Step

Procedure

Comment

1

Inspect insertion site: Select a point just abouve apex of each ear.

Rule out depressed skull fracture in this area.

2

Shave & prep pin insertion site.

3

Inject local anesthetic: Inject 2-3 cc of 1% xylocaine or equivalent agent one centimeter above each ear in line with the external auditory meatus.

May omit if patient is unconscious.

4

Advance Gardner-Wells tong Pins: Insert pins into skull by symmetrically tightening the knobs.

A spring loaded device in one or the two pins will protrude when the pins are appropriately seated. (A data plate on the tongs provides additional information.)

5

Apply skeletal traction: Use a pulley fixed to the head of the litter or frame to direct horizontal traction to the tongs.

Use 5 lbs. rule (i.e. 5 lbs. of weight for each level of injury, (see text)). High cervical fractures usually require minimal traction ot reduce. Monitor with series X-rays. The tong-pin site requires anterior or posterior positioning to adjust for cervical spine flexing or extension as indicated.

6

Elevate head of litter: Use blocks in order to provide body-weight counter traction.

The knot in the cord should not be permitted to drift up against the pulley. Should this occur, traction is no longer being applied.

7

Decrease Traction Weight: When X-rays confirm that reduction is adequate, decrease traction to 5-15 lbs.

Unreducible or unstable fractures should be maintained in moderate traction until surgical intervention. If neurological deterioration occurs, immediate surgical intervention must be considered.

8

Daily pin care.

Cleanse tracts with saline and apply antibiotic ointment to the pin sites. Maintain pin force (see Step 4) by tightening as necessary to keep spring-loaded device in the protruded position.

9

Turn patient appropriately: Use Stryker, Foster, or similar frame and turn patient every four hours.

When initially proned, obtain X-rays to ensure that the reduction is maintained. If reduction is not maintained when the patient is proned, rotate the patient only between the 30° right and left quarter positions. The use of a circle electric bed is contraindicated with injuries of the spinal cord or column.

10

If satisfactory alignment cannot be obtained, further workup is necessary.

Consider myelogram, CT scan, tomograms, and neurosurgical/orthopedic consultations.