Chapter 121. Skeletal Traction (Gardner-Wells Tongs) for Cervical Spine Dislocations and Fractures

Traumatic injuries to the cervical spine result from forces acting on the head and neck. The incidence of spinal cord injury in the United States is approximately 5 per 100,000 population.1 Approximately 60% to 80% of spinal cord injuries involve the cervical spine. Motor vehicle collisions are the most common cause and account for almost half of the cervical spine injuries.2 The remaining cervical spine injuries result from falls, sports injuries, violence, penetrating wounds, and miscellaneous causes.

The primary aims of therapy in the treatment of the patient with an acute spinal cord injury are to minimize secondary injury to the spinal cord, to realign the spine, to improve neurological recovery, to maintain spinal stability, and to obtain an early functional recovery. This is achieved by decompression of the spinal cord by restoring the normal sagittal diameter of the spinal canal or by removing a compressive lesion surgically. This is particularly important in patients who have sustained an incomplete spinal cord lesion and are found to have a progressing neurological deficit. Restoring the normal anatomic position also provides for pain relief.

Early operative intervention can be performed for the treatment of acute cervical fractures to achieve decompression and restore normal alignment. The use of skeletal traction in the acute spinal cord injury patient remains a very safe and straightforward method of reducing fractures and maintaining the spinal canal in anatomical alignment.

Fabricius Hildanus utilized forceps in treating fractures or dislocations of the cervical spine as early as 1646. Crutchfield developed a pair of self-tightening tongs in 1933 that allowed him to apply traction to the cranium in a patient with a cervical spine fracture.3 These tongs were subsequently modified and have essentially been replaced by the Gardner-Wells tongs.4

Cervical spinal cord injuries can be divided into upper (occiput to C3) and lower (C3 to C7) injuries. Numerous classification systems exist. These are based upon the morphology and the mechanism of injury.5 No classification is ideal. However, critical to all cervical classifications is the determination of stability of a fracture or dislocation. Stability of the vertebral column is dependent upon the integrity of the vertebra, the intervertebral disk, the facet joints, and most importantly the ligamentous structures.

Clinical stability of the cervical spine is determined by the ability of the spine under physiological loads to maintain its normal anatomical relationship so that there is no damage to the spinal cord or nerve roots. It has been proposed that spinal instability be separated into mechanical, neurologic, and combined types. Mechanical instability implies that the injured spine could collapse or distort under normal physiological stresses. Neurological instability implies a risk of neural injury (spinal cord and/or nerve root) subsequent to the initial injury.

It is exigent that a thorough clinical and radiological evaluation be completed to determine if the patient has suffered an unstable cervical spine injury. This begins with a thorough history and physical examination, including a complete neurological examination with particular attention to spinal cord function. Cervical spine radiography (including possibly CT, MRI, and myelography) is indicated to evaluate fracture patterns, disk disruption, vertebral subluxation, vertebral dislocation, vertebral angulation, and ligamentous injury. Ligamentous injury evaluation should look for disruption of each of the major spinal ligaments including the anterior longitudinal ligament, the posterior longitudinal ligament, the apophyseal ligamentous complex, and the posterior ligamentous complex. Radiological findings that indicate instability include vertebral displacement, interspinous process widening, diastasis of the apophyseal joints, widening of the spinal canal, and disruption of the posterior vertebral body line.

White and Panjabi proposed a checklist point value system (Table 121-1).6 A point value is assigned to each of the injuries appreciated on the cervical spine radiographs. A specific point value is allotted to the location of injuries, sagittal plane translation or rotation, spinal cord injury, nerve root injury, and the presence of intervertebral widening, rotation, or angulation. The total point values are then summated. A score of five or more is suggestive of clinical instability. A discussion of the indications for the application of the Gardner-Wells tongs includes evidence of cervical spine instability.

Crutchfield is credited for introducing skeletal tongs in the management of cervical spinal injuries.3 Gardner-Wells tongs were introduced in the early 1970s and utilize the principle of a spring-loaded point for cervical traction.4 The spring-loaded pin design and tilting of the pins in the direction of pull ensure a firm and prolonged grasp of the skull. These tongs have the capacity to tolerate at least 65 pounds or more of traction. The amount of weight necessary to accomplish reduction varies considerably. As a rule, 5 pounds of weight should be applied for each vertebral level above the level of the fracture or the dislocation. Most authors have recommended the use of up to 50 to 60 pounds of weight.7 Others have, on occasion, applied weights in excess of 100 pounds to reduce a cervical subluxation.8

The concern for using an excessive amount of traction weight is overdistraction that can result in a traction type of spinal cord injury. Begin by applying 5 to 10 pounds of weights.2 Add additional weight in 3 to 5 pound increments if the initial application of weights fails to achieve spinal alignment. Obtain lateral cervical spine radiographs 10 to 15 minutes after each addition of weight until the cervical spine is realigned. This time is needed after the application of weight to allow the soft tissues to accommodate. It is of paramount importance to monitor the patient's neurological status during the entire procedure to prevent iatrogenic injury from overdistraction of an unstable motion segment.

Definitive management of the cervical spine injury would include skeletal traction with Gardner-Wells tongs if clinical instability is demonstrated or suspected. Other indications for the application of Gardner-Wells tongs in a neurosurgical setting are cervical spondylosis, anterior cervical diskectomy with graft fusion, and certain cervical infections or neoplasms. Gardner-Wells tongs should only be applied if the patient requires temporary longitudinal traction.9 Their use requires the patient to remain bedridden, as compared to halo vest traction.

Cervical traction is contraindicated in someone who has sustained posttraumatic disc herniation with spinal cord compression. Hence, a good neurological evaluation and an MRI scan should be performed prior to applying cervical traction. Fractures of the skull and infections overlying the potential pin sites are contraindications to the use of skeletal traction. Other contraindications are diseased bone, children less than 3 years of age, atlantooccipital dislocations, and C1-C2 dislocations. Applying Gardner-Wells tongs to someone who survives an atlantooccipital type injury could worsen the patient's condition and/or neurological deficit.

• Prep kit
• Povidone iodine or chlorhexidine solution
• 1% or 2% lidocaine with epinephrine
• 5 mL syringe
• 18 gauge needles
• 22 gauge needles
• Gardner-Wells traction tongs
• Pulley traction system
• Traction weights, 3 to 5 pound increments

Gardner-Wells tongs are a simple device (Figure 121-1). It consists of a contoured and rigid stainless steel rod that follows the coronal contour of the calvarium. Gardner-Wells tongs are also available in versions composed of graphite or titanium alloy. These versions are compatible with and facilitate subsequent CT and MRI scans without producing artifacts. It has a threaded hole on each end that accommodates the pins. The spring-loaded pins are threaded screws with sharp cone-shaped points. One of the pins is the calibration pin (Figure 121-2). It contains an indicator pin that extends and retracts as the tip penetrates the skull. The pins screw into the rigid rod so that the points are tilted in the direction of the pull. This results in the pins pressing into the skull when traction is applied and ensuring that they do not pull out. A squeezing pressure of 30 pounds is applied to the skull when the pins are properly positioned.3 An S-shaped hook is permanently attached to the top of the Gardner-Wells tongs. The string and traction weights are attached to this hook. Permanently attached to the S-hook is a metal plate that is engraved with the instructions (Figure 121-3). The instruction plate faces upward and is readable when the Gardner-Wells tongs are properly applied (Figure 121-4).

Explain the procedure, its risks, and benefits to the patient and/or their representative. Obtain an informed consent to apply the Gardner-Wells tongs. Signed consent may be omitted in cases where the patient is immobilized or has an altered mental status. Document the reason for the lack of a signed consent in the medical record. Intravenous sedation may be required in certain cases, at the discretion of the treating Emergency Physician.

Consider the use of some form of deep venous thrombosis prophylaxis since the application of Gardner-Wells tongs requires the patient to remain bedridden. The use of sequential compressive devices (SCDs) is simple, easily applied in the Emergency Department, and will not cause complications. Consult a Spine Surgeon or Neurosurgeon before prescribing intravenous, oral, or subcutaneous anticoagulants.

Identify the anatomic landmarks required to place the Gardner-Wells tongs. The pins are introduced in the temporal region, 2 to 3 finger-breadths (3 to 4 cm) above the pinna of the ear (Figure 121-5). Place them directly above the external auditory meatus for neutral distraction, 2 to 3 cm posterior to the external auditory meatus for flexion distraction, and 2 to 3 cm anterior to the external auditory meatus for extension distraction. A helpful landmark is the squamosal line where the temporalis muscle inserts into the skull. Tong placement should be below this line to allow adequate traction. Another useful landmark is to observe for the widest biparietal diameter of the patient's skull. This usually corresponds to the landmark just inferior to the squamosal line.

The use of Gardner-Wells tongs does not require shaving the patient's hair at the proposed pin sites. Clean the skin and hair of any dirt and debris. Apply povidone iodine or chlorhexidine solution to the skin and hair at the proposed pin sites and allow it to dry. Infiltrate 1 mL of lidocaine with epinephrine into each of the two proposed pin sites. Infiltrate subcutaneously and down to the level of the periosteum of the skull.

The Gardner-Wells tongs are fast and easy to apply by one person. The patient should already be supine on the gurney. Stand above the patient's head. Assemble the Gardner-Wells tongs by inserting the pins into the threaded holes. Place the pins of the Gardner-Wells tongs over the proposed pin insertion sites. The instructions on the S-hook must be facing upward and readable. If not, the tongs are upside down. Apply the Gardner-Wells tongs so the pins are symmetrically located on each side of the head. Screw in the pins equally and symmetrically on both sides of the tongs (Figure 121-5B). Note that a small spring-loaded indicator pin is observed on one side of the tongs when adequate tension is applied (Figures 121-2 & 6). Recommendations by the manufacturer suggest that the pins should be tightened simultaneously until there is a 1 mm protrusion of the indicator pin beyond the flat surface (Figure 121-6). Tighten the securing nuts to prevent the tongs from loosening.

The points of the pins will not pull out when properly applied. The depth of penetration of the pins is self-limited by a gradual lessening of the spring tension and an increase in the surface area of contact between the tips of the pins and the skull. The pressure exerted by each pin is exactly the same, regardless if one pin has been advanced farther than the other. The curve of the rigid rod allows the traction loop to find its proper position.

Gently rock the Gardner-Wells tongs to assure that the pins are properly seated within the outer table of the skull (Figure 121-7). Place the patient in the reverse Trendelenburg position (Figure 121-8). Tie a rope to the S-shaped hook. Feed the other end of the rope through a pulley at the head of the bed and apply weights. Proper attention to the head position and the axis of distraction are important elements in achieving closed reduction. Initially apply a 10-pound weight for the head.6 Obtain a lateral cervical spine radiograph 10 to 15 minutes after the application of the weight. Add 5 pound weights, one at a time, for each vertebral segment above the level of the injury. Obtain a lateral cervical spine radiograph 10 to 15 minutes after each 5 pound weight is added. Continue to increase the traction weight in 3 to 5 pound increments. Obtain repeat lateral cervical spine radiographs 10 to 15 minutes after each additional weight is added. Stop adding weights when the radiographs demonstrate appropriate alignment of the cervical spine. Careful assessment and documentation of the patient's neurological function is mandatory throughout the application of weights and skeletal traction.

Clean the pin sites every shift with povidone iodine or hydrogen peroxide solution followed by iodine ointment. Obtain daily cervical spine radiographs to follow the spinal alignment. Reduce the weight by 50% to maintain the alignment if spinal realignment is obtained with traction.

The points of the pins tend to penetrate the outer table of the skull due to the continuous pressure exerted by the springs on a very small area. Readjust the pins in 24 hours, again setting the indicator pin so that it protrudes approximately 1 mm from the flat surface. Further adjustment of the Gardner-Wells tongs is not necessary and is not recommended as it can result in erosion of the pin point through the skull.

Skull penetration from placing the pins too low in the temporal region where the skull is thinnest can lead to dural tears, epidural hematomas, and possibly intracranial injury. Pins located in the temporal fossa pierce the temporalis muscle and can cause painful mastication. Overdistraction can lead to iatrogenic injury. This is best prevented by the initial use of a minimal amount of weight necessary to distract or reduce the cervical spine injury. Pin site infections are prevented by close attention to surgical technique and daily hygiene. Other complications reported include intracranial aneurysms, CSF leaks, and osteomyelitis of the skull.

The application of skeletal traction in the form of Gardner-Wells tongs is a safe, simple, and quick procedure when there is evidence of clinical or radiological cervical spine instability. It requires only local anesthesia and antiseptic preparation of the skin. Careful attention to the application technique utilizing the suggested anatomical landmarks will reduce the chances of complications. Monitoring realignment and/or reduction procedures with frequent cervical spine radiographs is prudent. Gardner-Wells tongs are not recommended as a long-term immobilization technique. Definitive management of cervical spine instability requires surgical stabilization and/or halo bracing.