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The authors present a study of experimental traction on 48 cervical spinal nerves obtained from fresh cadavers. 16 avulsions of the roots were produced, always after rupture of the dura mater. The different stages of traction and rupture are described, as well as the different specimens after rupture. Ways of protecting the spinal nerves against avulsion are discussed.
PURPOSE: To report a case of awake tracheal intubation through the intubating laryngeal mask airway (ILMA) in a patient with halo traction. CLINICAL FEATURES: A 16-yr-old, 40 kg, boy with atlanto-occipital instability and halo traction was scheduled for surgery under general anesthesia. The head of the patient was fixed in a position of flexion and extension was impossible. Cranial magnetic resonance imaging revealed that pharyngeal and laryngeal axes were aligned, but that the oral axis was in an extreme divergent plane. The tongue and oropharynx were anesthetized with 10% lidocaine spray and bilateral superior laryngeal nerve blockade was performed. Under sedation, awake orotracheal intubation via ILMA was successful. Fibreoptic bronchoscopy has been recommended for awake tracheal intubation in such patients. Other techniques, such as use of the Bullard laryngoscope have been described also but awake tracheal intubation through the ILMA in patients with a halo device in situ has seldom been reported in the medical literature. CONCLUSION: Airway management of patients with cervical spine instability includes adequate preoperative evaluation of the airway and choosing the appropriate intubation technique. We suggest that the ILMA may be an adequate alternative for awake tracheal intubation in patients with an unstable cervical spine and cervical immobilization with a halo device.
Pertrochanteric femur fracture is rare in patients with lower leg amputation. Using supracondylar traction takes full advantage of the extension table. Intraoperative insertion of a Steinmann pin for traction is a well-known low-risk procedure. In our opinion, this kind of extension is a simple procedure that carries no risks for postoperative prosthetic management in patients with lower leg amputation.
A retrospective study of 53 consecutive adult patients with 54 femoral shaft fractures treated with Perkins traction over a 25-month period was carried out. Mean length of stay was 52.1 days (range 25-108), and mean duration of traction was 45.0 days (range 23-66). At a mean follow-up of 4.6 months (range 3-9), 50 (92.6%) had healed and 5 (9.3%) had a malunion. There were 4 (7.4%) non-unions, 3 (5.5%) had shortening of more than 2.5 cm and 2 (3.7%) had a re-fracture. The rate of pin tract infection was very high at 42.6% (23 patients).
INTRODUCTION: Some have opined that caudal traction of the spinal cord may result in caudal descent of the hindbrain. MATERIALS AND METHODS: In fresh adult cadavers (n = 12; less than 6 h postmortem) with no CIM, distal tension (75 N) was applied to the conus medullaris with simultaneous observation of the cervical spinal cord, brainstem, and hindbrain and their relationship to the foramen magnum per occipital craniectomy and removal of the posterior arch of C1. RESULTS: After lumbar laminectomy in cadavers, caudal tension on the cord (conus medullaris) demonstrated negligible movement (less than 1 mm) of the caudal brain stem and cervical spinal cord. No movement of the cerebellar tonsils was identified. Moreover, after transection of the lumbar dural cul-de-sac and lumbar spinal dural nerve sleeves, distal traction produced only 2 to 3 mm of caudal descent of the brain stem and cervical spinal cord. Again, no movement of the cerebellar tonsils was visualized. CONCLUSIONS: Our findings in a fresh cadaveric model suggest that it is unlikely that caudal fixation of the distal spinal cord results in inferior displacement of the cerebellar tonsils, and a resultant Chiari I malformation or that transection of the filum terminale may reverse tonsillar ectopia. In vivo animal studies are now necessary to verify our findings.
INTRODUCTION: The lateral pillar (LP) grade changes detected during treatment periods have received a lot of attention recently. Lappin et al. reported LP collapses in 92 of 275 (33%) patients during the treatment, but did not provide information for comparing treatment methods and age of onset of the disease. The purpose of this study was to review radiological changes in LP grade in older patients with Perthes disease during 20 months of treatment with skin traction and ROM exercises. We have also reported any grade changes in the posterior pillar (PP) classification. MATERIAL AND METHODS: Twenty-one patients with unilateral disease who were 9 years or older at the onset of symptoms had been followed until skeletal maturity. RESULTS: Out of 21 older patients with Perthes disease, our study had two (9.5%) who experienced LP collapse and two (9.5%) who experienced PP collapse during the first 20 months of treatment. The average time from onset to hospitalization in hips, initially classified as LP group C and PP group C, was significantly longer than in LP and PP groups A and B. The LP collapse in two hips and PP collapse in two hips occurred during months 4-8 of treatment. On the other hand, of the patients allowed to ambulate with the Pogo stick orthosis from months 8 to 12 and without a brace from months 10 to 15, none had a collapse of their LPs or PPs during these periods. CONCLUSION: Lappin et al. reported that 92 of 275 patients (33%) who were managed conservatively in several hospitals experienced LP collapse during their treatment periods. Our results suggest that older patients with this disease treated with skin traction and ROM exercises rarely suffer a LP collapse, as compared with the Lappin et al. report.
Correction and stabilisation of the scoliotic spine in osteogenesis imperfecta is difficult. The optimal technique has yet to be determined, since no large series in which a single procedure has been carried out by a single surgeon using a single protocol has yet been described. The charts of 20 patients with osteogenesis imperfecta who had undergone halo gravity traction (HGT) and a posterior spondylodesis with Cotrel-Dubousset (n = 18) or Harrington (n = 2) instrumentation were reviewed. No correction was made at the time of the surgical spondylodesis. The average follow-up was 4.8 years (range 2-10.5 years). The preoperative traction improved the Cobb angle of the scoliosis by 32% (from a mean of 78.5 degrees to a mean of 53.3 degrees) and improved the kyphosis by 24% (from a mean of 56.0 degrees to mean of 42.5 degrees). This correction deteriorated slightly at final follow-up, for both the scoliosis and the kyphosis (mean 57.6 degrees and 44.4 degrees respectively). Few complications were encountered during the HGT period. In 16 cases no complications occurred during the follow-up period. Ambulation and functional ability were upgraded for 7 of 20 patients.
We designed a stabilizer to assist us in performing coronary artery bypass grafting on the beating heart. The stabilizer consists of a U-shaped holed platform, an articulating arm, and a clamp for attachment to an ordinary sternal retractor. The target coronary artery is dissected, then two elastic sutures, 15-20mm apart, are wrapped around it, proximal and distal to the anastomotic site. These sutures for traction are passed through holes in the U-shaped platform and tied. This traction immobilizes the target area of the coronary artery. The stabilizer described herein provides good exposure and steady immobilization to enable anastmosis to be more easily performed in the beating heart.
Basilar impression (BI) and hydrocephalus complicating osteogenesis imperfecta (OI) is usually treated by anterior transoral decompression and posterior fixation. Nevertheless, it may be questioned if posterior fusion following axial halo traction is adequate in patients with symptomatic BI complicating OI. We report on a case with progressive symptomatic hydrocephalus and BI complicating OI that was successfully treated by halo traction followed by posterior occipitocervical fusion. However, after a symptom free interval of 2 years the patient suffered from recurrence of symptomatic hydrocephalus needing additional ventriculoperitoneal (VP) shunt placement. In conclusion, posterior fusion without additional VP shunt placement may not be effective in the long term for ameliorating symptoms and signs and halting progressive hydrocephalus in BI complicating OI.
One hundred and sixty-one hips of 145 patients were treated with the Pavlik harness for developmental dysplasia of the hip. The patients were divided into two groups. Group A consisted of 65 patients (70 hips) who were treated between 1980 and 1987. The harness was applied immediately after the diagnosis. Group B consisted of 80 patients (91 hips) who were treated between 1988 and 1992. These patients received preliminary traction, and small pillows supported the lower extremities from just above the knee to the foot to prevent extreme abduction when the harness was applied. When the distance from the middle point of the proximal metaphyseal border of the femur to the Y-line (distance "a") was 8 mm or more on the initial X-ray picture, the rate of avascular necrosis in group A was 11% and that in group B was 0%; the difference was significant. However, when distance "a" was less than 8 mm, the rate of avascular necrosis in group A was 13% and that in group B was 12%, and there was no significant difference. Thus, we suggest that the Pavlik harness is indicated for developmental dysplasia of the hip in which distance "a" is 8 mm or more. Traction should precede application of the harness, and pillows placed under the thigh must be used during application.
Orthodontists are particularly interested in knowing exactly what skeletal and dental changes are produced by headgear. With headgear and fixed appliances, part of the observed change is due to the headgear, part to the fixed appliances, and part to growth. Since the maxillary traction splint moves the teeth en masse, the dentoskeletal changes are due primarily to the headgear force. Selective mandibular dental changes can be produced by adjusting the mandibular occlusal contacts against the splint. In this study forty-seven patients with maxillary dentoalveolar protrusions and Class II, Division 1 malocclusions were treated with orthopedic headgear that attached to a full-coverage maxillary occlusal splint. Fifty-two patients were selected as a control for evaluation of growth changes versus treatment changes. Lateral cephalograms were taken before and after treatment, and the sagittal skeletal and dental changes were evaluated and quantified. The results of the investigation revealed (1) the establishment of a Class I posterior occlusion, (2) a significant overjet reduction, averaging 4.24 mm, (3) inhibition of vertical development of the maxilla and slight intrusion of the maxillary dentition, (4) overbite reduction by leveling of the mandibular dentition, (5) no indication that mandibular growth is accelerated, and (6) no significant increase in the mandibular plane angle. The maxillary traction splint is an effective means of correcting maxillary dentoalveolar protrusion in growing patients prior to fixed appliance therapy. The second phase of treatment with fixed appliances is necessary for individual tooth positioning and for detailing the occlusion.
The problems of transcutaneous tibial pins for skeletal traction in elderly patients are considered, and the reasons behind loosening of the pin are discussed. A novel method of skeletal traction using two pins is proposed.
A simple method is described of treating severely displaced, supracondylar fractures of the humerus in children, and the results are reviewed. Treatment involves the use of overhead traction via an olecranon screw and a traction clip. Of 12 children treated in this way, 11 had excellent results with preservation of the normal carrying angle, and no significant loss of movement in any plane. There were no complications of the treatment and no cases of cubitus varus.
A case of cerebral abscess developing as a late complication of cervical traction by means of Crutchfield tongs is reported and compared with 18 published cases of cerebral abscess after cranial traction with tongs or halo fixation. Penetration of the inner table by the pins of the tongs or halo unit seems to be the main cause of this complication. The literature is reviewed.
Recent publications discussing fractures of the shafts of the phalanges of the fingers discount their management by traction because of possible complications and difficulties of application. A technique using splintage combined with isometric skin traction, used for many years in Southampton, has proved effective and free of complications. The results of the treatment of eighteen consecutive appropriate fractures using this technique are discussed.
A sensitive non-invasive diagnostic test for intrinsic ligament rupture in patients with chronic wrist pain has still to be found. Differential displacement of the scaphoid, lunate and triquetrum can in some instances be seen during arthroscopy of acute wrist injuries and also on overdistraction of distal radial fractures with an external fixator. We performed a prospective study on 20 patients with chronic wrist pain using 2 kg and 5 kg traction radiographs without and with the addition of an ischaemic block, to assess differential displacement as a diagnostic criterion for intrinsic ligament rupture. Arthroscopy was used as arbiter of diagnosis. The sensitivity ranged from 14% to 57% and the specificity ranged from 53.7% to 100% according to the amount of traction and ischaemic block. In view of these poor results we conclude the stretch test has no additional value in the preoperative assessment of chronic wrist pain.
The flexed PIP joint presents a particular problem in the treatment of advanced Dupuytren's disease. Following reports of the use of skeletal traction in the treatment of this condition, a simple device, the "Pipster" was developed to extend the PIP joint by skeletal traction before surgery. In seven fingers in five patients with severe contractures, there was a pre-operative improvement of at least 45 degrees in the flexion angle (measured as maximum achievable passive extension). The technique was effective in primary and recurrent disease. Subsequent surgery was facilitated and amputation avoided in five fingers. The optimum distraction technique was identified. The study continues with more patients.
PURPOSE: To evaluate the technique of tissue traction for the management of severe facial injuries. PATIENTS AND METHODS: Twenty patients, 15 adults and five children, with severe soft tissue facial disfigurement resulting from war injuries were treated by the tissue traction technique. RESULTS: This procedure provides a cosmetically acceptable appearance when used as an immediate measure. A few complications were encountered in delayed cases such as areas of skin breakdown and some stiffness. CONCLUSION: The described technique proved to have several advantages over other more commonly used methods for closure of large wounds.