Braces and splints for musculoskeletal conditions

Braces and splints can be useful for acute injuries, chronic conditions, and the prevention of injury. There is good evidence to support the use of some braces and splints; others are used because of subjective reports from patients, relatively low cost, and few adverse effects, despite limited data on their effectiveness. The unloader (valgus) knee brace is recommended for pain reduction in patients with osteoarthritis of the medial compartment of the knee. Use of the patellar brace for patellofemoral pain syndrome is neither recommended nor discouraged because good evidence for its effectiveness is lacking. A knee immobilizer may be used for a limited number of acute traumatic knee injuries. Functional ankle braces are recommended rather than immobilization for the treatment of acute ankle sprains, and semirigid ankle braces decrease the risk of future ankle sprains in patients with a history of ankle sprain. A neutral wrist splint worn full-time improves symptoms of carpal tunnel syndrome. Close follow-up after bracing or splinting is essential to ensure proper fit and use.     

Ultrasonographic examination for inversion ankle sprains associated with osseous injuries

OBJECTIVE: The study attempted to evaluate the value of ultrasonography in determining the therapeutic strategy for patients with osseous injuries caused by ankle sprains. DESIGN: A 10-MHz compact linear-array ultrasound transducer was used to assess patients with inversion ankle sprains. Eleven female and 12 male patients who had fractures detected by sonograms were included in the study. All 23 patients underwent radiographic examination for identification of fractures. Bone scintigraphy was performed for those who had negative x-ray findings. RESULTS: Eighteen patients had distal fibular tip fractures, three patients had the fifth metatarsal base fractures, one patient had a talar neck fracture, and one patient had a navicular fracture. These fractures were all detected by ultrasonography and then proved even by radiography or by bone scans. All the 23 patients had anterior talofibular ligament injuries. Among these patients, 11 had anterior ankle-joint recess effusion, and two had additional anterioinferior tibiofibular ligament injuries. Six weeks of immobilization with the ankle fracture brace was prescribed for all the patients after the identification of fractures. Their ankle pain symptoms soon improved. CONCLUSIONS: Ultrasonography is valuable in evaluating tiny foot and ankle fractures and coexistent soft tissue injuries. It can guide the treatment for patients with osseous injuries caused by ankle sprains.     

L’imagerie dans les traumatismes du poignet

Traumas of the wrist are very common and generally involve fractures, sprains or dislocations. The authors introduce the different imaging techniques, their indications and their results. Standard radiographies are usually sufficient to make a diagnosis. However, the scanner or IRM or, in some cases, ultrasound scans, sometimes enable fractures to be diagnosed that could not be seen on simple radiographies. The scanner is also useful for exploring complex traumas of the wrist, particularly fractures of the lower end of the radius. The arthro-scanner is especially used in the diagnosis of wrist sprains, when looking for lesions of the scapho-lunar or luno-triquetral ligament. In all cases, a clinical examination is essential, as this guides the various radiological examinations.     

Fractures and Chronic Recurrence are Commonly Associated with Ankle Sprains: a 5-year Population-level Cohort of Patients Seen in the U.S. Military Health System

BackgroundWhereas ankle-foot injuries are ubiquitous and affect ~16% of military service-members, granularity of information pertaining to ankle sprain subgroups and associated variables is lacking. The purpose of this study was to characterize and contextualize the burden of ankle sprain injuries in the U.S. Military Health System.MethodsThis was a retrospective cohort study of beneficiaries seeking care for ankle sprains, utilizing data from the Military Health System Data Repository from 2009 to 2013. Diagnosis and procedural codes were used to identify and categorize ankle sprains as isolated lateral, isolated medial, concomitant medial/lateral, unspecified, or concomitant ankle sprain with a malleolar or fibular fracture. Patient characteristics, frequency of recurrence, operative cases, and injury-related healthcare costs were analyzed.ResultsOf 30,910 patients included, 68.4% were diagnosed with unspecified ankle sprains, 22.8% with concomitant fractures, (6.9%) with isolated lateral sprains, (1.7%) with isolated medial sprains and 0.3% with combined medial/lateral sprains. Pertaining to recurrence, 44.2% had at least one recurrence. Sprains with fractures were ~2-4 times more likely to have surgery within one year following injury (36.2% with fractures; 9.7% with unspecified sprains) and had the highest ankle-related downstream costs.ConclusionFractures were a common comorbidity of ankle sprain (one in five injuries), and operative care occurred in 16.4% of cases. Recurrence in this cohort approximates the 40% previously reported in individuals with first-time ankle sprain who progress to chronic ankle instability. Future epidemiological studies should consider reporting on subcategories of ankle sprain injuries to provide a more granular assessment of the distribution of severity.Level of evidence3b     

快速诊断规则用于鉴别足踝扭伤有无骨折的临床分析

目的探讨应用快速诊断规则（OAR）鉴别足踝扭伤伴骨折的漏诊原因,指导OAR的合理应用。方法选择2005年3月至2010年3月在泸州医学院外科门诊就诊的足踝扭伤患者,应用OAR进行临床检查并做出有无骨折的判断,于受伤后24h内和第15天进行足踝x线摄片,验证OAR诊断结果的准确性。结果根据OAR原则,踝关节扭伤105例中初步诊断16例合并骨折,经x线检查合并骨折17例,漏诊1例（6．2％）;足扭伤50例患者中21例合并骨折,OAR原则与x线摄片诊断结果一致。结论OAR对足踝扭伤并骨折的判断准确率高,但也有漏诊的可能,临床要警惕。     

Traction splint. An EMS relic?

Traction splints have been used in EMS for more than 40 years. However, they were originally designed for the treatment of femoral fractures -- not temporary stabilization. Multisystem trauma and other injuries contraindicate traction splint usage for many femoral fractures. Thus, with the relatively low usage of the traction splint, it may be time to revisit guidelines that require traction splints on every ambulance and rescue vehicle. They may be, in essence, an EMS relic we may want to part with.     

Common injuries of the foot. Often more than 'just a sprain'

While most foot injuries heal without treatment, failure to recognize and treat some can have disastrous consequences. The exact mechanism of injury must be determined for accurate diagnosis. Many injuries, such as plantar fasciitis, "pump bump," sesamoiditis, and stress fractures, are the result of cumulative, repetitive stress rather than of an acute event. Others, such as injuries to tendons, may be chronic or acute. The foot is susceptible to numerous types of acute trauma, including sprains, fractures, dislocations, crushing, freezing, thermal injury, puncture wounds, and penetration by foreign bodies. Special care is required to minimize the danger of serious complications when treating foot injuries in diabetic patients.     

Management of common finger injuries

Family physicians can manage most finger injuries, including uncomplicated fractures, proximal interphalangeal joint dislocations, closed tendon injuries and ligament sprains. Finger injuries that can cause long-term morbidity may present as minor sprains. Diagnosis requires a thorough history, systematic examination and radiographic evaluation.     

Splinting versus casting of “torus” fractures to the distal radius in the paediatric patient presenting at the emergency department (ED): A literature review

AimTo compare outcomes regarding splinting versus casting of paediatric torus fractures in the ED with the aim of establishing the preferred treatment.MethodsEvidence was collated using electronic databases; Pubmed, Ovid, Medline and Cochrane library. Search terms included [torus fractures; buckle fractures; splinting distal radius fractures; paediatric wrist fractures; paediatric forearm fractures/injuries; cast versus splint]. Searches identified papers published between 1984 and June 2008.ResultsThe review demonstrated that children with removable splints preferred them to casts, in terms of improved physical functioning and lower pain scores reported after initial injury than those with casts. Children demonstrated this by using their wrists in the first week after injury to shower and bathe more easily. The cast group reported unscheduled visits to ED due to problems with the cast, such as discomfort or re-application of the cast from getting it wet. Using a splint will have considerable economic implications, money was found to be saved in terms of time and resource management. Radiographs taken at 4 weeks in both the cast and splint group confirmed that all fractures healed without significant change in alignment, suggesting that neither clinical nor radiographic follow-up is necessary for injury.ConclusionTorus splints in all the studies were consistently better than plaster immobilisation in terms of clinical outcome, patient preference and cost, with the exceptions of young children or children with special needs who can easily remove the device. Splinting torus fractures may reduce cost, time and resource management if used instead of casting in the ED.     

X线检查在踝关节骨折诊断中的应用及影像学特点研究

目的:探讨X线检查在踝关节骨折诊断中的应用及影像学特点。方法:回顾性分析我院2018年10月至2019年6月收治的50例踝关节扭伤导致踝关节骨折的患者,所有患者进行X线检查,并将检查结果与多层螺旋CT作对比。结果:50例踝关节骨折的患者均经多层螺旋CT检查证实为骨折。其中中X线检查诊断出45例,诊断符合率为90.00%。其中包括9例内踝骨折,11例外踝骨折,19例踝骨粉碎性骨折,5例距骨骨折,1例合并根骨骨折。5例为踝关节周围软组织肿胀合并关节囊肿胀。结论:X线检查在踝关节骨折诊断中的应用价值高,诊断符合率高,X线表现中踝关节周围软组织肿胀合并关节囊肿胀的患者需要着重考虑是否存在踝关节骨折。该检查方法值得临床推广应用。     

Foot fractures frequently misdiagnosed as ankle sprains

Most ankle injuries are straightforward ligamentous injuries. However, the clinical presentation of subtle fractures can be similar to that of ankle sprains, and these fractures are frequently missed on initial examination. Fractures of the talar dome may be medial or lateral, and they are usually the result of inversion injuries, although medial injuries may be atraumatic. Lateral talar process fractures are characterized by point tenderness over the lateral process. Posterior talar process fractures are often associated with tenderness to deep palpation anterior to the Achilles tendon over the posterolateral talus, and plantar flexion may exacerbate the pain. These fractures can often be managed nonsurgically with nonweight-bearing status and a short leg cast worn for approximately four weeks. Delays in treatment can result in long-term disability and surgery. Computed tomographic scans or magnetic resonance imaging may be required because these fractures are difficult to detect on plain films.     

Towards evidence based emergency medicine: best BETs from the Manchester Royal Infirmary. BET 2: do wrist splints need to have a thumb extension when immobilising suspected scaphoid fractures?

A short cut review was carried out to establish whether wrist splints require a thumb extension when immobilising suspected scaphoid fractures. 63 papers were found using the reported searches, of which 2 presented the best evidence to answer the clinical question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these best papers are tabulated. It is concluded that while there is no direct evidence to answer the clinical question, the research available strongly suggests that it is reasonable to continue using standard wrist splints to immobilise patients with suspected scaphoid fractures.     

Lateral and syndesmotic ankle sprain injuries: a narrative literature review

Objective

The purpose of this article is to review the literature that discusses normal anatomy and biomechanics of the foot and ankle, mechanisms that may result in a lateral ankle sprain or syndesmotic sprain, and assessment and diagnostic procedures, and to present a treatment algorithm based on normal ligament healing principles.

Methods

Literature was searched for years 2000 to 2010 in PubMed and CINAHL. Key search terms were ankle sprain$, ankle injury and ankle injuries, inversion injury, proprioception, rehabilitation, physical therapy, anterior talofibular ligament, syndesmosis, syndesmotic injury, and ligament healing.

Discussion

Most ankle sprains respond favorably to nonsurgical treatment, such as those offered by physical therapists, doctors of chiropractic, and rehabilitation specialists. A comprehensive history and examination aid in diagnosing the severity and type of ankle sprain. Based on the diagnosis and an understanding of ligament healing properties, a progressive treatment regimen can be developed. During the acute inflammatory phase, the goal of care is to reduce inflammation and pain and to protect the ligament from further injury. During the reparative and remodeling phase, the goal is to progress the rehabilitation appropriately to facilitate healing and restore the mechanical strength and proprioception. Radiographic imaging techniques may need to be used to rule out fractures, complete ligament tears, or instability of the ankle mortise. A period of immobilization and ambulating with crutches in a nonweightbearing gait may be necessary to allow for proper ligament healing before commencing a more active treatment approach. Surgery should be considered in the case of grade 3 syndesmotic sprain injuries or those ankle sprains that are recalcitrant to conservative care.

Conclusion

An accurate diagnosis and prompt treatment can minimize an athlete's time lost from sport and prevent future reinjury. Most ankle sprains can be successfully managed using a nonsurgical approach.     

Brief or new: two pronation splints

For two years we have made pronation splints to assist quadriplegic patients who lack adequate forearm pronation but who have enough upper extremity strength to feed themselves and perform other self-care or functional activities. We have found the splints to be an appropriate alternative to the MAS. The first pronation splint fits underneath the arm, is simple in design and fabrication, and is hidden. However, occasionally the lever of the splint hangs up in the shirt, catches on the post of the wheelchair, or slips out from underneath the arm when the patient reaches away from the body. To eliminate these problems, we designed a second splint. But, this splint requires more time to make and adjust, has two parts to put on instead of one, and is more noticeable because it is worn on top of the arm rather than underneath it. When a patient uses either splint, the degree of pronation may be adjusted according to the activity by slightly rotating the splint either way when strapping it on. For example, full pronation may be required for feeding, but only half the range is necessary to operate the keyboard of a computer or typewriter. Once the Velcro straps are applied, the splints do not slip. The splints are not interchangeable from left to right and assistance is always needed to put them on. For patients with "weak" or "absent" wrist extensors, a wrist support and cuff splint may be used along with the pronation splint or a universal cuff, if wrist extension is adequate. The pronation splints are appropriate for those patients whose forearms supinate when they reach their hand to or near their mouth.     

Manual reduction with traditional small splints for distal radius fracture in older patients

Objective: To investigate the effect of manual reduction with traditional small splints fixation for distal radius fractures in older patients in the emergency department.Methods: Older patients (aged at least 60 years) with distal radius fractures were enrolled in this study. The patients were randomly divided into the treatment group and the control group. The treatment group was treated with manual reduction and small splints fixation. The control group was treated with manual reduction and resin plaster fixation. Before treatment, after reduction, and 3 months after treatment, the palmar tilt angle, ulnar deviation angle, and radial length were recorded. Before treatment and 3 months after treatment, the Cooney wrist joint scores were recorded. The time of fracture healing and related adverse events during the treatment were recorded. Results: Before treatment and after reduction, there were no statistically significant differences between the two groups in palmar tilt angle, ulnar deviation angle, or radial length (P>0.05). Three months after treatment, the palmar tilt angle, ulnar deviation angle, and radial length of the treatment group were better than those of the control group (P<0.05). The Cooney wrist scores of the treatment group was significantly higher than that of the control group three months after the treatment (P<0.05). The time of fracture healing of the treatment group was shorter than that of the control group, but the difference was no statistically significant (P>0.05). Conclusions: Compared with resin plaster fixation, traditional small splints fixation for distal radius fractures in older patients have the advantages of less loss of fracture reduction and faster functional recovery. Besides, the method is simple and low cost thus, it needs to be promoted.     

Traumatismes ligamentaires aigus du poignet

The anatomy and physiology of the wrist are very complex, which is why it is difficult to diagnose a severe wrist sprain, which, if inadequately treated, will result in wrist pain and degenerative arthritis. We propose a clinical algorithm for assessing both scapholunate and lunotriquetral sprains. We also propose a radiological analysis of wrist fractures based on anatomical concepts, so as to avoid missing ligamentous lesions associated with wrist fractures.     

Injury patterns in children with frequent emergency department visits

Objectives

To compare injury patterns in children with many and few emergency department (ED) visits in order to reveal the causes for the frequent visits.

Methods

Three cohorts of Danish children (total 579 721 children) were followed for three years when their ages were 0–2, 6–8, and 12–14 years. Information on all ED visits was obtained from the Danish National Patient Registry. Injury type, place of accident, injury mechanism, admission, and distance to ED were compared between children with frequent ED visits (five or more during the three years) and children with only one visit.

Results

Children with frequent visits had a different injury pattern with 0–46% more superficial injuries and 25–82% more dislocations, sprains, and strains. There was 20–30% fewer fractures and 12% fewer falls from a higher level. 15–51% fewer were admitted.

Conclusions

Children with many ED visits had less severe injuries and more dislocations, sprains, and strains.     

Overutilizers Anonymous

In spite of improvements in facilities and equipment, skiing injuries still run the gamut from minor tendinitis to complete disruption of a ligament or fracture of a bone. Dr Johnson notes that knee injuries are predominant in both downhill and cross-country skiers, commonly as a result of internal rotation and valgus stress. Snowboarding injuries, such as ligament sprains and fractures, are usually due to direct impact.     

Sonographic diagnosis of a medial talar avulsion fracture

Occult talus fractures can be easily misdiagnosed as simple ankle sprains, resulting in painful nonunion, arthrosis, avascular necrosis, and long‐term disability. We present a case of ankle injury with medial talar fracture that was negative on plain radiography but was diagnosed with sonography. Sonography is a valuable tool in screening ankle sprains and may assist clinicians in diagnosing the nature of ankle injury, thus guiding the most appropriate therapeutic strategy. © 2012 Wiley Periodicals, Inc. J Clin Ultrasound 41 :570–573, 2013.     

Comparison of custom-made and prefabricated neoprene splinting In patients with the first carpometacarpal joint osteoarthritis

Aim: The objective of this study was to compare the effect of prefabricated and custom made thumb splints on pain, function, grip strength and key pinch In patients with basilar joint osteoarthritis. Method: Volunteer patients (n = 35) with first carpometacarpal joint osteoarthritis were assigned randomly to wear either a prefabricated or custom-made thumb splint or assigned to a control group. This was designed as a cross over study with two 4-week treatment periods, 2 weeks of wash out time for intervention groups between the test conditions and 10-weeks follow-up for the control group. All parameters were measured at the first visit and during the 4th, 6th and 10th weeks In the three groups. Results: In the control group, paIn increased and pinch strength decreased but no statistically significant differences were found In function and grip strength. Both splints changed grip strength with no significant differences between them. PaIn was reduced with the splints, and functions and pinch strength increased significantly as compared to the baseline and control groups. In comparing the two splints only significant differences were observed In pain. Conclusion: In comparing two splints, paIn was the only significantly different parameter between tested parameters; with the custom-made splints demonstrating better results In paIn reduction.

Implications for Rehabilitation

• A high level of disability has been reported In those patients with thumb carpometacarpal joint osteoarthritis.

• Custom-made and prefabricated neoprene splinting is an effective method to improve pain, pinch strength and function by patients with the first carpometacarpal joint osteoarthritis.

• The custom made splint demonstrated better results In paIn reduction.