adjust the height of the pulley vertically.

NURSING Turn the patient 2 hourly-left side, supine, right side. Alternate periods in which he is turned completely left and right with periods in which he is turned partly left and right. Take great care to move his head ’in one piece’ with the rest of his body. You will need 3 nurses while you do this, with one to look after his head and neck. At 6 weeks, when traction is replaced with a cervical collar, add the prone position when he is turned. Rub his pressure areas 2 hourly.

X–RAYS Either apply traction in the X-ray department, or wheel him there in traction for films to be taken.

SEDATION Give the patient diazepam with pethidine. Don’t give him a general anaesthetic. Intubating him may be difficult and dangerous.

CAUTION! (1) Monitor his neurological state carefully. if you apply too much traction too suddenly, you may injure his spinal cord or his medulla. (2) Never apply more traction than the maximum indicated. (3) if at any time there are signs that his neurological state is getting worse, reduce traction immediately. (4) If you are in doubt as to what to do, be safe and reduce the traction or take it down.

GARDNER WELLS TONGS FOR CERVICAL TRACTION

These grip a patient’s skull a finger’s breadth above his ears in the line of his mastoid processes. Fit them in the ward. Apply them symmetrically without shaving his scalp. The pins should enter his skull just caudal to its maximum diameter, so that they don’t slip. Sterilize the points. Dab iodine on the place where you want them to go, raise a wheel of lignocaine and anaesthetize his scalp right down to his periosteum. Apply iodine to the points of the screws.

One screw is spring loaded, so that as the tension is increased a small nipple protrudes. When it protrudes about 1 mm the tension is correct. Twist the screws so that their points go through his anaesthetized skin, and grip the outer table of his skull. Tighten them until the small nipple in one of the screws protrudes 1 mm from its hole, then tighten the lock nut.

A HALO FOR CERVICAL TRACTION

Fit this in the ward. Support the patient’s head off the bed, try the halo for fit, and decide which screw holes to use. Shaving the skin in the areas where the pins will go is optional. Anaesthetize his skin, and apply the halo in the same way as for Gardner Wells tongs. Tighten the screws alternately, so that the halo is not pulled to one side. Tighten them as securely as you can, using only your thumb and three fingers on the screwdriver: more force is dangerous. After tightening, secure each pin with lock nuts on either side of the halo.

Thread cords through four of its unused holes, bring the cords together into two slings, and tie the main traction cord to them. Adjust them to determine the flexion and extension of his head.

CAUTION! With both forms of traction device: (1) Make sure the points of the screws are needle sharp. (2) Try to keep them still, because this will minimize the risk of infection. (3) Tighten up the screws several times during the first 24 hours, then don’t tighten them any more. Don’t tighten them unnecessarily, or they may perforate his inner table. (4) if the traction sites become infected, move the pins on the halo.

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Figure 64.12: HOEN’S TRACTION. Wires are passed through burr holes. Traction is easier to align by this method than with a halo, and cannot slip off a patient can move his head freely, and you can leave him in traction for months if necessary. Kindly contributed by Laurence Levy.

HOEN’S TRACTION FOR CERVICAL TRACTION

ANAESTHESIA (1) If anaesthetic skills are good, consider general anaesthesia with intubation, taking due care of the patient’s spine. (2) Or, use local anaesthesia, with intravenous diazepam if he is restless.

METHOD Make two linear 5 cm incisions in the parasagittal plane centred on the patient’s mastoid processes and 3 to 4 cm from the midline. Place these so as to straddle the desired line of pull, which is usually in line with his cervical spine.

Reflect the skin and make two burr holes (63.4) 3 cm apart, with a 2 cm bridge of bone between them.

Loop a pice of stainless steel wire into 4 or more strands, depending on its strength. Pass the blunt looped ends from one burr hole to another. You may need the help of the guide of a Gigli saw, or the the blunt end of a long slightly curved needle, with the wire in its eye.

CAUTION! (1) Position the incisions and the burr holes away from the mid line, so as to avoid the patient’s sagittal sinus. (2) Separate his dura very carefully, because infection may follow if you pierce it.

Pull the wires through until they are equal in length. When you have done the same thing on the other side, tension all four wires together to provide equal tension on all four.

Close the incisions. As you do so, make four slightly slanting nicks to prevent the medially slanting wires from pressing on the skin edges, where they would be uncomfortable, cause necrosis, and so promote infection. The wound will soon heal and a dressing is rarely needed.

Connect the wires to a rope passing over a pulley, apply a weight, and raise the patient’s bed to apply counter traction.

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Figure 64.13: A LOCALLY MADE HALO. A garage mechanic can make this if you give him some stainless steel Steinmann pins. Kindly contributed by Alan Workman.

APPLYING TRACTION FOR CERVICAL SPINE INJURIES

HOW MUCH TRACTION? This depends on: (1) The type of traction. With a halter 4 to 5 kg is the maximum, but with skeletal traction you will need 5 to 15 kg. (2) The build of the patient; large men need more than small women. (3) What you are trying to do. To begin with you may need 15 kg to reduce a dislocation. Later, you may only need 3 to 5 kg to maintain traction. (4) The position of the injury. Higher up the spine less traction is required (2 to 5 kg), than with the common C5 C6 injuries (5 to 15 kg).

Here is a rough guide, C1 2.5 to 5 kg, C2 3 to 5 kg, C3 4 to 7 kg, C4 5 to 10 kg, C5 and 6, 7 to 15 kg. Apply the weights over a pulley. Raise the head of the bed about 4 cm for each kilo, as for a fracture of the femur.

TRACTION FOR A FRACTURE DISLOCATION

The weights which follow apply to a large adult with a hyperflexion injury in his C4-C6 region, as A, Fig. 64-13. With other injuries adjust the weight appropriately. His X-ray may show: (1) a flattening, reversal, or distortion of the normal spinal curve, (2) displacement of the body of a vertebra forwards on the one below, (3) a compression fracture, (4) fracture of the pedicles.

Apply traction in a straight line, avoid flexion, extension or, rotation and start with 7 kg. Cautiously add 2 kg every 15 minutes, checking constantly for neurological changes.

When you have applied 15 kg for 30 minutes, x–ray him. The facets may begin to disengage (B), but you may have to wait longer.

If there is no disengagement, leave him with 15 kg traction for a maximum of 12 to 48 hours, taking X–rays every 6 to 12 hours.

As soon as: (1) the articular processes are completely disengaged, (2) overriding is corrected, and (3) the distance between the fragments of the pedicles is narrowed, reduce the weights and keep the patient’s neck in a straight line. Usually, the facets will come into line.

At 2 to 3 weeks you can reduce traction to 3 to 5 kg. Take weekly lateral check X–rays for the first month, or after you have altered the weights.

At 6 weeks replace traction by a cuirasse or a collar (64.6). Leave this on for another 6 weeks. if immobilization is going to stabilise his spine, 3 months will do it.

At 3 months remove his cuirasse or collar. Take AP and lateral X–rays. if these still show reduction, take flexion and extension views.

If the patient’s vertebrae show no signs of slipping in normal or in flexion or extension views, advise Rim to increase the movements of his neck gradually, to avoid sudden movements, and to restrict his outdoor activities.

If he still has a painful unstable neck after 3 months, (6 weeks in traction followed by 6 weeks in a collar or cuirasse), refer him. This is rare. Fusion of his cervical spine may be indicated. if you cannot refer him, fit him with a collar.

If his injury is mainly bony, the fragments will probably fuse and his injury will become stable.

If his injury mainly involves the ligaments, stable union may not be achieved. He should be watchful for up to a year in case late displacement occurs.

DIFFICULTIES WITH CERVICAL TRACTION

If you have MADE THE DIAGNOSIS LATE, the patient’s fracture may or may not be stable. Fit him with a collar for 3 months. If this does not relieve his symptoms in 2 weeks, apply traction for 2 weeks and then replace his collar.

If a patient with a recent cervical injury has OTHER SERIOUS INJURIES which make cervical traction impossible, fit him with a cervical collar.

If a FRACTURE REDISPLACES, Immediately traction is reduced, or later, or if a dislocation of the articular facets recurs as traction is reduced, reapply it, especially if nerve root symptoms recur. You may need more weight (up to 17 kg). The danger of quadriplegia is great, so refer him if you can.

FOLLOW UP THE PATIENT CAREFULLY