Background:
It is recommended to have early closed reduction of cervical spinal fracture/dislocation injuries with craniocervical traction in the initial phase for the restoration of anatomic alignment of the cervical spine. During the traction, some patients experience considerable discomfort in the temporomandibular joint(TMJ).
We present a case which illustrates unanticipated difficulty in mouth opening after cervical traction was applied.

Case Report:
A 24-year-old man without any specific medical history was hospitalized with a burst fracture of atlas in a car accident. He underwent surgery for posterior screw fixation after 5kg G-tong traction was applied for 4 days. Anesthesia was induced with propofol and remifentanil. Muscle relaxation was with 0.6 mg/kg rocuronium. Then, the patient's mouth was opened for intubation, but only one finger wide was opened, so 30 mg of rocuronium was administered in more. However the mouth did not open any further. So we could use the lightwand to perform the intubation successfully and proceed with the surgery. The patient was consulted to the department of oral and maxillofacial surgery(OMS) about the patient’s mouth opening defect. The patient could open his mouth 2 fingers wide and he experienced TMJ ankylosis when his mouth was forced to open. Swelling with Rt TMJ on the preauricular area was observed and there was Rt side disclusion in the dental interlocking.
Clinical and CT findings showed complications caused by G-toneg traction that muscle contusion induced myositis and TMJ disc dislocation.
The patient underwent reoperation after 8 months, and his mouth was extended 3 fingers and performed intubation without any problems

Discussion:
We suspect that the use of G-tong may cause the patient myositis and TMJ dislocation. It was suspected that he had myositis and TMJ disc dislocation. It may cause TMJ ankylosis, which can result in a mouth opening problem.
A TMJ dislocation is the displacement of the head of the condyle from its normal position in the glenoid fossa. Signs and symptoms of TMJ dislocation involve inability to occlude the teeth, gagging of occlusion, pre-auricular depression and preauricular pain2. G-tong ca result in a permanent TMJ problem if it is not applied properly andcarefully.

Learning points:
A preoperative assessment of patient's mouth opening should be done before endotracheal intubation for a patient who is scheduled to get an operation during or after cervical traction.

09 / Unanticipated difficulty in mouth opening after applying skull traction for cervical spine injury