Guideline | CLOSED REDUCTION

PATIENT SELECTION

The decision on which patients may benefit from an urgent closed reduction is made with the on-call spine specialist (OCSS). Relevant factors include:

Does the patient have a significant (or worsening) neurological deficit following a cervical spinal cord injury?
- Full ASIA assessment preferred (includes motor score, sensory testing and perianal examination). For patients with minor motor deficits (ASIA D) transfer to a spinal centre for reduction may be considered more appropriate.
- At least document motor function (MRC) in myotomes distal to the injured level and perianal examination
Is there radiological evidence of ongoing cord compression?
- A CT scan is mandatory
- MRI scans are not always essential as significant delays can eventuate – discuss with OCSS.
Is the patient sufficiently alert and awake to report neurological changes during reduction?
Is the skull compromised rendering pin placement unsafe? (eg. skull fracture, congenital skull abnormality, previous bony cranial intervention)
Is traction contraindicated due to the presence of cervical injuries made worse by distraction? (eg. occipitocervical dissociations or certain Hangman (C2) fractures)
Is traction contraindicated due to presence of degenerate disease of the spine? (eg. fixed deformity, ankylosing spondylitis/diffuse idiopathic skeletal hyperostosis)
Comorbidities, concurrent injuries, medication allergies, cardiovascular stability and suitability for procedural sedation should all be considered.

PRE-PROCEDURE PREPARATION

Who? Staffing requirements

This procedure should be conducted according to your local procedural sedation guidelines. Essential staff include

Orthopaedic consultant/senior registrar
Assisting doctor
Anaesthetist
Nurse
Radiographer

What? Equipment checklist

EQUIPMENT (drug doses based on 70kg adult)	CHECKED (date)
Traction bed
Gardner Wells tongs
Spanner (to tighten tongs)
Rope
Weights and spike (50% patient’s body weight should be available in 1-4kg increments)
S hook (connecting rope to tongs)
Hair shaver and skin prep
Scalpel and 11 blade
Morphine – 2mg initial bolus – 1mg further increments
Midazolam – 2.5mg initial bolus – 1mg further increments OVER SEDATION MUST BE AVOIDED
Naloxone (opioid reversal) – 0.4-2mg IV bolus – Reassess in 2 minutes then give further 1mg
Flumazenil (benzodiazepine reversal) – 0.2mg IV bolus – 0.1mg increments (60 second intervals)
Lignocaine (1-2% without adrenaline 5-10ml)
Image intensifier and radiographer
Lead gowns
Sandbags
Pillows (5 available)
Towels (10 available)

Where? Environment requirements

Theatre if unavailable consider ICU bay, ED resus bay, large/procedural ward side room Important that there is space available for

Traction bed
Image intensifier and monitors
Patient monitoring

PROCEDURE PROTOCOL

STANDARD EQUIPMENT

Review full protocol and end points prior to commencing protocol

Stage 1 – Patient positioning and Gardner-Wells tongs application

Complete equipment checklist
Patient positioned supine on Howard Wright bed with head support and immobilisation collar. Traction cage set up as demonstrated
Hair shaved in 5cm radius from external auditory meatus
Pin sites marked as discussed with OCSS
Assemble Gardner-Wells tongs
1. Slide S hook onto Gardner-Wells tongs (this may require one pin to be removed)
2. Pins should start from even positions with lock nut on OUTSIDE of tongs
Collar removal and manual maintenance of head position by assistant or towels/sandbags
Pin site skin prepped with chlorhexidine and 5-10mL 1-2% lignocaine without adrenaline infiltrated into pin site
1. 1cm longitudinal skin incision made using 11 blade at marked pin site
Tongs held in position by senior clinician, pins evenly tightened symmetrically by assistant
1. Pins tensioned using fingers into skull until spring loaded indication protrudes 1 mm above the surface (equivalent 139 newtons)
2. Lock nuts are tightened onto outside of tongs using spanner
Patient position checked, rope run through pulley and weight spike attached
X-ray C-arm positioned and initial X-ray obtained ensuring visualisation of bony abnormality

Stage 2 – Traction application

Analgesia and sedative given as required – patient to remain able to report neurological symptoms

Brief neurological exam focused on identified deficits
1. Subjective report
2. Distal light touch
3. Gross finger and toe movement
Initial weight: 2-4kg (5-10lb)
1. Brief neurological exam and lateral cervical spine X-ray
2. Pin sites checked
Increment 2-4kg (5-10lb) every 5 minutes
1. Brief neurological exam and lateral cervical spine X-ray
2. Repeat until maximum weight or other end point
Reverse Trendelenberg can provide counter traction using patients body weight

END POINTS

Reduction successful

Reduce traction weight gently to 1kg per vertebrae above injury level and add slight extension to cervical spine position
Contact OCSS and continue definitive management planning

Maximum traction weight reached without reduction

Reduce traction weigh gently to 1kg per vertebrae above injury level
Contact OCSS, plan for urgent MRI, proceed to open decompression or expedite transfer

Tip to tip/locked facet joints

Undertake manual manipulations only if experienced in doing so

Do not add further traction weight
Undertake manual manipulations if experienced in doing so
- Manual traction added to Gardner-Wells tongs on at unreduced facet side
- Add manual rotating force to manual distraction force, rotating head 40 degrees as tolerated towards side of dislocation

Radiological evidence of over distraction

Reduce traction weight until over distraction resolved
Contact OCSS, plan for urgent MRI, proceed to open decompression or expedite transfer

Neurological deterioration

Reduce traction weight until new neurological deficit resolves
Contact OCSS, plan for urgent MRI, proceed to open decompression or expedite transfer

Following reduction attempt. Document the following in the notes

Neck position
Maintenance traction weight
Nursing and medical reviews required
Management of other injuries/comorbidities, clinician responsible and contact details
Transfer plan

PROCEDURE PROTOCOL

SINGHAL TRACTION BED

Review full protocol and end points prior to commencing protocol

Stage 1 – Patient positioning and Gardner-Wells tong application

Complete equipment checklist
Patient positioned supine on traction bed with immobilisation collar, head support and shoulder straps secured
Hair shaved in 5cm radius from external auditory meatus
Pin sites marked as discussed with OCSS
Assemble Gardner-Wells tongs and S hook
1. Slide S hook onto Gardner-Wells tongs (this may require one pin to be removed)
2. Pins should start from even positions with lock nut on OUTSIDE of tongs
Collar removal and manual maintenance of head position by assistant or towels/sandbags
Pin site skin prepped with chlorhexidine and 5-10mL 1-2% lignocaine without adrenaline infiltrated into pin site
1. 1cm longitudinal skin incision made using 11 blade at marked pin site
Tongs held in position by senior clinician, pins evenly tightened symmetrically by assistant
1. Pins tensioned using fingers into skull until spring loaded indication protrudes 1 mm above the surface (equivalent 139 newtons)
2. Lock nuts are tightened onto outside of tongs using spanner
Patient position checked, rope run through pulley and weight spike attached
X-ray C-arm positioned and initial X-ray obtained ensuring visualisation of bony abnormality

Stage 2 – Traction application

Animation

Analgesia and sedative given as required – patient to remain able to report symptoms

Brief neurological examination with focus on prior deficits identified
1. Subjective report
2. Distal light touch
3. Gross finger and toe movement
Ensure mast is in neutral/horizontal position, in line with Gardner-Wells tongs
Attach the wire to the S hook
Initial weight: Wind on 2.5kg using Load Cell Tensioner Handle
1. Lift bed to full height and tilt leg end down fully (note this will apply further weight)
2. Brief neurological exam
3. Pin sites checked
4. Position image intensifier unit and acquire lateral X-ray
Wind Mast Tensioner Handle to increase traction force in 5kg increments every 5 -10 minutes
1. Brief neurological exam and lateral cervical spine X-ray at each increment
2. As the neck flexes, put towel under pillow to support the neck
3. Repeat until maximal flexion reached

Once maximum flexion reached, if reduction not achieved, wind the Load Cell Tensioner Handle at 5kg increments every 5 minutes until maximal traction weight reached or other end point Do NOT exceed traction weight passed maximum weight (50% body weight for adults, 25% for children)