Gardner-Wells Tongs

Introduction
In 1933, Crutchfield introduced the use of cranial tongs for cervical traction . These tongs
required pin placement near the cranial vertex, which limited the amount of traction that could
be safely applied . In 1973, Gardner improved on the system described by Crutchfield by
creating tongs with cranial pin angulation for improved skeletal fixation5 (Fig. 1). These
larger GardnerWells tongs did not require placement close to the vertex of the skull, and the
tapered pin design allowed for greater force application without penetration of the inner table
of the skull.1

Fig. 1 Photograph showing Gardner-Wells tongs. The tapered-pin design allows for greater force application
without penetration of the inner table of the skull. Pins are angled toward the vertex of the skull and are placed
below temporal ridges to maximize the strength of the pin-bone interface and to reduce the chance of pin cut-out
with large traction weights.

Tongs most commonly consist of pins that are placed through the outer table of the skull at a
point 1 cm above and in line with the pinna bilaterally (Fig. 3, A); a third pin can be inserted
for greater control of flexion and extension. Pin placement anterior to the pinna will place the
head in relative extension, whereas pin placement posterior to the pinna will produce flexion
(Fig. 3, B).2
Fig. 2 Fig. 2A Illustration showing tong position placed 1 cm above the pinna.Fig. 2B Anterior tong placement
leads to relative neck extension, whereas posterior placement leads to neck flexion. 2

Application of Gardner-Wells Tongs

Fig 3. Photograph showing Gardner-Wells tongs

The optimal location for pins is 1 cm above the pinna of the ear, in line with external auditory
meatus and below the equator of the skull (Fig 3).3
 A pin that is too anterior will place the temporalis muscle and the superficial temporal
artery and vein at risk.
 Pins proximal to the equator of the skull can pull out with traction.
 Fig 4 A-B Proper pin location for Gardner-Wells tongs

 Prep the area with povidone iodine solution or alcohol. If patient is awake during
application of the tongs, infiltrate the skin down to the skull with several milliliters of
0.5% Marcaine with epinephrine.
 Tighten the pins sequentially, going from side to side to evenly tension them, until the
spring-loaded indicator protrudes 1 mm above surface, equal to about 30 lb of force.
 An anterior pin applies a flexion moment to the cervical spine.
 A posterior pin applies an extension moment to the cervical spine.
 Rope is tied to the S hook and passed over a fulcrum at the top of the bed. Weight is
tied to the other end of the rope hanging from the bed as needed.
 An average head weighs around 10-13 lbs. Therefore, this is a reasonable
amount of weight to initiate traction.
 Weight is gradually added as needed, carefully assessing neurologic status and
taking x-rays to verify position.

Gardner-Wells tongs, which constitute of two pins, pointing upward (towards the vertex of
the head), to be placed below the temporal ridge, bilaterally. In both cases, careful pinning is
to be applied with a torque pressure of 2 lb to 4 lb in the pediatric population, and up to 8 lb in
adults.4
Mechanical traction requires a 0-degree angle pull for C1 and C2 pathologies, and a 20-degree
angle flexion for below C2 cases. Moreover, the force applied during pull tension must not
exceed 10 lb in cases of C1-C2 subluxation, but can otherwise increase up to 45 lb. Some
practices require a gradual increase of the pull tension, while others prefer choosing the lowest
weight inciting an effective response.4
Fig.5 Flowchart demonstrating clinical strategies to manage cervical trauma using Gardner-Wells tongs. 4
Patient position

Preferred setting
o emergency room, operating room, ICU for close observation and frequent
fluoroscopy/radiographs

Patient position
o supine with reverse trendelenburg or use of arm and leg weights can help
prevent patient migration to the top of the bed with addition of weights.

Sedation
o small doses of diazepam can be administered to aid in muscle relaxation however patient
must remain awake and able to converse

Pin placement

Pin placement (Gardner-Wells pins)

o pin placement is 1 cm above pinna, in line with external auditory meatus and below the
equator of the skull.
 if the pin is placed too anterior, the temporalis muscles and superficial temporal
artery and vein are at risk
 an anterior pin will apply an extension moment to the cervical spine
 if the pin is placed too posterior, it can apply a flexion moment to the cervical spine.
 a posterior pin with a flexion moment may facilitate reduction of a facet dislocation.

Pin tightness
o On Gardner-Wells tongs, pins are tightened until spring loaded indicator
protrudes 1 mm above surface
 this is the equivalent of 139 newtons (31 lbs) of force
 overtightening by 0.3 mm leads to 448 newtons (100 lbs)
 failure of temporal bone occurs at 965 +/- 200 newtons (216 lbs)
 note Mayfield pins are tightened to 60 lbs
o overtightening of the pins can result in penetration of the inner table of the
calvarium
 this may cause cerebral hemorrhage or abscess

Pin strength
o stainless steel pins have higher failure loads than titanium and MRI-compatible
graphite and should be used with traction of > 50lbs.
Indication
1. Spine trauma and spinal deformity
Tong or halo traction is most often used for the treatment of cervical spine trauma and
spinal deformity. Tongs are temporary devices. When longer-term traction is needed, a
halo ring is utilized.
Traction also may be used for temporary immobilization and stabilization while a patient
awaits definitive fixation.

2. Cervical Facet Dislocation

Unilateral or bilateral cervical facet dislocation in an awake and cooperative patient is
typically treated with an initial attempt at closed reduction followed by internal fixation. 5
Traction with use of Gardner-Wells tongs is an effective means of reducing dislocated
facets, with reported success rates of as high as 80%. 6 A slightly posterior pin position
provides for neck flexion, which can aid facet relocation. A pad placed under the head,
with the pulley positioned anterior to the tongs, also can facilitate unlocking of the facets.
Commonly, traction is initiated at 10 lb (4.5 kg), followed by sequential increases of 10 to
15 lb (4.5 to 6.8 kg) every few minutes. A lateral cervical radiograph is made after each
weight increase to monitor spinal alignment and occipitocervical joint congruity, and a
thorough neurological examination is performed after the initial application and after each
subsequent weight increase. The weight must be immediately decreased if over
distraction is identified or neurological symptoms or signs develop.

3. Traumatic Spondylolisthesis of the Axis (Hangman Fracture)

Treatment of a displaced hangman fracture (traumatic spondylolisthesis of the axis) with
traction reduction followed by halo-vest immobilization has been well described.
However, there is a difference between the treatment of Type-II and Type-IIa fractures as
characterized by Levine and Edwards. Type-I fractures are characterized by ,3 mm of
horizontal displacement, with no angulation and an intact C2-C3 disc and ligaments.
Type-II fractures result from hyperextension-axial loading forces followed by flexion and
are characterized by anterior translation of C2 by 3 mm and angulation of .10°. Type-IIa
fractures result from flexion-compression forces and are associated with substantial
angulation but minimal anterior translation of C2 over C3. Type-III fractures are
characterized by all of the characteristics of Type-II fractures, with the addition of
bilateral facet dislocation.While most Type-II injuries can be treated with traction
followed by halo-vest immobilization (Fig. 5), the traditional teaching is that traction
should be avoided for Type-IIa injuries because of the potential for increased fracture
displacement and neurological injury with traction. Instead, gentle cervical spine
 extension followed by compression in a halo vest may be used for the treatment of Type-
IIa injuries. Type-I injuries are typically treated with collar immobilization, whereas
Type-III injuries require open reduction and internal fixation. More recently, Gardner-
Wells tong traction with weights of 5 to 15 lb (2.3 to 6.8 kg) followed by halo-vest
immobilization has been described for both Type-II and IIa fractures. 7 Traction resulting
in a pure axial tensile force should be avoided for Type-IIa fractures, which should
instead be treated. with a traction force vector that will produce extension at the fracture
site. In a retrospective study of twenty-seven patients with Type-II fractures and four
patients with Type-IIa fractures, the patients with Type-II fractures who had 12° of
fracture angulation tended to have a failure of maintenance of the initial traction
reduction, whereas no patient with a Type-IIa fracture had a failure of maintenance of
initial traction reduction.8

4. Atlanto-Axial Rotary Subluxation

Atlanto-axial rotatory subluxation is a cause of childhood torticollis and may occur as a
consequence of a variety of etiologies. Atlanto-axial rotatory subluxation can be
idiopathic, can result from trauma, or can occur in association with upper respiratory tract
infection (Grisel syndrome).9 It can also occur in association with congenital conditions
such as Down syndrome, Morquio syndrome, or Marfan syndrome. The treatment of
torticollis due to atlantoaxial rotatory subluxation in children can involve a combination
of analgesic medication, soft cervical collar or fourpost bracing, halter or skull traction,
and, if conservative measures fail, C1-C2 arthrodesis. The order and duration of each of
these measures varies depending on the extent to which the subluxation improves with
each intervention. A soft cervical collar in addition to analgesic medication and physical
therapy may be initially attempted in acute cases. When deformity correction is not
achieved within first two weeks of nonoperative therapy, traction is typically initiated.
Favorable results have been reported in association with an extended period of halter
traction lasting for as long as six weeks, followed by collar application for one to six
months. In cases in which halter traction is unsuccessful or is not tolerated, immediate
C1-C2 arthrodesis may be performed, but, more frequently, a trial of skull traction (halo
or GardnerWells) is attempted for as long as two months before proceeding to C1-C2
arthrodesis.10

Contraindications

Contraindications to the application of skull traction in cervical spine injuries will include
distractive injuries, associated skull fracture, local sepsis, and stable fractures, especially
without neurological signs when only collar or other forms of bracing may suffice.11
Complication

One study in the literature reported a complication rate of skull traction. In a study of 16
patients, complications were observed in 6 (37.5%) patients. These complications included
loosening of the pins (3; 18.8%), asymmetrical positioning of the pins (2; 12.5%), and
superficial infection (1; 6.3%). However, this author concluded that “no serious complication
was noted, but the marked protrusion of the screws made turning to the full lateral position
difficult”.12

Perhaps the most serious complication observed is perforation of the pins through the skull.
Incidence rates of this complication are not available in the literature, but rather, cases are
sporadically reported. The first such case occurred in 1984; on day 35 of traction, the patient
felt sudden, severe pain at the pin entry site. Radiography performed revealed that one of the
pins had perforated the inner table of the skull by 5 millimeters (mm). However, the patient
did not develop any neurological deficits or infections, but was treated prophylactically with
antibiotics. Another similar case was reported in 1996; on day 37 of traction, the pin entry site
appeared mildly inflamed. On day 42, the patient reported a headache, vomiting, and fever.
Radiography revealed that the pin had penetrated 5 mm into the inner table of the skull.
Shortly thereafter, the patient had transient episodes of contralateral weakness and numbness.
Neurology was consulted, and these symptoms were attributed to a transient ischemic attack,
with complete resolution by his four-month visit . There were no studies of cranial perforation
during acute reduction . One study utilized cadaveric samples to examine the force necessary
to penetrate the inner table of the skull. They reported that the average weight necessary for
perforation of a properly placed pin was 162 lbs far exceeding the 140 lb maximum weight
utilized clinically.12

Whereas perforation is uncommon, loss of attachment of the pins appears to be more common
and more widely cited in the literature. It was reported that loss of attachment, or “pull-off,”
generally occurred days to weeks following initial traction . This phenomenon may be due to
resorption of the bone underlying the pin due to pressure or infection . One study investigated
the mean weight needed to pullout the pins. For a stainless steel pin, an average of 225 lbs
was necessary, which is significantly more than the acceptable weight for clinical settings.
Pull-out was observed with MRI-compatible tongs at mean weights of 75 lbs.12

Brain abscess is another rare complication of GWT. Although an incidence rate pertaining
specifically to the use of these tongs is unavailable in the literature, it is estimated that
abscesses occur in 0.4–0.7% of cases utilizing any method of cervical traction. The abscess is
usually caused by a superficial skin infection which tracts through the pin entry site, thus
causing a brain abscess. This may occur when the pins loosen and are retightened, as this
allows entry of bacteria through the pin entry site. Sterile dressing and pin site care are
considered good preventive measures.12

Neurovascular complications, although rare, have been reported in the literature as well. There
is one case report available regarding the development of a transient Abducens Nerve (CN VI)
palsy following cervical traction with GWT during surgery. Following surgery, the patient
complained of diplopia and was found to have a CN VI palsy. His symptoms completely
resolved 6 months post-operatively. Complications with other cranial nerve palsies, including
CN IX, XI, and XII, have been reported with other types of cervical traction (i.e., halo), but
not with GWT.12

Vascular injury with GWT has also been reported. One case report describes a laceration of
the superficial temporal artery. Cervical traction was applied during surgery with GWT; 10
weeks post-operatively, the pin insertion site did not heal, and the patient experienced
intermittent pulsatile bleeding through the eschar. It was determined that he had suffered a
laceration to the superficial temporal artery, likely secondary to improper placement of the
pin. The tongs are generally placed 1–2 cm posterior to the course of the superficial temporal
artery, just above the pinna. Bleeding is not unusual with the use of GWT, but it often
subsides spontaneously in a short amount of time.12

Alternative of GWT

1. Head Halter Traction

The head halter device provides a noninvasive means of applying traction to the cervical
spine. Indications for head halter traction include atlantoaxial rotatory subluxation
(AARS), stable cervical fractures, and conservative management of neck pain and
cervical radiculopathy. The head halter devices consists of two pads, placed under the
chin and occiput attached to a rope connected to a pulley and weights. The device may be
used in the inpatient setting or at home, though the patient must have the pads properly
fitted to ensure even distribution of force to both pads.
In a study of 40 children with AARS, treatment with a cervical collar was effective in
reducing subluxation in 21 patients, and of the 7 patients requiring halter traction, 4
patients demonstrated progression of subluxation and required halo traction. In a study of
14 children with acute AARS, all patients experienced spontaneous reduction with a
cervical collar and bed rest without the need for halter traction, suggesting that most
patients with acute AARS do not require halter traction to achieve reduction.
In a retrospective review of 81 patients with cervical radiculopathy treated with 8 to 12
pounds of halter traction applied for 15 minutes three times per day for 3 to 6 weeks, 78%
of patients experienced significant or complete resolution of painful symptoms. Halter
traction may also be used to reduce stable cervical fractures. In a study of 20 patients with
traumatic spondylolisthesis, fracture union was achieved at a mean of 13 weeks.13

2. Cranial Halo

The halo device includes a ring that utilizes four-point skeletal fixation used to apply
weighted traction in a manner similar to Gardner-Wells tongs. The four-pin design of the
cranial halo allows it to support greater traction loads, and greater force is required to
detach pins than with two-pin systems. Different manufacturers may have different
specifications of the maximum amount of weight that may be applied with a halo ring
fixator. The cranial halo can be attached to a rigid vest once spinal reduction has been
confirmed in order to provide cervical spine stabilization while the patient is mobile.
Prior to applying the halo ring, the patient’s head circumference is measured and a halo
ring that provides 1 to 1.5 cm of clearance from the scalp is selected. A local anesthetic
solution is injected in the location of the four pin sites before the pins are applied to the
outer table of the skull. The anterior two pins should be placed 1 cm superior to the
eyebrow with care taken to avoid injuring the supraorbital nerve. The posterior pins are
placed 1 to 1.5 cm superior to the ears bilaterally. While an assistant holds the head in
place, hexagonal lock nuts are placed outside the ring before the four pins are threaded
through the ring in a manner perpendicular to the skull until the pins penetrate the outer
layer of the dermis. Care is taken to not shift the pin locations during tightening by
tightening two diagonally opposed pins at a time until the pins have engaged the outer
table. Diagonal sets of pins are then tightened alternately with a torque wrench to 8 inch
pounds. Pin torque above 10 inch pounds is associated with increased risk of penetrating
the inner table and should be avoided. After this has been achieved with each pin, the nuts
are threaded into place against the halo ring to prevent the pins from backing off the outer
table. After 24 hours, the hexagonal nuts are loosened and the skull pins are retorqued to
8 inch pounds. As pin site infection is one of the most common complications of the halo
device, pin sites should be treated daily with an antiseptic solution such as bacitracin or
dilute hydrogen peroxide. Other complications of cranial halo include pin loosening,
cranial nerve injury, bradycardia in children, and penetration of pins through the inner
table, which can lead to pneumocranium.13
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