Section Fourteen Traction Management

PROCEDURE Cervical Tongs or Halo Ring : 101 Application for Use in Cervical Traction (Assist)

Jennifer Massetti PURPOSE: Cervical tongs or a halo ring is inserted into the skull so that weighted traction can be applied to the cervical spine. Cervical traction decompresses the spinal cord and immobilizes and realigns the cervical spine. Realignment and immobilization of the cervical spine may decrease the severity of secondary spinal cord injury. Spinal realignment and immobilization allow spinal fractures and supportive structures to heal properly.

PREREQUISITE NURSING fractures depends on the injury classifi cation and provider KNOWLEDGE or institutional preference. • Tongs consist of a body with one pin attached at each end • The nurse must be knowledgeable about the anatomy and ( Fig. 101-2 ). Tong pins are applied to the outer table of physiology of the spinal column, the anatomy of the cervi- the skull on both sides of the skull. Cervical tongs are cal vertebrae, the spinal cord, the cervical spinal nerves, available in a variety of types, such as Crutchfi eld, and the areas of peripheral innervation. In addition, it is Gardner-Wells, and Vinke tongs. important that the nurse understands the pathophysiology ❖ The shape, features, insertion site, and placement vary and manifestations of spinal cord injury, including ascend- slightly, but the purpose, principles, and care are the ing edema, spinal shock, and neurogenic shock. same. Preference of the physician, advanced practice • The nurse should observe the patient for signs of shock, nurse, or other healthcare professional is an important understand the phases of neurogenic and spinal shock, and deciding factor in choosing the specifi c device to be know the appropriate interventions to implement. used.2,11 • The nurse needs to continuously monitor the patient for ❖ The insertion of Crutchfi eld and Vinke tongs necessi- changes in motor and sensory function during and after tates an incision to expose the skull. Two holes are the procedure. made in the outer table of the skull with a twist drill, • The nurse should continuously assess for changes in res- and the pins are inserted and tightened until there is a piration during the procedure and continue to monitor fi rm fi t. 2,11 while the patient is in traction. ❖ Gardner-Wells tongs are inserted by placing the razor- • Cervical spine traction is provided to realign, immobilize, sharp pin edges to the prepared areas of the scalp and and stabilize the cervical spine when it has become unsta- tightening the screws until the spring-loaded mecha- ble as a result of a cervical spine fracture or dislocation nism indicates that the correct pressure has been caused by trauma or disease, degenerative processes of achieved. To decrease the possibility of tong displace- the cervical vertebrae, or spinal surgery (Fig. 101-1). 3,4 ment, all types of pins are well seated into the outer After initial medical stabilization of the patient and assess- table of the skull and angled inward. 2,6,11 ment and documentation of neurological function, cervi- ❖ Tongs are made of stainless steel or a graphite body cal skeletal traction with the tongs or halo ring can be with titanium pins. The graphite body with titanium applied to realign the cervical spine. Traction is used to pins is compatible with magnetic resonance imaging reduce cervical dislocation before the patient undergoes (MRI). surgery. Occasionally, an unstable cervical spinal injury • Traction can be applied with the use of a rope and may necessitate long-term cervical traction for a period of pulley system or a cable and alignment bracket. Weights weeks to attain realignment and immobilization to stabi- are added gradually and followed with radiographic lize the spine. The defi nitive method used to treat cervical imaging. The physician, advanced practice nurse, or other

904 101 Cervical Tongs or Halo Ring: Application for Use in Cervical Traction (Assist) 905

SAFE ZONE (a)

a.

Figure 101-1 Continuous traction provided by weight applied to Figure 101-3 Placement of halo pins and ring. The anterior a cervical external fi xation device via a rope and pulley system. pins are placed anterolaterally 1 cm above the orbital ridge. This (From McRae R: Practical fracture treatment, ed 2, Edinburgh, “safe zone” avoids the temporalis muscle laterally and an orbital 1989, Churchill Livingstone.) nerve plexus and frontal sinus medially. (From Batte M, Garfi n SR, Byrne TP, et al: The halo skeletal fi xator: Principles of applications and maintenance, Clin Orthop 239:14, 1989.)

molded body jacket. The patient then is able to move while the head and neck remain immobile. A B EQUIPMENT • Tongs or halo ring • Insertion tray, including either the specifi c type of tongs to be used or the halo ring with insertion pins • Local anesthetic: lidocaine, 1% to 2% (with or without epinephrine, depending on the preference of the phy- C sician, advanced practice nurse, or other healthcare Figure 101-2 All three types of cervical tongs consist of a stain- professional) less steel body and a pin with a sharp tip attached to each end. • Needles (18- and 23-gauge) A, Crutchfi eld tongs are placed about 5 inches apart in line with • Sterile and nonsterile gloves the long axis of the cervical spine. B, Vinke tongs are placed on the parietal bones, near the widest transverse diameter of the • Gowns, masks, and eye shields skull. C, Gardner-Wells tongs are inserted slightly above the • Antiseptic solution patient ’ s ears. • Sterile sponges • Sterile drill and bits (for insertion of Crutchfi eld and Vinke tongs) healthcare professional uses serial radiographs of the cer- • Rope and traction assembly for the bed (if a RotoRest vical spine to assist in determining the optimal amount of Delta Kinetic Therapy™ bed is used, a cable and bracket traction (measured in pounds) needed to reduce a fracture alignment system is needed; see Procedure 99) and provide optimal alignment. Excessive traction may • S and C hooks (to attach to the distal end of the rope for result in stretching of the spinal cord and subsequent weight application) damage. 2–4 • Weights to attach to the traction • Cervical traction also may be applied with a halo ring • Torque wrench for the halo apparatus as well as the halo device. This is a stainless steel or graphite ring that is vest if this is the defi nitive treatment attached to the skull by four stabilizing pins (two anterior Additional equipment, to have available as needed, includes and two posterolateral; Fig. 101-3 ). Skull pins can be the following: made of stainless steel, titanium, or ceramic material.1,2,5,7 • Hair clippers Pins are threaded through holes in the ring, screwed into • Emergency equipment the outer table of the skull, and locked into place. Traction can be applied to the ring device with the use of a rope PATIENT AND FAMILY EDUCATION and pulley system or a cable and bracket alignment system. Weights are added gradually. After alignment of • Explain the procedure and the reason for cervical traction. the cervical spine is achieved, the spine can be immobi- Clarify or reinforce information as needed by the patient lized by attaching the ring to a body vest or a custom or family. Discuss use of any special equipment, such as 906 Unit III Neurologic System

a special bed, that may be needed. Rationale: Patient and • Inspect the scalp for abrasions, lacerations, or sites of family anxiety is decreased. infection. Rationale: Any potential sites of infection that • Explain the patient ’ s role in assisting with insertion of the may contraindicate the insertion of a cervical fi xation tongs. Rationale: Explanation elicits patient cooperation device into the infected area are identifi ed. and facilitates insertion. The nonintubated patient should • Assess the level of pain or discomfort and anxiety. Ratio- be communicating with the team during traction if he or nale: Assessment establishes data for decision making she feels any changes in sensation, new or worsening pain, regarding the need for analgesia or anxiolytics for comfort or new or worsening change in motor function. and cooperation during the insertion procedure. • Explain that the procedure can be uncomfortable when • Assess for any allergies to an antiseptic agent, local anes- the incisions are made but that an anesthetic will be thetic, or analgesia and anxiolytics. Rationale: Review of administered by the physician, advanced practice nurse, medication allergies before administration of a new medi- or other healthcare professional. Rationale: This informa- cation decreases the chances of an allergic reaction. tion prepares the patient for what to expect. Patient Preparation PATIENT ASSESSMENT AND • Ensure that the patient and family understand prepro- PREPARATION cedural teaching. Answer questions as they arise, and reinforce information as needed. Rationale: Understand- Patient Assessment ing of previously taught information is evaluated and • Conduct a complete neurological assessment that includes reinforced. evaluation of cranial nerve function, motor strength of • Verify that the patient is the correct patient using two major muscles, sensation (assessment of light touch, pain, identifi ers. Rationale: Before performing a procedure, the and proprioception, noting highest dermatome level), and nurse should ensure the correct identifi cation of the patient deep tendon refl exes (biceps, triceps, patella, and Achil- for the intended intervention. les) and superfi cial refl exes (abdominal and anal wink). • Ensure that informed consent has been obtained. Ratio- Rationale: Baseline data are provided for comparison of nale: Informed consent protects the rights of the patient postinsertion assessments to determine the presence of and makes a competent decision possible for the patient. neurological compromise or extension of spinal cord • Perform a preprocedure verifi cation and time out, if non- injury. emergent. A time out (per institutional practice) should be • Assess the patient ’ s vital signs. Rationale: Baseline performed before placement of cervical tongs or halo ring data are provided for comparison with assessments after and traction. Rationale: Ensures patient safety. insertion. • Ensure that the head of the bed is fl at and that the patient’ s • Assess the patient ’ s respiratory pattern and auscultate lung head is in a neutral position by whatever approved means sounds. Note the use of accessory respiratory muscles and (e.g., hard/rigid collar) have been instituted. Rationale: any signs or symptoms of dyspnea. Rationale: Baseline This measure prevents movement of the neck, which may data are established to determine any compromise to increase the risk of injury or extension of spinal cord respiratory function as a result of the procedure. injury.

Procedure for Assisting With Application of Tongs or Halo Ring for Cervical Traction Steps Rationale Special Considerations 1. Obtain a bed with an orthopedic Traction must be ready to May require assistance from other traction frame, weights, and rope and reduce the potential for departments; therefore, plan ahead pulley system attached to the bed or, movement of the head and to coordinate. if prescribed, obtain a RotoRest neck. Kinetic Therapy™ bed with the wire and bracket alignment device. 2 . HH 3 . PE All healthcare personnel involved in the procedure need to apply personal protective and sterile attire (e.g., fl uid shield masks, eye shields, gowns, and sterile gloves). 101 Cervical Tongs or Halo Ring: Application for Use in Cervical Traction (Assist) 907

Procedure for Assisting With Application of Tongs or Halo Ring for Cervical Traction—Continued Steps Rationale Special Considerations 4. Assist the physician, advanced Facilitates the procedure. Because of the high risk for practice nurse, or other healthcare extension of cervical injury, this professional with tong or halo ring procedure usually is performed by insertion: a neurosurgeon, who can respond rapidly if neurological deterioration becomes evident. A. Assist as needed with preparation Clipping the hair may prevent of the pin sites (clipping a small it from being trapped when area of scalp hair if indicated and the pins are inserted. cleansing with antiseptic solution). Cleansing decreases skin surface bacteria. B. Assist if needed with draping the Aids in maintaining sterility. patient, leaving insertion sites exposed. C. Assist as needed with local Decreases patient discomfort anesthesia administration. during pin insertion. D. Stabilize the patient ’ s head and Maintains alignment of the Cervical stabilization can be neck during the procedure. cervical spine and provides maintained with the use of a rigid support to the injured areas. collar or other devices that prevent head rotation and neck fl exion or extension. A soft collar is not considered a stabilizing device. The head and shoulder packs of the RotoRest Kinetic Therapy™ bed provide some cervical stability but should not be used as the primary means of stabilizing cervical spine fractures before, during, or after tong or halo insertion. Utmost care must be taken to prevent head and neck fl exion or extension. Be prepared for the possibility of respiratory insuffi ciency, respiratory arrest, hypotension, bradycardia or cardiac arrest. E. Carefully follow institutional Institutional policies may Follow institutional policy for policies regarding manual provide strict guidelines for confi rmatory radiographic studies cervical spine immobilization. nursing role in manual following the procedure. cervical spine immobilization during traction placement. 5. Monitor the patient for changes in Identifi es evidence of untoward In addition to untoward effects, the respiratory function, neurogenic effects or complications patient may need additional shock, spinal shock, changes in motor related to the procedure, and reassurance, support, sedation, and function, and changes in sensation and identifi es the need for analgesia. pain. analgesia. 6. Follow hospital policy for pin site Maintains asepsis. care (see Procedure 104 ). 7. Assist with application and connection to traction as needed (see Procedure 102 ). A. Maintain the patient ’ s head in a Ensures accurate and safe use neutral position. of the traction. Procedure continues on following page 908 Unit III Neurologic System

Procedure for Assisting With Application of Tongs or Halo Ring for Cervical Traction—Continued Steps Rationale Special Considerations B. Assist if needed with the Provides assistance. application of prescribed weights. C. Ensure that weights are Ensures safe use of equipment unobstructed and hanging and maintains principles of freely.2,8–11 (Level E * ) traction. 8. Discard used supplies in an Removes and safely discards appropriate receptacle. used supplies. 9 . HH

Expected Outcomes Unexpected Outcomes • Tong or halo ring device inserted • Slippage of tongs or halo pins • Head and neck immobilized to allow for alignment, • Extension or deterioration of neurological defi cits or stabilization, and healing of fractures spinal cord injury • Prescribed amount of weight applied to tongs or halo • Respiratory compromise or arrest • Traction weights unobstructed and hanging freely • Hypotensive episode, bradycardia, cardiac arrest • Improved or stable neurological function (motor and • Pain sensory) • Bleeding at pin site • Patient discomfort minimized

Patient Monitoring and Care Steps Rationale Reportable Conditions These conditions should be reported if they persist despite nursing interventions. 1. Assess neurological status every Facilitates early recognition of • Any deterioration or extension 5 minutes during the procedure, neurological deterioration. of baseline neurological function including assessment of level of Bitemporal tongs may interfere with • Increased or new loss of consciousness, movement in arms mastication and eyelid closure.2,5,7 sensation and legs, sensation, mastication, • New or worsening decrease in and eyelid closure.2,5,7 (Level E) motor strength 2. Assess respiratory function Early identifi cation of hypoxia or • Changes in respiratory function (respiratory rate, pulse oximetry, respiratory distress from (e.g., decrease in oxygen

lung sounds) before, during, and neurological deterioration or other saturation [Sao 2 ], increase in end after the procedure. potential complications such as tidal carbon dioxide [Et co2 ]; aspiration or sedation. increase or decrease in Decrease in peripheral oxygen respiratory rate, abnormal lung saturation may be an early indicator sounds) of respiratory compromise. • Oversedation 3. Assess for neurogenic shock. Neurogenic shock can occur rapidly • Hypotension and requires prompt intervention. • Bradycardia • Decreased vascular tone • Hypoxia • Poikilothermia 4. Provide emotional support and Decreases anxiety and facilitates • Unrelieved anxiety reassurance to the patient during patient cooperation. the procedure.

* Level E: Multiple case reports, theory-based evidence from expert opinions, or peer-reviewed professional organizational standards without clinical studies to support recommendations. 101 Cervical Tongs or Halo Ring: Application for Use in Cervical Traction (Assist) 909

Patient Monitoring and Care —Continued Steps Rationale Reportable Conditions 5. Monitor pin sites for hemostasis The scalp is vascular, and continued • Unresolved bleeding immediately after the procedure, bleeding may occur at the pin sites every 15 minutes × four, every 30 that requires assessment and minutes × two, and hourly, or as cleansing.5,6 indicated by institutional policy. 6. Check the security of the traction, The traction frame is attached to the • Break in the integrity of the bed frame, and bed. bed and must be secure. traction equipment or the bed frame 7. Maintain the patient ’ s head fl at The head must be fl at on the bed to • Neck or head out of neutral on the bed and ensure that the maintain a neutral position. alignment bed is fl at. The head of the bed Countertraction is often provided to frame may be on shock blocks or prevent the patient from being placed in reverse Trendelenburg ’ s pulled toward the top of the bed. position to provide countertraction.8,9 8. If the knot on the traction rope The knot of the traction rope must • Evidence of loss of effective nears the pulley or the wire band not be resting against the pulley for traction nears the bracket, several effective traction. The cover over physicians, advanced practice the wire and bracket alignment nurses, or other healthcare device must not be against the professionals may slowly pull the alignment screw (head of the bed) patient down in bed. The patient for effective traction. should never be pulled up in the bed or traction will be released. Do not remove the weights to move the patient toward the foot of the bed.8–11 (Level E * ) 9. If cervical traction is lost for Immediate intervention is needed to • Changes in motor and/or sensory whatever reason (e.g., the loop in immobilize the patient’ s head and assessment traction rope holding the weights neck. • Changes in respiratory effort, slips or the pins dislodge), signs of respiratory distress maintain manual cervical spine • Evidence of loss of effective immobilization, place the patient traction in a hard/rigid cervical collar, and notify the physician, advanced practice nurse, or other healthcare professional. Elicit the patient ’ s cooperation to minimize extraneous movement. 10. Prepare the patient for a bedside A radiograph is taken to verify • Abnormal radiographic results confi rmatory radiograph of the alignment of the cervical spine. cervical spine immediately after insertion and application of weights and as prescribed by the physician, advanced practice nurse, or other healthcare professional.

* Level E: Multiple case reports, theory-based evidence from expert opinions, or peer-reviewed professional organizational standards without clinical studies to support recommendations.

Procedure continues on following page 910 Unit III Neurologic System

Patient Monitoring and Care —Continued Steps Rationale Reportable Conditions 11. If additional weights are added or Monitors for possible risk of • Changes in motor and/or sensory removed by the physician, secondary spinal cord injury. assessment advanced practice nurse, or other • Changes in respiratory effort, healthcare professional in an signs of respiratory distress attempt to realign the cervical spine, increase the frequency of neurological checks. Expect more frequent cervical radiographs or MRIs to verify alignment. 2,3 12. Follow institutional standards for Identifi es need for pain interventions. • Continued pain despite pain assessing pain. Administer interventions analgesia as prescribed.

Documentation Documentation should include the following: • Patient and family education • Ongoing comprehensive assessment data and action • Completion of informed consent taken for abnormal response • Preprocedure verifi cations and time out • Verifi cation of proper functioning and security of • Type of cervical traction applied traction equipment • Date and time traction is applied • Documentation of radiographic confi rmation of • Local anesthetic used alignment • Sedation and analgesia used • Occurrence of unexpected outcomes • Amount of weight applied to the traction • Patient response to care • Weights hanging freely • Additional interventions • Pins secure • Pain assessment, interventions, and effectiveness • Appearance of pin-insertion site and care

References and Additional Readings For a complete list of references and additional readings for this procedure, scan this QR code with any freely available smartphone code reader app, or visit http://booksite.elsevier.com/9780323376624 .