(rear view) The technique described in photograph 22.9 is set up. Note that the patient is sidebent toward the operator at the pelvis, and away at the neck. Note the supinated upper arm that is maintaining the compression. Note that the upper arm hand is not in contact with the patient. Note that the patient's head is in a position of almost no rotation but a contra-rotation force is, nevertheless, being applied to the occipito-atlantal joint.
22.11 • Thrust using minimal leverage to gap occipito-atlantal joint supine This technique is designed to gap the occipito-atlantal joint on the side where the thrust is applied. It is a minimal leverage technique as the neck is not taken to full rotation, but merely placed in an available position so that the contact point is available for the thrust. Some small quantities of levers are used, but the emphasis is mostly on carefully applied compression, and high velocity with very short amplitude. Keep the vertex of the head in the midline and take up the chin hold with one hand. Keep the head resting on the forearm applied anterior to the ear. Ensure that the head is against your upper arm and thorax so that it is firmly controlled, cradled and supported. Place the applicator, the first metacarpo-phalangeal joint of your thrusting hand, on the posterior aspect of the arch of the atlas. Keep the vertex midline and press firmly into the atlas to take up the slack in the soft tissues. Apply the thrust with a rapid force toward the patient's opposite eye and a simultaneous force of the other forearm against the side of the head.
The total of these forces should keep the head still while the atlas is driven forwards underneath the occiput. This is not a torsional force of the head on the neck, but a force of the atlas under the occiput to break fixation on the side of the thrusting hand. If excessive head movement is allowed, the occipito-atlantal joint on the other side will be strained, with a sidebending force. There will also be a tendency to strain the atlanto-axial joint into excess rotation. Note: this is an extremely difficult technique to perform well as there is no sense of accumulating barrier. The control of acceleration and braking and accurate directions of force are the governing factors. If it is performed as described here there is little chance of trauma but if torsion is added instead of the method described it is then no longer a minimal lever technique and tissue stress is more likely.
Tips: Most useful where torsion is best avoided and fixation is not too severe. Least useful if the operator is not able to develop the skill to apply the necessary ultra-high velocity, and the strict control of the braking force. Extra considerations: Try asking the patient to look over the shoulder of the side to which the head is being rotated. This will increase the effect of the small amount of levers applied as the eye torsion tenses the cervical musculature. Conversely, try asking the patient to turn the eyes to the other side if the tension accumulates too fast as this will have the effect of reducing neck tension.
22.12 • (see previous page, bottom right) Thrust atlanto-axial joint cradle hold supine As the main movement of the atlanto-axial joint is into rotation, thrust techniques normally used are rotatory types. This technique is designed to break fixation on the side of the thrusting hand. Apply the proximal metacarpo-phalangeal joint of the thrusting hand behind the arch of the atlas. Support the head in the palm of the underneath hand and apply a compression force toward the thrusting hand to absorb the slack into compression to avoid excess torsion. Keep the vertex in the midline and gently rotate the head to about 50% of its available range. Apply a small amount of sidebending opposite to the rotation and a very small extension of the head on the neck to take the posterior tissues off tension. This will make room for the applicator to reach the atlas. Slowly increase the compression while gently oscillating the head into rotation until a sense of barrier accumulates under the thrusting hand. Apply a short amplitude and high velocity force to the atlas to break fixation in a forward or rotation direction of the atlas on the axis.
Tips: Most useful in older necks as the compression force helps to minimize the torsion necessary. Least useful if the operator is not able to develop the speed necessary to break fixation in this type of technique. Extra considerations: This hold makes several variations of the technique available. It is possible to thrust into sidebending to gap the other side of the occipito-atlantal joint. It is possible to thrust on the occiput itself to gap the occipito-atlantal joint on the same side. It is possible to thrust on the posterior aspect of the atlas while holding the head still to gap the occipito-atlantal joint of the same side.
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