Failure of attachment ("pull-off") of Gardner-Wells tongs from the cranium occasionally occurs, and may cause problems, especially in cases of significant cervical spinal instability. The optimal method for Gardner-Wells tongs attachment is not well defined: the effect on pull-off strength of stem protrusion of the spring-loaded pin, and user accuracy in setting stem protrusion do not appear to be documented in the medical literature. The authors measured pull-off strength from five fresh cadaveric crania, for each of five stem protrusion settings. In a related experiment, staff surgeons were asked to follow the standard instructions for applying clinically available Gardner-Wells tongs (smooth, unmarked indicator stems on the spring-loaded pins), after which the actual stem protrusion lengths were recorded. When the indicator stem protruded 1.0 mm (manufacturer's recommendation), the mean pull-off strength (+/- standard deviation [SD] was 137 +/- 34 pounds (610 +/- 151 N). Even with stem protrusions as low as 0.25 mm, the lowest pull-off strength was 60 pounds. Failures of fixation occurring with traction loads of 35 to 50 pounds are almost surely associated with stem protrusions of less than 0.25 mm. Even without an indicator line on the stem at 1 mm, all of the 13 orthopaedists tested produced an actual stem protrusion of 0.37 mm or more. Secure attachment of larger cranial traction loads requires careful attention to pin tightening. Proper location on the skull and the risk of penetration through the inner table must also be kept in mind.