Mayfield head holder pin placement is the step that turns a skull clamp from an accessory into a rigid fixation, and it is also where most avoidable problems begin. This article describes the general workflow for a three-pin clamp, the checks that scrub nurses and residents should run, and the areas surgeons usually avoid. It is educational material for equipment users and buyers; the surgeon's judgement and the manufacturer's instructions for use always take priority.
Before you place the pins: preparation
Confirm the set is complete and the right type: adult or pediatric pin holders, pins in sterile packaging, a clamp that locks and releases smoothly, and the torque device or indicator in working order. Check that the base unit and swivel adaptor are attached to the table rail in the correct position, and that the table can reach the required position before the patient is clamped.
Decide with the anaesthesia team where the head will be after pinning. Securing the airway and positioning the patient comes first; skull pins are usually placed after induction and with local anaesthetic at the pin sites, as per the team's protocol. For an overview of the device itself, read our explainer on the Mayfield head holder.
Mayfield head holder pin placement step by step
The general logic is a triangle: two pins on one half of the clamp and a single pin on the other, positioned so that the head is stable along the line of the planned approach. Skin is cleaned, the pins are opened sterile, and the clamp arms are brought to the head with the pin holders aligned. The pins should meet the skull perpendicular to the bone surface, not at an angle, to avoid slipping.
Pressure is then applied with the torque mechanism according to the manufacturer's setting. The DORO Multi-Purpose clamp offers an optional 90 N torque screw for finer control of lower pin forces; the right setting for adults, children or thin bone is defined in the instructions for use and by the surgeon. After tightening, lock the swivel adaptor, check that the pin-force indicator is in the required range and recheck after the patient has been moved.
- Check clamp, pins, torque device and base before the patient is brought in
- Set two pins on one side, one on the other, perpendicular to the bone
- Apply pressure through the torque mechanism as per the IFU
- Lock the adaptor and re-check the indicator after final positioning
Skull clamp placement: sites to avoid
Teams usually avoid placing pins over thin areas of bone, such as the temporal squama, over the frontal sinus, over sutures and fontanelles, over burr holes, skull defects or implants, and over a ventriculoperitoneal shunt. Superficial vessels and the temporalis muscle are also considered. Exact choices depend on the planned incision, imaging and the patient's anatomy.
Avoid placing pins in the path of the incision or where the navigation reference or retractor arms will need space. A clamp that offers a Quick-Rail and starburst interfaces, such as the DORO QR3, helps with planning, but the pin position should be decided together with the surgeon.
Children, thin bone and non-invasive alternatives
Pediatric skulls are thin and do not tolerate adult forces. Specific pediatric pin holders, lower forces and sometimes non-invasive supports are therefore used. The DORO Multi-Purpose skull clamp is designed for patients from newborns to seniors and includes adult and pediatric pin holders and gel pads, so the team can choose invasive, non-invasive or combined fixation.
If you are unsure whether a patient should be pinned, that is a clinical decision for the surgeon and anaesthetist. Read our overview of skull clamp types to compare options and skull clamp safety and complications for risks.
Training and equipment support
A short checklist at each step and a regular in-service session for scrub nurses reduce errors more than any single device feature. Ask your supplier for an instructions-for-use briefing and an in-service demonstration when new clamps are delivered.
Beckfinity supplies Black Forest Medical DORO skull clamps to hospitals in the UAE and can arrange product training with the delivery. Contact our specialists to discuss your set-up.
Frequently asked questions
How many pins does a Mayfield clamp use?
A classic clamp uses three pins: two on one side and one on the opposite side. Some pediatric holders use two pins, and non-invasive options avoid pins entirely.
How much pressure should be applied to the pins?
The value depends on the clamp model, patient age and bone quality and is defined in the manufacturer's instructions for use and by the surgeon. Use the supplied torque mechanism or indicator and do not estimate by feel.
Where should skull pins not be placed?
Teams generally avoid thin temporal bone, the frontal sinus, sutures, burr holes, skull defects, implants and shunt hardware, and the planned incision. The surgeon decides the exact sites.
Who places the pins?
Usually the neurosurgeon or a trained resident, with the scrub nurse and anaesthesia team assisting. Local protocols apply.
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