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An improved halo for fixing facial fractures
British Journal of Plastic Surgery (1972), zS, 4o7-4'Io
AN I M P R O V E D HALO FOR FIXING FACIAL F R A C T U R E S By JOHN GROCOTT,F.R.C.S.
North Staffordshire Royal Infirmary, Hartshill, Stoke-on-Trem TRAUMATIC maxillary displacement in most cases is posterior and downwards in direction. The maxillary block slides under the curving base of the skull and comes to lie in the open bite position with varying degrees of posterior shift and impacfion. This position is often forcibly maintained by the spastic contraction o f the injured pterygoid muscles, the externus pulling the block towards the temporomandibular joint and the internus aided by the masseter muscle pulling the back of the block closer to the descending ramus of the mandible. In the majority of cases this displacement is easily corrected by manipulation under general anaesthesia and the maxilla can be held in the corrected position by a light halo apparatus in the usual way. There are, however, cases that do not respond so readily ; some early ones and nearly all late ones. After a few days an unreduced fracture becomes daily more firmly fixed and continuous traction rather than forcible disimpaction becomes the only way to effect reduction. This has led to the development of a halo which can exert pressure on the displaced maxilla in any direction through the medium of two self tapping screws inserted in the premaxilla (Grocott and Wilson, I972). A number of different frame types were tried ; that finally selected is an adjustable but rigid structure which gives access to the vault of the skull and is comfortable to the patient in bed. Necessarily this means a heavier structure than the standard halo but the weight has been progressively reduced to about 350 gm. by the use of light alloy. The frame (Fig. I) consists of a horizontal metal platform conforming in contour to the forehead and adjustable side arms pivoted at the outer ends of the platform. The platform itself carries 2 insulating blocks or bushes which in turn carry the stainless steel frontal screw pins (Fig. 2). In the centre of the platform is a ball or universal joint which forms the pivot for a vertical extensible beam dropping down to the maxillary attachment. The joint is fully adjustable by screws so that the beam may rotate and swing in an antero-posterior or lateral direction in any combination. The pivoted side arms are adjustable by screws and can be locked in final adjustment by nut and bolt. They are drilled and can carry vertical arms if desired. The posterior ends are slotted to carry the nylon insulated bushes which hold the mastoid screw pins. It is very advantageous to have as short a length of screw pin as possible between the frame and the skull. This ensures greater rigidity and obviates movement of the pin carriers or bending of the pins under stresses tangential to thc ~t'ull The skull strong points selected for insertion of the pins are on each temporal ridge area and each mastoid area at the level of the floor of the anterior fossa. The pin holders are first adjusted for position and then the angles are set for radial contact with the bone. The clamp is applied so that the mastoid pins register just in front of the mastoid suture line with the occipital bone; there is a depression here which is easily felt behind the ear. The lateral arms are tightened until the pins register against the bone in the depression. The pins, which are hollow ground, are screwed in a few turns until the whole clamp can be hinged up and down with the frontal pins just clearing the forehead. The frontal pins are now screwed home to register just above the superciliary ridges and just medial to the temporal ridges of the frontal bone. When these and the mastoid pins are tightened the platform is solidly fixed to the base of the skull. 4o7
408
BRITISH JOURNAL OF PLASTIC SURGERY
FIG. I. Most adjustments are made by 2BA hexagon headed bolts and a tubular box spanner is used. Adjustment is effected by slackening the opposing bolt, tightening the acting bolt and then retightening the opposer. This gives accurate fine adjustment without backlash. In some cases the threaded bolt acts as a screwed pivot, for example B2 for the vertical beam and A-A screws for the beam carrier. Screw and A-A B2 BI C-C D-D E F-F p-p-p-p
Bolt Code Pivots for the beam carrier adjustment for the sideways movement of the beam. Adjustment to move the beam antero-posteriorly. B2 is beam main pivot. Bolts to adjust rotation of beam carrier about pivot bolt G. Bolts to tighten and close side beams of halo on to skull about pivots L. These are locked when adjustment is complete. One long 2BA screw to adjust beam length. 2BA screws with locking nuts to tip or tilt the alloy plate which grips the premaxillary pins by the universal joints J, which have slotted tips for use with screw driver. Stainless steel screw pins with hexagonal head fitting universal joint spanner (see Fig. 2).
AN I M P R O V E D H A L O FOR F I X I N G F A C I A L F R A C T U R E S
409
The connection to the pins in the maxilla is made by a square beam of German diver attached to the universal joint in the centre of the platform. The square tube -arries a sliding square German silver rod in its lower end which can be adjusted for ength. The solid rod carries a triangular light alloy plate with the apex of the triangle pivoted on to the rod by a spring loaded pivot giving a limited range of rocking or Lipping movement to the plate and allowing antero-posterior and lateral tilt of the maxilla to be corrected. The triangular plate has 2 slots just forward of the base which carry normal universal joints with slightly heavier tightening screws. They are attached to the alloy plate so that the corrugated face of the joint can grip the metal of the plate when the joints are tightened up. LONG SECTION _~Nut
and washer clamping
E ...
~
-
,
.::7
-
-
~
3 I---_
/
1
6
Whit.stainless screw hollow ground point
//////2//////7"/tl
Steel tube brazed to 1/4 Whit. flat headed screw with pressed in nylon bush threaded 3/16Whir. FIG. 2
After the platform has been fixed the alloy plate is connected to the maxillary pins and reduction begun. Occasionally if the maxilla is very displaced and very fixed as much disimpaction as possible should be obtained before fixation to the frame. Complete reduction of the fracture to normal position and bite may take several days. The screws can be adjusted daily just up to the patient's limit of tolerance of pain. Usually after 3 or 4 days the position is greatly improved. The common open bite defect can be overcome by lengthening the beam--by putting a forward pull on the maxilla by the screw adjustment on the platform and by tipping the alloy plate. This type of frame can also be used to deal with depressed fractures of the bridge of the nose involving the medial walls of the orbit. Such fractures involve a great deal of comminution of the bones and the small fragments are almost impossible to deal with individually. In my experience it is preferable to provide a fixation which will mould this mush of tissue into a reasonably normal shape and then to reposition it by means of traction, so that approximately normal anatomy is restored. Large lateral lead plates, shaped and smoothed so that there are no sharp edges to cut the covering skin are held in place by through and through sutures and used to mould the nose. A small saddle attached to the descending beam of the halo carries 2 stainless steel rods of the usual ~- inch diameter with nicely rounded ends which are passed into the nose so that they run along the vault of each nasal cavity. The plates .and their through and
41o
BRITISH JOURNAL OF PLASTIC SURGERY
through sutures lie behind the rods. Elevation of the rods gives very adequate lift to the depressed naso-orbital block (Fig 3). Rods may also be attached to the side arms for fixation of certain malar fractures.
SCHEMATIC N A S A L BLOCK TRACTION
! • (a) Section of nose
(b) Side elevation: Stainless rods curved to attach to universal joints on a carrier on the long vertical beam
Dished lead plates Nylon thro and thro suture Stainless rods one in each nasal vault
FI~. 3
In practice the use of the whole apparatus appears to be reasonably trouble flee. The care of the pin punctures is simple ; they are all accessible to cleaning and toilet. The one outstanding advantage is that the maxilla can be positioned accurately to the lower teeth with micrometer adjustment of the screws ; therefore the mouth does not need to be wired up for a period of 3 weeks or even more, and dental hygiene and general comfort of the patient is infinitely improved. The insulated bushes on the fixation pins into the skull prevent electrolytic action thus making it possible to use a variety of metals in construction. REFERENCE GRocoTT, J. and WILSON, A. N. (1972). Control of maxillary fractures by screw pins in the premaxilla. British Journal of Plastic Surgery, 25, 4o4-4o6.
AN I M P R O V E D HALO FOR FIXING FACIAL F R A C T U R E S By JOHN GROCOTT,F.R.C.S.
North Staffordshire Royal Infirmary, Hartshill, Stoke-on-Trem TRAUMATIC maxillary displacement in most cases is posterior and downwards in direction. The maxillary block slides under the curving base of the skull and comes to lie in the open bite position with varying degrees of posterior shift and impacfion. This position is often forcibly maintained by the spastic contraction o f the injured pterygoid muscles, the externus pulling the block towards the temporomandibular joint and the internus aided by the masseter muscle pulling the back of the block closer to the descending ramus of the mandible. In the majority of cases this displacement is easily corrected by manipulation under general anaesthesia and the maxilla can be held in the corrected position by a light halo apparatus in the usual way. There are, however, cases that do not respond so readily ; some early ones and nearly all late ones. After a few days an unreduced fracture becomes daily more firmly fixed and continuous traction rather than forcible disimpaction becomes the only way to effect reduction. This has led to the development of a halo which can exert pressure on the displaced maxilla in any direction through the medium of two self tapping screws inserted in the premaxilla (Grocott and Wilson, I972). A number of different frame types were tried ; that finally selected is an adjustable but rigid structure which gives access to the vault of the skull and is comfortable to the patient in bed. Necessarily this means a heavier structure than the standard halo but the weight has been progressively reduced to about 350 gm. by the use of light alloy. The frame (Fig. I) consists of a horizontal metal platform conforming in contour to the forehead and adjustable side arms pivoted at the outer ends of the platform. The platform itself carries 2 insulating blocks or bushes which in turn carry the stainless steel frontal screw pins (Fig. 2). In the centre of the platform is a ball or universal joint which forms the pivot for a vertical extensible beam dropping down to the maxillary attachment. The joint is fully adjustable by screws so that the beam may rotate and swing in an antero-posterior or lateral direction in any combination. The pivoted side arms are adjustable by screws and can be locked in final adjustment by nut and bolt. They are drilled and can carry vertical arms if desired. The posterior ends are slotted to carry the nylon insulated bushes which hold the mastoid screw pins. It is very advantageous to have as short a length of screw pin as possible between the frame and the skull. This ensures greater rigidity and obviates movement of the pin carriers or bending of the pins under stresses tangential to thc ~t'ull The skull strong points selected for insertion of the pins are on each temporal ridge area and each mastoid area at the level of the floor of the anterior fossa. The pin holders are first adjusted for position and then the angles are set for radial contact with the bone. The clamp is applied so that the mastoid pins register just in front of the mastoid suture line with the occipital bone; there is a depression here which is easily felt behind the ear. The lateral arms are tightened until the pins register against the bone in the depression. The pins, which are hollow ground, are screwed in a few turns until the whole clamp can be hinged up and down with the frontal pins just clearing the forehead. The frontal pins are now screwed home to register just above the superciliary ridges and just medial to the temporal ridges of the frontal bone. When these and the mastoid pins are tightened the platform is solidly fixed to the base of the skull. 4o7
408
BRITISH JOURNAL OF PLASTIC SURGERY
FIG. I. Most adjustments are made by 2BA hexagon headed bolts and a tubular box spanner is used. Adjustment is effected by slackening the opposing bolt, tightening the acting bolt and then retightening the opposer. This gives accurate fine adjustment without backlash. In some cases the threaded bolt acts as a screwed pivot, for example B2 for the vertical beam and A-A screws for the beam carrier. Screw and A-A B2 BI C-C D-D E F-F p-p-p-p
Bolt Code Pivots for the beam carrier adjustment for the sideways movement of the beam. Adjustment to move the beam antero-posteriorly. B2 is beam main pivot. Bolts to adjust rotation of beam carrier about pivot bolt G. Bolts to tighten and close side beams of halo on to skull about pivots L. These are locked when adjustment is complete. One long 2BA screw to adjust beam length. 2BA screws with locking nuts to tip or tilt the alloy plate which grips the premaxillary pins by the universal joints J, which have slotted tips for use with screw driver. Stainless steel screw pins with hexagonal head fitting universal joint spanner (see Fig. 2).
AN I M P R O V E D H A L O FOR F I X I N G F A C I A L F R A C T U R E S
409
The connection to the pins in the maxilla is made by a square beam of German diver attached to the universal joint in the centre of the platform. The square tube -arries a sliding square German silver rod in its lower end which can be adjusted for ength. The solid rod carries a triangular light alloy plate with the apex of the triangle pivoted on to the rod by a spring loaded pivot giving a limited range of rocking or Lipping movement to the plate and allowing antero-posterior and lateral tilt of the maxilla to be corrected. The triangular plate has 2 slots just forward of the base which carry normal universal joints with slightly heavier tightening screws. They are attached to the alloy plate so that the corrugated face of the joint can grip the metal of the plate when the joints are tightened up. LONG SECTION _~Nut
and washer clamping
E ...
~
-
,
.::7
-
-
~
3 I---_
/
1
6
Whit.stainless screw hollow ground point
//////2//////7"/tl
Steel tube brazed to 1/4 Whit. flat headed screw with pressed in nylon bush threaded 3/16Whir. FIG. 2
After the platform has been fixed the alloy plate is connected to the maxillary pins and reduction begun. Occasionally if the maxilla is very displaced and very fixed as much disimpaction as possible should be obtained before fixation to the frame. Complete reduction of the fracture to normal position and bite may take several days. The screws can be adjusted daily just up to the patient's limit of tolerance of pain. Usually after 3 or 4 days the position is greatly improved. The common open bite defect can be overcome by lengthening the beam--by putting a forward pull on the maxilla by the screw adjustment on the platform and by tipping the alloy plate. This type of frame can also be used to deal with depressed fractures of the bridge of the nose involving the medial walls of the orbit. Such fractures involve a great deal of comminution of the bones and the small fragments are almost impossible to deal with individually. In my experience it is preferable to provide a fixation which will mould this mush of tissue into a reasonably normal shape and then to reposition it by means of traction, so that approximately normal anatomy is restored. Large lateral lead plates, shaped and smoothed so that there are no sharp edges to cut the covering skin are held in place by through and through sutures and used to mould the nose. A small saddle attached to the descending beam of the halo carries 2 stainless steel rods of the usual ~- inch diameter with nicely rounded ends which are passed into the nose so that they run along the vault of each nasal cavity. The plates .and their through and
41o
BRITISH JOURNAL OF PLASTIC SURGERY
through sutures lie behind the rods. Elevation of the rods gives very adequate lift to the depressed naso-orbital block (Fig 3). Rods may also be attached to the side arms for fixation of certain malar fractures.
SCHEMATIC N A S A L BLOCK TRACTION
! • (a) Section of nose
(b) Side elevation: Stainless rods curved to attach to universal joints on a carrier on the long vertical beam
Dished lead plates Nylon thro and thro suture Stainless rods one in each nasal vault
FI~. 3
In practice the use of the whole apparatus appears to be reasonably trouble flee. The care of the pin punctures is simple ; they are all accessible to cleaning and toilet. The one outstanding advantage is that the maxilla can be positioned accurately to the lower teeth with micrometer adjustment of the screws ; therefore the mouth does not need to be wired up for a period of 3 weeks or even more, and dental hygiene and general comfort of the patient is infinitely improved. The insulated bushes on the fixation pins into the skull prevent electrolytic action thus making it possible to use a variety of metals in construction. REFERENCE GRocoTT, J. and WILSON, A. N. (1972). Control of maxillary fractures by screw pins in the premaxilla. British Journal of Plastic Surgery, 25, 4o4-4o6.