The Current Fracture Bracing Treatment of the Lower Extremity

Braulia J. Pena-White

October 2004

"Splints of wood padded with vegetable fibres," was one of the known fracture treatment modalities used nearly five thousand years ago in ancient Egypt. (Said, 2002, 12) The orthopedic practice of fracture bracing in the early days has been found in wall paintings, hieroglyphs, and in a medical written discourse known as the Edwin Smith's Surgical Papyrus. (Said, 2002, 12) It is interesting to see that the foundation and fundamentals that led to the modern medical approach of fracture management were practiced back as far as the 30th century B.C. Since then, the evolution of fracture bracing has been progressing. More recently, in 1963, Dr. Augusto Sarmiento was recognized as the first person to introduce the concept of functional fracture bracing in the management of most fractures. (Conry, 1992, 151) Treating fractures is a large part of the Orthopedic and Orthotic practice. In fact, fracture treatment plays a significant role in what orthotists do each day. This is why the understanding of fractures and their treatment is of great importance. This paper will focus on the basic aspect of lower limb fractures and their prospective bracing treatments.

The first step is to learn and to be able to comprehend the basic description and classifications of fractures. Later, we will discuss their suitable treatment. A fracture is defined by Robert B. Salter, MD as a "structural break in continuity." Bones break due to tension failures of the bone's structure caused by forces imposed on it. Bending, twisting, or pulling of the bone's structure are some mechanical descriptions of why they break. A force and the magnitude of the force are variables that determine directly or indirectly how the bone will break. Furthermore, additional variables on how a bone reacts to the imposed force, depends on bone density and age. Symptoms of a fracture can include localized pain, edema in the affected area, and loss of limb function. (Salter, 1999, 423)

The following pages of review will help you refresh some of the most common used descriptions of fractures. Victoria R. Masear in her book, "Primary Care Orthopaedics," describes how to classify fractures. She states that one must be able to note the following when evaluating the fracture:

• Which bone is involved?

• What segment of the bone is involved?

• Is it affecting a joint?

• Did it penetrate the skin?

• What fracture pattern does it have?

• Is there any displacement of the bone?

By answering these questions while diagnosing the fracture, it will enable clear communication of the same information to all of the involved healthcare professionals, and will help to achieve the best care for the patient.

Some important descriptive medical terms are as follows. The Epiphysis is the end portion of a long bone. The Diaphysis is the shaft or body of a long bone. (Venes, 2001, 585) The Metaphysis is the bone that is between the diaphysis and the epiphysis, and is the zone that allows growth during skeletal immaturity (Venes, 1341); it is sometimes called the growth plate. Fractures can also be classified as open or closed type fractures. This is an important distinction because it largely determines how the fracture will be treated. An Open type fracture is when the bone penetrates the skin and underlying tissues. It is also known as the compound fracture. A Closed type fracture is one that involves the breakage of the bone without any, or with minimal soft tissue damage. It is also referred to as a simple fracture.

Open type fractures are usually the result of a higher energy accident that requires full examination of the entire body. With an open fracture, the internal body is exposed to the outside environment. The wound is at risk of acquiring infection and other complications. Bracing is usually not indicated for fractures that are classified as open type fractures because of the soft tissue injury.

Extra-articular is the term used when the fracture does not compromise the joint. Intra-articular is the description given for a fracture that involves a joint. (Masear, 1996, 34) For bracing to be effective, it must have plenty of bracing on both sides of the break in order to stabilize the fracture site. When the fracture is intra-articular, it is very difficult to have control and stabilize the fractured bone with an orthosis. Consequently, the conservative treatment plan of fracture bracing in this case is not recommended.

When bones break, they are unique in that they tear in different patterns. A Transverse fracture has a cross-wise or perpendicular break to the long axis of the bone. An Oblique fracture has a slanting or diagonal type break. A Spiral fracture is a break that winds or coils around downward or upward from a fixed point. (Costello, Berube &, Pritchard, 1994, 786) A Compression fracture is a crush type fracture that usually involves cancellous type bone. (Salter, 1999, 419) A Stress fracture is an incomplete bone break that "results from excessive, repetitive, sub-maximal loads on bones that cause an unbalance between bone re-absorption and formation." (Boden & Osbahr, 2000, 344). This type of fracture is easily treated by simply resting and reducing the amount of activity. However, if the patient maintains too much activity, the stress fracture can become a complete fracture, dislocation, delayed union, or a non-union. It is then important to treat these high risk fractures as acute fractures because this will increase the success rate of non-operative type treatment. (Boden & Osbahr, 344 & 347) An Incomplete fracture is a bone that cracks, that is un-displaced, and has an intact periosteum. Incomplete fractures include the Greenstick fracture, Hairline fracture and the Buckle fracture. The buckle fracture is also known as a "Torus Fracture". (Salter, 419) A Comminuted fracture is a bone with two or more fragments. (Salter, 1999, 421) These are typically harder to treat because stabilization of the fractured pieces is harder to achieve.

Another fracture characteristic to observe is fracture displacement, or how the fracture moved when the break occurred. An Un-displaced fracture is when the bone breaks yet remains intact and in alignment. A Displaced fracture on the other hand, is when the bone breaks and the segments are not intact. They override each other and are not in alignment. When a bone breaks and the two segments shift, it is known as Translation. Angulation is the term used when an angle to the bone develops while healing. Rotation is a twisting or rotational motion between the two broken segments. Finally, the term, Shortening is used when there is a loss of the over all bone length.

Being able to understand the basic natural process of bone healing gives the healthcare professional an expected time frame for healing. "An understanding of the response of living bone and periosteum during the healing of a fracture is pivotal in the appreciating of how fractures should be treated." (Salter, 1999, 425) When first evaluating the fracture, any injury to the blood supply, possibility of infection, the pattern of the fracture, and damage to the surrounding soft tissue must be considered as factors that may determine the rate of healing. If a fracture has not healed in 16 to 20 weeks, it is known to be a Delayed Union fracture. (Wiss & Stetson, 1996, 250) A fracture is considered a Non-Union fracture when the break does not calcify after nine months of treatment. Salter gives a general guideline for the expected timeline for bone healing. If the bone break occurs during birth, healing of the fractured bone may be within 3 weeks. A child of 8 years old may expect calcification in 8 weeks, a 12 year old in 12 weeks, a 20 year old in 20 weeks and from this point, the older the person is, the longer it will take for the fractured bone to heal.

During the time of bone healing, the healthcare professional must choose which treatment plan best suits the type of fracture. It is very important to keep in mind all the goals of treatment management. The general goals of fracture management are pain relief, maintaining alignment of the fractured segments, and beginning "muscle function and joint motion as soon as possible." (Zagorski, Zych, Latta &, Finnieston, 1992, 126) & (Koval & Helfet, 1995, 86)

Functional fracture bracing, one of several treatment modalities, has been a major breakthrough in the field of medicine because it can provide the support, protection, and stability to an injured extremity, decreasing the risks of surgical complications. The goal of functional fracture bracing is to "control the bone fragments through soft tissue compression and molding of the soft tissue parts." (Zagorski et al., 126) The brace protects the extremity and at the same time promotes early ambulation. The use of a functional brace with early weight bearing provides a "stimulus that alters the fracture environment, leading to callus formation and fracture consolidation." (Wiss, Tibial Nonunion, page 251) The main goal of fracture bracing is to avoid surgical risks and complications such as infection, tissue compromise, and neurovascular injury when possible. (Bono, Levine, Rao &, Behrens, 2001, 179) Although bracing has many benefits, "fracture bracing should not be considered as primary care following injury," according to Walter Racette, CPO. Nonetheless, bracing must "begin within the six-week golden period if one expects to achieve the benefits of early function on the biology of repair. This means that many Grade III injuries may not be able to be braced early enough to maintain alignment and still achieve early function." (Zagorski, et al., 1992, 126) However, "Any delay in application of the functional brace results in slower healing." (Sarmiento, 2000, 199)

In the past, the prime way to treat fractures was with immobilization in a plaster cast. It was later learned that such treatment lead to joint stiffness (fracture disease) and atrophy of the surrounding musculature. Since the introduction of functional fracture bracing, range of motion in the joint is no longer compromised and muscle atrophy is not the problem that it was. (Conry, 1992, 151) Edema is also considerably reduced by the early restoration of function and graduated weight-bearing. As a result, the chances of compartment syndrome decrease.

The use of an orthosis is also beneficial because it allows micro motion to occur between the fractured segments of bone which increases blood circulation. This, in turn, promotes the formation of cartilage and fibrous tissue to the injured bone. The design of the orthosis should be made to provide structural integrity and rigidity to the fractured bone as well as soft tissue constant compression. Made this way, the orthosis will prevent angulatory deformities. (Zagorski et al., 1992, 126) "The brace contains soft tissue, and the soft tissue supports the fracture site," explains Walter Racette, CPO. Adjustability to volume fluctuation is what makes bracing a marvelous innovation in fracture management because soft tissue compression can be maintained, unlike a plaster cast.

Another important consideration when treating fractures with an orthosis is that bracing is cost effective compared to other treatment modalities. The patient often avoids the cost of surgery, and the hospitalization period also tends to be shorter.

It is essential to note that only a skilled orthotist or trained professional must apply the brace as an improperly fitted orthosis can have severe consequences. Ill-fitting fracture bracing may cause sores, disruption of the venous or arterial circulation, and angulatory deformities by misplaced forces of padding or trim-lines. However, the key to "success of conservative approach depends on patient education and compliance." (Chao & Wapner, 2003, 73)

Although bracing has its benefits, not all fractures may be treated by this method. Indications for fracture bracing according to Mark Conry, CPO, in the article, "Orthomedics Fracture Bracing at La County USC Medical Center," include the following:

• Diaphyseal type fractures

• Subsiding of initial pain and swelling

• Intact sensation is crucial and necessary when using a brace

• Adequate reduction with acceptable alignment

• Minimal shortening is evident

• Can be used as a supplement for support when intramedullary rods are used.

A brace cannot be used or is not recommended when there is:

• Open fractures with soft tissue damage

• Shortening of more than 2cm or 12 millimeters (more than 3/8")

• Angulation more than 8 degrees exists (Sarmiento, 2000, 200)

• Excessive pain or swelling

• Failure to maintain alignment of fracture

• Wound drainage

• Spastic or insensate limbs

• Internal fixations (Racette)

• Unreliable or uncooperative patients (Zagorski, et al.)

When a brace is to be used for the treatment of the fracture, the orthotist must determine the type and design of the orthosis. Orthoses are available prefabricated or they can be custom molded. Prefabricated orthoses are off-the-shelf braces that fit the average population. "Off-the-shelf fracture braces have become popular." (Porter, Villareal, May &, Baxter, 1996, 644) Eighty-five percent are prefabricated. (Racette, 1992, 142) Paul Webber, C.O. believes that "increased outcome awareness has influenced advances in prefabricated bracing." Advantages of having manufacturers produce fracture braces similar in construction throughout the entire country are that it is economical because the cost is kept low; the follow up care is more easily feasible since orthotists around the country are familiar with the device; and faster service can be provided because the brace is already fabricated. This is especially beneficial because a fracture needs to be stabilized quickly after the cast is removed. It cannot wait a day or two until a brace can be fabricated. However, when the patient size is too large, or the shaping is not normal, a custom fabricated orthosis is recommended. A custom molded orthosis is a brace made for that particular patient. Also, if a significant time has passed since the injury, custom bracing is indicated. "As a general rule, the longer the time from injury to brace application, the greater the possibility custom-molded and custom manufactured braces will be indicated," according to Walter Racette, CPO.

The design of the orthosis plays a crucial part in the success of the fracture healing. There are certain basics to observe in order to have a successful outcome. Walter Racette, CPO, suggests that trim-lines should not restrict range of motion of the adjacent joint. Restricting the joint may cause undesired forces that can possibly mal-align the fractured bone. Thick dressing under the brace should not be used because it can wrongfully apply force that will also cause mal-alignment of the bone. Furthermore, thick dressing can create a larger wound because of the added compressive pressure of the dressing inside the brace. In addition, a fracture sock should always be used to maintain good skin integrity as it absorbs the excess moisture and dissipates heat away from the skin.

Selecting the appropriate material for brace construction is important. The more rigid the material, the less adjustable the orthosis is, making it difficult to load soft tissue, thereby hindering the goal of constant hydrostatic pressure. It also makes weight bearing almost impossible for the patient. Orthoplast is a plastic that is flexible and highly moldable. In the article "Clinical Experience with Functional Fracture Bracing of the Tibial Diaphysis," Walter Racette, CPO, encourages the use of this material when limb shape is expected to change, as well as for those fractures that require corrective forces and for those that need alignment correction. This type of plastic allows itself to be molded directly onto the patient. (Lusardi & Nielsen, 2000, 15) Mr. Racette also states that Polyethylene should be used in a custom type brace when there is a non-union or delayed union fracture. He believes that this material "provides an excellent adjustable container." With it, one is able to achieve the fundamental concept of functional bracing because the hydrostatic pressure is maintained by loading soft tissue and maintaining fracture alignment regardless of the limb's volume change. Polypropolyene is the plastic type that offers the most support and rigidity. However, because of its rigidity, it fails to maintain the hydrostatic compression needed as volume fluctuates.

Despite the benefits of fracture bracing, there are factors that indicate discontinuing its use. Bracing treatment must be stopped if compartment syndrome develops. Compartment syndrome can be very dangerous. The pressure in the limb increases due to edema which in turn compromises circulation, damaging muscles and nerves. (Salter, 1999, 468) Bracing can worsen the condition by not allowing volume of the limb to increase with the increasing pressures inside the limb. This causes further damage to the muscles, blood supply, and nerves. Bracing must also be halted if an allergic reaction to the plastic occurs. And of course, bracing must be discontinued if you suspect the patient to be incompliant.

BRACING OF THE LOWER EXTREMITY

Treating a femoral fracture present a challenging problem. Allan E. Peljovich, MD and Brendan M. Patterson, MD, authors of "Ipsilateral Femoral Neck and Shaft Fractures" offer several treatment modalities, however "no clear consensus exists regarding the optimal treatment of these complex fractures." The more proximally the fracture presents itself in the femur, the less likelihood it will be treated with an orthotic device. In fact, bracing is contraindicated for intertrochanteric, subtrochanteric, and mid-shaft fractures of the femur. (Salter, page 453)

Femoral neck fractures are rare and problematic to treat. They are usually a stress type fracture. (Boden & Osbahr, 2000, 348) These types of fractures have been classified as either a compression type fracture or a tension type fracture. Blickenstaff and Morris further subdivided these fractures into types. (Bailie & Lamprecht, 2001, 813) "Type I has a callus without a fracture line; type II has a fracture line across the neck without displacement; and type III is a displaced fracture." (Bailie & Lamprecht, 813) Femoral neck fractures tend to occur for several reasons. Often times, when an activity such as running is prolonged, the hip musculature become fatigued, they lose their shock-absorbing ability, and this leads to a stress fracture. Coxa Vara and Osteopenia are also predisposing factors causing femoral neck stress fractures. Symptoms for this particular bone fracture are pain in the anterior groin (inguinal) area especially during weight bearing or internal and external rotation of the limb. (Bailie & Lamprecht, 813) Complications of such injury may be devastating, such as avascular necrosis (86%), malunion, nonunion (59%), and possible fat embolisms.

Treatment for femoral neck fractures depends on whether or not the fracture is displaced. Conservative non-operative treatment such as traction can be used for non-displaced fractures, however, literature and studies have also shown that complications are more prevalent in patients treated non-operatively. (Peljovich & Patterson, 1998, 107) Surgical intervention, such as open reduction internal fixation (ORIF), is usually recommended for displaced fractures of the femoral neck. An off-the-shelf hip orthosis or hip-spica cast after ORIF surgery can be used to stabilize and maintain the limb in a fixed position during healing. The patient will not be able to bear weight for 6 weeks post operatively. This is followed by a 6 week period of partial weight bearing. (Boden & Osbahr, 348) An ischial bearing custom or prefabricated KAFO may be used for the period during which the patient is partially weight bearing.

Femur shaft fractures usually heal quite well. "Nonunion of the shaft fracture is extremely uncommon." (Peljovich & Patterson, 108) In fact, these types of fractures tend to heal and unite rapidly. (Beaty, 1995, 207) Dr. Beaty believes in treating femoral shaft fractures with a hip spica cast when operative treatment is not indicated, especially when treating children. However, if a hip spica is used, angulation and shortening may become a problem. Functional fracture bracing can be used only after 5 weeks of traction has been done. (Salter, 1999, 631)

Supracondylar fractures are fractures that occur in the "terminal 9 cm of the femur, between the diaphyseal metaphyseal junction and the femoral condyles." (Albert, 1997, 163) Supracondylar fractures are classified at Type A with three subtypes. Subtype A1 is a simple fracture, subtype A2 is a metaphyseal wedge type fracture, and subtype A3 is a comminuted metaphyseal fracture. (Albert, 1997, 163). Of course, the higher the subtype, the more severe the condition of the fracture which will call for a more critical treatment modality.

In an article written by Mary J. Albert, MD, "Supracondylar Fractures of the Femur," she states that the goals in treating these types of fractures are to correct axial alignment, length, and rotation; to maintain motion; and to promote rapid union. A simple non-displaced or impacted fracture can be treated well with a hinged brace. In a situation where surgery is needed, yet can not be performed for whatever reason, skeletal traction may be the way to go by using a Thomas splint with a Pearson attachment. Motion is always recommended because it will prevent the formation of intra-articular adhesions and fibrosis. Therefore, a cast-brace is used when traction is no longer needed. The description of the following brace is taken directly out the article written by Dr. Albert in the above noted article. "Separate full-contact sections are applied to the thigh and to the leg and foot. The thigh section is carefully molded around the condyles, extending well above the level of the fracture. The sections are connected with hinges." This brace may be worn for 6 to 8 week until the patient can fully bear weight without pain. Although distal femoral fractures are particularly treated by operative means, bracing can be used post operatively, especially during the rehabilitation phase.

Knee fractures are common and treated differently according to the type of fracture. "Knee injuries such as patellar fractures, knee contusions and lacerations are the most commonly associated musculoskeletal injuries, coexisting in 14% to 40% of reported cases." (Peljovich & Patterson, 1998, 106) When dealing with Physeal Fractures, the treating modality of it is extremely important because there is a possible risk of bone growth disturbance. (Blanks, Lester &, Shaw, 1994, 257) At the distal end of the femur and proximal surface of the tibia exists a special plate called the physis which allows growth during the childhood years. When the knee is injured, the tubercle apophasis, the intercondylar eminence as well as the physis are areas of concern because normal limb growth can be impaired.

Let's start with the distal femoral type fractures. There are five types of distal femur fractures known as the Salter and Harris classification. Peter H. Edwards, Jr., MD and William A. Grana, MD define the Salter and Harris classification as follows: "A Type I fracture is a break that traverses the physis. Type II is also a line that traverses that growth plate for a variable length and then exits obliquely through the metaphysis. Type III fractures also begin in the physis but exit through the epiphysis toward the joint. Type IV fractures involve a vertical split of the epiphysis, physis and the metaphysis. Type V fractures are crush injuries to the physeal plate and usually are apparent only in retrospect."

Fractures that are non-displaced and those which are considered stable, making up to eighty percent of the cases, may be treated by immobilizing the limb by a long-leg cast or a hip- spica according to Dr. Lewis E. Zionts, MD. These types of fractures usually fall within the Salter-Harris classification of I and II. Knee positioning is very important in treating these types of physeal fractures in order to avoid complications. The basic principle is to place the knee in the direction of the displacement. Edwards and Grana place the knee in full extension if the fracture was displaced posteriorly or with a 30 degree of flexion with an anteriorly displaced fracture. It is important to note that if compartment syndrome is present, circumferential immobilization must not be used because this may compromise vascularity in the limb.

Most type III and IV type fractures present with displacement and require some sort of internal or external fixation. Common problems seen with distal femoral fractures are shortening and angular deformities. Conservative measures can be used to treat any leg length discrepancies of less than 2 cm with a simple heel lift. Angular deformities (valgus or varus angulation development) at the knee usually require surgery as the primary form of treatment. Bracing can then be used as post surgical stabilization.

Fractures of the proximal tibial physis are common knee injuries seen in children but even more common are distal femoral physis type fractures. A valgus force is usually the cause of this type of fracture usually producing a Salter-Harris type II fracture along with a greenstick fracture of the fibula. (Edwards & Grana, 1995, 65) Again, if the fracture is stable and non-displaced such as in a Salter-Harris type I fracture, immobilization by cast or brace, placing the knee in full extension, can be used. (Zionts, 2002, 349) & (Blanks et al., 1994, 349)

With a Salter-Harris type II fracture, internal or external fixation will be utilized along with non-circumferential immobilization. Salter-Harris type III and type IV fractures are treated with open reduction and internal fixation along with cast immobilization for 4 to 6 weeks. Zionts et al emphasize the importance in limiting the degree in knee flexion when placed in cast or brace. Too much knee flexion can "increase the risk of vascular compromise and thus should be avoided." Other complications such as limb shortening and angular deformities present themselves but not as frequently as in distal femoral physis type injuries.

Tibial tubercle apophysis fractures are a rare yet possible type of break in a growing child. There are three classifications of this type of fracture, from least to more severe. The main cause of this type of fracture is a forceful contraction of the extensor mechanism, such as a violent contraction of the quadriceps muscle. Interestingly, research suggests that there may be a link between Osgood-Schlatter disease and tibial tubercle apophysis fractures. If the patient has a history of having Osgood-Schlatter disease, he or she may be predisposed to having a tibial tubercle apophysis fracture. (Edwards & Grana, 1995, 67) Patella alta is usually seen in this type of fracture due to the shortening of the extensor mechanism.

The type I injury is typically non-displaced and treated with a cast or brace with the limb in full extension. Type II and III are usually displaced and treated with surgery, open reduction, and internal fixation along with immobilization for 6 weeks. A good prognosis is indicated with minimal complications or problems. However, pain or sensitivity may persist as a result of patella alta or patella baja.

Fractures of the intercondylar eminence, also known as anterior tibial spine fractures, are caused by a hyperextension force on knees of children under fifteen. Meyers and McKeever describe these fractures with four classification or types. Type I is a fracture that is not displaced. Type II fracture is partially displaced. Type III is a complete displacement and the type IV fracture contains a displaced segment along with rotation. As expected, the treatment modality depends on the type of fracture presentation.

Edwards and Grana suggest the following treatment protocol for intercondylar eminence fractures. Type I can be immobilized by cast or brace with the knee in preferably 20 degrees of knee flexion in order to exert less tension on the ACL ligament and broken segments. Zionts et al prefer to place the knee in 10 degrees of flexion and not in extension. Type II fractures may be treated conservatively or surgically depending on whether reduction is achieved by closed manipulation means. If the fragments are not able to be reduced while placing the knee in extension, open reduction surgery is necessary. Bracing can then maintain the reduction with immobilization. Open reduction and internal fixation is the optimal treatment option for Type III and Type IV type fractures. Immobilization is then required for 6 to 8 weeks.

Extensor lag has been noted as a problem after treating these types of fractures, especially if the knee was placed in flexion position during the healing process. ACL elongation and instability have also been reported outcomes affecting the activity levels of many patients with intercondylar eminence fractures. A study evaluating 61 patients with anterior tibial spine fracture reveal "persistent laxity of the anterior cruciate ligament." (Zionts, 2002, 352) Patients with any knee instability may later need a functional knee brace to increase knee stabilization and to protect and prevent further knee injury, especially if he/she is involved in high recreational activities.

Fractures of the patella are very common. The patella is a sesamoid bone that lies anterior to the distal tip of the femur and proximal tip of the tibia. Because of its location, the patella is exposed to injury. (Cramer & Moed, 1997, 323) The patella plays a major role in the extensor mechanism by increasing the knee extensor moment by almost 30% produced by the quadriceps muscles. Patellar fractures can be a result of direct or indirect forces. An example of an indirect type force is exceeding the amount of force the patella can handle from the extensor mechanism. Hitting the patella against a hard concrete floor would be an example of a direct force. According to the Wheeless' Textbook of Orthopaedics, "Fractures of the Patella," a patella fracture can introduce many complications. Avascular necrosis, delayed union, nonunion, malunion, chondromalacia, arthritis, quadriceps weakness, extensor lag, and arthrofibrosis of the joint are just some of the possible consequences from having a patella fracture. This is why treating this type of fracture is very important.

Patella fractures can be treated operatively and non-operatively depending on the nature of the fracture, bone condition, and other individual factors such as age. In order for a patella fracture to be treated in a conservative manner, it must be un-displaced (minimal displacement when dealing with an elderly or debilitated person), have an intact articular surface, and have an evident extensor mechanism. (Wheeless Textbook of Orthopaedics, 1) The patient must be able to raise the involved leg in extension against gravity. "Protected weight bearing in extension with a knee immobilizer or removable brace," is the suggested treatment protocol by Cramer and Moed. Barry P. Boden, MD and Daryl C. Osbahr, MD, simply treat un-displaced patellar fractures by restriction of activity and observation. Please note that immobilization should be kept to a minimum because prolonged restriction of motion can lead to the risk of joint stiffness. A ROM (Range of Motion) knee brace is often used to accommodate the needs of the patient during rehabilitation and can be adjusted from a locked position to a full ROM as needed. Literature review has stated that good results have been revealed in 90% of the patients who have been treated non-operatively. However, bracing is not limited to the non-operative type of treatment. Braces are also used if surgical intervention is the primary choice of treatment. A prefabricated Post-Op ROM knee brace can be utilized to maintain the knee in a fixed 40-60 degree of flexion position for 2-3 days. The brace is then adjusted to allow ROM as healing progresses and can protect the knee during the early phase of weight bearing of 4 to 6 weeks. (Wheeless' Textbook of Orthopaedics, pg 2)

Fracture of the Tibial Plateau is somewhat common resulting from a motor-vehicle accident or a fall. Coronal or compressive forces are the means by which a tibial plateau type fracture occurs. A varus force will likely produce a medial plateau fracture, whereas a valgus type force will create a lateral type fracture. In conjunction with a tibial plateau fracture, meniscal tears are present in 50% of the cases and ligamentous disruption in 30%. (Koval & Helfet, 1995, 87) There are six classifications of tibial plateau fractures known as the Schatzker classifications. According to Kenneth J. Koval, MD and David L. Helfet, MD in the article, "Tibial Plateau Fractures: Evaluation and Treatment," the descriptions of each classification are described as follows. Type I is a wedge (split) fracture of the lateral tibial plateau. Type II is a split-depression fracture of the lateral plateau. Type III is a pure central-depression fracture of the lateral plateau without an associated split. Type IV is a fracture of the medial tibial plateau, usually involving the entire condyle. This type of fracture usually involves the peroneal nerve. Type V is a bicondylar fracture, which typically consists of split fractures of both the medial and lateral plateaus without articular depression. And type VI is a tibial plateau fracture with an associated proximal shaft fracture.

There is a great deal of controversy about the treatment protocol of Tibial Plateau Fractures. If the injured knee presents with 10 degrees or more of coronal instability, surgical management will be indicated. However if the fracture is displaced minimally and is stable, it can be treated with protected mobilization such as a hinged cast brace. (Koval & Helfet, 86) ROM at this point is allowed with partial weight bearing for 8 to 12 weeks. As with patellar fractures that are treated surgically as the primary form of treatment, bracing can also be utilized as part of the postoperative care and rehabilitation process. (Masear, 1996, 108) Clinical practice has indicated that when using a ROM knee brace post operatively, the joint must be locked into 30 degrees of flexion. By doing so, the plateau is unloaded, reducing the unwanted compressive forces normally exerted when the leg is in full extension. One should continue to use the brace during the early stages of weight bearing because it offers the support and protection needed at this time. Ninety percent of patients treated non-operatively had good results with this method of treatment.

A Ségond fracture is a sports related type fracture in the lateral tibial plateau in conjunction to the tearing of the anterior cruciate ligament. (Hess, Rupp, Hopf, Gleitz &, Liebler, 1994, 193) This type of injury occurs when stress is exerted on the knee and the joint is in flexion with internal rotation of the tibia. After this type of injury, there is a possibility of medial or lateral knee instability. A knee brace would play an important role in protecting and adding the extra stability needed by the injured limb.

Tibial fractures, although common, remain controversial in regard to treatment. The behavior of tibial fractures is different from any other type of fracture. The involvement of the fibula bone determines how the particular fracture will be treated. A tibial alignment change is also to be expected depending on the fibula's involvement. For example, when the fibula is dislocated, tibial valgum will be evident. Tibial varum, as you can imagine, will be present when the fibula is fully intact. (Racette, 1992, 1) Mr. Racette, CPO, goes on to say that 3-5 degrees of varum is acceptable once the fracture has healed.

Angulation is another problem when the tibia is fractured. Angulation of the tibia consists of Apex Posterior or Apex Anterior. Apex Posterior is a condition that occurs when the foot/ankle complex is placed in 10-15 degrees of equinus in the primary plaster cast. After the four weeks of complete immobilization, the patient is then placed in a functional brace. One must be aware that mal-alignment will be produced when the foot/ankle complex is realigned to neutral in the brace creating a posterior force at the fracture site inducing an Apex Posterior on the tibia. This complication can be easily avoided by simply reducing the equinus foot from the initial plaster cast. An Apex Anterior on the tibia will occur if the limb is held up in the air horizontally while the cast or brace is being applied because gravity imposes a downward force on the foot creating pressure on the fracture site, producing this type of angulation. Thus, it is important to place the ankle in the proper position when treating tibial fractures.

Tibial fractures with more than twenty millimeters of shortening usually are accompanied by a fibular fracture. (Sarmiento, 2000, 202) Walter Racette, CPO, emphasizes that the patient must wait at least four weeks from the initial injury to be placed in a functional brace. After the primary method of treatment, such as in a plaster cast, fractures of the tibia can easily be stabilized by the use of an orthotic device only after length and rotation stability have been achieved. It is important to maintain the mobility of adjacent joints because they will maintain blood flow through the extremity. This promotes faster healing and maintains muscle activity thereby preventing atrophy and weakening. (Zagorski et al., 1992) & (Sarmiento, 200)

Treating proximal tibial fractures is much more difficult than more distal ones. The need to manage the short fragments makes functional bracing ineffective as primary method of treatment. (Bono et al., 2001, 178) One must also be aware that this area is more prone to compartment syndrome which also makes bracing contraindicated. A hinged knee fracture brace can be of use only after several weeks of immobilization when knee motion is recommended. The proximal trimlines should be extended as high up as possible close to the peroneal crease. The distal trimlines should be low enough around the malleolus. Long lever arms of the brace around the affected joint increases the amount of control offered by the orthosis.

A fracture that presents itself in the lower end of the proximal 1/3 to mid-shaft fractures can be easily treated with a patellar tendon bearing brace. (Bono et al., 179) According to Walter Racette, CPO, bracing is contraindicated when the tibia fracture presents without fibular displacement. However, other authors suggest that successful results may be obtained with fracture bracing even if the fibula is intact, if the fracture is stable. (Bono et al., 179)

When the fibula is involved, the fractured tibia may be braced with a below knee orthosis. Bracing with a Below-the-Knee Orthosis and early weight bearing for distal tibial fractures is widely recommended. A case study presented by the authors of "Orthotic Design and Application for Functional Treatment of Tibial Shaft Fractures," support functional bracing as an effective way to treat tibial fractures. A patient was placed in a prefabricated tibial orthosis four weeks after injury, and returned to normal activities. The results from functional fracture bracing have been satisfactory and far less risky than operative procedures. (Sarmiento, 2000, 199) Sarmiento conducted a study of 68 patients treated with functional bracing, 84% resulted in acceptable alignment. When external fixators are used as the primary way to treat the fracture, a Pressure Relief Ankle Foot Orthosis (PRAFO) may be utilized to unload undesired pressures on the calcaneous area of the foot in order to avoid bed sores during the enforced bed rest of the patient. From clinical experience, when intramedullary nailing is used as the primary way of treatment, a fracture boot may be useful in adding additional support and stabilization.

Brace detail for Tibial Fractures. Trimlines include a PTB style for the anterior proximal section along with a posterior proximal trim that will allow full knee flexion. A trimline placed too high on the posterior proximal will create an apex anterior angulation. (Racette) Therefore, one must assure proper trimlines for the brace being used. One must be careful not to compress the common peroneal nerve, which will result in loss of function of the foot dorsiflexors. (Bono et al., 2001, 177) The distal trimlines should allow relief for the malleoli and allow full dorsi and plantar flexion of the ankle. Any restriction to these motions can cause an apex posterior angulation on the tibia. (Racette) The foot section plays a crucial role. It keeps the brace from rotating, maintains stability, and suspends the orthosis by not allowing downward migration of the brace.

The shape of the leg section of the orthosis is also important because it will determine the overall function of the brace. By modifying the medial and lateral tibial flare sections and slightly flattening the calf section of the mold, the loading of soft tissue area is increased thereby providing better orthotic control and weight bearing. Of course, having the adjustability to adapt to volume change and maintain the compression forces throughout the entire leg creates the ideal tibial orthosis for the healing fracture. The use of an orthotic shoe is highly recommended because it provides a safer surface for the foot during ambulation.

The Maisonneuve fracture is "a proximal fibular fracture with associated syndesmotic ligament disruption and injury to the medial ankle structures." (Hensel & Harpstrite, 2002, 525) It is a common type fracture with prevalence in 1 out of 10 ankle fractures. An external rotation force to the ankle is described as the mechanism that produces this type of fracture. This type of fracture is treated operatively. A fracture boot such as a Cam Walker may be indicated 8-10 weeks post injury in order to support the beginning of weight-bearing.

The Foot fractures are often common usually resulting from having heavy object falling on to it. The Calcaneal fractures represent 1-2% of all adult fractures. This fracture in the foot can often lead to a debilitating state in an adult foot. (Mora, Thordarson, Zionts &, Reynolds, 2001, 474) The case is different, of course, with a child with a broken calcaneous. The child has the advantage and capacity for the growing bone to remodel and to accommodate the difference of the bony anatomy. The mechanism of the injury results from compression forces from activities such as jumping or from involvement in a motor vehicle accident. " After a tibial or calcaneal fracture, lesser toe deformity may result from compartment syndrome of the calf or the foot." (Chao & Wapner, 2003, 75)

Literature reports that non-operative treatment of the calcaneal fracture can result in great success (Mora et al., 471) if the break is extra-articular. (Ceccarelli, Faldini, Piras &, Giannini, 2000, 825) Articular fractures can also be treated non-surgically only if the patient is skeletally immature. Otherwise, surgery is recommended. The authors in the article, "Surgical Versus Non-Surgical Treatment of Calcaneal Fractures in Children: A Long-term Results Comparative Study," suggest that when treating a calcaneal fracture non-operatively, a plaster cast could be applied in addition to restricting weight-bearing for at least a month. A fracture boot may also be used for 10-12 weeks. However, others argue that "there isn't any consensus on its treatment protocol." (Aktuglu & Aydongen, 2002, 314)

Talus fractures are even rarer than calcaneal fractures. In fact, there are only two cases reported in the literature. Motor vehicle accidents are the main cause of such fractures resulting from the foot being severely dorsi-flexed. This type of fracture is divided into two classifications, either of the neck or the body. The body type fractures are then subdivided into compression, coronal shearing, sagittal shearing, posterior tubercle, lateral tubercle, and comminuted. Treatment differs depending on the type of fracture.

A study conducted in a level 1 trauma center concluded that degenerative joint disease was often found in fractures of the body of the talus. (Elgafy, Ebraheim, Tile, Stephen &, Kase, 2000, 1023) Non-operative treatment is normally recommended for this type of fracture. A cast may be applied if the fracture displays minimal displacement for 6 to 8 weeks. (Monroe & Manoli, 1999, 192) In instances where the fracture is in the neck, the foot needs to be placed in plantar-flexion for 6-8 weeks. (Fortin & Balazsy, 119) By clinical experience, a Patellar-Tendon-Bearing Ankle Foot Orthosis can also be utilized to reduce weight bearing of the foot and ankle complex. (Masear, 1996, 131) However, if there is displacement along with subtalar involvement, surgical procedures can be used, but only as the last alternative. (Ebraheim, Skie &, Podeszwa, 1994, 226) Correct treatment of the talus is not to be taken lightly because malunion can cause a painful cavovarus foot. The authors of, "Talus Fractures: Evaluation and Treatment," suggest that if the conservative method of treatment is used, the fracture needs to be observed closely in order to avoid future problems such as displacement during the healing process.

Metatarsal fractures usually result from crush injuries and are quite common. Chao and Wapner suggest treating stress fractures of the metatarsals by not allowing the patient to bear weight on the affected foot. They recommend using crutches, orthoses such as a walking boot, a shoe with a rigid sole, or a short leg plaster cast. (Chao & Wapner, 2003, 74) & (Schenck & Heckman, 1995, 74) Other treating physicians also agree with this protocol. (Olson, Mendicino &, Rockett, 2000, 150) & (Quirk, 1998, 494) & (Rosenberg & Sferra, 2000, 332) A CROW (Charcot Restraint Orthotic Walker) boot has also been used to heal these types of fractures when also dealing with a neuroarthropathic foot. (Mehta, Brown &, Sargeant, 1998, 621) It is important to note that "it is imperative to demonstrate weight-bearing stability if non-operative treatment is to be undertaken," according to Dr. Robert C. Schenck, Jr. and Dr. James D. Heckman. (Kay & Tang, 2001, 74) Elastic bandages are not recommended because they may impair circulation and later lead to compartment syndrome.

A Jones fracture is defined as a transverse fracture, short, oblique, and in the proximal shaft of the 5th metatarsal bone of the foot. (Josefsson, Karlsson, Redlund-Johnell &, Wendeberg, 1994, 252) This type of fracture is common. It is a stress break that happens when continuous loads are exposed to this certain bone, often occurring in athletes. Surgical intervention is the primary way of treating this type of fracture. "One fourth of the fractures treated non-surgically later had to be treated surgically because of delayed unions or refractures." (Josefsson et al., 252) However, the other three quarters have found great success in healing by using the conservative method of an elastic bandage or plaster cast, as long as the activity is limited. (Josefsson et al., 252) & (Dameron, 1995, 111) A hard-soled shoe may be used for tuberosity avulsion type fractures. (Rosenberg & Sferra, 2000, 332) Dr. Thomas B. Dameron, Jr. found using the functional fifth metatarsal brace developed by Reibel and Colditz in 1983 to treat this type of fracture quite successful. (Dameron, 113) A low temperature, moldable plastic is molded and placed over the metatarsals preventing motion in this area while continuing to allow metatarsophalangeal motion.

Even though phalanges also get broken, they are less of a concern because they are easily treated in most cases. Functional outcomes are good with few long term problems. (Mizel, Hwang &, Temple, 1998, 568) Immobilization of the phalange by the use of a simple postoperative wooden shoe or wedge shoe for 4-5 weeks is usually enough to treat this type of fracture. (Rosenberg & Sferra, 2000, 317) & (Schenck & Heckman, 1995, 77) Buddy-taping is also recommended depending upon the severity of the break. (Rosenberg & Sferra, 317)

People who suffer from a Sesamoid fracture or dislocation usually report having a lot of foot pain. Mechanical stress, such as overuse, imposed on these tiny bones in addition to hallux MP dorsiflexion can lead to dysfunction of the sesamoid bones. Surgery is not always successful. (Rosenfield, 2000, 914) An orthosis that can limit motion in the hallux MP joint such as a wooden-soled or wedge shoe is recommended as the initial treatment. (Schenck & Heckman, 1995, 77) A rocker sole shoe with a full length steel shank can also suffice in healing this type of fracture according the article, "Treatment of Sesamoid Disorders with a Rocker Sole Shoe Modification," written by Jeffrey S. Rosenfield, M.D. and Elly Trepman, M.D. The authors also recommend in addition to the modified shoe, an insert that can provide relief on the sesamoid area while loading behind the metatarsal heads and arch of the foot. Another conservative way to manage sesamoid fractures is to use a walking boot or a short leg cast. (Schenck & Heckman, 77) It can take up to a few years for the pain to fully disappear.

In conclusion, in recent decades, fracture bracing has been widely accepted as part of the treatment modality for many fractures. According to Salter in the textbook, Disorders and Injuries of the Musculoskeletal System, "The incidence of nonunion has been only 1%, which is remarkable." Other treating healthcare professionals have also had successful and satisfactory outcomes with this type of non surgical treatment. Functional fracture bracing not only allows early function and joint motion, it provides stability, protection, and support to the injured extremity. Most importantly, bracing decreases the risks of surgical complications like infection.

A skilled professional, such as a Certified Orthotist who has the appropriate training, must be the one to apply a functional fracture brace. The orthotist is familiar with the anatomy of the body, the function and expectations of a brace, and knows how to avoid possible complications from brace wear such as sores developing due to excessive pressure. He/she knows the construction of the device that would best benefit the injured limb. There are many common fractures, and the design of the brace differs every time. It is critical for the treating professional to be aware and familiar with all the different fractures because this will determine the appropriate treatment.

Even though fracture bracing has proven to be beneficial in so many ways, many in the health field have yet to see its advantages and effectiveness. Sadly, today, orthotists are noting a decrease in the use of fracture bracing despite the successful outcomes. Anthony Girard, CO, Senior Orthotist at Carrie Tingley Children's Hospital, reports that from his 25 plus years of clinical experience there has been a decline in the use of fracture braces. Yet, this may not be the case throughout the United States. Further investigation into the use of functional bracing would be beneficial to the orthopedic field. This could only highlight what a great breakthrough modern bracing methods have become in the field of medicine for the management of fractures.

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