Orthomedics Fracture Bracing at
LA County USC Medical Center
Mark A. Conry, CPO
Introduction
The concept of functional fracture bracing
was initiated in 1963 by Dr. Augusto Sarmiento at the University of Miami. Since
that time, the old standard philosophies of
(1) immobilizing the bone and the joints
above and below the fracture in casts or (2)
open internal fixation have given way to using hydrostatic pressure of soft tissue to
maintain length and alignment. Early joint
mobilization and early guarded weightbearing have become accepted components in
treating simple long bone fractures, minimizing such complications as joint stiffness
and muscle atrophy.
Orthomedics has worked with Dr. Sarmiento at the Los Angeles County/University of Southern California (LAC/USC) Medical Center for the past 12 years, during which
time the company has accumulated data on
more than 3,500 tibia, 900 humeral, 700
ulna, 130 femoral, 220 Colles' and 230 both-bone forearm fractures.
Functional fracture bracing has evolved
during that time. Fractures were first treated
with plaster casts with hinged joint components, then with low-temperature thermoformable plastics (mainly Orthoplast). Today, most of these fractures are treated in
prefabricated systems.
Indications and Contraindications
Clinical experience has allowed us to define
definite indications and contraindications to
using fracture bracing.
Indications include:
- diaphyseal fractures of the tibia, fibula,
ulna (isolated), radius (isolated), humerus
and distal one-third of the femur
- a subsiding of initial pain and swelling
- intact sensation
- adequate reduction with acceptable
alignment and minimal shortening
Contraindications include:
- intra-articular fractures
- excessive pain or swelling
- failure to maintain alignment of fracture
- wound drainage (our rule of thumb is
not more than can be absorbed by a single
four-by-four in 24 hours)
- spastic or insensate limbs
- excessive shortening (more than 3/8
inch)
Clinical experience also shows that prefabricated systems are used 75 percent of the
time for closed fractures treated within the
first two to four weeks and 71 percent of the
time in open fractures treated within four to
six weeks. Prefabricated systems were not
used if any soft tissue damage or superficial
bony prominences existed.
Normally, when a prefabricated system is
not applied, an Orthoplast brace is custom fit
on the spot (see Figure 1
). A cast was taken
for a custom brace in only 9 percent of the
closed fractures cases and in only 2 percent
of the open fractures cases. The percentages
of prefabricated braces in upper extremities
are much greater (see Figure 2
). (The small
number of custom braces for open fractures
in this study probably reflects the fact that
the majority of these high-energy injuries
were treated surgically.)
Additional Findings
The majority of fractures we braced were
closed, with more rights than lefts in lower
extremities and more lefts than rights in upper extremities (see Figure 3
and Figure 4
).
For the population in this study, motor
vehicle accidents were by far the largest
cause of injury. Accidental falls were the
second highest cause. Violent injuries, such
as direct blows and gunshot wounds, are increasing (see Figure 5
and Figure 6
).
The entire range of fracture types has been
treated in braces, but the best results and
quickest healing times are in low-energy injuries.
Transverse, oblique and spiral fractures
are most common (see Figure 7
and Figure 8
). In
tibia fractures, most patients had injured the
middle third (see Figure 9
and Figure 10
).
Fracture braces tend to be worn for a longer time than casts even though healing times
are comparable. Patients will voluntarily
stay in the brace on a limited-use basis for
several weeks after solid union is demonstrated on X-ray.
Generally, simple closed fractures heal
more rapidly than do high-energy or open
fractures (see Figure 11
).
Conclusion
Our clinical experiences of the past 12 years
show most types and levels of fractures can
be managed with either prefabricated or
Orthoplast braces if treated before peripheral callous forms.
We have continued to collect data on the
type of bracing performed at LAC/USC
Medical Center; and although follow-up results are not part of this study, the frequency
of fracture types, treatment times, types of
fractures braced and cause mechanisms
should be of great interest to orthotic practitioners.
MARK A. CONRY, CPO, is a staff specialist with
Orthomedics Inc., 2950 E. Imperial Highway,
Brea, CA 92622; (714) 996-9500.
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