SEQUENTIAL REDUCTION PROTOCOL FOR CERVICAL FRACTURE DISLOCATIONS USING THE VECTOR PRINCIPLE

Abstract

Introduction Management of cervical fracture-dislocation varies greatly. When using closed reducition it is not known what are the upper limits of skeletal-traction, the indications and approach of surgery. This study was done to evaluate a stepwise closed reduction protocol using vector principles and define the upper limit of weight tolerated by skeletal traction and manipulation under anaesthesia

Methods This study includes 47 patients of traumatic tetraplegia reporting within three weeks of injury. A sequential protocol was followed using the vector principle for closed reduction by skeletal traction. To begin with, three bricks (18.42 pounds) sustained traction was applied keeping the vector in flexion for five to six hours. This was followed by straightening of the spine and observing realignment. Check x-rays were taken. Acceptable reduction were maintained in extension. If reduciton was unacceptable, weights were added in one brick (6.14 pound) increments and sequential steps repeated. Vector angle in flexion, neutral and extension was easily maintained with bolsters, neck rolls and balancing bar. Manipulation under anaesthesia was tried when this protocol failed

Results Reduction was achieved in 41 of 47 (87.22%) within 24 hours. Maximum weight needed was six bricks (36.84 pounds). All irreducible dislocations showed symptoms of cord stretching when higher weights were applied in terms of pain, dizziness, nausea and hypotension with neurological deterioration in two. Maximum weight that could be tolerated was only up to 28% of body weight. MUA was associated with high risk because of compromised cardio-pulmonary status in majority. It was tried only when this protocol failed in four of six unacceptable reductions. In all four reduction could not be achieved by MUA and they required open reduction. Two patients did not give consent for MUA and for surgery and remained unreduced. Distal neurological recovery was seen in 23.33% of complete and 88.23% of incomplete cases. Rapid root recovery at the site of cord injury was seen in all 47 patients suggesting zonal segmental recovery. Pain function score as per Porlo’s scale was satisfactory in 43 of 47 patients. Loosening and infection at pin site was observed in four. Two patients who deteriorated neurologically on increasing the weights of skeletal traction recovered to initial level within a week when weights were brought back to tolerance limits.

Conclusions Cervical fracture-dislocations can easily be reduced without the need of heavy traction if traction is applied on vector principles. Manipulation under anesthesia with associated risks seem to have no advantage over reduction by this protocol.