What Is the Role of Splinting for Comfort?

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Chapter 46 What Is the Role of Splinting for Comfort?

HANS J. KREDER, MD, MPH, FRCSC

External immobilization is used in three situations: the provisional (and sometimes the definitive) nonoperative treatment of unstable bone and soft-tissue injuries, the treatment of stable bone and soft-tissue injuries, and after surgical fracture or soft-tissue stabilization.

Unstable injuries involve bone or soft-tissue discontinuity to the extent that the pieces move independently with minimal force. Immobilizing unstable limb injuries is a basic principle of emergency fracture management designed to decrease pain and to minimize additional soft-tissue damage and hemorrhage. Provisional immobilization of unstable injuries may be followed by surgical intervention or definitive nonoperative treatment. External immobilization such as casting for the definitive treatment of unstable injuries usually requires that at least one adjacent joint near the injury is immobilized to prevent displacement during healing. When the decision is made to treat an unstable injury (e.g., a displaced tibia fracture) without surgery, the deleterious effects of joint immobilization,1 such as muscle atrophy, weakness, and joint stiffness, are generally unavoidable. For unstable injuries, some form of immobilization is mandatory.

In the treatment of stable soft tissue or bone injuries such as sprains and undisplaced or impacted fractures, uncertainty exists regarding the role of rigid versus dynamic immobilization or, indeed, whether any immobilization is necessary and for how long immobilization should continue. The goal of treatment is to maximize patient function and to prevent a stable injury from becoming unstable because of reinjury or excessive loading. Thus, immobilization may be considered for comfort and for protection.

The goal of surgical fracture fixation is to provide absolute or relative stability that is biomechanically sufficient to allow the adjacent joints to be mobilized. However, many clinicians routinely immobilize a limb, including one or more joints, after surgery with the intention of minimizing pain and soft-tissue contractures caused by persistent painful joint positioning (e.g., ankle equinus), and promoting soft-tissue healing by preventing shear stress across the incision. Given the known deleterious effects of joint immobilization, especially when the articular surface is involved, the need for postoperative immobilization has been questioned. This debate is complicated by issues of weight bearing or not, the type of fixation that was used, and patient factors such as the ability to use crutches or to participate actively in range-of-motion exercises.

OPTIONS

The treatment of unstable fractures and soft-tissue injuries does involve provisional external immobilization or traction, which occasionally becomes the definitive treatment; however, the main point of debate for these injuries is operative versus nonoperative care because clearly some form of immobilization is required for controlling an unstable injury. This topic is addressed separately under the chapters relevant to a specific type of injury and is not considered further here.

When a bone or soft-tissue injury is stable, treatment options include either no immobilization or some form of static or dynamic immobilization. Does immobilization improve patient comfort and return to activities? Does immobilization reduce the risk for a stable injury becoming unstable? How long should a stable injury be immobilized? The same questions of patient comfort and return to function apply to the postoperative immobilization of joints adjacent to a surgically fixed bone or soft-tissue injury. Additional concerns include the following: Does immobilization prevent complications related to the incision such as wound dehiscence and infection? Is immobilization necessary to prevent deformity in some situations (e.g., ankle fractures with a concern of possible equinus deformity)?

The purpose of this chapter is to provide guidance to the clinician with respect to the immobilization of stable injuries and postoperative patients, and to highlight areas where further study would be helpful in strengthening the evidence base for treatment.

EVIDENCE

A number of randomized clinical trials of varying quality have been undertaken to address the issue of immobilization versus functional treatment for stable injuries and after open reduction and internal fixation of ankle fractures. Most of these studies have been summarized in meta-analyses (Table 46-1). Most studies have dealt with ankle injuries.2–10 Few studies have addressed upper extremity injuries.11–13

TABLE 46-1 Summary of Evidence

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Ankle Sprain

Faster return to normal activities such as work and sport with functional mobilization versus rigid immobilization has been the most consistent finding across trials. An industry-sponsored randomized clinical trial2 (Level I) graded the degree of ankle sprain and then randomized grade 1 sprains to an elastic wrap, an ankle stirrup brace, or a combination of both2 (Fig. 46-1). Grade 2 sprains were randomized to the same groups as grade 1 sprains or a cast, and grade 3 sprains were allocated to either a stirrup brace or cast. For grade 1 sprains, the combination of an elastic wrap under an ankle stirrup resulted in a return to normal walking and stair climbing that was roughly twice as fast as either alone (4–6 vs. 10–12 weeks; P

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