What Is the Role of Splinting for Comfort?

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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.

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

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 trial ² (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 < 0.01). For grade 2 sprains, the combination of elastic wrap beneath an ankle stirrup brace was similar to a wrap alone or a brace alone, with these functional treatments all resulting in a significant decrease in the time to normal weight bearing and stair climbing versus cast immobilization (10–12 vs. 24–28 weeks; P < 0.01). There was no difference in return to these activities for grade 3 sprains treated with either stirrup bracing or cast immobilization (18–21 weeks for both groups with grade 3 sprains). When comparing the different types of functional treatments, Kerkhoff and colleagues⁷ note that a semirigid brace led to faster return to work (4.2 days; 95% confidence interval [CI]: 2.4–6.1 days) and sport (relative risk [RR], 9.6; 95% CI, 6.3–12.9) than an elastic bandage alone. Lace-up ankle supports were best at decreasing swelling, with elastic bandages the worst for swelling (RR, 5.5; 95% CI, 1.7–17.8). Taping led to the most skin irritations.

FIGURE 46-1 Combination of both elastic wrap and ankle stirrup brace.

(From Beynnon BD, et al: A prospective, randomized clinical investigation of the treatment of firsttime ankle sprains. Am J Sports Med 34:1401-1412, 2006, reprinted with permission of SAGE Publications.)

Kerkhoff and colleagues’ systematic review ⁶ (Level II) reports on early mobilization with “functional treatment” versus cast immobilization for ankle sprains. Functional treatment was defined as any treatment that did not rigidly immobilize the ankle joint, but that may involve elastic wraps, braces, or other support. All patients were allowed weight bearing as tolerated. A second review compared the various forms of functional treatment⁷ (Level I). Return to work was faster (8.2 days; 95% CI, 6.3–10.2 days), as was return to sport (4.9 days; 95% CI, 1.5–8.3 days). Patients were also more likely to be satisfied with functional treatment (RR, 1.8; 95% CI, 1.1–3.1), and they suffered less swelling at 6 to 12 weeks of follow-up (RR, 1.7. 95% CI, 1.2–2.6). Instability on stress films was less likely at follow-up after functional treatment (RR, 2.6; 95% CI, 1.2–4.0). When only the highest quality studies were included, return to work remained significantly faster in functionally treated patients (12.9 days; 95% CI, 7.1–18.7 days).

Ankle Instability Surgery

de Vries and coauthors ³ summarize the results of two studies^6,⁷ that compared functional treatment versus immobilization after surgical repair for chronic ankle instability. Patients experienced faster return to work (1.8 days; 95% CI, 0.9–2.7 days) and earlier return to sport (3 days; 95% CI, 2–4 days) with functional treatment versus immobilization. Pain scores and Tegner function score favored functional treatment but did not reach significance.³

Ankle Fracture Fixation

The studies that address the issue of ankle fracture fixation are difficult to summarize.^4,^{5, 10, 13} Some immobilize both groups for varying periods, and some allow weight bearing in the casted group but not the functional treatment group, and still others exclude patients with osteoporosis and questionable fixation from randomization considering these patients ineligible for potential functional treatment. Is early functional treatment safe? None of the comparisons notes an increased rate of wound problems or loss of fixation, but the study issues noted earlier demand that this result be interpreted with caution. When similar weight-bearing protocols were used in the functional and the casted group after ankle fracture fixation, there is a consistent finding of faster return to work and to function with early mobilization^4,^{5, 13} (Level II), with no difference in function noted across treatment groups by 3 months given the available sample sizes. Egol and researchers⁵ note better vitality and general health scores (36-item short form [SF-36]) at 6 weeks with early functional treatment. These authors also note a significantly faster return to work in the functional group (53.8 vs. 106.5 days; P = 0.007).

Weight bearing after ankle fixation improved patient satisfaction and allowed faster return to activities of daily living ^10,¹³ (Level II). Weight bearing was accompanied by cast immobilization. A 2-week period of non–weight bearing associated with range-of-motion exercises followed by 4 weeks of weight bearing in a cast gave similar results at 3 months as 6 weeks of continuous cast immobilization, except that the gait pattern was more symmetric in the early mobilization group.⁴

Other Injuries

Nash and coworkers ¹³ summarize the evidence from 49 randomized clinical trials regarding immobilization versus functional treatment for stable fractures or soft-tissue injuries and for postoperative treatment¹⁴ (Level II). Early functional treatment was not associated with displacement of stable fractures and was not associated with increased wound problems. Patients generally preferred early mobilization and experienced earlier return to work and sport, decreased pain, swelling, and stiffness.^13,¹⁴

AREAS OF UNCERTAINTY

Uncertainty exists because of lack of research involving many specific injuries, protocols that include varying periods of immobilization and varying rigidity of immobilization in both treatment arms, protocols that are confounded by weight-bearing status, and imprecise definitions of fracture stability or fixation quality.

Most studies have addressed injuries of the ankle joint and may not be generalizeable to other areas, especially the upper extremity, which is generally non–weight bearing. In many of the protocols discussed earlier, the so-called early functional treatment included a period of immobilization immediately after injury or surgery for up to 2 weeks, whereas some used a period of mobility followed by subsequent cast immobilization, potentially diluting the effects of early mobility. Studies were also confounded by weight bearing; usually restricting the “early function group” from weight bearing. This leads to confusing results regarding patient preferences, pain, and function, and it is difficult to know whether the outcome is due to early weight bearing versus early range of movement. The ability to weight bear seems to confer considerable functional benefits and is preferred by patients, but there has been insufficient evaluation of the safety and utility of early weight bearing without rigid immobilization.

Cast immobilization has been used to “protect” stable fractures from unexpected force such as a fall; however, there is little work to guide the clinician as to what the risk for displacement is without cast immobilization in specific injuries, how a stable fracture is defined, and what parameters render a nonoperative stable fracture or an injury treated with surgery vulnerable.

RECOMMENDATIONS

Patients generally benefit from being able to use their limbs after injury for weight bearing. Early mobility helps speed return to work and sports, and there appears to be little danger that “stable” injuries will become unstable if treated with mobilization and early function. Table 46-2 provides a summary of recommendations.

TABLE 46-2 Summary of Recommendations

RECOMMENDATION	LEVEL OF EVIDENCE/GRADE OF RECOMMENDATION
1. Adult with lateral ankle ligament injury should be treated with WBAT in a semirigid brace in preference to a rigid cast and in preference to taping or an elastic wrap alone.

2. Adult with surgical repair for chronic lateral ankle instability should be treated with early mobilization.

3. Adults after ankle ORIF should be treated with support that allows early range of motion as opposed to a rigid cast.

4. Adults after ankle ORIF: There is insufficient evidence to recommend for or against immediate mobilization versus an initial period of a few days in a splint immediately after surgery.

5. Adults after ankle ORIF: There is insufficient evidence to recommend for or against immediate weight bearing after ankle ORIF (with or without immobilization).

6. Adults and children with stable fractures and soft-tissue injuries can be treated with early functional mobilization.

ORIF, open reduction with internal fixation; WBAT, weight bearing as tolerated.

REFERENCES

1 Pathare NC, et al. Deficit in human muscle strength with cast immobilization: Contribution of inorganic phosphate. Eur J Appl Physiol. 2006;98:71-78.

2 Beynnon BD, et al. A prospective, randomized clinical investigation of the treatment of first-time ankle sprains. Am J Sports Med. 2006;34:1401-1412.

3 de Vries JS, et al. Interventions for treating chronic ankle instability. Cochrane Database Syst Rev. 2006;4:CD004124.

4 Dogra AS, Rangan A. Early mobiliation versus immobiliation of surgically treated ankle fractures. Prospective randomised control trial. Injury. 1999;30:417-419.

5 Egol KA, Dolan R, Koval KJ. Functional outcome of surgery for fractures of the ankle. A prospective, randomised comparison of management in a cast or a functional brace. J Bone Joint Surg Br. 2000;82:246-249.