Attività

We compared patterns of bony and ligamentous injury with distal radial fractures in braced and unbraced wrists using 20 paired fresh cadaveric upper extremi ties. A commercially available wrist brace was placed on one wrist in each pair. Specimens were then placed in a fast-loading gravity-driven device and subjected to loads averaging 16 kg from an average height of 78 cm. Postfracture radiographs were obtained, the spec imens were dissected, and fracture patterns and liga mentous integrity were assessed. The following frac ture types were produced: distal radial fractures (eight unbraced, seven braced) and intraarticular (seven un braced, four braced). Radiographically, seven un braced wrists demonstrated carpal bone fracture and one braced wrist demonstrated carpal fractures. Eight unbraced and three braced wrists sustained carpal intrinsic ligament injuries, four unbraced and one braced wrists demonstrated extrinsic ligament injuries. More capsular tears occurred in the unbraced group (N = 8) than in the braced group (N = 1). This model demonstrated a difference in the patterns of injury in unbraced and braced wrists subjected to the same mechanical conditions, which suggests that use of a wrist brace may alter patterns of wrist injury.

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. Am Fam Physician 2007;75:342–8. Copyright © 2007 American Academy of Family Physicians.)

Family physicians often must make decisions regarding the use of braces or splints in the management of musculoskeletal disorders. Bracing can be useful for acute injuries, and also for chronic conditions and in the prevention of injury. The purpose of braces and splints is to improve physical function, slow disease progression, and diminish pain. They can be used to immobilize an unstable joint or fracture, to unload a portion of a joint and improve pain and function, to eliminate range of motion in one direction, or to modify range of motion in one or more directions. They do not replace a good rehabilitative program, and the entire spectrum of treatment options should be explored and used as needed.

Accurate diagnosis of the injury is important in determining whether a brace or splint is indicated. Generally, splints are for short-term use. Excessive, continuous use of a brace or splint can lead to chronic pain and stiffness of a joint or to muscle weakness.
Given the limited evidence on the use of braces and splints, it is particularly important to use a patient-centered approach, with consideration for individual patient's expectations and concerns and an understanding of the nature of their activity. For example, for high school and collegiate athletes, there are specific rules on the types of protective equipment, splints, and braces that may be worn during competition.1 Close follow-up after bracing or splinting is essential to ensure proper fit and use.

The most common types of braces and splints used in primary care and the quality of evidence to support current recommendations are discussed in the following.

Relatively few studies on bracing have been published, and most are not randomized controlled trials. A Cochrane systematic review4 identified only one randomized controlled trial.2 In this study, 119 patients who had osteoarthritis associated with varus deformity of the knee were randomized to receive usual treatment, unloader knee brace, or neoprene sleeve to evaluate the effect of these therapies on functional status and quality of life.2 Although both the sleeve and the brace reduced pain and improved function, greater benefit was found with the unloader brace. In a randomized crossover trial, 12 patients with varus osteoarthritis were given a simple hinged brace or an unloader brace during two six-month periods. Because patients acted as their own controls, it was possible to identify statistically and clinically significant benefits for the unloader brace that were greater than those of the hinged brace despite the small number of patients involved in the study.5 The American Academy of Orthopaedic Surgeons recommends unloader braces for the reduction of pain in patients with osteoarthritis of the knee.6 This conservative option is thought to extend the time before patients need to undergo knee arthroplasty; it also can be considered for those who are not candidates for surgery.

ANTERIOR KNEE PAIN BRACE

Anterior knee pain, also called patellofemoral pain syndrome (PFPS), is a common complaint among young, active patients. Its etiology is multifactorial and controversial, and the treatment can be frustrating for the physician and the patient. Braces have been developed to address the most commonly accepted etiology: malalignment of the patellofemoral joint. Typically, these braces are made of neoprene or a similar elastic material, with additional straps or a buttress for patellar support. The buttress can be circular, C-shaped, J-shaped, or H-shaped to help maintain tracking of the patella in the femoral groove. These braces are reasonably priced, and off-the-shelf models are adequate (Figure 2).

Evidence of the effectiveness of braces for treatment or prevention of PFPS is limited because of methodologic differences and shortcomings across studies. Two systematic reviews published in 2002 and 2003 concluded that, because of the low quality of available studies, there is insufficient evidence to support or to discourage the use of patellar bracing for PFPS.7,8 Likewise, an American Academy of Pediatricians technical report stated that there is no scientific evidence to support the use of knee sleeves.

Two studies, published after the systematic reviews, produced contradictory results.10,11 In one small, anatomic study using magnetic resonance imaging, researchers examined patellar alignment, patellofemoral joint contact area, and pain response in patients with and those without bracing.10 They found significant changes in contact area and improvement in pain in the braced group but little change in patellar alignment. In a prospective randomized clinical trial published in 2005, researchers randomized 136 patients with anterior knee pain to treatment with home exercises, patellar bracing, exercises plus bracing, or exercises plus knee sleeve, and found no difference in pain ratings between the four groups after 12 weeks.