Chapter 46 What Is the Role of Splinting for Comfort?
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.
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
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