When to Use Braces, Splints: An A-Brace-Ive Situation
Abstract & Commentary
By Matt Shores, MD, St. Joe's Hospital and Medical Center, Family Medicine Residency, Phoenix, AZ, is Associate Editor for Urgent Care Alert.
Dr. Shore reports no financial relationships relevant to this field of study.
Synopsis: Evidence-based recommendations for the use of braces and splints in various musculoskeletal conditions.
Source: Gravlee JR, Van Durme DJ. Braces and splints for musculoskeletal conditions. Am Fam Physician. 2007;75:342-348.
The use of various braces and splints is often implicated in many musculoskeletal conditions, ranging from acute injuries to chronic debilitations. It is a difficult task to differentiate between when the use of a particular brace or splint is warranted, with a strong evidence-based foundation versus their use being perpetuated by anecdotal rigmarole. In a February 2007 review published in the American Family Physician, Gravlee and Van Durme lay a solid framework for the appropriate use of various braces and splints in a wide variety of musculoskeletal conditions. Beginning with the knee and following with the ankle and the wrist, they highlight brace and splint use in various conditions.
In patients with medial compartment osteoarthritis, unloader (valgus) braces may reduce pain and improve function. The evidence surrounding unloader braces is not particularly overwhelming (evidence rating B), however, unloader braces ultimately may offer a good option for those patients who are not surgical candidates, or for patients who would like to buy some time prior to undergoing surgery.
Anterior knee pain, more specifically, patellar femoral pain syndrome (PFPS), is a frustrating entity in and of itself. So, it should come as no surprise that the evidence in treating anterior knee pain with braces is not strong. The type of brace utilized in PFPS is typically a neoprene sleeve with added patellar support in the form of a C-shaped, J-shaped, H-shaped, or circular buttress. Given that the evidence is limited and the few studies available produced conflicting results, patellar bracing is neither recommended nor discouraged in treating anterior knee pain.
Immobilization of the knee is generally not a good idea in treating knee injuries. However, there are a few incidences when a knee immobilizer brace would be recommended. These include quadriceps rupture, patellar tendon rupture, MCL rupture, patellar fracture, patellar dislocation, and other acute traumatic knee injuries. Typically, given the injuries that precipitate its use, the knee immobilizer is part of presurgical treatment.
Ankle braces basically come in 2 varieties: rigid and functional. Rigid braces completely immobilize the ankle and are not recommended in the treatment of ankle sprains. The 2 main types of functional ankle braces are lace-up braces and semi-rigid braces that consist of lateral stirrups lined with foam pads. Evidence supporting the use of functional ankle braces is strong (evidence rating A), including multiple randomized trials. However, evidence does not point to either lace-up or semi-rigid braces as a more appropriate option than the other, although lace-up braces have been shown to reduce short-term swelling more so than semi-rigid braces. In terms of wearing an ankle brace as primary prevention or prophylaxis in patients who have had previous ankle injuries, there is strong evidence that semi-rigid braces help prevent ankle sprains in high-risk sports (evidence rating A).
Carpal tunnel syndrome is a complaint growing in relevance as computer use becomes commonplace. Wrist splints are often used in the treatment of carpal tunnel syndrome. The type of splint, and its use, vary. Splints may be used in the neutral position or in an extended (cock-up) position. Also, splints are often prescribed to be worn either full-time or only at night. The recommendation in regard to wrist splints treating carpal tunnel syndrome is that splints should be worn in the neutral position full-time for at least 4 weeks (evidence rating B).
Commentary
Musculoskeletal conditions are a mainstay of urgent care centers across the country. Acute injuries, in particular, are the backbone of urgent care musculoskeletal presentations, although at times, the management of more chronic problems arises. The section of Gravlee and Van Durme's article most relevant to the practice of the urgent care medicine touches on the use of ankle braces. Ankle sprains are perhaps the most common musculoskeletal injury that presents in the urgent care setting. It is important to recognize the difference between a rigid brace and a functional brace. The use of functional braces in ankle sprains has strong evidence-based support. The addition of a functional brace to a treatment plan that already includes rest, ice, compression, and elevation should be a foregone conclusion. In his 2006 article in American Family Physician, Ivins details the PRICE approach to treating ankle sprains, including functional treatment and the use of lace-up and semi-rigid ankle braces.2 It would be prudent for all urgent care centers to have a sufficient quantity of both lace-up braces and semi-rigid ankle braces on hand.
Although carpal tunnel syndrome does not present as commonly in an urgent care setting, it is typically easy to recognize, and it is easy to treat conservatively with an evidence-based approach. Prescribing a neutral position wrist splint to be worn full-time for at least 4 weeks is something that can be easily done by any physician, whether it be a patient's PCP or an urgent care physician the patient is seeing for the first time.
Knee injuries that require bracing are not often seen in urgent care centers. However, it is important to recognize the traumatic injuries that require a knee immobilizer. In addition to traumatic injuries of the knee, there are multiple acute musculoskeletal injuries that occur all over the body in which various braces and splints are indicated. Although Gravlee and Van Durme's article does not touch on many other injuries, Primary Care: Clinics in Office Practice has produced 2 great musculoskeletal review articles that touch on a multitude of acute injuries. Patel and Baker produced "Musculoskeletal Injuries in Sports"3 in June of 2006, and Rooks and Corwell published "Common Urgent Musculoskeletal Injuries in Primary Care."4 Both are solid reviews, as is this article by Gravlee and Van Durme.
References
- Gravlee JR, Van Durme DJ. Braces and splints for musculoskeletal conditions. Am Fam Physician. 2007;75:342-348.
- Ivins D. Acute ankle sprain: An update. Am Fam Physician. 2006;74:1714-1720.
- Patel DR, Baker RJ. Musculoskeletal injuries in sports. Prim Care. 2006;33:545-579.
- Rooks YL, Corwell B. Common urgent musculoskeletal injuries in primary care. Prim Care. 2006;33:751-777.
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