Vernon L. Nickel

Complications in the Use of the Halo Fixation Device

The medical records of 179 patients were reviewed to identify complications related to the use of the halo external skeletal-fixation device. The complications that were identified included pin-loosening in 36 per cent of the patients, pin-site infection in 20 per cent, pressure sores under either a plastic vest or a plaster cast in 11 per cent, nerve injury in 2 per cent, dural penetration in 1 per cent, dysphagia in 2 per cent, cosmetically disfiguring scars in 9 per cent, and severe pin discomfort in 18 per cent. One hundred and eighty (25 per cent) of the 716 pins used had become loose at least once, and an infection had developed at sixty-seven pin sites (9 per cent). Two-thirds of the pins that were loose or associated with infection required change or removal. These complication rates, particularly of pin-loosening and infection, are exceedingly high. Attention to details in pin application, pin maintenance, and proper pin-site care may minimize the number of complications.

Recovery of Motor and Intellectual Function in Children Sustaining Severe Head Injuries

Forty‐six patients aged from 2 to 18 years were evaluated 1–7 years after sustaining severe head trauma. The average duration of coma in this series was 7 weeks.

The halo. A spinal skeletal traction fixation device.

Experience with 204 patients has demonstrated that the halo traction apparatus is a safe, effective method of traction and immobilization for the cervical and upper thoracic spine. The unit, its application, and its management are described in detail.

Spasticity and contracture. Physiologic aspects of formation.

Disruption of the upper motor neuron inhibitory pathways by stroke, brain trauma, or spinal cord injury leads to muscle spasticity. Spasticity is characterized by increased muscle tone, hyperactive reflexes, and possible clonus or rigidity. The increased muscle tone may result in loss of joint motion, leading to contractures. Treatment of established contractures is difficult. Prevention of contractures by joint mobilization is emphasized as a goal in the management of patients with spasticity.

The halo vest: an evaluation of motion and forces across the neck.

Flexion-extension motion and compression-distraction forces across the cervical spine were evaluated in 6 patients in halo vests and in 1 patient in a halo cast. Motion in the vest was evaluated in supine and upright positions and averaged 31% of normal motion at the levels tested. Compression-distraction forces showed great individual variation and frequent compression. The average distraction force varied in different positions by nearly 20 pounds in the vest and over 30 pounds in the cast. Methods of improving cervical spine stability in halo orthoses are discussed.

Surgical Treatment of the Painful Shoulder Contracture in the Stroke Patient

Spastic hemiplegic patients are frequently afflicted with painful shoulder contractures. Although most patients will respond to a limited exercise program and mild analgesics, there are some patients who continue to demonstrate increasing localized shoulder pain associated with spasticity of the internal rotator mechanism. These patients can be assisted with surgical release and an immediate postoperative exercise regimen. The results of such a program designed to diminish pain and increase range of asymptomatic motion are presented.

Cast-brace Treatment for Fractures of the Distal Part of the Femur: A Prospective Controlled Study Of One Hundred And Fifty Patients

1. A total-contact, lower-extremity plaster device incorporating brace-joints at the knee has been described for the early ambulatory care of healing fractures in the distal part of the femur. 2. Prospective study of consecutive cases has demonstrated no non-unions or refractures in 150 patients treated with traction followed by early mobilization in a cast-brace and a mean healing time of 14.5 weeks. In a similar but smaller group of fractures treated in the traditional manner by preliminary traction and then immobilized in a spica cast, there were three non-unions, and three refractures occurred after longer periods of immobilization. 3. The factor considered most important for rapid and efficient fracture healing is an environment of function for the healing fracture. Ambulatory function is possible with an unfixed healing fracture of the distal part of the femur when appropriate total-contact support to the limb is provided.

Electrically Powered Orthotic Systems

Electrically powered orthotic systems have been devised at Rancho Los Amigos to provide quadriplegic and other severely paralyzed patients with mobility and voluntary hand movements. The equipment necessary to fit a totally paralyzed patient for maximum restoration of upper extremity function includes an electric wheelchair, a Rancho electric arm with a flexor hinge hand splint and a Rancho tongue control switch to operate the arm and drive the wheelchair. Externally powered devices have been made available to 176 patients with two known failures. The equipment has proved reliable and can easily be attached and removed by untrained personnel. Details as to patient selection and patient fitting are given. A case report is included illustrating the benefits to be derived from the use of the equipment.

Osteology of the skull as it affects halo pin placement

Twenty-seven cadaver skulls and 20 CT scans of skulls were measured above the orbital rim and ear but below the greatest diameter to determine optimal placement of halo pin sites. At the antero- and posterolateral portions of the calvaria, the outer table averaged 2 mm, the diploe 3 mm, and the inner table 2 mm. At the temporal fossa, the outer cortex averaged 1.7 mm, the diploe 2.0 mm, and the inner table 1.6 mm. Average distance between the anterior edge of the temporal fossa and the frontal sinus approximated 3 cm. These data confirm previously recommended halo pin insertion sites, anterolaterally and posterolaterally, where the bone is thickest and the thinner frontal sinus and temporal fossae are avoided.

The Orthopaedic Management of Brain-Injured Children

This survey emphasizes the important role the orthopaedic surgeon plays in the treatment of brain-damaged children. In one institution in ten years, 122 brain-damaged children were admitted and 112 were evaluated: 21 per cent walked in the first year after injury, and 83 per cent walked at the time of final evaluation; 68 per cent of the patients had joint deformities on admission, and 8 per cent had joint deformities at discharge. Scoliosis occurred in four patients, limb-length inequalities in three, and ectopic ossification in six. The problems of management of a total of sixty-nine fractures were described. Internal fixation was necessary in two of the fractured femora and would have been advisable in a third.