I. MEDICAL SUPPLIES

■ Arm Sling (Figure 10-1)

■ Indications: Minimally displaced clavicle fractures, proximal humerus fractures, immobilization after shoulder dislocations, strains, and postoperative immobilization after upper extremity surgery.

■ Application: Position the elbow in the pocket of the sling. Place the strap over opposite shoulder, feed through the D-ring, and secure to itself. Hand should be elevated slightly above the elbow when secured. Many different variations of the arm sling are available in the market.

■ Advantages: Easy to use. Provides proper immobilization and support of the shoulder and elbow joints.

■ Disadvantages: Can cause discomfort and skin irritation.

■ Sarmiento Brace (Figure 10-2)

■ Indications: Closed humeral shaft fractures in acceptable alignment. Acceptable alignment of humeral shaft fracture is considered to be:

• 20 degrees anterior/posterior angulation

• 30 degrees of varus/valgus angulation

• Up to 3 cm of shortening

■ Application: The brace consists of 2 shells applied either anterior–posterior or medial–lateral, and secured with Velcro straps. Use a collar and cuff to support the forearm. Provide additional padding around the collar to reduce discomfort and avoid skin irritation. Avoid the use of a standard sling, which could cause fracture angulation.

Figure 10-1 Arm sling. Proper placement of arm sling.

Figure 10-2 Sarmiento brace. Proper placement of Sarmiento Brace.

■ Advantages: The fracture alignment is maintained through soft-tissue compression and gravity assistance. The brace permits early motion of the adjacent joints, giving providers the opportunity to encourage patients to begin early range-of-motion (ROM) exercises of the finger, wrist, elbow, and shoulder as tolerated.

■ Disadvantages: Contraindicated in patients with massive soft-tissue injury. Requires close supervision and follow-up with radiographs to ensure maintenance of reduction. Frequent brace adjustments are needed as swelling subsides.

■ Hinged Elbow Brace (Figure 10-3)

■ Indications: Elbow instability, dislocation, collateral ligament repair or biceps/triceps repair. Also applicable in postsurgery or postinjury patients who have regained inadequate motion.

■ Application: Adjust the brace to fit the patient’s arm. Apply the brace, fasten the straps, and adjust the ROM dial as needed.

Figure 10-3 Hinged elbow brace. Proper placement of hinged elbow brace.

■ Counterforce Tennis Elbow Strap (Figure 10-4)

■ Indication: Lateral epicondylitis.

■ Application: Wrap around the forearm, approximately 2.5 cm distal to the lateral epicondyle. Some straps have additional gel pads or pillows which should be placed against the radial muscles of the extensor forearm compartment.

Figure 10-4 Tennis elbow strap. Proper placement of tennis elbow strap.

Figure 10-5 Cock-up wrist splint. Proper placement of cock-up wrist splint.

■ Cock-up wrist splint (Figure 10-5)

■ Indications: Carpal tunnel syndrome, wrist sprain or tendinitis, buckle fracture, post-wrist or hand surgery.

■ Application: This is a removable wrist orthosis that can be applied and secured with Velcro straps. It typically contains a metal or thermoplastic insert in its volar (or dorsal) compartment providing rigid support.

■ Advantages: Provides wrist stability/immobilization, while allowing digital motion and forearm rotation. Easy to use and cost-effective.

■ Disadvantages: More rigid and less comfortable than custom-made thermoplastic splints.

■ Hinged knee brace (Figure10-6)

■ Indications: MCL or LCL tear, MCL or LCL repair, post-op use after knee surgery to prevent valgus and varus stress.

Figure 10-6 Hinged knee brace. Proper placement of hinged knee brace.

■ Advantages: Because it is custom-made, it can accommodate a broad spectrum of knee sizes. It can be customized with a variety of options and accessories. It has been reported to subjectively improve stability and function and can be used as an adjunct to graft protection after ACL reconstruction.1,2

■ Disadvantages: Expensive. It can require multiple trips to the orthotist for proper fitting. It can increase energy expenditure and decrease agility.^3,4 Relative lack of conclusive research on prophylactic benefits. Brace effectiveness diminishes at physiologic stress levels.^5,6

■ Patellofemoral brace (“J” brace, Palumbo brace) (Figure 10-7)

■ Indications: Patellofemoral syndrome, patellar subluxation or dislocation, patellar tendinitis, post-op management (lateral release).

■ Application: Usually made from an elastic material such as neoprene and may include straps and buttresses to stabilize the patella. To apply, pull the brace onto affected leg and align patella in center of cutout. Secure the counterbalancing straps, if present, in moderate tension.

■ Advantages: Low cost, ease to use, widely available. Designed to improve patellar tracking with medially directed force.7 Changes in regional temperature, neurosensory feedback, and circulation may also contribute to its effects.⁸ Has been shown to improve anterior knee pain in several studies.^9,10

Figure 10-7 Palumbo brace. Proper placement of palumbo brace.

■ Disadvantages: Subjective benefits exceed objective findings. Some studies found the brace to be ineffective.^11,12 Can cause skin irritation.

■ Knee Immobilizer (Figure 10-8)

■ Indications: Stabilization after acute knee injury, quadriceps or patellar tendon rupture, patellar fracture or dislocation, post-op immobilization.

■ Application: Consists of rigid struts, foam liner, and Velcro straps. To apply, open all the Velcro straps and liner, place behind the leg with the strut centered, wrap the foam liner around the leg and secure the Velcro straps.

■ Advantages: Inexpensive, widely available, easy to apply.

■ Disadvantages: Tends to slide down when ambulating, thus requiring frequent adjustments. Extended use may lead to knee stiffness and muscle atrophy.

■ Unloader Knee Brace for Osteoarthritis (Figure 10-9)

■ Indications: Unicompartmental knee osteoarthritis, knee malalignment.

■ Application: Can be off-the-shelf or custom-made. Most braces use a three-point leverage design applying external varus or valgus force to the knee which distracts the involved compartment and reduces the load.^13–15

■ Advantages: Shown to reduce pain, improve function, and reduce the use of pain meds in patients with unicompartmental OA.^14,16

■ Disadvantages: Expensive. Brace efficacy depends on proper application. Low compliance rate due to brace discomfort, poor fit, and skin irritation.¹⁷

■ CPM Machine (Figure 10-10)

■ Indications: Commonly used to maintain joint motion after knee manipulation and release of arthrofibrosis. May be used after knee replacements, ACL reconstructions, microfracture, autologous chondrocyte transplantation, and chondroplasties.

Figure 10-8 Knee immobilizer. Proper placement of knee immobilizer.

Figure 10-9 Unloader brace. Proper placement of unloader brace around knee.

■ Application: Motorized device applied externally to enable the joint to move passively through a predetermined ROM. ROM, speed, and hold times can be altered as needed.

■ Advantages: Helpful in maintaining ROM and reducing edema. Movement of synovial fluid allows for better diffusion of nutrients into damaged cartilage.^18,19

■ Disadvantages: Does not improve long-term knee function. Can be cumbersome and difficult for patients to use properly at home. Can cause increased discomfort. Some studies show no added benefit in functional recovery after TKR.²⁰

Figure 10-10 CPM machine. Proper patient positioning in CPM machine.

Figure 10-11 Steerable knee walker. Proper use of steerable knee walker.

■ Steerable Knee Scooter (Roll-A-Bout walker) (Figure 10-11)

■ Indications: Also known as a knee walker, coaster, or cruiser. Any ankle or foot injury/surgery/condition that requires the patient to be nonweight bearing (NWB) on the lower extremity.

■ Application: A two-, three-, or four-wheeled device that has a knee pad to support the shin of the affected extremity. The opposite foot makes contact with the ground to provide propulsion.

■ Advantages: Excellent alternative to crutches. Allows patients to be NWB safely. Comfortable and easy to maneuver. Allows patients to be active and mobile during the rehabilitation period. Can be rented temporarily.

■ Disadvantages: Heavier and more difficult to load in a vehicle than crutches. Cannot negotiate stairs.

■ Ankle Air-Stirrup brace (eg, Aircast) (Figure 10-12)

■ Indications: Acute ankle sprain.

Figure 10-12 Aircast. Proper placement of Aircast.

■ Advantages: Provides ankle support, protection, and comfort. It allows dorsiflexion and plantarflexion of the ankle, while providing medial and lateral control. Can be worn inside most wide shoes or sneakers. Studies have shown that functional treatment of acute ankle sprains promotes better outcomes.21

■ Disadvantages: The brace may loosen, slip, and require frequent adjustments.

■ Lace-up ankle brace (Figure 10-13)

■ Indication: Acute and chronic ankle sprain/injury.

Figure 10-13 Lace-up ankle brace. Proper placement of lace-up ankle brace.

■ Advantages: Easy to use, reusable, and adjustable. Easily fits inside most athletic shoes. External ankle support has been shown to improve proprioception.22,23

■ Disadvantages: The effectiveness of the lace-up ankle brace is controversial, with studies revealing conflicting results. A common concern is that prolonged lace-up ankle brace may lead to ankle weakness, which would consequently make the ankle prone to injury.

■ Arizona brace (Figure 10-14)

■ Indication: Designed for treatment of posterior tibialis tendon dysfunction (PTTD).

■ Application: This is a custom-fabricated orthoses typically made from leather and thermoplastic. It holds the foot in a neutral position and out of valgus by using a three-point fixation similar to a well-molded cast. It requires custom casting and fitting and is designed to fit inside a comfort shoe.

■ Advantages: The Arizona brace is clinically proven to be effective at treating Stage I and II PTTD. It has been shown to improve clinical symptoms, ankle and foot alignment, and functional outcomes in patients with PTTD, with success rates up to 90%.^24–27

■ Disadvantages: The Arizona brace relies on passively correcting the deformity, thus the results are less favorable in patients with Stage III PTTD.

■ Ankle–Foot Orthoses (AFO) (Figure 10-15)

■ Indication: Mainly used to correct foot drop.

■ The AFOs are classified into four major categories^28,29:

• Flexible AFO: Provides dorsiflexion assistance, but poor stabilization of subtalar joint.

Figure 10-14 Arizona brace. Depiction of Arizona brace.

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