Dụng Cụ Chỉnh Hình Và Chân Tay Giả Trong Phục Hồi Chức Năng (Ấn Bản Thứ 3)

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Section II  Orthoses in Rehabilitation
Incidence and Etiology of Developmental
Dysplasia of the Hip
Instability of the hip due to DDH occurs in 11.7 of every 1000
live births, with most of these classified as hip subluxation
(9.2/1000), followed by true dislocation (1.3/1000) and dislo­
catable hips (1.2/1000).33,35 Hip dislocation is more common
in girls (70%) than in boys and among white than among
black newborns. Approximately 20% of all hip dislocations
are associated with breech presentation, although the inci­
dence of breech presentation in the normal population is
approximately 4%.36 A familial tendency is also found: DDH
is much more likely to occur when an older sibling has had
congenital subluxation or dislocation. The risk of dysplasia
increases with any type of intrauterine malpositioning lead­
ing to extreme flexion and adduction at the hip. This occurs
more commonly during first pregnancies if and when tight­
ness of maternal abdominal or uterine musculature is present,
when the infant is quite large, or when insufficient amniotic
fluid restricts intrauterine motion.32,37 A higher incidence of
DDH is also found among newborns with other musculo­
skeletal abnormalities including torticollis, metatarsus varus,
clubfoot, or other unusual syndromes.
At birth the acetabulum is quite shallow, covering less
than half of the femoral head. In addition, the joint cap­
sule is loose and elastic. These two factors make the neo­
nate hip relatively unstable and susceptible to subluxation
and dislocation. Normal development of the hip joint in
the first year of life is a function of the stresses and strains
placed on the femoral head and acetabulum during move­
ment. In the presence of subluxation or dislocation, mod­
eling of the acetabulum and femoral head is ­compromised.
The most common clinical sign of DDH is limitation
in hip abduction.38 On clinical examination, a “click”
(Ortolani sign) felt when upward pressure is applied at the
level of the greater trochanter on the newborn or infant's
flexed and abducted hip (Figure  12-8) indicates that a
dislocated hip has been manually reduced.39 The goal of
orthotic management in developmental dysplasia is to
achieve optimal seating of the femoral head within the
acetabulum while permitting the kicking movements that
assist shaping of the acetabulum and femoral head for sta­
bility of the hip joint.40,41 This is best achieved if the child
is routinely positioned in flexion and abduction at the hip.
If DDH is recognized early and appropriate intervention
is initiated, the hip joint is likely to develop normally. If
unrecognized and untreated, DDH often leads to signifi­
cant deformity of the hip as the child grows, resulting in
compromised mobility and other functional limitations.
Early Orthotic Management of Developmental
Dysplasia of the Hip: Birth to 6 Months
In 1958 Professor Arnold Pavlik of Czechoslovakia described
an orthosis for the treatment of dysplasia, subluxation, and
dislocation of the hip.42,43 The orthosis he developed, the
Pavlik harness, relies on hip flexion and abduction to sta­
bilize the hip at risk. Although a multitude of braces and
orthoses have been used historically in the treatment of hip
instability, including hip spica casts, the Frejka pillow, the
Craig splint, the Ilfeld splint, and the von Rosen splint, the
Pavik harness, has become widely accepted as a mainstay for
the initial treatment for the unstable hip in ­neonates from
birth to 6 months of age.
A
B
“Click”
FIGURE  12-8  Test position for developmental dysplasia of the
hip in the newborn. A, The hip is moved into flexion, adduction,
and internal rotation. B, A “click” when upward pressure is applied
at the greater trochanter suggests that the dislocation has been
reduced. (From Magee DJ. Orthopedic Physical Assessment. 3rd ed.
Philadelphia: Saunders, 1997. p. 477.)
Normal
Abnormal
Retroversion
8-15º
normal
Axis of
femoral
condyles
at knee
Axis of
femoral
head
2
S
D
a
ge

se
x
M
e
d
ia
l
f
e
m
or
al
t
o
r
s
i
o
n
L
a
te
ra
l
f
e
m
or
al
t
o
r
s
i
o
n
A
nt
ev
er
si
on
FIGURE 12-7  Normal relationship between the axis of the femoral
neck and the axis of the femoral condyles (viewed as if looking down
the center of the femoral shaft) is between 8 and 15 degrees. Excessive
anteversion leads to medial (internal) femoral torsion. Insufficient
angulation, retroversion, is associated with lateral (external) femo­
ral torsion. (From Staheli LT.Medical Femoral Torsion. Orthop Clin
North Am. 1980;11:40.)

Chapter 12  Orthoses in Orthopedic Care and Trauma
343
At first glance, the Pavlik harness seems a confusing col­
lection of webbing, hook-and-loop material, padding, and
straps. In reality, this dynamic orthosis (Figure  12-9) has
three major components:
1. A shoulder and chest harness that provides a proximal
anchor for the device
2. A pair of booties and stirrups used as the distal attachment
3. Anterior and posterior leg straps between chest harness
and booties used to position the hip joint optimally
The anterior strap allows flexion but limits extension,
whereas the posterior strap allows abduction but limits adduc­
tion. The child is free to move into flexion and abduction, the
motions that are most likely to assist functional shaping of
the acetabulum in the months after birth.42–44 To be effective,
however, the fit of the harness must be accurately adjusted for
the growing infant and the orthosis must be properly applied.
The family caregiver must be involved in an intensive educa­
tion program when the newborn is being fit with the Pavlik
harness. Nurses, physical and occupational therapists, pedia­
tricians, and orthopedic residents who work with newborns
also need to understand the function and fit of this important
orthosis. The guidelines for properly fitting a Pavlik harness
include the following key points40,45:
1. The shoulder straps cross in the back to prevent the orthosis
from sliding off the infant's shoulders.
2. The chest strap is fit around the thorax at the infant's
­nipple line.
3. The proximal calf strap on the bootie is fit just distal to the
knee joint.
4. The anterior leg straps are attached to the chest strap at the
anterior axillary line.
5. The posterior leg straps are attached to the chest strap just
over the infant's scapulae.
In a correctly fit orthosis, the lower extremity is positioned
in 100 to 120 degrees of hip flexion, as indicated by the phy­
sician's evaluation and recommendation. The limbs are also
positioned in 30 to 40 degrees of hip abduction. The distance
between the infant's thighs (when the hips are moved pas­
sively into adduction) should be no more than 8 to 10 cm.
In a well-fit orthosis, extension and adduction are limited,
whereas flexion and abduction are freely permitted: The
infant is able to kick actively within this restricted range while
wearing the orthosis. This position and movement encour­
age elongation of adductor contractures, which in turn assists
in the reduction of the hip and enhances acetabular devel­
opment. Three common problems indicate that the fit of the
harness requires adjustment40,46:
1. If the leg straps are adjusted too tightly, the infant cannot
kick actively.
2. If the anterior straps are positioned too far medially on the
chest strap, the limb is positioned in excessive adduction
rather than the desired abduction.
3. If the calf strap is positioned too far distally on the lower
leg, it does not position the limb in the desired amount of
hip flexion.
Optimal outcomes in infants with DDH are associated
with early aggressive intervention of the unstable hip using
the Pavlik harness.47,48 Families and health care professionals
must seek proper orthopedic care to avoid misdiagnosis and
mistreatment. One of the most common misdiagnoses is mis­
taking dislocation for subluxation and implementing a triple-
or double-diapering strategy for intervention. Although this
strategy does position the infant's hip in some degree of flex­
ion and abduction, bulky diapers alone are insufficient for
reducing dislocation.
Initially, most infants wear the Pavlik harness 24 hours
a day. The parents can be permitted to remove the harness
for bathing, at the discretion of the orthopedist. Importantly,
especially early in treatment, the fit and function of the ortho­
sis must be reevaluated frequently to ensure proper position
in the orthosis. The many straps of the Pavlik harness can be
confusing to the most caring of families. The proper donning
and doffing sequence should be thoroughly explained and
demonstrated to the family. Additional strategies to enhance
optimal reduction of the hip such as prone sleeping should be
encouraged.
Families must be instructed in proper skin care and in
bathing the newborn or infant wearing the orthosis. Initially,
they may be advised to use diapers, but not any type of shirt,
under the orthosis. The importance of keeping regularly
scheduled recheck appointments for effective monitoring of
hip position and refitting of the orthosis as the infant grows
cannot be overstressed to the parents or caregivers.48–50 Missed
appointments often result in less than optimal positioning of
FIGURE 12-9  A Pavlik harness positions the infant's lower extrem­
ities in hip flexion and abduction in an effort to position the femoral
head optimally within the acetabulum, assisting normal bony devel­
opment of the hip joint. The anterior leg straps allow hip flexion
but limit hip extension; the posterior flaps allow abduction but limit
adduction.

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Section II  Orthoses in Rehabilitation
the femoral head with respect to the acetabulum, a less than
satisfactory outcome of early intervention, and the necessity
of more invasive treatment procedures as the child grows.
As a general rule, the length of treatment in the har­
ness is equal to the child's age when a stable hip reduction
is achieved plus an additional three months. Thus if a stable
reduction is achieved at 4 months of age, the total treatment
time would be 7 months. Over time, when hip develop­
ment is progressing as desired, the wearing schedule can be
decreased to night and naptime wear. This often welcomed
change in wearing time can begin as early as 3 months of
age if x-ray, ultrasound, and physical examination demon­
strate the desired bone development. When the orthopedist
determines that the hip is normal according to radiographs
and ultrasound and is satisfied with the clinical examina­
tion, the orthosis can be discontinued. If development of the
hip is slow or the infant undergoes rapid growth, it may be
advisable to continue the treatment with another type of hip
abduction orthosis designed for older and larger babies, to
maintain the position of flexion and abduction for a longer
period of time.
Management of Developmental Dysplasia of the
Hip: 6 Months and Beyond
For older infants and toddlers (6 to 18 months) whose DDH
was unrecognized or inadequately managed early in infancy,
intervention is often much more aggressive and may include
an abduction brace, traction, open or closed reduction, and
hip spica casting.33,51 For infants who are growing quickly or
whose bone development has been slow, an alternative to the
Pavlik harness is necessary. After the age of 6 months, espe­
cially as the infant begins to pull into standing in prepara­
tion for walking, the Pavlik harness can no longer provide the
desired positioning for reduction. Often, the infant is simply
too large to fit into the harness. By this time, families who
have been compliant with harness application and wear­
ing have grown to dislike it and are ready for other forms of
intervention.
A custom-fit prefabricated thermoplastic hip abduc­
tion orthosis is often the next step in orthotic management
of DDH. This orthosis consists of a plastic frame with waist
section and thigh cuffs, waterproof foam liner, and hook-
and-loop material closures. The static version is fixed at
90 degrees of hip flexion and 120 degrees of hip abduction
(Figure 12-10). An adjustable joint can be incorporated into
the abduction bar; however, hip flexion is maintained at 90
degrees. This orthosis appears to be static, but the child is able
to move within the thigh sections while the safe zone for con­
tinued management of hip position is maintained.
Many families view the hip abduction orthosis as an
improvement over the Pavlik harness: The caregivers and the
infant are free from cumbersome straps, the orthosis is eas­
ily removed and reapplied for diaper changing and hygiene,
and the orthosis itself is waterproof and easier to keep clean.
Parents and caregivers can hold the infant without strug­
gling with straps, and the baby is able to sit ­comfortably for
­feeding and play.
Because most hip abduction orthoses are prefabricated, the
knowledge and skills of an orthotist are necessary to ensure a
proper custom fit for each child. To determine what the nec­
essary modifications are, the orthotist evaluates three areas:
1. The length of the thigh cuffs. Thigh cuffs are trimmed
proximal to the popliteal fossae. Cuffs that are too long
can lead to neurovascular compromise if the child prefers
to sleep in a supine position, as the risk of compression of
the legs against the distal edge of the cuffs is present.
2. The width of the anterior opening of the waist component.
Although the plastic is flexible, the opening may need to
be enlarged for heavy or large-framed infants.
3. The foam padding of the thigh and waist components. All
edges must be smooth to avoid skin irritation or break­
down, and the circumference of the padding should fit
without undue tightness.
Modifications may require reheating or trimming of the
plastic or foam padding. Usually this fitting takes place in
the orthotist's office or the clinic setting, where the neces­
sary tools are readily available. Once the fit is evaluated and
modified as appropriate for the individual child, the parents
or caregivers are instructed in proper donning/doffing and
orthotic care.
The static hip abduction orthosis is used in either of two
ways. First, the orthosis may be a continuation of the course
of treatment established by the Pavlik harness, as determined
by the orthopedist's evaluation of the child's hip. As a contin­
uation of treatment, the orthosis can be worn day and night;
most often, however, it is reserved for nighttime use while
the child is sleeping.38,40,51 The use of the orthosis at night is
believed to assist development of acetabular growth cartilage.
If the orthosis is worn consistently for several months and
evidence of effective reduction and reshaping of the joint is
present, it is less likely that more aggressive forms of treat­
ment will be necessary as the child grows.
The second application for the hip abduction orthosis
is for follow-up management for children with DDH who
require an orthopedic intervention such as traction, surgical
FIGURE 12-10  A posterior view of a static hip abduction ortho­
sis, which positions the infant in 90 degrees of hip flexion and 120
degrees of abduction.

Chapter 12  Orthoses in Orthopedic Care and Trauma
345
reduction, or casting. In this case the orthosis provides exter­
nal stability to the hip during the postoperative weeks and
months, while the baby regains range of motion and contin­
ues to grow and progress through the stages of motor devel­
opment. This extra stability reduces parental and physician
concern about dislocation and other undesired outcomes of
the orthopedic procedure.
The static hip abduction orthosis has obvious advantages
over plaster or synthetic hip spica casts including greater
ease in diaper hygiene and bathing and is often welcomed by
families as a positive next step in treatment. Fitting requires
the knowledge and skills of an orthotist familiar with proper
fitting techniques and who can manage potentially irritable
babies just freed from a confining hip spica cast.
Goals of Orthotic Intervention for Children
with Developmental Dysplasia of the Hip
To be effective, orthotic intervention for DDH must have a set
of clearly described treatment objectives against which suc­
cess can be measured. The components necessary for effec­
tive orthotic interventions for children with DDH include the
following:
1. Clearly presented verbal, psychomotor, and written ins­
tructions for the child's family or caregivers, with an addi­
tional goal of minimizing stress in an already stressful
situation.
2. Effective communication among members of the health
care team about the appropriate use and potential pit­
falls of the orthosis. This often includes education about
the orthosis provided by the orthotist and careful mon­
itoring of family compliance and coping by all members
of the team (orthotists, orthopedists, pediatricians, thera­
pists, nurses, and other health professionals who may be
involved in the case).
3. Safe and effective hip reduction to minimize the necessity
of more aggressive casting or surgery. This requires proper
orthotic fit and adjustment, as well as consistency in wear­
ing schedules.
The ultimate goal is to facilitate normal development of
the hip joint, providing the child with a pain-free, stable,
functional hip that will last throughout his or her lifetime.
Complications of Orthotic Management
of Developmental Dysplasia of the Hip
In most cases the Pavlik harness, perhaps followed by abduc­
tion splint use as the child grows, is a successful intervention
for DDH. A small percentage of infants with DDH man­
aged by the Pavlik harness (<8%) develop complications, the
most serious of which is avascular necrosis of the femoral
head, which may be caused by overtightening the posterior
straps to force a position of abduction.33,49–54 Children who
have complications differ from those without complications
in a number of ways. They tend to have larger acetabular
angles (>35 degrees) and less total coverage of the femoral
head within the acetabulum (<20%) on radiography or ultra­
sound, have an irreducible dislocation at initiation of orth­
otic intervention, have delayed diagnosis and intervention
(older than 3 months of age), and have not demonstrated a
prior ossific nucleus on radiograph or ultrasound.49,50,52,55
Orthotic Management of Legg-Calvé-Perthes Disease
LCPD is a hip pathology that affects otherwise healthy
school-aged children. Although the clinical signs and symp­
toms of LCPD, as they differ from tuberculosis involving
the hip, were first described by Arthur T. Legg in 1910,56
the etiology of this condition is not clearly understood and
its treatment and orthopedic management continue to be
controversial. The hallmark of LCPD is a flattening of the
femoral head, thought to be a result of an avascular necro­
sis insult. Left untreated, LCPD leads to permanent defor­
mity and eventual osteoarthritis in the adult hip. The disease
is four times as common in boys between the ages of 4 and
8 years old as in girls, although outcomes in girls tend to be
less satisfactory.57–59 LCPD generally involves only one hip;
only approximately 12% of cases are bilateral. It is rare within
the black population. Several options for orthotic manage­
ment of LCPD have evolved. All are designed to help main­
tain a spherical femoral head and normal acetabulum.
Etiology of Legg-Calvé-Perthes Disease
The etiology of LCPD remains controversial more than
100 years after it was first described. Most researchers believe
that LCPD is a result of some event or condition that compro­
mises blood flow to the femoral head and leads to avascular
necrosis. The exact mechanism that triggers this compromise
is unknown. Some theories focus on an acute trauma that
damages the vascular system of the femoral head, whereas
others suggest that repeated episodes of a transient synovi­
tis may compromise blood flow.58,60,61 Another theory sug­
gests an abnormality of thrombolysis in children who develop
LCPD.62 A genetic predisposition to delayed bone age that
exposes vessels to high rates of compression as they pass
through cartilage to the bony head has also been suggested.60
Although the exact etiology of LCPD remains a mystery, it is
certainly linked to episodes of avascular necrosis in the femo­
ral head. The goal of intervention in children with LCPD is
to assist revascularization of the femoral head and to restore
normal anatomical shape and alignment of the hip joint.
Evaluation and Intervention for Legg-Calvé-Perthes
Disease
LCPD should be suspected in children with one or more of
the following signs or symptoms63,64:
1. A noticeable limp, often with a positive Trendelenburg sign
2. Pain in the hip, groin, knee, or a combination of these
locations
3. Loss of range of motion of the hip joint
When these symptoms are present, radiographic, ultra­
sound, or magnetic resonance imaging studies of the hip are
used to discriminate between LCPD (Figure 12-11) and other
hip disorders (e.g., slipped capital femoral epiphysis, fracture,
rheumatic disease, infection).65 These studies are used by the
orthopedist to determine severity and progression of the dis­
ease, considering stage of disease, shape of femoral head,

346
Section II  Orthoses in Rehabilitation
degree of congruence with the acetabulum, and length and
angle of the femoral neck.66,67 A variety of classification sys­
tems have been developed to rate severity of involvements. The
Catterall system describes four groups on the basis of the loca­
tion of involvement and identifies four “head at risk” signs for
the orthopedist or radiologist to focus on in interpreting radio­
graphs.68 Studies of the interrater and concurrent reliability of
the Catterall systems have not all been positive.69–71 The Salter-
Thompson system rates severity of involvement on the basis
of the location and extent of subchondral fracture that may be
observed early in the disease process.72,73 The Herring system
examines the condition of the lateral pillar of the femoral head
on radiographs.65,71,74 Refer to texts on orthopedic conditions in
pediatrics for further information about classification.60,61
LCPD is a self-limiting process that often resolves in 1 to
3 years. The disease progresses through three stages:
1. Necrotic stage: avascular necrosis
2. Fragmentation stage: resorption of damaged bone
3. Healing/reparative stage: revascularization, reossification,
and bony remodeling
Factors that influence the eventual outcome of the disease
include age at onset, severity of damage to the femoral head
and epiphysis, and quality of congruency of the acetabulum
and femoral head.58–61
Because the disease process is self-limiting, the optimal
intervention strategy is controversial. The three most com­
monly used avenues of treatment for LCPD are observation,
surgical intervention, and conservative orthotic management.
Decisions about treatment are often guided by age of the child,
extent of femoral head deformity, and severity of ­incongruency
between the femoral head and acetabulum.60,61,75 More recent
data suggest that patients younger than 6 years of age at the
time of disease onset are best managed nonsurgically, whereas
the treatment for patients older than 8 years may involve
­surgery and is less well defined.76
For children with minimal bony deformity, observa­
tion and exercise may be the most appropriate intervention.77
Because the child is likely to continue to limp until suf­
ficient revascularization and remodeling have occurred
(which may require several years), parents may be uneasy,
preferring instead a more aggressive intervention. Parents are
reassured when close clinical follow-up is performed, with
periodic reexamination by x-ray evaluation to monitor pro­
gression of the disease process.
Surgical intervention is based on the principle of con­
tainment, optimally positioning the femoral head within
the acetabulum. Proximal femoral derotation osteotomy
is used to decompress and center the femoral head within
the acetabulum for more functional weight bearing in an
extended position.78,79 A pelvic osteotomy, which repositions
the acetabulum over the femoral head, is sometimes neces­
sary when a significantly enlarged or subluxed femoral head
cannot be effectively repositioned by femoral derotation
osteotomy.80,81 Shelf arthroplasty to reshape the acetabulum
to better accept the femoral head has also been used as an
intervention.82,83 The outcome of surgery is likely to be most
positive for children who have full hip range of motion pre­
operatively. Parents must understand the goals and risks of
the surgical procedure and must be actively involved in post­
operative rehabilitation efforts.
The goal of conservative orthotic management of LCPD
is similar to that of surgical intervention: to contain the fem­
oral head within the acetabulum during the active stages of
the disease process so that optimal remodeling can occur.41,84
Much debate has taken place concerning whether surgery
or orthotic intervention is most efficacious. If both are via­
ble methods of treatment, the end result should be the same:
a well-shaped femoral head and pain-free hip. Comparing the
efficacy of surgical versus orthotic management of LCPD is
challenging because of relatively low incidence as well as dif­
ferences in study design and definition of control for variables
such as age of onset, duration of the disease, gender, and inad­
equate interobserver reliability of classification systems.84,85
Although two reports published in 1992 question the effi­
cacy of orthotic treatment,86,87 other studies advocate orthotic
treatment even in severe cases of the disease. Because studies
have reported success, as well as lack of success for all three
types of intervention (noncontainment/observation, surgery,
and the use of orthoses), the most appropriate management
of LCPD has not been clearly determined.
Orthotic Management in Legg-Calvé-Perthes Disease
Currently the most commonly used orthosis in the nonop­
erative management of LCPD is the Atlanta/Scottish-Rite hip
abduction orthosis (Figure 12-12). The design of this orthosis
allows the child to walk and be involved in other functional
activities while containing the femoral head in the acetab­
ulum with abduction of the hips.88–90 The Atlanta/Scottish-
Rite orthosis has three components: a pelvic band, a pair of
single-axis hip joints, and a pair of thigh cuffs. An abduction
bar may also be included, interconnecting the thigh cuffs
with a ball-and-socket joint as an interface. This orthosis
holds each hip in approximately 45 degrees of hip abduction,
permits flexion and extension of the hip, and can be worn
over clothing. While in the orthosis the hips are abducted
and flexed but the patient has no limitation in knee range of
FIGURE 12-11  A radiograph of a child with Legg-Calvé-Perthes
disease comparing the shape and density of the head of the femur
and of the capital epiphysis on the normal (right side of image) and
affected (left side of image) right hip.

Chapter 12  Orthoses in Orthopedic Care and Trauma
347
motion and therefore can sit or walk without difficulty. The
orthosis is not designed to control internal rotation of the
hip. This type of orthosis is most effective if the child who
is wearing it has close to normal range of motion at the hip
joint. Limitations in range of motion cause the child to stand
asymmetrically in the orthosis, which effectively reduces the
amount of abduction and containment of the femoral head.
Historically (in the 1960s and 1970s), a number of other
orthoses were developed on the basis of the ­principles of
containment of the femoral head. The Toronto ­orthosis
(Figure 12-13A) and the Newington orthosis (see Figure 12-13B)
hold both limbs in 45 degrees of abduction with internal
­rotation, but unlike the Atlanta/Scottish Rite orthosis, require
the use of crutches for safe mobility.91,92 Both of these ­orthoses
are cumbersome to wear and significantly affect the ease of
daily function. Because the efficacy of the Atlanta Scottish-
Rite orthosis is as high as or higher than the efficacy of the
Toronto and Newington orthoses, the latter two orthoses are
not commonly used in current management of children with
LCPD.41,93 In addition, orthoses like an “A-frame” may be
used after several weeks of Petrie casting, another nonsurgical
­treatment option enforcing hip abduction.76
If the disease process progresses and the hip begins to
lose additional range of motion, the orthotist may be the
first to recognize this problem. The parents may bring the
child to the clinic for an orthotic adjustment because the
thigh cuffs have become uncomfortable. If loss of addi­
tional range of motion is noticed by parents or by therapists
who are working with the child, an immediate referral to
the orthotic clinic or physician is necessary. The Atlanta/
Scottish-Rite orthosis is not designed to increase range of
motion; its primary function is to hold the hips in abduction
comfortably. Using the orthosis to restore range of motion
defeats the purpose of the orthotic design and compromises
treatment principles.
Communication among the orthopedist, orthotist, ther­
apist, and family is essential. Parents must understand that
this is a demanding form of treatment. Typically, the orthosis
is worn continually for 12 to 18 months. Once radiographic
evidence of femoral head reossification is seen, time in the
orthosis is gradually reduced.
Absolute compliance with the wearing schedule is neces­
sary for maximum effectiveness: A well-designed and well-fit
orthosis can only work if it is being used. The first few days
and weeks in the orthosis are often stressful for the parent and
the child. With the hips held in an abducted position, rou­
tine tasks including walking may require assistance until the
child learns effective adaptive strategies. Physical therapists
may work with the child on crutch-walking techniques on
level surfaces, stairs, inclines, and uneven surfaces. They may
FIGURE  12-12  The Atlanta/Scottish-Rite hip abduction ­orthosis
(anterior view), used in the conservative management of Legg-
Calvé-Perthes disease. This orthosis has three components: the
pelvic band, the free-motion hip joints, and the thigh cuffs. An
abduction bar can be placed between the thigh cuffs to provide extra
stability in the desired position of 45 degrees of hip abduction.
A
B
FIGURE 12-13  Earlier designs for hip abduction knee-ankle-foot orthoses used to manage Legg-
Calvé-Perthes disease. The Toronto hip-knee-ankle foot orthosis (A) and Newington orthoses
(B) were more cumbersome to don and to function with than the Atlanta/Scottish-Rite hip abduc­
tion orthoses. (From Goldberg B, Hsu JH [eds], Atlas of Orthotics and Assistive Devices. 3rd ed.
St. Louis: Mosby, 1997.)

348
Section II  Orthoses in Rehabilitation
make suggestions for adaptation of the home and school envi­
ronments so that sitting and transitions from flooring, chairs,
and standing quickly become manageable. If family educa­
tion and support efforts are effective and enable parents and
children to weather this difficult initial stage in orthotic man­
agement well, the likelihood of compliance in the remaining
months of intervention is significantly enhanced.
Pediatric Postoperative Care
Numerous musculoskeletal and neuromuscular conditions,
in addition to LCPD and developmental dysplasia, may neces­
sitate surgical intervention for children with hip and lower
extremity dysfunction or deformity. Orthoses that control
hip and leg position are often used in the weeks and months
after surgery as an alternative to traditional plaster casts or
as a ­follow-up strategy once casts are removed. Although a
cast may be applied in the operating room for immediate
postoperative care, orthoses are often fit soon afterward and
effectively shorten the time that a child spends in a cast. Hip
orthoses are used when immobilization and support will be
required for a long period of time, when complications arise,
or when a child's special needs demand their use.
One of the major benefits of an orthosis (as compared with
a plaster cast) is in regard to hygiene, especially for children
who have not yet developed consistent bladder and bowel
control. Additional benefits of postoperative hip orthoses
include the following:
1. Being much lighter than traditional casts, hip orthoses
reduce the burden of care for parents and caregivers who
must lift or carry the child.
2. Hip orthoses can be removed for inspection of surgical
wounds and for bathing and skin care.
3. Hip orthoses can be removed for physical therapy, range of
motion, mobilization, strengthening, or other appropriate
interventions.
4. Thermoplastic orthoses are waterproof; therefore, residues
of perspiration or urine can be easily cleaned and sanitized
with warm soap and water.
5. A well-fit orthosis is less likely to cause skin irritation or
breakdown and, unlike a cast, can often be adjusted if areas
of impingement develop.
6. The position and amount of abduction can be easily
adjusted.
7. A hip orthosis can be custom designed for a patient with
complicated needs, especially those who have had multiple
surgical procedures.
Postoperative Hip Orthoses
Two basic designs are available for children's postoperative
orthoses. The first is composed of thigh cuffs that fit between
the knee and hip joint, an abduction bar, and hook-and-loop
material closures (Figure 12-14). This orthosis can be fabri­
cated from measurements taken before surgery and fit with
no delay as soon as the cast is removed. It can also be fit in
lieu of a cast if the surgical procedure was minor or when
static positioning of the hip is required. This type of orthosis
is commonly used after adductor release or varus osteotomy
with adductor release or for the management of a septic hip.
A postoperative hip orthosis is most often used for extended
periods of nighttime-only wear but in some circumstances
can also be worn during the day.94 In many clinics this ortho­
sis is used after hip procedures in children with cerebral palsy.
Parents and caregivers find the postoperative hip orthosis
a welcome relief from a cast. Despite its simple appearance,
families should be given special instructions about how the
orthosis is worn and cared for. It can be worn over clothing
or pajamas or next to the skin if necessary. It should not cause
skin irritation or discomfort on either side of the hip joint.
If the patient experiences any hip joint pain, the orthotist
should consult with the orthopedist to determine if the angle
of abduction can be safely adjusted. Overzealous attempts
to abduct the hip can cause pain and reduce compliance.
Occasionally, this orthosis may be difficult to keep in place
even though it has been properly fit. A simple suspension belt
can be added to ensure optimal positioning.
The second option for postoperative care is a modifica­
tion of a knee-ankle-foot orthosis. This orthosis is composed
of two thermoplastic knee-ankle-foot orthoses without knee
joints but with an abduction bar and hook-and-loop mate­
rial closures (Figure 12-15). Fabrication of this type of ortho­
sis requires that plaster impressions be taken: Simple length
and circumferential measurements are not adequate to ensure
proper fit. Ideally, these impressions are taken at the first post­
operative cast change. The orthosis is then fabricated, and fit­
ting occurs during the next clinic appointment. Taking the
impressions before surgery is not advisable. Postoperatively,
each joint will be at a new angle, compromising the fit of
the orthosis based on preoperative impressions. This type
of orthosis is recommended for patients who have had bony
procedures around the hip, as well as extensive soft tissue pro­
cedures such as hamstring or heel cord release, which require
protection in the early stages of healing. In our clinic, this
orthosis is most often used for children with cerebral palsy or
myelomeningocele. In some circumstances, when more pre­
cise control of the hip joint is desirable, the orthosis can be
extended upward to include the pelvis.
FIGURE  12-14  A postoperative hip abduction orthosis has two
components: a pair of thigh cuffs held in position by an abduction bar.

Chapter 12  Orthoses in Orthopedic Care and Trauma
349
Because of the intimate fit of this orthosis, parents and
caregivers must be given careful education concerning proper
fit and cleaning. Especially important is a careful inspection
of the posterior aspect of the calcaneus: This area is vulner­
able to skin breakdown from prolonged pressure and may
be overlooked during skin checks that focus on the healing
surgical wounds. Because the foam lining and thermoplastic
material do not breathe, perspiration cannot effectively evap­
orate. The orthosis should be removed periodically for clean­
ing to minimize the risk of skin maceration or infection from
microorganisms that thrive in warm moist environments.
The postoperative orthosis has proven useful in the overall
orthopedic management of children with musculoskeletal or
neuromuscular diseases. The orthosis is an effective substi­
tute for heavy casts, especially when skin irritation and incon­
tinence are concerns. The postoperative hip orthosis helps
to ensure healing in the optimal joint position and reduces
the likelihood of recurrence of the deformity that prompted
­surgical intervention.
Management of the Adult Hip
Orthotic intervention for the hip in the adult population is
limited, focusing on two groups of patients. Hip orthoses
are most commonly used as postsurgical and postcast care
of adult patients who have sustained a complex hip or proxi­
mal femoral fracture from a traumatic event such as a motor
vehicle accident, industrial accident, or fall. In some circum­
stances a hip orthosis can be used for older adults after a total
hip procedure, revision of a total hip, or fracture associated
with total hip arthroplasty.95,96 Although injury that affects
the hip can occur at any point in the life span, most adults
with trauma-related fractures who are managed with hip
orthoses are young and middle aged, and many of those who
are undergoing a new or revised total joint arthroplasty are
65 years or older. As the number of older adults increases in
the U.S. population, so will the number of hip fractures. One
estimate suggests that as many as 512,000 hip fractures will
occur in the United States by the year 2040.97
In both of these circumstances, stabilization of the ortho­
pedic injury and rehabilitation planning are important issues.
Patients with this type of injury of the hip often require
extensive physical therapy programs. Clinicians must under­
stand age-related pathophysiological changes that affect the
healing musculoskeletal system, the impact and detrimental
effects of prolonged bed rest, and the optimal point at which
an orthosis should be integrated into the overall treatment plan.
Total Hip Arthroplasty
Although a hip orthosis is usually not indicated in most sim­
ple, elective total hip arthroplasties, in some circumstances
this orthosis can assist healing and rehabilitation. Hip ortho­
ses can be used for patients with significant osteoporosis in
whom femoral fracture occurs during total joint surgery or
for those who require emergency total joint replacement as a
result of trauma. Hip orthoses are also used for patients who
are undergoing revision of a total hip replacement as a con­
sequence of recurrent dislocation or of aseptic loosening of
the femoral component. If control of rotation is desired, an
HKAFO can be prescribed to provide additional support and
protection to healing structures.
Most HKAFOs have a pelvic band and belt and an adjustable
hip joint that can be locked or can allow free motion or limit
motion within a specific range (Figure 12-16). An adjustable
anterior panel can be added to the thigh section if a ­fracture
FIGURE 12-15  For postoperative management of children after extensive bony and soft tissue sur­
gery, knee-ankle-foot orthoses with the addition of an abduction bar are often used subsequent to cast
removal. Rotation of the hip is well controlled by the intimate fit of the orthosis including the ankle-
foot complex. When precise control of the hip is necessary, the postoperative hip abduction orthosis
encompasses the pelvis as well.

350
Section II  Orthoses in Rehabilitation
has occurred during the surgical procedure and requires
additional protection. The knee joint can also be locked, free
motion, or adjustable for specific ranges of motion, depending
on the patient's need. The ankle-foot orthosis component is
necessary to provide maximum control of unwanted rotation
of the hip.
Typically, HKAFOs are custom fabricated on the basis of
an impression of the patient's limb. This increases the likeli­
hood of an optimal fit and allows customization of the ortho­
sis to meet the specific needs of the patient. If this approach
is not amenable to certain health care environments, prefab­
ricated custom-fit HKAFOs and hip orthoses are available as
alternatives to custom-molded orthoses.96 These orthoses are
fabricated from components that are then custom fit on the
basis of the patient's limb measurements. Most postoperative
hip orthoses are designed to limit flexion and adduction of
the hip joint (Figure 12-17). They try to prevent dislocation
by supporting the optimal position of the hip joint within a
safe range of motion and by providing a kinesthetic reminder
when patients attempt to move beyond these ranges.96 Many
of the prefabricated hip orthoses that are commercially avail­
able are unable to provide maximum control of rotation
because they do not encompass the foot. Careful evaluation
of the patient is required to determine which alternative is
most appropriate. In both cases the orthosis is worn when­
ever the patient is out of bed and, in some instances, while the
patient is in bed as well. The orthosis is usually worn for at
least 8 weeks after total hip revision.
Because lower extremity orthoses add weight to a lower
extremity that is already compromised, orthotists must be
sensitive to the selection of lightweight materials and compo­
nents. This is especially true for older patients, who may have
limited endurance because of cardiac or respiratory ­disease.
Although the initial orthosis may restrict joint motion to pro­
vide external stability to a vulnerable hip joint, the orthotic
hip, knee, and ankle joints can be adjusted to meet the
patient's needs as the rehabilitation program progresses. Hip
orthoses and HKAFOs may be important adjuncts for reha­
bilitation in the following ways:
1. A well-fit hip orthosis provides protection against disloca­
tion in patients who are predisposed to this problem.
FIGURE  12-16  Lateral view of a hip-knee-ankle-foot orthosis,
prescribed for postoperative management after a complex total hip
arthroplasty. Note the pelvic band, free hip joint, supportive thigh cuff,
and free knee joint. The ankle-foot orthosis component is necessary
for effective control of rotary forces through the femur and hip joint.
FIGURE  12-17  A postoperative hip abduction orthosis has three
components. The proximal component is a padded pelvic band with
a lateral extension and anterior closure that fits snugly around the
upper pelvis. The distal component is a thigh cuff with a medial
extension across the medial knee joint. These two pieces are con­
nected by uprights and an adjustable hip joint, angled toward hip
abduction and adjusted to limit hip flexion or extension. (From
Orthomerica Newport. JPO 1995;7[1]:advertisement on front cover.)

Chapter 12  Orthoses in Orthopedic Care and Trauma
351
2. Hip orthoses protect and support healing fracture sites,
often allowing earlier mobility and gait training than
would otherwise be possible.
3. Early and safe weight bearing for older patients with dislo­
cation or fracture reduces the risk of secondary complica­
tions associated with prolonged bed rest or immobility.
4. The orthotic hip, knee, and ankle joints can be adjusted to
restrict or permit motion to match the patient's specific needs
at initial fitting and as the treatment program progresses.
Following surgical intervention after fracture or total joint
arthroplasty, the focus of the rehabilitation program shifts
to mobility training, strengthening, flexibility, and endur­
ance. The decision to recommend a hip orthosis is individual,
influenced by the severity of the musculoskeletal problem,
the patient's particular circumstances, and the experience
and preferences of the health professionals involved in post­
operative care. Few definitive guidelines or documentation
are available concerning the efficacy of hip orthoses in the
postoperative management of hip fracture or arthroplasty.
An orthosis is best used to augment the goals of rehabilitation
including the return to preoperative ambulatory status, safe
and protected weight bearing during activities of daily living,
facilitation of union of the fracture site, and ultimately return
to presurgical social and self-care independence.
Posttrauma Care
The other group of individuals who may benefit from hip
orthoses are those who have experienced traumatic fractures
of the femur, hip, or pelvis as a result of motor vehicle acci­
dents, industrial accidents, or falls from great heights. Most
of these patients are fit with their orthosis after stabilization
of the fracture with internal fixation. The HKAFO is similar
in design to the orthosis described for older patients after hip
fracture or arthroplasty. Depending on the need for external
support and stability, the hip joint can be locked to prevent
flexion and extension or may allow motion within a limited
range. For some patients, it may be necessary to incorporate
a lumbosacral spinal orthosis to achieve the desired control
of pelvic and hip motion. The ankle-foot orthosis component
provides control of hip rotation in the transverse plane.
When complete immobilization is warranted after ortho­
pedic trauma of the lower spine, pelvis, and hip, a custom-
molded thermoplastic version of a hip spica cast can be
fabricated (Figure 12-18). This hip orthosis has anterior and
posterior components, extending from the mid- to lower tho­
racic trunk to just above the femoral condyles of the frac­
tured extremity and to the groin of the intact extremity. This
design provides maximum stability and can be used in lieu of
or after casting. The position of the lower extremity within
the orthosis is determined by the type and extent of the sur­
gical repair. When the patient is lying in the supine position,
the anterior component can be removed for skin inspection
and personal care. Similarly, the posterior component can be
removed when the patient is prone. This is an advantage for
patients with open wounds or difficulty with continence and
is especially appreciated if immobilization will be required for
an extended period.
Many patients who are recovering from musculoskeletal
trauma involving the pelvis and hip joint require physical
therapy for gait and mobility training after surgery and an
intensive rehabilitation program to regain preinjury muscle
strength, range of motion, and functional status. The ortho­
pedic surgeon and therapists, as well as the patient and fam­
ily, must clearly understand the advantages provided and the
mobility limitations imposed by postsurgical hip orthoses.
An optimal orthosis can assist rehabilitation if fabricated with
lightweight but durable components that can be adjusted as
the patient progresses, while meeting the individual patient's
need for stability or supported mobility of the hip. An appro­
priate hip orthosis also enhances early mobility and protected
weight bearing, reducing the risk of loss of function related to
bed rest and deconditioning.
FRACTURE MANAGEMENT
A fracture occurs when there is disruption in the continuity
of bone.98 Fractures are common consequences of trauma
from falls, sports, work-related injuries, motor vehicle acci­
dents, or violence.99–101 Many disorders and diseases (e.g.,
osteopenia, malnutrition, paralysis, osteoporosis, medica­
tions (e.g., corticosteroids), as well as primary or metastatic
malignancies of bone, increase vulnerability to fracture.102,103
Habitual activity level over the life span, health habits (e.g.,
smoking), and gender and age (e.g., bone density and meno­
pausal status) influence bone density and, subsequently,
the risk of fracture during daily activity.104–107 Orthopedic
intervention for fractures is dictated by the severity of the
fracture, as well as etiology. Simple fractures, those with
minimal fragmentation or displacement, are often managed
with closed reduction followed by initial management in
a plaster or fiberglass splint to provide stabilization while
allowing for swelling, and then a period of immobilization
in a plaster or fiberglass cast or a custom-fit, prefabricated
fracture orthosis until bony union is achieved.108 More com­
plex fractures, those with multiple fragments or ­significant
FIGURE  12-18  A postoperative custom-molded hip orthosis is
sometimes used instead of a plaster hip spica cast when complete
immobilization of the hip joint is required.

352
Section II  Orthoses in Rehabilitation
displacement, often require open (surgical) reduction with
internal fixation (with plates, screws, or wires) (ORIF),
prosthetic replacement (arthroplasty), or stabilization in
an external rigging or fixator until there has been sufficient
bony healing.109
The care provided to individuals recovering from a frac­
ture is founded on understanding the mechanism of injury,
fracture classification, and process of bone repair and heal­
ing.110,111 The orthopedic surgeon and orthotist choose from
a variety of casts, cast braces, splints, and fracture orthoses to
provide the most effective fracture management strategy for
each patient on the basis of the fracture type and location,
degree of reduction, skin condition, mobility needs, and like­
lihood of compliance. Geographical and personal preferences
regarding design, device selection, and treatment influence
the choice of fracture management strategy, as do the train­
ing and experience of the health professionals involved. Few
strategies for immobilization can provide 100% rigid fixation.
Absolute immobilization is only possible with direct skeletal
attachment. A variety of factors influence the quality of fit
and function of any cast, cast brace, splint, or fracture ortho­
sis. Each device has the potential to contribute to a successful
result but only if used appropriately, with absolute attention
to detail by each of the treatment team members.
Mechanisms of Fracture Healing
Three distinct stages of physiological fracture healing occur:
inflammation, repair, and remodeling.111 Fracture damages
bone, its periosteum, nutrient vessels, marrow, and often
surrounding soft tissue and muscle. Disruption of vascu­
lar supply leads to ischemia and necrosis of bone cells and
other injured tissues. These damaged tissues release inflam­
matory mediators into intracellular space, triggering an
inflammatory response: A shift in plasma from capillary to
intracellular space leads to significant edema. Migration of
polymorphonuclear leukocytes, macrophages, and lympho­
cytes to the injured area is the first step in clearing necrosis.
A hematoma forms; in a simple nondisplaced fracture on
the shaft of a long bone, this hematoma provides the ini­
tial reconnection of edges of the fracture (Figure  12-19A).
In more complex fractures, the process of reducing the frac­
ture to align bony fragments further irritates tissues, aug­
menting the inflammatory response that is the first necessary
step in fracture healing. This initial inflammatory response
to fracture can last 5 or more days, depending on the severity
of injury and extent of tissue disruption.
The next stage of healing is the repair stage, a period
of cell migration, proliferation, and granulation. The com­
bination of chemotactic factors and bone matrix proteins
released by damaged bone and during inflammation trig­
gers the initiation of bony repair. The hematoma organizes
into a fibrin “scaffold,” and cells within the hematoma
begin to release growth factors and other proteins that
trigger cell migration and proliferation of osteoblasts from
the periosteum and endosteum, as well as synthesis of a
fracture callus matrix for bony repair (see Figure 12-19B
and C).112 Initially the pH of the area around the fracture
is acidic, and the fracture callus is primarily cartilaginous.
As the repair stage progresses, the pH becomes more alka­
line, creating an environment that enhances activity of the
alkaline phosphatase enzyme, and subsequently mineral­
ization of the cartilage of the fracture callus into woven
bone tissue (see Figure  12-19D). The deposition of new
cartilage within the callus is accompanied by both endo­
chondral and intramembranous ossification. Clinical
union of the fracture during the repair stage can last up
to 3 months postinjury (hence the need for long periods of
immobilization).
periosteal proliferation
endosteal proliferation
proliferating
osteoprogenitor cells
B
D
endochondral bone
formation
(primary bone)
hyaline cartilage
healing bone marrow
periosteum
endosteum
bone marrow
cortical bone
blood
clot
A
C
secondary bone
formation
Nadav Kupiec 1999
intramembranous
ossification
FIGURE 12-19  Healing and repair of a long bone fracture. A, Disruption of blood vessels in the
bone, marrow, periosteum, and surrounding tissue at the time of injury results in extravasation of
blood at the fracture site and the formation of hematoma. B, Initiation and development of the frac­
ture callus. C, Note the simultaneous occurrence of chondrogenesis, endochondral ossification, and
intramembranous bone formation in different regions of the fracture site. D, Union of a long bone
fracture. (From Lundon K. Orthopedic Rehabilitation Science: Principles for Clinical Management of
Bone. Boston: Butterworth-Heinemann, 2000.)

Chapter 12  Orthoses in Orthopedic Care and Trauma
353
The final stage of healing is the remodeling stage, dur­
ing which the new bone woven within the callus is reshaped
into the more mature lamellae of long bone and excess cal­
lus resorbed. During this phase osteoclasts are active to
reshape trabeculae and lamellae along the lines of weight-
bearing forces. The process of maturation of the callus
into a fully repaired bone can last a year or more, espe­
cially in complex fractures, whether managed by casting or
ORIF. Factors that influence the duration of the remodel­
ing stage include age, severity of injury, nutritional status,
concurrent chronic illness, and medication use (especially
corticosteroids).113
Fracture Classifications
Fractures are classified as either open or closed injuries on the
basis of the presence of an open communication between the
fracture and the outside world through a disruption of the soft
tissues and skin.114 In a closed fracture, the soft tissue envelope
of muscles and skin around the bone fracture site is completely
intact. Although muscle around the fracture site may be sig­
nificantly damaged, the intact skin provides a barrier that pre­
vents bacterial invasion of the injured muscle or bone. When
an open or compound fracture occurs, the soft tissue envelope
has been violated: The wound leaves muscle and fractured
bone open to the environment and susceptible to infection.
In many cases bone may actually protrude through the skin.
Open injuries are orthopedic emergencies; patients are taken
urgently to the operating room for debridement of the wound
and fracture. Severely damaged or contaminated tissue is
removed, and the wound is carefully cleaned in an effort to
avoid infection and provide optimal circumstances for heal­
ing.109 The fracture is then stabilized with a cast or ­surgical
implant.
Gustilo and Anderson114 have developed a classifica­
tion system applied interoperatively that rates the severity
of open or compound fractures. The least severe is a type
I injury, in which a small wound with minimal soft tissue
damage (1 cm) communicates with the fracture. The wound
in a type II fracture is generally between 1 and 12 cm, and
significant soft tissue injury may be present underneath the
laceration or wound. In a more severe, type III injury, the
wound diameter is often greater than 12 cm, there is con­
siderable periosteal stripping, and barely enough muscle or
skin is present to cover the injured or fractured bone ade­
quately. Type III open fractures are subdivided into another
three categories—A, B, and C—on the basis of whether the
soft tissue can cover the bone and whether neurological or
vascular involvement is present in association with the open
fracture. It should be noted that more important than the
size of the skin defect is the damage to soft tissues and peri­
osteum in determining type. Therefore a 1-cm open hole in
a crushed and comminuted fracture may well be classified
as a type III.
The particular location and pattern of fracture deter­
mine whether the fracture is stable and can be effectively
managed with a cast or brace, or unstable, requiring surgi­
cal intervention. A fracture with concurrent joint dislocation
creates an extremely unstable condition, requiring surgical
management of the fracture/dislocation and a long period of
rehabilitation.
Fractures (whether closed or open) are described as
displaced or nondisplaced on the basis of the degree of
malalignment or overlap that is observed on a radiograph
(Figure 12-20). They are described as complete or incom­
plete, depending on whether the bone has fully transected.
In children, a greenstick fracture is an incomplete oblique or
spiral fracture that extends only partially through bone. Exact
location of the fracture is also important: Fractures of the
diaphysis or metaphysis of a long cortical bone are extraar­
ticular (Figure  12-21), while those involving the epiphy­
sis within the joint capsule are intraarticular. Intraarticular
fractures, especially when displaced, have a high likelihood
of causing posttraumatic arthritis, and often require surgical
reconstruction of the joint surface.
Extraarticular fractures can be transverse (mostly perpen­
dicular to the axis of the bone), oblique (diagonal to the axis
of the bone), or spiral (typically a result of torsional forces),
depending on the direction of force contributing to the injury
and the resulting alteration in bone configuration. When one
or more substantive fragments are seen on the radiograph,
the fracture is segmental; if there are multiple small frag­
ments, the fracture is comminuted. In high-impact, complex
fractures there is often enough destruction of bone that there
will be loss of bone length or substance. Fractures of the
metaphysis are determined to be nondisplaced or displaced,
simple, compressed, or comminuted (Figure 12-22). Before
and during puberty (during times of rapid bone growth),
there can be displacement of the ­proximal or distal ­epiphysis
Displaced
Nondisplaced
FIGURE  12-20  Diagram of a displaced and nondisplaced frac­
ture of the diaphysis of the femur. (From Gustilo RB. The Fracture
Classification Manual. St. Louis: Mosby, 1991.)

354
Section II  Orthoses in Rehabilitation
from the metaphysis through the cartilaginous epiphyseal
plate (Figure 12-23); the proximal (subcapital) epiphysis of
the femur is particularly vulnerable.
Intraarticular fractures are classified as linear, comminu­
ted, impacted, or having a percent of bone loss (Figure 12-24);
complex intraarticular fractures involve both proximal and
distal components of the joint (Figure  12-25) and typically
require ORIF.
In the proximal femur, fractures of the metaphysis are
described as intertrochanteric fractures (extracapsular, linear
or oblique, through or between the trochanters) or femoral
neck fractures (intracapsular across the neck of the femur)
or comminuted (with multiple fragments of neck and or tro­
chanters) (Figure 12-26). These fractures fall into the category
of hip fractures, and typically require ORIF or replacement
with a femoral prosthesis (hemiarthroplasty) or even a total
hip arthroplasty (Figure 12-27). Fractures of the acetabulum
are the result of either a longitudinal force through the femur
into the pelvis or an upward oblique lateral force through
the greater trochanter; if the hip happens to be adducted
at the time of injury, this may lead to posterior dislocation
(Figure 12-28).
Fractures of the pelvis are classified as stable or unstable
on the basis of the extent of damage that disrupts the circum­
ferential integrity of the pelvis (Figure 12-29). Persons with
unstable fractures of the pelvis are at risk for life-threatening
hemorrhage, as well as residual genitourinary or neurological
complications, given the vessels, nerves, muscles, and organs
that are housed within the pelvis.115
Fractures of irregularly shaped bones such as the tar­
sals and vertebrae tend to fall into three categories. Stress
or
Talus
A
B
Tibia
Medial
malleolus
Lateral
malleolus
FIGURE 12-22  A, Extraarticular metaphyseal fracture of the malleoli of the tibia and fibula is often the
result of rotational injuries. B, Intraarticular fractures of the ankle mortis (also called plafond or pylon
fractures) result from high-energy compressive injury. (Modified from Clark CR, Bonfiglio M [eds],
Orthopaedics: Essentials of Diagnosis and Treatment. Philadelphia: Churchill Livingstone, 1994.)
Transverse
A
D
E
F
B
C
Oblique
Spiral
Segmented
Comminuted
Complete bone loss
FIGURE 12-21  Examples of types of long bone fractures, illustrated
in the diaphysis of the femur: A transverse fracture (A) is primarily
perpendicular to the long axis of the bone, while an oblique fracture
(B) diagonally transects the bone. A spiral fracture (C) is the result
of a rotary force during injury. Segmental fractures (D) have one or
more noncontinuous segments, while a comminuted fracture (E) has
multiple small fragments. In cases of significant trauma, there may
actually be loss of bone substance (F). (Modified from Gustilo RB.
The Fracture Classification Manual. St. Louis: Mosby, 1991.)

Chapter 12  Orthoses in Orthopedic Care and Trauma
355
­fractures result from repetitive loading of the bone, are
often nondisplaced, and can disrupt either the inner scaf­
folding of the cancellous bone or the outer shell of cortical
bone. Simple stress fractures typically heal well with immo­
bilization; more complex stress fractures may require surgi­
cal stabilization. Pathological fractures occur when there is
underlying disease (e.g., osteoporosis, Charcot's osteopathy,
neoplasm) that compromises bone density or metabolism. In
pathological fractures the trabeculae are overwhelmed by the
magnitude of force exerted through the bone, and the bone
A
B
FIGURE 12-23  Lateral view of an avulsed distal femoral condyle (A) before and (B) following closed
reduction. (From Clark CR, Bonfiglio M [eds], Orthopaedics: Essentials of Diagnosis and Treatment.
Philadelphia: Churchill Livingstone, 1994.)
Femoral neck or
subcapital
Intertrochanteric
FIGURE  12-24  Femoral neck fractures are intracapsular and
traverse the blood supply to the femoral head. Intertrochanteric
fractures spare the blood supply but are a greater risk for failure
of fixation. (From Clark CR, Bonfiglio M [eds], Orthopaedics:
Essentials of Diagnosis and Treatment. Philadelphia: Churchill
Livingstone, 1994.)
FIGURE  12-25  A radiograph of a repaired complex fracture of
the proximal femur, with prosthetic total hip replacement and open
reduction internal fixation with circumferentially wrapped wires to
stabilize a spiral fracture of the proximal femoral diaphysis.

356
Section II  Orthoses in Rehabilitation
A
B
FIGURE 12-26  A, Acetabular fractures occur from a lateral blow over the greater trochanter or a
proximally directed force transmitted up the length of the femur. B, If the limb is injured with the
hip in adduction and flexion, a posterior hip dislocation is likely. (From Clark CR, Bonfiglio M [eds],
Orthopaedics: Essentials of Diagnosis and Treatment. Philadelphia: Churchill Livingstone, 1994.)
Linear
Comminuted
Impacted
Articular bone loss
FIGURE 12-27  Examples of types of intraarticular fractures, using
the head of the femur as an example. (From Gustilo RB. The Fracture
Classification Manual. St. Louis: Mosby, 1991.)
FIGURE  12-28  Major intraarticular fractures of the distal femur
and proximal tibia are typically managed by surgical open reduc­
tion internal fixation using a combination of bone screws or nail and
an external plate. (From Clark CR, Bonfiglio M [eds], Orthopaedics:
Essentials of Diagnosis and Treatment. Philadelphia: Churchill
Livingstone, 1994.)

Chapter 12  Orthoses in Orthopedic Care and Trauma
357
is compressed or fractured into fragments. Management
of pathological fractures can be challenging, as bone heal­
ing is often compromised by the underlying disease process.
Traumatic fractures are often comminuted; depending on
severity, they may be managed by immobilization in a cast or
orthosis, ORIF, or placement of an external fixation apparatus
(Figure 12-30).
Casts and Splints
The primary goal of fracture management is to restore mus­
culoskeletal limb function of the injured extremity with
optimal anatomical alignment, functional muscle strength,
sensory function, and pain-free joint range of motion. The
most common methods used for immobilization of closed
fractures include casts, splints, fracture orthoses, or a hybrid
cast-orthosis.108,116 Immobilization may also be used after
ORIF of open fractures.
In choosing the appropriate immobilization strategy for
an individual's fracture, the orthopedist considers several
issues. The first is the stability of the fracture site and how
well a device will be able to maintain fracture reduction and
achieve the desired anatomical result. The condition of the
skin and soft tissue is also an important consideration, espe­
cially if wounds are present that must be accessed for proper
care. Limb volume must be evaluated, especially if edema is
present or anticipated: How will limb size change over time
in the device? Length of immobilization time varies as well: Is
the device designed for a short-term problem, or will protec­
tion of the limb be necessary for an extended period? Will the
device need to be removed for hygiene or wound care? Can
the limb be unprotected while sleeping or when not ambu­
lating? Availability (time to application) may also influence
decision making. Casts and cast braces can be applied quickly.
Custom orthoses need additional fabrication and fitting time;
an alternative means of protection is often required while the
device is being fabricated.
The individual's ability to comply consistently and reliably
with weight-bearing restrictions and other aspects of fracture
management must also be considered. Factors such as cogni­
tive ability, emotional status, motivation, and physical abil­
ity, as well as the availability of assistance and environmental
demands, influence the decision to provide additional exter­
nal support. An unstable fracture managed by ORIF may not
require additional support for those with sufficient strength
and balance who have a clear understanding of the healing
process. If the individual with a fracture cannot understand
the need to protect the involved limb from excessive loading
or is physically unable to do so, additional external support is
essential. If compliance is questionable, the device of choice is
usually a nonremovable cast or cast brace.
To effectively stabilize a fracture, the joints above and
below the fracture site must be immobilized. The period of
immobilization varies with fracture severity and location; in
most cases the cast remains in place from 6 to 8 weeks or until
a radiograph indicates that bone healing has progressed suf­
ficiently for safe weight bearing and function. The time for
immobilization is often less for children, due to their rapid
healing response. Although immobilization is essential for
effective bone healing, it also has significant consequences on
other tissues: while in a cast, patients are likely to develop sig­
nificant joint stiffness (contracture), as well as disuse atrophy
and weakness of the muscles of the immobilized limb. Once
the cast is removed, rehabilitation professionals are called
on to help the patient regain preinjury muscle performance,
­flexibility, and range of motion.
2
3
A
B C
1
FIGURE 12-29  Unstable pelvic fractures occur when pubic rami
fractures (A), symphysis disruption (B), or pubic body fractures
(C) are accompanied by fractures through the iliac wing (1), sac­
roiliac joint (2), or sacrum (3). (From Clark CR, Bonfiglio M [eds],
Orthopaedics: Essentials of Diagnosis and Treatment. Philadelphia:
Churchill Livingstone, 1994.)
FIGURE 12-30  Open fractures of the tibial shaft often require skel­
etal stabilization with external fixation, as well as soft tissue repair.
(From Clark CR, Bonfiglio M [eds], Orthopaedics: Essentials of
Diagnosis and Treatment. Philadelphia: Churchill Livingstone, 1994.)

358
Section II  Orthoses in Rehabilitation
A cast is a rigid, externally applied device that provides cir­
cumferential support to an injured body part.108 Casts immo­
bilize a body segment to maintain optimal skeletal alignment
(Figures 12-31 and 12-32). Once a cast has been applied, a
radiograph can be used to assess the effectiveness of skele­
tal alignment. The cast may need to be modified, wedged, or
replaced to improve alignment.117
A splint is a temporary supportive device, usually fabri­
cated from rigid materials, held in position on the fractured
extremity with bandages or straps. Splints can be used for
temporary immobilization before casting or surgical stabili­
zation. They can be used to maintain fracture reduction while
waiting for swelling to diminish or fracture blisters to clear or
to provide comfort. The most commonly used splints include
sugar tong splints (a long, U-shaped, padded plaster forearm
splint named for its similarity to the tool used to pick up sugar
cubes), short or long leg splints, thumb spica splints, ulnar or
radial gutter splints, and coaptation splints.117
Casting and Splinting Materials
Before the 1800 s, fracture casts were made from linen ban­
dages soaked in beaten egg whites and lime. The modern era
in fracture care began with the discovery of plaster of Paris
(calcium sulfate), first used in the Turkish Empire as reported
by Eaton in 1798.118 Plaster of Paris was used in Europe in the
early nineteenth century, and a Flemish surgeon (Mathijsen)
is credited with combining the use of plaster of Paris and
cloth bandages to form casts for the treatment of fractures
in 1852.117–119
Plaster of Paris is created when heat is used to dehydrate
gypsum. When water is added to plaster of Paris powder, the
dehydration process is reversed, and crystals of gypsum are
formed again. The new crystals interlock in a chemical exo­
thermic (heat-producing) process.120 The setting process is
complete when heat is no longer being produced, although
the cast remains wet to the touch until the excess water used
in the process evaporates. Maximum cast strength is not
reached until the plaster is completely dry. Drying time varies
Femoral long leg cast
Tibial long leg cast
Patella tendon
bearing cast
Short leg cast
Distal trimlines
Knee cylinder cast
FIGURE  12-31  Proximal and distal trimlines used in standard
lower extremity casts. Typically, the joints above and below the frac­
ture site are immobilized. Trimlines can be extended to provide
­better control and stabilization.
FIGURE 12-32  A medial view of a patellar tendon–bearing short
leg cast. The proximal anterior area of the cast has been molded by
pressing inward at the level of the patellar tendon, while the proxi­
mal posterior of the cast has been molded over the calf and then
trimmed to allow knee flexion. (From Moore TJ. Functional bracing
of lower extremity fractures. In Goldberg B, Hsu JD [eds], Atlas of
Orthoses and Assistive Devices. St. Louis: Mosby; 1997.)

Chapter 12  Orthoses in Orthopedic Care and Trauma
359
with the thickness of the cast, ambient humidity, and the type
of plaster used. In most instances maximum cast strength is
reached in approximately 24 hours.
Various types of plaster of Paris with different working
characteristics are available. Manufacturers may add accelera­
tors to the material that shorten the setting time: The limb has
to be held still for less time while the plaster sets. Although
this may be advantageous when a cast is applied to the limb of
an anxious child or when an unstable fracture is cast, it also
means that less working time is available to manipulate the
extremity and optimally shape the cast. Setting time can be
prolonged slightly if cold water is used. If warm or hot water
is used to reduce setting time, care must be taken to protect
the limb from injury from the higher heat that can be gener­
ated during the setting process.117 Cast temperatures as high
as 68.5°C have been reached with water temperatures of 40°C;
burns can occur if cast temperature is maintained at 44°C for
6 hours or more.121,122 To minimize any potential for burns
in cast or splint application, room temperature tepid water
(24°C) is recommended. If higher water temperatures have
been used, the newly casted limb must not be placed on a pil­
low or other type of support that is likely to retain or reflect
heat. Cast burns can also occur when insufficient padding has
been placed between the plaster of Paris and the surface of
the skin. Cast burns are avoidable if simple procedures are
followed.
Cast strength is determined by three factors: the type of
casting material used, the thickness of the cast, and the effec­
tiveness of lamination among the layers of the cast material.
The cloth mesh material that serves as the carrier for the plas­
ter of Paris provides little strength for the cast. A plaster cast
must be kept absolutely dry to prevent it from becoming soft
and ineffective in immobilization.
The difficulties associated with the use of plaster of Paris
have led to the development of newer and improved cast­
ing materials. Polyurethane-impregnated casting tapes have
gained widespread popularity because of their superior
strength, light weight, shorter setting time, cleaner applica­
tion, and low exothermic reaction. Polyurethane casts are also
radiolucent, permitting x-ray evaluation of fracture site heal­
ing while the limb remains encased in the cast.
Polyurethane is a plastic material that can be impregnated
into a fabric substrate. Although the polyurethane bonds the
layers of substrate together, it is actually the substrate that
determines the strength of the cast. A variety of substrate
materials are available. The weave determines how elastic the
material will be during cast application and how strong the
cast will be when set. Cotton, polyester, fiberglass, polypro­
pylene, and blends of these materials and others are used in
synthetic casting tapes.120,121,123,124
Immersing the synthetic casting tape in room tempera­
ture water for 10 seconds begins a heat-producing exother­
mic reaction and causes the material to harden (polymerize).
Setting is complete for most synthetic casting materials in
5 to 10 minutes. Because of this short setting time, the rolls
of bandage material cannot be opened until they are ready
to be applied as a cast. The application process requires skill
and must move quickly to ensure adequate molding time.
Unlike plaster of Paris, the plastic bandage does not need to
be massaged to ensure proper lamination between the lay­
ers of material. Also unlike plaster of Paris, which can easily
be washed from the hands or clothing, polyurethane is not
easily removed: Adequate protective padding must be placed
around the patient's limb, and protective gloves worn to safe­
guard the applicator's hands. Polyurethane resin in its natu­
ral state is tacky. An additive may be incorporated into the
casting tape to reduce its tackiness. In some cases the man­
ufacturer provides special gloves with an antitacky additive
to further minimize the tack.120 The exothermic polymeriza­
tion of polyurethane resin produces much less heat (44.9°C in
40°C water) than that of setting plaster of Paris. In addition,
heat is quickly dissipated so that burns are much less likely to
occur when synthetic materials are used. To further minimize
the risk of burns, immersion of cast tape in room temperature
water (24°C) is recommended.117,121,125
Cast Application
Stockinet is the first layer of a cast, applied over the skin,
before any padding is added. The most common stockinet
material is cotton. Synthetic materials such as polyester or
polypropylene or Gore-Tex can be chosen in place of cot­
ton because they do not retain water like cotton materials do.
Stockinet also helps to position dressings over wounds and
provides extra circumferential control of soft tissue within the
cast. Stockinet is folded over the proximal and distal edges
to finish the cast (and prevent inadvertent removal of cast
­padding by a nonresponsible individual or a child).
Next, a layer of cast padding is added over the stockinet.
A variety of materials are available to pad casts. Sheet cot­
ton comes in various forms and is used to provide a barrier
between the rigid walls of the cast and surface of the skin. Some
cast materials have been elasticized for easier application and
conformation, and others require more technique to ensure
that they uniformly conform to the body part being casted.
Although synthetic cast tapes are not affected by water,
cast padding or stockinet does retain water. The risk of skin
maceration and breakdown is present if the inside of a cast
remains damp for long periods of time. Some manufactur­
ers market cast padding that reportedly permits exposure
to water; however, manufacturer recommendations must be
­followed carefully.
The thickness of cast padding varies; ⅛ to ¼ inch is suffi­
cient for most individuals. The goal is to protect bony promi­
nences and soft tissue from the rigid walls of the cast while
effectively immobilizing the fracture site. Soft tissue usually
does well with a fairly thin, uniform two- or three-layer wrap.
Extra padding is added to smooth and protect the irregu­
lar surfaces around bony prominences. Excessive padding
reduces the ability of the cast to provide adequate immobi­
lization. A well-molded cast that accurately follows the ana­
tomical contours of the extremity requires less padding.
Cast padding also provides a barrier so that the cast can be
removed more easily when it needs to be changed or is no
longer necessary.

360
Section II  Orthoses in Rehabilitation
Lower Extremity Casts
The short leg cast is used in the management of fractures
involving the distal tibia or fibula, or both; the ankle joint; or
the rear foot or midfoot. The foot is positioned in a functional
neutral ankle position (90 degrees) or in slight dorsiflexion.
This positioning prevents a plantarflexion contracture from
developing by the time of cast removal. The foot can also be
casted in a plantarflexed position to accommodate repair of
an Achilles tendon rupture. The proximal trimline falls at the
level of the tibial tubercle; the distal trimline usually encloses
the metatarsal heads. The area around the fibular head is pro­
tected by adding extra cast padding to minimize the risk of
compression of the peroneal nerve. A cast shoe should be
used to protect the bottom of the cast if weight bearing is to
be permitted.
For persons with midshaft fractures of the tibia, a patel­
lar tendon–bearing cast (PTB) may be applied. This design
incorporates a patellar tendon bar, which directs some of the
limb loading force to the external shell of the cast, thus pro­
tecting the full length of the tibia against bending moments
(see Figure 12-32). This type of cast is not effective, however,
in reducing axial loading of the tibia or hind foot. The PTB is
most often used when extra stability is desired for individu­
als who will be allowed some degree of weight-bearing activ­
ity. The cast is applied with the ankle maintained in neutral
or slightly dorsiflexed position, to minimize potential hyper­
extension moment at the knee in stance. Trimlines are simi­
lar to those used for a PTB transtibial prosthetic socket: at
the midpatella (or sometimes suprapatella) anteriorly but
trimmed and slightly flared posteriorly to permit knee flex­
ion of at least 90 degrees. Proximally, the cast is well molded
to the tibia in the area of the medial flare and around the
patella.126,127 Care must be taken to ensure that no pressure is
placed on the peroneal nerve.
A knee cylinder cast is often applied when there have been
fractures of the patella or surgical repair of the knee joint
when the knee must be immobilized in full extension. To
ensure the necessary stability for the knee joint, the proximal
trimline encompasses the lower two thirds of the thigh and
the distal trimline the entire tibial segment to just above the
malleoli. The cast can be applied using either plaster of Paris
or synthetic casting tape. To limit the risk of pistoning when
the person wearing the cast is standing or walking, the cast
is carefully molded to fit the contours of the medial femoral
condyle.
For closed fractures of the upper tibia, knee joint, or lower
femur, a long leg cast provides the necessary stability for heal­
ing. Depending on the site of fracture and its relative stabil­
ity, the limb is immobilized in nearly full extension or in a
bent knee position.127 A straight knee cast is usually applied
with a slight (5-degree) knee flexion angle to enhance patient
comfort. Bent knee casts are usually chosen when non–
weight bearing must be ensured during ambulation or to aid
in controlling rotation of the tibia. With the relatively mobile
arrangement of soft tissue that surrounds the femur, it is chal­
lenging to provide adequate immobilization, especially for
persons who are particularly muscular or overweight. For this
reason, control of rotational forces through the femur within
a long leg cast is questionable. If the cast is being used to sta­
bilize the tibia, the proximal trimline is at the junction of the
middle and proximal third of the femur. If the cast is being
used to stabilize the distal femur, the proximal trimline is at
the level of the greater trochanter. Distally, the cast immobi­
lizes the ankle and extends to a point just beyond the metatar­
sal heads. The fibular head should be well padded within the
cast to minimize the risk of entrapment of the peroneal nerve.
A hip spica cast, which encases the hip and pelvis in addi­
tion to the lower extremity, is necessary for effective con­
trol of fractures of the proximal femur and of the hip joint128
(Figure 12-33). The hip spica is the primary method of treat­
ment of femoral fractures in children under five years of age
and is used in adults when a prefabricated hip orthosis is not
appropriate. Several variations of the hip spica are available.
In a single hip spica, the plaster or synthetic cast material is
anchored around the entire pelvis and lower trunk but immo­
bilizes only the hip and knee of the involved side, allowing
fairly unrestricted hip motion of the opposite limb. In a 11⁄2
hip spica, the cast encases the entire lower extremity on the
affected side, as well as the lower trunk, pelvis, and thigh on
the uninvolved side. Usually the knee on the affected side is
completely immobilized; however, an articulated knee joint
can be incorporated if specific circumstances so dictate. In
most instances the hip joint of the affected limb is immobi­
lized in 30 degrees of flexion and 30 degrees of abduction,
and the perineal edges are trimmed back to allow for per­
sonal care and hygiene. The knee is usually positioned in 30
degrees of flexion. The proximal cast encases the lower to
middle trunk (to the level of the costal margin or nipple line),
depending on the amount of spinal immobilization required.
FIGURE 12-33  This child has been placed in a 11⁄2 hip spica cast to
stabilize a fracture of the proximal femur. Note the opening for per­
sonal hygiene and the additional diagonal support bar incorporated
between the short and long sections of the cast.

Chapter 12  Orthoses in Orthopedic Care and Trauma
361
The 11⁄2 hip spica cast is often reinforced by the incorpora­
tion of a lightweight diagonal bar between the short and long
extremity segments. Ambulation is possible but often quite
challenging, requiring significant upper body strength to
manage the adapted crutch-walking gait that the cast position
makes necessary.
Cast Removal
A cast cutter or saw with a vibrating disk is used to cut the
cast during cast removal. Modern cast cutter blades recip­
rocate back and forth approximately 1⁄8 inch in either direc­
tion. The vibrating blade easily cuts rigid materials such as
metal, wood, plaster, or synthetic cast materials but does not
cut through materials that are elastic or mobile. If used prop­
erly, a cast cutter does not cut skin. Incorrect or inappropri­
ate use of a cast cutter can seriously cut or burn a patient. To
reduce the risk of injury, the blade should not directly contact
the patient's skin. Friction between the blade and cast signifi­
cantly heats the blade, creating a potential for burns. A sharp
new blade has less potential for burning the patient than does
a blade that has become dull or worn out. The noise of the
cast cutter can be quite frightening to children or other par­
ticularly anxious patients. A careful explanation and a dem­
onstration of the cast cutter's action are the first steps in the
process of cast removal.
To remove a cast safely, the cutter is used in a repetitive in-
out motion, to progressively open the cast, instead of sliding
the blade through the cast. This strategy reduces the risk of a
cut or burn on the patient's skin.129 Safety strips may be incor­
porated into the cast at the time of application to allow for a safe
path for the saw blade to penetrate through without damaging
skin. These strips are especially important when friable liners
like Gore-tex are used under the cast. Safe technique involves
the operator's thumb serving as a fulcrum on the cast as down­
ward pressure is applied through the wrist. The thumb also
controls the depth of the blade. Care is taken to avoid position­
ing the cast cutter in areas where skin is vulnerable: over a bony
prominence or where significant edema or fragile healing skin
is present. As the blade breaks through the inner wall of the
cast, the sensation of reduced resistance to downward pressure,
as well as a change in sound, occurs. Once an area of cast has
been cut, the blade is repositioned farther along the cast and
the process is repeated until the cast can be pried open com­
pletely. Bandage scissors are used to cut through padding and
stockinet, and the limb is then extracted from the open cast.
For infants and young children with small limbs, an alternative
strategy can be used: A plaster of Paris cast can be removed by
soaking in water. This method works particularly well when a
corrective clubfoot cast is removed from an infant's limb.
Hybrid Cast Braces
Hybrid cast braces were first developed as a method of man­
agement of proximal tibial and distal femoral fractures near
the knee just after World War I but then fell out of use until
the mid-1960 s130–132 (Figure 12-34). In some centers the cast
brace is the method of choice for the management of nondis­
placed tibial plateau fractures. The cast brace is often used
for additional support of fractures near the knee or of the
femur that have been stabilized via ORIF surgery for external
fixation (Figure 12-35). This method is also used to control
motion after knee ligament injury or reconstruction.
Cast braces incorporate orthotic components (e.g., hinge
joints, range of motion locks) into a plaster or synthetic
cast in an effort to provide additional stability to a healing
limb.133–141 The cast brace can be applied using either plaster
of Paris or synthetic cast materials. Depending on the nature
of the fracture and its stability, the orthotic knee joints incor­
porated into the cast brace may be chosen to provide limited,
controlled, or free-knee range of motion. Because the ana­
tomical center rotation of the knee moves in an arc centered
over the femoral condyles, it is essential that the mechanical
joints be carefully aligned with the anatomical knee joint to
reduce the abnormal stress that occurs across the joint and
fracture site.142,143
FIGURE 12-34  A tibial cast brace with polycentric adjustable range of motion hinges. The patient
has undergone an open reduction internal fixation surgery after fracture of the tibial plateau. Note
that synthetic cast tape is available in a wide variety of colors and patterns.

362
Section II  Orthoses in Rehabilitation
Many orthotists and orthopedic surgeons choose a poly­
centric orthotic knee joint because its motion more closely
­follows anatomical motion and reduces the torque-related
stress that results from a single-axis mechanical joint.
Palpating the condyles on a patient who has had recent
trauma about the knee is difficult; the midpatella is a some­
what less precise alternative landmark for alignment. A properly
placed polycentric metal joint will be proximal to the joint
line and slightly posterior to the midline. Orthotic knee joints
are positioned close to but not quite contacting skin. This
is especially important medially, where contact between the
knees during functional activity is likely.
Medial and lateral uprights are incorporated into the cast
above and below the orthotic knee joint to provide protection
against unwanted varus and valgus stress and help control
anteroposterior displacement of the tibia or femur.
The distal tibial cast holds the ankle in a neutral posi­
tion and extends distally to encompass the metatarsal heads.
The proximal trimline of the tibial cast is typically at the tib­
ial tubercle, and the distal trimline of the femoral cast is an
equal distance from the midpatella. Posteriorly, both tibial
and femoral casts are trimmed to permit at least 90 degrees of
knee flexion. If warranted, a slight varus or valgus stress can
be applied at the time of cast brace application, or a varus/
valgus strap can be added to aid in unloading a knee com­
partment. For persons with fractures of the upper tibia and
knee, the proximal component encases the lower two thirds
of the femur. If fracture of the femur has occurred, the prox­
imal component extends upward to the level of the greater
trochanter. To be effective, careful molding of the proximal
portion of the cast around the trochanter and medial wall is
required. For fractures of the mid to upper femur, an orthotic
hip joint and pelvic band must be added to ensure alignment
and stability.
Fracture Orthoses
A custom-fabricated or custom-fit fracture orthosis is desi­
gned to maintain a body part in an optimal anatomical
position, limit joint motion, and unload weight-bearing
forces.144–147 The major advantage of a fracture orthosis,
as compared with a cast brace, is that the orthosis can be
removed for wound or skin care. Fracture orthoses are fab­
ricated from high-temperature thermoplastic materials. They
are designed to provide total contact, circumferential con­
trol of a fracture while allowing the individual with a heal­
ing fracture to have functional mobility. Fracture stability is
enhanced in two ways: by hydrostatic pressure forces cre­
ated as the rigid walls of the orthosis compress soft tissue
and muscles in the extremity and by the lever arm created by
extension of the orthosis above and below the fracture site.
Fracture orthoses do not entirely unload the lower extrem­
ity during weight bearing. If complete unloading or reduced
loading is required to protect the fracture site, an appropriate
assistive device (crutches or a walker) and a single limb gait
pattern must be used.139
Two types of fracture orthoses are available: (1) those that
are custom fabricated from a mold of the patient's limb and
(2) prefabricated orthoses that are custom fit to match the
patient's needs. Because of the wide variation in anatomical
characteristics among individuals, it is not always possible to
use a prefabricated orthosis. Likewise, because of anatomical
similarities in the human skeleton, it is not always necessary
to create a custom-fabricated device. In certain instances an
orthosis must be precisely fit to provide the desired stabiliza­
tion of the fracture; in other cases the orthosis must be heav­
ily padded so that a precise fit is less important. The orthotic
prescription must clearly designate the motions to be permit­
ted and controlled, the corrective forces to be applied, and a
precise diagnosis and description of the fracture.
Types of Fracture Orthoses
Fracture orthoses are named by the joints they encompass
and the motion that they are designed to control. An ankle-
foot orthosis (AFO) with an anterior shell is used to con­
trol ankle and distal tibia motion (Figure 12-36). It encases
FIGURE 12-35  This cast brace provides medial/lateral stability for
a comminuted grade 3 open tibial fracture. The length of the tibia
is being maintained by an external fixation device. The patient also
sustained a closed femoral fracture, which has been supported by
an intramedullary rod fixation. Because the proximal portion of the
cast must not terminate near a fracture line, the femoral portion of
the cast has been extended up to the level of the trochanter to avoid
stress on the femoral fixation.

Chapter 12  Orthoses in Orthopedic Care and Trauma
363
the injured limb completely, limiting motion of the foot or
ankle for patients with distal tibial or fibular fractures. The
AFO fracture orthosis has two advantages: It can be removed
for wound care and hygiene, and it can be worn with stan­
dard lace-up shoes if weight bearing is permitted. The appli­
cation of a cushion heel and rocker sole may be necessary
on the shoe to compensate for limited heel, ankle, and toe
rocker motion during gait. Because total contact is essential,
this thermoplastic orthosis is vacuum molded over a positive
impression of the patient's limb. The anterior shell may be
lined with soft-density foam to accommodate bony deformity
or insufficient soft tissue. Perforated thermoplastic material
is often used for the anterior section as a means of ventila­
tion for patient comfort. The proximal anterior trimline is at
the tibial tubercle. Adequate clearance must be provided for
the head of the fibula and the peroneal nerve. The distal pos­
terior section usually extends to just beyond the metatarsal
heads on the plantar surface, whereas the anterior section is
trimmed just proximally. A stocking or thin sock is worn to
protect the skin and for comfort. The anterior section is held
in place with a series of hook-and-loop material straps. Shoes
must be worn if weight bearing is permitted.
A number of prefabricated short leg walkers are also com­
mercially available; these devices are designed to substitute for
a short leg cast and are intended to be removable by the patient.
They are heavily padded and, if properly fit, provide excellent
immobilization of the distal tibia, ankle, rear foot, and forefoot
(Figure 12-37). The various designs are similar, but manufactur­
ers’ instructions should be followed to maximize their effective­
ness. The short leg walker's advantage is that it can be removed
for wound and skin care. Its disadvantage may be slightly less
effective immobilization. The ankle is positioned at a neutral
(90-degree) angle. Some designs have an adjustable orthotic
ankle joint that permits a controlled, limited range of motion, to
assist forward progression during walking. The components of
a short leg walker include a rigid foot piece that is attached to a
pair of metal or thermoplastic uprights and a proximal cuff that
helps to suspend a foam liner. Short leg walkers are manufac­
tured in various styles and sizes. To ensure proper fit, the manu­
facturer's recommendations must be followed carefully.
The PTB fracture orthosis is the removable version of the
PTB cast, providing significant protection from bending and
rotatory torque for the tibia during weight-bearing activities.
This thermoplastic orthosis is most often vacuum molded
over a positive mold of the patient's limb for optimal total
contact fit. Ankle position within the orthosis is often in slight
dorsiflexion, once again to minimize hyperextension moment
at the knee during the stance phase of gait. Trimlines are simi­
lar to those of an AFO with anterior shell, with the proximal
trimline extending somewhat more proximally to the proxi­
mal pole of the patella anteriorly, medially, and ­laterally. The
posterior trimline should permit free knee ­flexion beyond
FIGURE  12-36  Ankle-foot fracture orthosis with a patellar
­tendon–bearing design incorporated to protect the tibia for bending
moments during weight bearing. This patient was originally man­
aged with an external fixation device, which had to be removed
­secondary to pin loosening before union of the fracture was solid.
Note that the shoe has been modified with a cushion heel and rocker
sole to compensate for a fixed ankle position and to improve forward
progression during the stance phase of gait.
FIGURE 12-37  An example of a commercially available short leg
walker with a rocker bottom sole that can be used for individuals
with Achilles tendon repair, stable healing fractures of the distal tibia/
fibula, ankle, or foot, or with severe ankle sprain. This particular
walker has an orthotic ankle joint that can be preset to limit or allow
motion at the ankle joint. (Courtesy of DJ Orthopedics, Vista, CA.)

364
Section II  Orthoses in Rehabilitation
90 degrees. Hook-and-loop material straps are used to secure
the anterior and posterior sections together. The anterior and
the posterior sections can be hinged at the proximal edge for
improved anteroposterior control.
The purpose of the knee-ankle-foot fracture orthosis is to
provide long-term protection for fractures of the distal to mid­
dle femur or for fractures about the knee (Figure 12-38). This
orthosis is often used as an alternative to a hybrid cast brace
for persons who have had ORIF for fractures of the proxi­
mal tibia, knee, or distal femur. The orthosis is removable for
wound care and personal hygiene and when protection is not
required. Depending on the location of the fracture, the ortho­
sis can be designed to limit range of motion or to permit full
motion of the knee. Drop locks can be used to stabilize the
knee in full extension during ambulation. The design of the
orthosis also protects the knee from excessive mediolateral
and anteroposterior shear stress during ambulation. If maxi­
mum stability is necessary, a solid-ankle design can be incor­
porated; if mobility of the ankle is desired, an articulated ankle
joint with an appropriate motion stop mechanism can be used.
The orthosis requires total contact within the femoral and
tibial components. Proximal trimlines follow the anatomical
contours of the proximal femur to the greater trochanter to
provide femoral protection. To stabilize the knee or proximal
tibia, encasement of the lower two thirds of the femur is suffi­
cient. The orthosis alone cannot effectively unload the femur,
tibia, or foot: If axial unloading is desired, appropriate assistive
devices (crutches or walker) must be used.
For individuals with proximal femoral fractures, a hip joint
and pelvic band are often incorporated into a total contact knee-
ankle-foot orthosis in an effort to control motion and rota­
tional forces through the femur (Figure 12-39). Depending on
the patient's specific needs, hip flexion/extension motion can
be restricted or free; abduction/adduction is usually restricted.
The placement of the orthotic hip joint is approximately 1 cm
anterior and 1 cm proximal to the tip of the greater trochanter
in most adults. Knee and ankle motion can be free or limited,
given the location and stability of the fracture. A variety of sin­
gle-axis or polycentric orthotic hip joints can be incorporated.
A pelvic belt is used to maintain the orthotic hip joint in proper
functional position. The belt should fit midway between the
crest of the ilium and the greater trochanter.
FIGURE 12-39  A lumbar sacral orthosis with an orthotic hip joint
has been added to this knee-ankle-foot orthosis to provide better
control of hip abduction/adduction and rotation while a proximal
femoral fracture heals. The lateral uprights limit angulation through
the healing femur during ambulation. Weight-bearing status is
determined by the physician on the basis of the severity of the frac­
ture and stability of the reduction.
FIGURE 12-38  A prefabricated functional fracture orthosis must
be adjusted regularly to ensure snug compression of soft tissues so
that stability and alignment across the fracture will be maintained.
(From Moore TJ: Functional bracing of lower extremity fractures. In
Goldberg B, Hsu JD [eds], Atlas of Orthoses and Assistive Devices.
St. Louis: Mosby, 1997.)

Chapter 12  Orthoses in Orthopedic Care and Trauma
365
External Fixation Devices
External fixation devices have evolved primarily to care for
initial management of complex open or severely comminuted,
unstable fractures that are most often the result of high-energy
injury or multiple trauma (see Figures 12-30 and 12-35).148–152
In particular, external fixation is used for severe metaphyseal
fractures, severe intraarticular fractures, when there has been
nonunion, in cases of substantial bone loss with allograft, and
for fractures in osteoporotic bone.150,153 They are particularly
useful when fracture disrupts pelvic stability.154–156
Pins are placed into bone on either side of the fracture and
then clamped onto lightweight rods in an external frame. The
external frame can be a single rod, a set of articulated rods
that cross the joint axis, circumferential, or a combination
of these options.157–161 The goal is to provide optimal skeletal
alignment while providing visual access to healing skin and
muscle. The external fixator permits active range of motion
of the joint above and below the fracture. It is removed when
soft tissues have adequately healed and radiographs demon­
strate healing of the fracture. Casts or orthoses can be used to
provide immobilization after fixator removal to support and
protect the fracture until healing is complete.
Postfracture Management and Potential Complications
The postfracture issues and complications that are of concern
to the managing physician and rehabilitation team include
vascular injury, compartment syndrome, appropriate weight-
bearing status, loss of reduction, delayed or nonunion, infec­
tion, implant failure (for ORIF), compression neuropathy, and
skin breakdown. Each patient who presents to the emergency
department with a fracture must be assessed for potential vas­
cular injury and risk of developing compartment syndrome
by careful physical examination. Whether a splint, cast, sur­
gical ORIF, or placement of external fixators has been used
to stabilize the fracture, the condition of the extremity must
be monitored carefully by the physician, rehabilitation profes­
sional, patient, and family caregivers.
Fractures or dislocations around joints may have a con­
comitant arterial injury that can bruise or completely disrupt
an artery, compromising or completely interrupting blood
flow beyond the site of fracture.162–164 This creates a grave sit­
uation: The physician has a window of less than 6 to 8 hours
in which to restore blood supply and nutrition to the distal
muscle and bone before significant tissue death occurs. The
longer the period of ischemia, the greater the likelihood of
delayed healing, infection, and necrosis.
Compartment syndrome evolves when bleeding or inflam­
mation exceeds the expansive capacity of semirigid muscle or
soft tissue anatomical spaces (compartments) of the fractured
limb.165–167 Once interstitial pressure exceeds a critical level,
blood vessels and muscle are compressed and oxygen sup­
ply to the muscles is significantly compromised. Irreversible
muscle or nerve damage occurs if compartment syndrome
continues for longer than 6 to 8 hours. Presenting signs and
symptoms include extreme pain and significant swelling of
the extremity with taut skin. Passive motion of the fingers
or toes causes excruciating pain. Compartment syndrome is
­considered a medical emergency: The treating physician must
be notified immediately so that a fasciotomy can be performed
to relieve excessive compartment pressures. All health profes­
sionals who are involved in the treatment of extremity trauma
should be aware of the signs and symptoms of compartment
syndrome. If unrecognized and untreated, compartment syn­
drome has devastating results.
One of the most important considerations for lower
extremity fractures is weight-bearing status. A patient's
weight-bearing status (full weight bearing, weight bearing as
tolerated, partial weight bearing, toe-touch weight bearing, or
non–weight bearing) is determined by the physician on the
basis of the stability of the fracture and the immobilization
method used. Once a patient is stable after an operation or a
cast has been applied and is properly set, rehabilitation profes­
sionals work with the patient and family on mobility and gait
training. The rehabilitation professional selects the appropri­
ate assistive device for a patient's weight-bearing status, given
the patient's physical and cognitive status and the character­
istics of his or her usual living environment. Communicating
quickly to the referring physician any signs of developing
complications or difficulty with compliance that might put
the fracture site at risk is important.
Loss of reduction of the fracture is a serious complication
and can occur whether a splint, cast, ORIF, or external fixator
has been used to realign and stabilize the limb.158,167–169 A pro­
gressive angular deformity or abnormal position of the limb
suggests loss of reduction and must be quickly reported to the
managing physician. Even if reduction appears to be appro­
priate, inadequate immobilization within a splint or cast can
lead to delayed union, nonunion (nonhealing), or malunion
(healing in an abnormal position).
Any patient who has sustained an open fracture is at risk of
developing infection of skin, deep tissue and muscle, or even
bone. Both intravenous and local antibiotics are administered
in the emergency department and operating room to mini­
mize likelihood of infection from contamination sustained at
the time of injury.170,171 Infections may also be iatrogenic.171,172
An infection is a serious complication that requires aggressive
antibiotic treatment or debridement, or both. If an infection
occurs after ORIF, the implanted hardware may have to be
removed and an external fixation device applied. For individ­
uals with external fixation, the pins provide a tract for infec­
tious organisms directly into bone.173 Appropriate wound
and pin care is essential to minimize the risk of infection.174
Osteomyelitis, or infection of bone, is a serious situation
that can result in deformity; joint destruction; and, in some
circumstances, amputation.174–177
Patients who have undergone ORIF are at risk of implant
failure if repeated loading causes fatigue and ultimately
exceeds the strength of the implant material and design.178–180
Loosening or breakage of implanted screws, plates, or other
devices also indicates excessive motion of the fracture site
and increases the risk of delayed healing or nonunion. The
patient's ability to function within weight-bearing limits
established by the physician must be carefully assessed and
monitored to reduce the risk of implant failure.

366
Section II  Orthoses in Rehabilitation
Complications also occur in patients whose fractures are
managed by casting. The patient's neurovascular function is
documented before cast application and carefully monitored
while the cast is in place. In the distal lower extremity, the
peroneal nerve is susceptible to prolonged pressure (com­
pression-induced peroneal palsy) as it wraps around the head
of the fibula.108,181,182
Complaints of edge pressure or toes being squeezed can
be solved with cast modifications; however, excessive pres­
sure and discomfort inside the cast often require removal
and reapplication of a new cast.183 On initial application,
a cast is designed to have a snug but not tight fit. Signs of
distal vascular compromise such as delayed capillary refill
on compression of the nail bed suggest that the cast may
be excessively tight.108,183 It is not uncommon for cast fit to
loosen over time as a result of several factors: Initial edema
resolves, compressive forces modify soft tissue composition,
disuse atrophy occurs, and cast padding compresses over
time. Fit must be carefully monitored over time: A loose cast
provides less control of the skeleton, and fracture reduc­
tion may be lost. Pistoning of a loose cast on the extrem­
ity is likely to lead to skin breakdown and shear over bony
prominences.
Casts applied postoperatively while the patient is anesthe­
tized are usually univalved (split down the front) to accom­
modate postoperative swelling.109 Excessive swelling is
accompanied by significant pain. Limb elevation is the first
defense against excessive swelling and pain; however, the cast
can be opened further or bivalved to relieve extreme pres­
sure.3 The risk of compartment syndrome must always be
considered: If the patient experiences significant pain on pas­
sive motion of the fingers or toes, the physician must be con­
tacted immediately. Failure to recognize and appropriately
treat a compartment syndrome results in muscle necrosis and
possible loss of the limb.165
Occasionally, a window can be cut into a cast to inspect a
wound or relieve a pressure area. If the limb is edematous, it is
likely that soft tissue will begin to protrude through the win­
dow, resulting in additional skin irritation and breakdown.
For this reason, any piece of cast that is removed to make a
window must be reapplied and secured to the cast after modi­
fications have been made.183
Patients with foot pain try to reposition the foot within
the cast to make it more comfortable. Inappropriate plantar
flexion of the foot within the cast creates excessive pressure
on the posterior heel and dorsum of the foot. Discomfort can
be reduced if the patient is able to push the relaxed foot gen­
tly downward while pulling the cast upward, as if pulling on a
boot. If this fails to relieve pressure, the cast must be removed
and reapplied.183
Foreign objects introduced into a cast are the most com­
mon cause of discomfort and pressure. In an attempt to relieve
itching of dry skin, patients are sometimes tempted to insert
coat hangers, rulers, sticks, pens, and similar objects into the
cast to scratch the itchy areas. This strategy often leads to dis­
placement of cast padding, creating lumps and bumps where
smooth surface contact is essential. Objects can break off or
become trapped within the cast as well. The best way to relieve
itching is by tapping on the cast or blowing cool air into it.
Another common complication is skin maceration, which
is the result of prolonged exposure to water or a moist envi­
ronment within the cast. Although, ideally, a cast is kept com­
pletely dry, many become wet at some point after application.
Plaster casts that become wet lose significant stability and
must be replaced. Synthetic casts can be towel dried as much
as possible and then further dried using a cool setting on a
blower or hairdryer.
SUMMARY
In this chapter the reader has discovered that orthoses play
an important role in the management of traumatic (e.g., frac­
ture) and developmental (e.g., DDH, LCPD) musculoskeletal
conditions. Each member of the interdisciplinary rehabili­
tation team has a contribution to make to the care of indi­
viduals with pathologies of the musculoskeletal system, as
well as shared responsibility to monitor for changes in func­
tion and potential complications. Although many prefab­
ricated orthoses are available, knowledge of appropriate fit,
design, and dynamics of the orthoses is essential so that the
device will most closely match the intention of intervention.
Precise communication about the goals of the orthosis (e.g.,
to fully immobilize the limb or to allow joint motion within a
restricted range), wearing schedule (e.g., all the time or during
particular activities), and weight-bearing status while using
the orthosis has a major impact on efficacy of the orthotic
intervention. All team members participate in patient and
family education about the orthosis and its purpose, mainte­
nance and cleaning, signs that indicate problems, and strate­
gies to put in place should problems arise.
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Chapter 12  Orthoses in Orthopedic Care and Trauma
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135. Stills M, Christiansen K, Bucholz RW, et al. Cast bracing bicon­
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142. Kapandji IA. The Knee. The Physiology of the Joints. 25th ed.
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152. Babar IU. External fixation in close comminuted femo­
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371
Orthoses for Spinal Dysfunction
Jeff Coppage and S. Elizabeth Ames
External orthoses are used to manage a variety of spinal con­
ditions. The general purpose of a brace is to limit the motion
of a spinal region, decreasing the amount of load applied to
the region treated. Orthoses are most frequently used when
there is concern that loading the spine may result in defor­
mity (i.e., treating an unstable fracture), when the spine is
compromised in a way that requires additional support for
healing (i.e., postsurgical management or osteoporosis), when
the patient is experiencing low back pain that can be relieved
by either limiting motion or increasing abdominal support,
or when there is existing spinal deformity such as scoliosis.
Another major function of a spinal orthosis is to serve as a
psychological reminder to restrict trunk or neck motion, or at
least to encourage the patient to move cautiously.1
For spinal conditions, an orthosis is defined as an external
device applied to the body to restrict motion in a particular
body segment or spinal region. The American Academy of
Orthopaedic Surgeons standardized the nomenclature used
for describing orthoses in spinal management in 1973 and
divided them broadly into five categories (Table 13-1)2:
• Sacroiliac
• Lumbosacral
• Thoracolumbosacral
• Cervical thoracic
• Cervical
Orthoses may also be classified by their rigidity (i.e., rigid,
semirigid, or flexible) or by a combination of their materials
and whether they are prefabricated or custom fit. Historically,
orthoses have been named according to their inventor or
city of invention. This chapter provides an overview of spi­
nal anatomy and biomechanics as they apply to orthotic use,
highlights tips to ensure optimal fit and avoid complications,
and discusses each of the three major spinal regions that are
amenable to orthotic management and the orthoses used in
each region as well as the various types of pathology for which
brace treatment is used. This chapter describes common spi­
nal orthoses, grouped by region (cervical, thoracic, and lum­
bosacral) and describes the clinical conditions that are most
often assisted by the use of spinal orthoses.
Managing a patient who may benefit from a spinal ortho­
sis requires an interdisciplinary team approach. Direct com­
munication between the patient, physician, orthotist, nurse,
physical therapist, and other rehabilitation personnel is nec­
essary to ensure that the health care professionals, the patient,
and caregivers all understand the rationale, limitations, and
expected outcomes when prescribing and using an orthosis.
In the use of spinal orthoses there are specific instructions
that accompany orthotic management to avoid complica­
tions and promote optimal care. Rehabilitation professionals
are responsible for designing therapeutic interventions that
optimize function while carefully observing precautions and
treatment goals of patient management for persons with spi­
nal orthoses. Understanding the design of and rationale for
the orthosis being used is critical to the overall success of the
program.
ANATOMY AND BIOMECHANICS
The spine consists of seven cervical vertebrae, 12 thoracic
vertebrae, five lumbar vertebrae, five sacral vertebrae, and
three to four coccygeal segments. Load sharing intervertebral
13
LEARNING OBJECTIVES
On completion of this chapter, the reader will be able to:
1. Identify the nomenclature for spinal orthoses.
2. Describe the basic structural and functional anatomy of
the spine and its alignment.
3. Discuss the three-column concept of spine stability as it
pertains to spine trauma.
4. Identify the types of injury and pathology for which spi­
nal orthoses are used.
5. List the different types and functional use of spinal
orthoses.
6. Describe the potential complications associated with the
use of spinal orthoses and methods of prevention.
7. Evaluate different areas of the spine as being amenable to
bracing.
8. Discuss indications and contraindications for using spi­
nal orthoses.
9. Describe basic pathophysiology of scoliosis and its
implications.
10. Identify common braces used in the treatment of
scoliosis.
11. Discuss the prescription process for a spinal orthoses.
12. Value the importance of a multidisciplinary team approach
in treating disorders of the spine.

372
Section II  Orthoses in Rehabilitation
discs are interposed between adjacent vertebrae in the cervi­
cal, thoracic, and lumbar segments; in the sacral and coccy­
geal regions, the segments are fused. Two adjacent vertebrae
and the intervertebral disc define the functional spinal unit
(FSU). Multiple FSUs are combined in a superstructure capa­
ble of lateral bending, flexing, extending, and axial rotation.
Different levels of the spine vary in their contribution to over­
all spine range of motion. In the cervical spine, the major­
ity of motion in the sagittal plane (flexion-extension) occurs
through Occ-C2, C4-5, and C5-6 (Figure 13-1).3 The major­
ity of axial rotation occurs at the level of C1-C2 and is made
possible by the unique anatomy of the atlantoaxial articula­
tions. Lateral bending of the cervical spine is more evenly dis­
tributed with the upper subaxial cervical spine contributing
only slightly more than other regions. Sagittal motion in the
thoracic spine increases in a cranial to caudal direction. The
upper segments provide approximately 4 degrees at each level
and the lower segments provide approximately 6 degrees and
increase to approximately 12 degrees per level at the thora­
columbar junction.3 Axial rotation is greatest in the upper
thoracic spine and gradually decreases caudally. Segmental
contribution to lateral bending is fairly well distributed over
the length of the thoracic spine. The lumbar spine contrib­
utes more flexion-extension (Figure  13-2) but significantly
less axial rotation. These regional differences in motion are
related to anatomical differences, primarily articular process
orientation, between the thoracic and lumbar vertebrae. The
ligamentous structures of the spinal column play an impor­
tant role in spine kinematics by augmenting overall spinal
stability while maintaining flexibility.
The normal spine is essentially vertical in the coronal plane
but exhibits four curves in the sagittal plane. The terms kypho­
sis and lordosis are used to describe sagittal curves. Kyphosis
refers to a curve in the sagittal plane with a posterior convex­
ity (forward bend). The thoracic and sacral portions of the
spine demonstrate kyphosis. The normal amount of thoracic
kyphosis ranges from 20 to 50 degrees.4 The term lordosis
describes a curve in the sagittal plane with an anterior con­
vexity (posterior bend). The cervical and lumbar portions of
the spine demonstrate lordosis. The mean lordosis in the cer­
vical spine is 35 to 40 degrees.5,6 The normal range of lordosis
in the lumbar spine is from 20 to 60 degrees.4 Although mul­
tiple curves are present, an overall sagittal balance is main­
tained (Figure 13-3). The sagittal balance of the spine can be
assessed using a plumb-line, or gravity-line, technique. In a
normal balanced spine, a plumb-line from the center of the
C7 should fall ±2 cm from the sacral promontory in the sagit­
tal plane (see Figure 13-3).7 These curves, as well as appropri­
ate coronal and sagittal balance, allow for increased flexibility
and shock-absorbing capacity while maintaining necessary
stiffness and stability.3
The major load on the spine under normal physiological
conditions is axial. Axial loading causes compression of the
vertebral column and its individual FSUs. The natural kyphotic
and lordotic curves of the spine increase in magnitude and
components of individual FSUs (vertebrae and intervertebral
discs) deform slightly in response to compression.3 Soft tis­
sue (ligaments and musculature) as well as bony architecture
serve limit the degree to which the gross architecture of the
TABLE 13-1  Nomenclature for Spinal Orthoses
Acronym
Name
RIGID THERMOPLASTIC OR METAL ORTHOSES, OR BOTH
SIO
Sacroiliac orthosis
LSO
Lumbosacral orthosis
TLSO
Thoracolumbosacral orthosis
CTLSO
Cervicothoracolumbosacral orthosis
CTO
Cervicothoracic orthosis
CO
Cervical orthosis
SOFT GARMENTS AND SUPPORTS
SI belt
Sacroiliac belt
LS corset
Lumbosacral corset
DL corset
Dorsolumbar corset
Soft collar
Nonreinforced cervical collars made from
foam or any low modulus material
0
10
20
30
C7-T1
C6-7
C5-6
C4-5
C3-4
C2-3
C1-C2
Occ-C1
Flexion-Extension by Cervical Level
Flexion-Extension (Degrees)
FIGURE 13-1  Flexion-Extension by cervical level. (Adapted from White AA, Panjabi MM. Clinical
Biomechanics of the Spine, 2nd ed. Philadelphia: JB Lippincott, 1990.)

Chapter 13  Orthoses for Spinal Dysfunction
373
spine can be deformed and the properties intrinsic to the ver­
tebrae and intervertebral discs counter the effects of compres­
sive forces. The spine must resist tension and shear forces in
addition to axial loads. The properties of the spine conform to
Wolff's law, which states that form follows function. Studies
of the spine reveal that the spine as a whole can resist higher
compressive loads than tension or shear.3 Furthermore, seg­
ments of the spine that experience greater compressive loads
in vivo have been found to be capable of withstanding higher
loads before failure. Biomechanical studies demonstrate
that the ability of the spine to withstand forces increase in
a cephalocaudal direction such that the lumbar spine, which
must withstand the sum weight of the body above it, has the
greatest compressive strength.8,9 The vertebral body (anterior
column and anterior aspect of the middle column) provide
the majority of this resistance to compression, which trans­
lates into increased overall stability in fractures in which the
vertebral body is intact and a greater likelihood that bracing
may not be necessary. This structure-function relationship is
vital to understanding the rationale behind bracing and other
treatments of back pain, spinal deformity, or spine injury.
THE THREE-COLUMN CONCEPT
An understanding of spine injury and stability is vital to
understanding the role that bracing and various orthoses
play. The concept of the three-column spine was initially
described by Denis10 in 1984 and is widely used as a means
to help define spinal stability. Denis used the three-column
model as a basis for his classification of traumatic spine inju­
ries. The three columns are the anterior, middle, and poste­
rior columns (Figure 13-3). The anterior column consists of
the anterior aspect of the vertebral body, anterior annulus
fibrosis, and anterior longitudinal ligament. The middle col­
umn includes the posterior longitudinal ligament, posterior
annulus fibrosis, and posterior aspect of the vertebral body.
The posterior column consists of the posterior vertebral arch
as well as the supraspinous and interspinous ligaments, facet
joints, and ligamentum flavum. Debate exists as to whether
injury to the posterior column or the middle column is
the main factor that destabilizes thoracolumbar spine frac­
tures3,11–15; a combination of both, however, results in a highly
unstable spine. Compression fractures and burst fractures are
the most common clinical entities where orthoses are consid­
ered. Denis defined these types of fractures using the three-
column concept (Box 13-1).
Compression fractures are defined as failure and wedging
of the anterior column and occur with axial forces combined
0
5
10
15
20
L5-S1
L3-4
L1-2
T11-10
T8-9
T6-7
T4-5
T2-3
Flexion-Extension by Thoracolumbar Level
Flexion-Extension by Thoracolumbar
Level (Degrees)
FIGURE 13-2  Flexion-extension by thoracolumbar level. (Adapted from White AA, Panjabi MM.
Clinical Biomechanics of the Spine, 2nd ed. Philadelphia: JB Lippincott, 1990.)
Spinous
process
Transverse
process
Posterior
column
Vertebral
body
Anterior
column
Middle
column
Posterior
column
Anterior
longitudinal
ligament
Inter-
vertebral
disc
Supra
spinal
ligament
Posterior
longitu-
dinal
ligament
FIGURE 13-3  Three columns.

374
Section II  Orthoses in Rehabilitation
with spine flexion about an axis located in the middle col­
umn. The middle column remains intact, which provides sta­
bility and prevents retropulsion of bony fragments into the
spinal canal. Some degree of partial failure of the posterior
ligamentous structures may be present due to the tension
forces present during the initial forced flexion. Depending
on the degree of anterior column failure, some compres­
sion fractures may undergo progressive collapse and lead to
increasing posttraumatic kyphosis.16 Compression fractures
with greater than 50% of vertebral body height loss are more
likely to have instability due to associated posterior ligamen­
tous involvement, which may result in progressive injury and
kyphotic deformity due to the compressive forces conveyed
by an upright posture.3,16
Burst fractures generally involve failure of the anterior
and middle columns due to axial loading with or without
additional moments, depending on the fracture pattern.17
Although these fractures are defined as two-column involve­
ment, Holdsworth13 described an associated greenstick frac­
ture of the lamina (posterior column). These injuries are
referred to as three-column burst fractures. Involvement of the
middle column is significant because it may lead to retropul­
sion of bony fragments in the spinal canal and lead to spinal
cord injury. Controversy exists regarding which burst fractures
are “stable” and are amenable to bracing, and which require
surgery. A recent randomized trial of hyperextension cast­
ing followed by brace management compared with operative
management demonstrated that patients treated operatively
experienced improved functionality more rapidly than those
immobilized, but long-term outcomes in terms of deformity,
chronic pain, and neurological status were equivalent.18
FIT AND FUNCTION OF THE SPINAL ORTHOSIS
All spinal orthoses have several common effects on the spi­
nal region they treat. Their primary action is to reduce gross
spinal motion, and the degree to which they accomplish this
depends on both their materials and their design. Secondary
effects include the stabilization of individual FSUs, reducing
the range of motion of one vertebra relative to another. Spinal
orthoses also apply closed chain forces designed to counter a
deforming force, such as providing hyperextension to a frac­
ture that is vulnerable in flexion. Finally, they reduce loads
on the spine itself by preventing specific actions, such as pre­
venting bending and twisting to reduce stress on surgical
implants. Each region of the spine has specific needs based on
its predominant motions, loads, anatomic features, and physi­
cal condition.
The shape of a spinal orthotic, much like the natural shape
of the spine, has an intimate relationship with the desired
function. Braces often help restore or exaggerate natural spine
structure. When thoracolumbar body casts were more com­
monplace in clinical practice, the casts were applied with the
patient positioned supine on a casting table with a belt under
their lumbar spine such that they were casted in a position of
hyperextension.19 This hyperextension (hyperlordosis) has
COMPRESSION FRACTURES (DENIS TYPE 1)
Mechanism of Injury: Spinal Flexion with Compression
Subtype
I-A
Anterior fracture only

I-B
Anterior fracture with lateral components
BURST FRACTURES (DENIS TYPE II)
Mechanism of Injury: Spinal Compression with Flexion
Subtype
II-A
Fracture of both end plates or retro­
pulsion, or both, of the posterior wall
as a free fragment

II-B
Fracture of the superior end plate,
occasional retropulsion of inferior
wall as a free fragment

II-C
Fracture of the inferior end plate

II-D
Burst fracture with rotational injury

II-E
Burst fracture with lateral flexion injury
SEAT BELT INJURIES (DENIS TYPE III)
Mechanism of Injury: Spinal Flexion with Distraction
Subtype
III-A
(Chance fracture) single segment, pos­
terior or middle column opening


III-B

(Slice fracture) single segment, pos­
terior and middle column opening
through soft and bony tissue

III-C
Two segments, posterior and mid­
dle column opening through soft and
bony tissue

III-D
Two segments, posterior and middle
column opening through soft tissue
only
FRACTURE DISLOCATIONS (DENIS TYPE IV)
Mechanism of Injury: Translation, Flexion, Rotation, with
Shear
Subtype
IV-A
Flexion and rotation injury with dis­
ruption through bone or interverte­
bral disc, or both

IV-B
Due to shear (anterior-posterior or
posterior-anterior) with fracture and
dislocation of facet joints

IV-C
Ligamentous injury to posterior and
middle column, with failure (marked
instability) of the anterior column




IV-D
Oblique shear forces resulting in
significant instability of involved seg­
ment (bone or disc)
BOX 13-1  Classification System for Traumatic Fractures of the Thoracolumbar Spine

Chapter 13  Orthoses for Spinal Dysfunction
375
been used in many types of braces (i.e., Jewett and CASH)
because it removes or decreases the amount of flexion, which
reduces compressive force on the fractured vertebral body and
limits distraction of the posterior elements. Hyperextension
braces achieve the intended positioning by using a three-point
mold. A three-point mold refers to three points of applied force:
one posteriorly and two anteriorly, with one located cephalad
to the level of the posterior force and one caudal.3 An anal­
ogy to this concept is if one was trying to break a pencil using
two hands with his or her thumbs in the center and fingers
located at either end. The bending that results is the intended
effect of the three-point mold. The desired result is prevention
of the progressive kyphotic deformity that is associated with
significant compression and burst fractures. Another example
of three-point molding is seen in corrective braces used for
scoliosis, except that the forces are directed in a coronal plane
instead of a sagittal plane. It is imperative to ensure that the
contour and fit of the brace promotes adequate alignment of
the spine and avoids potential complications associated with
forces applied to the body for long periods of time.
An orthosis must have intimate contact with bony prom­
inences to be effective.20 The biomechanical principles of
bracing the spine itself can be understood in these terms; in
reality, however, using an orthosis to treat a human condi­
tion is subject to other variables. Compliance and the psycho­
logical effects of bracing can be significant issues including
developing a psychological dependence on the orthosis.21–26
The financial burden can be significant, with costs ranging
from $32 to greater than $5000.1 Physical issues also apply,
particularly in an increasingly obese population. The ability
of a brace to apply appropriate forces, either stabilizing or cor­
rective, depends on its ability to act on the structures of the
spine. This in turn depends on the soft tissue envelope in the
contact areas around the spine. Too little or excessive pres­
sures transmitted through soft tissues can result in signifi­
cant physical complications including skin breakdown, loss
of reduction or spinal alignment, pain due to the brace, weak­
ening of the immobilized muscles, and soft tissue contrac­
tures.26–32 The prescription and use of a spinal orthotic should
always be prescribed with an appropriate monitoring system
and rehabilitation program. Orthoses must be modified peri­
odically, and a comfortable and appropriate fit is critical to
preventing skin problems and ensuring compliance.
Compliance with brace wear is a significant clinical issue,
particularly because the orthosis is specifically designed
to restrict motion, which is neither an accommodating nor
pleasant approach to therapy. Studies in adolescent patients
with scoliosis wearing “smart braces” that can track wear time
indicate compliance rates of 9% to 30%; similar studies have
not been done for orthoses used for other conditions. In the
current health care environment most patients with signifi­
cant spinal conditions recover at home rather than in rehabil­
itation facilities. Orthosis designs that increase the difficulty
of donning or doffing decrease the patient's ability to use the
brace effectively if they are not supervised and assisted daily.
The only orthoses that ensure compliance are fiberglass casts,
which are very rarely used in current times.
Regional Orthoses
Cervical
The cervical spine is the most intuitively easy structure to
consider bracing, in that the bony occiput, mandible, ster­
num, and clavicles provide appropriate supporting structures.
Unfortunately this advantage is offset by the limited surface
area available for contact and the fact that the mandibles
and clavicles are often in motion during normal activities.
The complexity of the cervical soft tissues—vessels, airway,
esophagus—is a disadvantage, in that significant forces can­
not be applied directly to the spine without significant vis­
ceral effects. Orthoses for the cervical spine can be limited to
the subaxial spine itself—a cylinder that fits around the neck
with a trimline at the occiput, mandible, and sternoclavicu­
lar structures—or may extend proximally and distally (halo
vest) or distally onto the thoracic cage for additional control
(cervicothoracic orthosis [CTO]).
Cylindrical cervical braces limit a variable degree of
motion depending on the design and primarily provide
proprioceptive feedback as a reminder to limit the range of
motion of the neck. Available choices are many and this list is
not exhaustive; commonly used choices include the soft col­
lar, the Stifneck (Laerdal, Armonk, NY) , the Philadelphia
(Philadelphia Cervical Collar, Thorofare, NJ), and the Miami J
(Össer, Foothill Ranch, CA) (Figure 13-4).
Soft collars tend to be the most comfortable of the available
cervical collars but provide little stability to the cervical spine.
The collar is a soft foam rubber covered with stockinet or
other gentle fabric with a Velcro-type fastener. These collars
have been shown to provide up to 10% restriction to cervical
motion in all planes.33–35 Conversely, Miller et al36 analyzed
differences in functional cervical spine motion between no
collar, a soft collar, and a rigid collar while performing 15 dif­
ferent activities of daily living* (ADLs). The authors found
that there was no significant difference in limitation of sagit­
tal range of motion between the soft and rigid collars during
13 of the 15 ADLs tested (significant differences were noted
while reversing a car and sitting down in a chair). No signifi­
cant differences were noted during lateral bending, and the
difference in rotational movement restriction was only signif­
icant while reversing a car. The soft cervical orthosis is used
primarily as a comfortable reminder to the patient to limit
exaggerated neck movements and may be useful in cases of
minor whiplash, cervical spondylosis, or as a postoperative
adjunct with a stable spine.3 Soft collars are inappropriate for
an unstable cervical spine.
A great deal more support is required in patients with
injuries that compromise spinal stability. This prompted the
*ADLs tested include standing to sitting, backing up a car, putting
on socks, tying shoelaces, reading a magazine in lap, cutting food
with knife and fork and bringing food to mouth, rising from a sit­
ting position, washing hands in a standing position, shaving facial
hair (men)/applying makeup (women), washing hair in shower,
picking up object from floor (bending technique), picking up object
from floor (squatting technique), walking, walking up stairs, walk­
ing down stairs.

376
Section II  Orthoses in Rehabilitation
development of the reinforced cervical collar, which is a com­
mercially produced, prefabricated orthosis that combines
some of the soft materials found in soft collars with a semi­
rigid, contoured plastic external frame. Many different types
of reinforced collars are available, such as the Philadelphia,
Aspen (Aspen Medical Products, Irvine, CA), Miami J,
NecLoc (Össur, Foothill Ranch, CA), and Stifneck. Most rein­
forced collars have anterior and posterior shells with inner
padding and trim that close around the neck and fasten with
Velcro-type fasteners. The collars are contoured such that
they abut the sternum, clavicles, trapezius, and upper tho­
racic spine inferiorly and the mandible and occiput superi­
orly, which provides some degree of end-point control. Most
have openings anteriorly to accommodate respiratory and
ventilator equipment.
Although there are many similarities between the differ­
ent cervical collars, studies have found significant differences
in the degree to which different collars restrict cervical spine
motion. The ability for a cervical collar to provide cervical
stability is very important in that approximately 3% to 25%
of spinal cord injuries occur after the initial spine injury.37
Multiple studies have evaluated the various reinforced collars
for their ability to promote cervical stability as well as avoid
complications. Askins and Eismont37 studied five common
reinforced cervical collars by using anteroposterior and lat­
eral radiographs to assess cervical spine motion in normal,
healthy volunteers. They found the NecLoc to be statistically
superior with respect to limitation of cervical motion in all
planes, followed by the Miami J collar, when compared the
Philadelphia and Aspen collars. Kaufman and colleagues38
found the NecLoc to provide superior restriction of motion
versus the Philadelphia collar and a soft collar. Ducker39
found the NecLoc and Miami J collars to be statistically supe­
rior to the Stifneck, Philadelphia, and soft collars.
The treating physician must consider fit and skin protec­
tion when selecting a reinforced cervical collar in addition
to selecting a collar that is capable of providing adequate sta­
bility. Fisher29 studied the importance of proper fit of a cer­
vical orthosis and found that an inappropriately fitted collar
was equivalent to not wearing any collar at all. Bell and col­
leagues32 analyzed the effects that ill-fitted Miami J collars
have on the degree of cervical motion restriction. They found
that in flexion-extension, the braces that were too large and
too small allowed increased motion but only extension in the
too large brace produced a statistically significant increase
in allowed motion. Both the too small and too large braces
allowed significantly more motion in left and right axial
rotation. The too large and too small braces allowed signifi­
cantly more lateral bending motion to the right but only the
too small brace allowed a significant increase in left lateral
bending. Plaisier and colleagues28 evaluated common cervical
collars and the pressures they exerted on craniofacial tissues
with respect to capillary closing pressure. The pressure at the
collar-skin interface was measured using an electropneumatic
sensor placed between the collar and skin. This measurement
was compared with a value of 32 mm Hg, which represents
A
B
C
FIGURE 13-4  A, Soft collar. B, Philadelphia collar. C, Miami J collar.

Chapter 13  Orthoses for Spinal Dysfunction
377
capillary closing pressure as defined by Berne and col­
leagues.40 They found significant differences between collars
in the amount of pressure exerted on the tissues. The Stifneck
collar produced pressures in excess of capillary closing pres­
sure at most collar-tissue interfaces, whereas the Miami J col­
lar exerted pressures well below the capillary closing pressure.
Braces that need to immobilize the occipitocervical spine
require fixation to the skull and significant rotational con­
trol. The most commonly used example is the halo vest
(Figure  13-5). Facial fracture fixation with traction applied
through a skull ring was developed by Frank Bloom, MD, dur­
ing World War II to treat pilots with facial fractures and severe
burns. The device was then adapted by Vernon Nickel, MD, and
first reported in 1959.8 Primary features include a ring anchored
to the skull with skeletal pins and connected to a body jacket by
four vertical uprights. Changes in material design and advances
in plastic technology have allowed significant modifications to
the halo vest—molded thermoplastic jackets, radiolucent rings
and uprights, shaped rings open posteriorly for patient comfort
while supine, and multidirectional adjustments in the connect­
ing mechanisms—but the principles of fixation have remained
the same. Six to eight transcranial pins provide secure proximal
fixation (end point control), and full contact support around the
thorax and torso provide the distal fixation.
The ring of the halo is positioned 1 cm above the eyebrows
and the tip of the ears, with care taken to keep the ring well
clear of the skin surface. Four pins are inserted into the outer
table of the skull with 6 to 8 lb/in of torque.41 The anterior
pins are placed at the equator (widest point) of the skull above
the lateral one third of the eyebrow to avoid the frontal sinus,
supraorbital and supratrochlear nerves, and temporalis mus­
cle. Posteriorly, pins are placed 1 to 2 cm posterior to the ear
diagonally opposite the anterior pins. This provides secure
fixation to allow for manipulation in both flexion/extension
and in translation.
The halo vest itself was originally a plaster cast fit over
the torso with a trimline at or slightly above the inferior cos­
tal margin of the last rib.42 Advances in materials allow for
bivalved thermoplastic shells that can be released with the
patient supine to allow for hygiene, and some designs are
fleece lined. A four-pad halo vest that completely avoids the
shoulder girdle has been proposed to avoid scapular move­
ments transferring loads to the neck.43,44 Two anterior and
two posterior rods link the vest to the ring through a series of
connectors. Modern connectors allow translation in multiple
planes with the ability to lock them into position once reduc­
tion has been achieved.
Complications can occur with halo vest use, including pres­
sure sores, loss of reduction (particularly in injuries involving
the posterior elements), and pin infection and loosening.45–49
A higher rate of complications occurs in older patients. In a
review of 53 patients with a mean age of 79.9 years, Horn and
colleagues50 recorded 31 complications in 22 patients. Serious
complications included respiratory distress and dysphagia,
and the cause of death in 6 of 8 patients who died within the
treatment period was thought to have some relationship to
the halo treatment. Modern day halo vests should always
have a wrench attached to the front of the halo vest for quick
removal in case of a cardiac emergency.
Studies comparing the halo to other types of cervical brac­
ing with respect to the ability to limit motion have had variable
findings. Johnson et al51 found that the halo allowed only 4%
of normal sagittal motion, 1% of normal rotation, and 4% of
lateral bending in normal subjects. A cadaveric study of simu­
lated odontoid fractures demonstrated the halo was superior
in all planes versus a Miami J collar, a Minerva brace, and a
soft collar.34 In vivo studies comparing subjects in various posi­
tions and activities demonstrated a maximum reduction of
sagittal motion of only 30%.52 A study of injured patients by
Benzel et al53 demonstrated paradoxically increased movement
at the injured levels in the halo versus a Minerva brace, which
they attributed to the pull of the neck muscles with attempted
flexion or extension against the rigidly fixed head. Ivancic and
Telles54 studied neck motion in a normal versus loosely applied
halo vest in the supine and prone positions using a cadaveric
cervical spine between an anthropometric dummy and surro­
gate head. Results showed significantly increased motion in the
loose vest with respect to the normal vest. The authors con­
clude that such increased motion may play a role in delayed
unions and nonunions of cervical spine fractures.
The halo vest is useful in providing reduction and provi­
sional stabilization of injuries or conditions causing instability at
FIGURE 13-5  Halo vest.

378
Section II  Orthoses in Rehabilitation
the occipitocervical junction, and can be used to provide addi­
tional support after these patients have surgery. It is best used for
reducing angular and translational deformities in cervical spinal
fractures at the proximal and distal regions of the spine; in the
midportion, studies have shown that a halo actually increases
the forces on the injured vertebrae.53 It is commonly used for
complex combined C1 and C2 fracture patterns where internal
stabilization is not ­possible without extension to the occiput,
which results in severe loss of motion for the patient.55,56 It is
used to provide additional stability after complex surgical recon­
structions or noninstrumented fusion or wiring constructs after
surgery at C1-2, and may be used to supplement instrumented
fusions in situations with poor bone quality or significant insta­
bility, such as in osteoporosis or rheumatoid arthritis patients.57
The halo is no longer used as frequently in subaxial (i.e., C3-C7)
trauma due to the advances in spinal instrumentation. It is still
considered the treatment of choice for some types of fractures
of the axis (hangman's fractures) and in some flexion-compres­
sion injuries.58,59 A fracture of the odontoid process at C2 is a
common injury among older patients and historically has often
been treated with a halo vest.60–62 Currently the optimal treat­
ment for these patients is a topic of debate, with some authors
reporting that simple collar immobilization provides equivalent
results.63–69 Significantly higher mortality has been reported in
older patients treated with a halo compared with those treated
with a cervical collar.61,70 Daentzer and colleagues71 performed a
retrospective study of 29 patients divided into two groups based
on age less than or greater than 65 and found that while clini­
cal and radiographic results were equivalent between the two
groups, the interval to healing and rate of complications were
higher in the older than 65 age group.
Rehabilitation of the patient with a halo is challenging.
The fixed head position results in a different ability to use
visual cues, and the weight of the vest and position of the head
combine to change the patient's center of mass. Ambulatory
patients in halo vests may exhibit a forward-flexion posture
to accommodate this; a cane or walker may be required while
the halo is in place. Likewise, there is a readjustment period
after the halo is removed that may require postural reeduca­
tion as part of the rehabilitation strategy.
Cervicothoracic and Thoracic
CTO can be divided into two categories: those that use the
thoracic spine to support treatment of a subaxial cervical
spine or upper thoracic spine problem, and those that sup­
port treatment at the upper cervical spine. Examples in the
first category include thoracic extensions added to a cylin­
drical cervical orthosis (i.e., Extended Miami J), or an ortho­
sis that utilizes pads on the chin and occiput to connect to
the trunk by four stiff uprights or circumferential supports
(i.e., Minerva). The Minerva brace (Figure 13-6) is the most
effective method for immobilizing C1-2, and has been shown
to limit flexion-extension by approximately 79%, axial rota­
tion by 88%, and lateral bending by 51%.72 The cervicotho­
racic area is a particularly challenging area to immobilize in
that it is a transitional area between the very mobile and lor­
dotic cervical spine and the kyphotic thoracic spine. Little
data exist in the literature regarding immobilization of the
upper thoracic spine; for those conditions not requiring sur­
gery, an extended cervical orthosis can be used.1 The Minerva
brace, SOMI brace (Figure 13-7), or a custom-molded CTO
can be used for conditions extending as far caudally as T5. In
general, increasing the length of the orthosis down the trunk
enhances its capabilities.51
The most common condition that affects the thoracic spine
is the vertebral compression fracture (VCF). Approximately
700,000 vertebral compression fractures occur each year, and
it is estimated that 25% of American women will experience
at least one VCF in their lifetime.73 Most patients will have a
benign course, but up to 30% are significantly symptomatic
and seek treatment for pain that limits function either short or
long term.74 A study of patients with multiple VCFs found sig­
nificant decreases in trunk extension torque, spinal motion,
functional reach, mobility skills, and walking distance com­
pared with the normal age-matched population.75 The treat­
ment of VCF is aimed at pain relief, rather than at fracture
treatment as with other types of fracture management. The
main objective is to improve quality of life and decrease pain.
Treatment of painful fractures may necessitate a short
period of bed rest followed by gradual mobilization. Bracing
with an orthosis may be beneficial for the first 6 to 8 weeks
until the acute pain resolves. Unfortunately bracing is often
FIGURE 13-6  Minerva brace.

Chapter 13  Orthoses for Spinal Dysfunction
379
poorly tolerated. The efficacy of bracing VCF has not been
established.76 For osteoporotic women in general, one study
demonstrated that wearing a TL orthosis that emphasized
postural control for 6 months resulted in improvements in
back extensor strength, abdominal flexor strength, decreased
kyphosis, decrease in pain, increase in well-being, and
decrease in limitations.77 One study suggested efficacy for this
orthosis in patients with VCF and demonstrated potentially
better tolerance than other braces.78 Further study is required
to outline optimal general management strategies for using
spinal orthoses in this population.79 Typically a symptom­
atic patient requesting bracing is trialed in an extended cer­
vical orthosis, a hyperextension TL brace (CASH or Jewett,
see later), or a CTO depending on the level involved.53 If the
orthosis is not helpful it is discarded.
Thoracolumbar
The thoracolumbar region is the most common region of
the spine affected by traumatic fracture, and the most likely
region of the spine to benefit from orthotic support for the
surgically treated spine. The integrity of the vertebral body
is of primary importance to resisting compressive forces and
axial loads, and this region is a transitional zone that should
be neutral in alignment. Fractures involving the anterior
body greatly decrease the spine's ability to withstand com­
pressive load and tend to collapse into kyphosis, particu­
larly if the posterior elements are also involved (i.e., a burst
­fracture). This results in displacement of the patient's sagittal
balance, spinal deformity, pain, and in the worst cases, neu­
rological deficit. Fractures of this area may be treated with
orthoses or surgically, and there is some consensus in the lit­
erature for surgical management when the vertebral body is
severely comminuted, the patient has a neurological deficit,
or the initial fracture alignment is unacceptable.76,80 Advances
in spinal instrumentation and techniques such as interbody
support have improved the surgeon's ability to counteract
kyphosis, but at the thoracolumbar junction this requires a
combined thoracolumbar surgical approach through the
thoracic and abdominal cavities, which carries significant
morbidity. Surgeons often choose to use posterior spinal
instrumentation alone in these cases. Posterior instrumenta­
tion is least effective in resisting kyphosis, so orthoses that
reduce kyphotic forces on the thoracolumbar spine may be
used to supplement internal fixation techniques.
When orthoses are used for thoracolumbar fracture man­
agement, the same principles apply. Optimal management
includes a strategy to resist anterior flexion and therefore the
development of a kyphotic deformity. They are best used for
fractures from T10 to L2, although some types of orthoses
can be adjusted to control up to T8. Several thoracolumbar
hyperextension orthoses are designed to unload the ante­
rior column.1 The most common types are the Jewett brace
(Figure 13-8A) and the cruciform anterior spinal hyperexten­
sion brace (CASH) (see Figure 13-8B). Both of these braces
are available in prefabricated styles from various manufac­
turers. The Jewett orthosis has an aluminum frame anteriorly
that is stabilized on the pubis, sternum, and lateral midline
of the trunk against a posterior pad. The frame is open and is
particularly suitable for patients with coexisting abdominal
trauma or obesity. Trunk flexion is limited by a single three-
point pressure system with posteriorly directed forces at the
sternum and pubis opposing an anteriorly directed force
applied by the posterior pad. Therefore it is contraindicated
in patients with sternal fractures or an inability to tolerate
direct pressure from the posterior pad. The goal of the Jewett
is to prevent flexion while still allowing active hyperexten­
sion. The CASH brace uses the same three-point system.
It has an adjustable-length anterior cross with sternal and
pelvic pads at the end of the vertical bar, and lateral pads
on the horizontal bar. It also uses an anteriorly directed
force provided by a posterior belt. Both the Jewett and the
CASH are options for those patients who cannot tolerate
the constriction of a molded thermoplast thoracolumbosa­
cral orthosis (TLSO) but are contraindicated in patients with
injuries including significant three-column instability such
as the thoracolumbar burst fracture.
The TLSO is the recommended treatment for significant
fractures at the thoracolumbar junction being treated con­
servatively. TLSOs can be used to manage fractures from
T6 to L4. Molded TLSOs provide total contact designed to
restrict range of motion in all planes. In one study, a cus­
tom-molded thermoplastic TLSO showed 94% restriction
in lateral bending and 69% restriction of flexion-extension
in the lumbar spine.81 In the thoracic spine, there was 49%
FIGURE 13-7  SOMI brace.

380
Section II  Orthoses in Rehabilitation
restriction of flexion-extension and 38% restriction of lat­
eral bending. The thoracic spine normally also allows rota­
tion, and a reduction of 60% in total rotation was also shown.
The superior trimlines of the TLSO are at the sternal notch
and have an anterior-inferior trimline at the groin; they are
carefully shaped to envelop the pelvis, arching slightly lat­
erally anteriorly to accommodate the thigh while sitting
and trimmed low at the sacrococcygeal junction posteri­
orly. The superior-posterior trimline falls just below the
spine of the scapula. The custom molds are made of a ven­
tilated thermoplastic, which may be lined with closed cell
foam to increase comfort. They can be bivalved with side
closures to facilitate donning and doffing, and are generally
worn over a light T-shirt for comfort and hygiene. Straps
over the shoulders may increase the rigidity, particularly if
a semiflexible or prefabricated model is chosen. TLSOs are
also available in prefabricated models, although for maxi­
mum control of motion, a custom mold is preferred. There
is some controversy as to whether the made-to-measure or
prefabricated orthoses fit and function as well as the custom-
fabricated ones.
Lumbosacral
Immobilization of the lumbosacral spine presents a unique
set of challenges. It is a transition zone between the highly
mobile, lordotic, lumbar spine and the rigid sacropelvic
structures; it has the largest absolute range of flexion-exten­
sion motion, and it bears the most load of any of the spinal
regions. A rigid LSO, which is simply a shorter version of
the TLSO braces described earlier, is appropriate for bracing
fractures at L2, L3, and L4, but the FSU at L4-5 and L5-S1
require special treatment. Fidler and Plasmans82 found that
a unilateral thigh extension is necessary to effectively immo­
bilize L4-5 and L5-S1. A thigh extension is generally a cuff
attached by two longitudinal struts that have hinges, allowing
a variable degree of flexion at the hip to facilitate toileting and
sitting; generally, it is set at allowing 20 to 30 degrees of flex­
ion at a maximum. The mean percentage of motion allowed
in the brace was 32% at L4-5 and 70% at L5-S1 in a brace
without the extension; adding the extension resulted in an
additional 15% to 30% reduction of motion.83,84 At best,
restriction at the L5-S1 level still allows 40% of normal range.
For this reason fractures at these levels are best treated with
surgery (using an orthosis for postoperative support if neces­
sary) if the treating physician desires to mobilize that patient
during the healing period.
LSOs have commonly been used in the postopera­
tive period up until the last few years. Advances in spi­
nal instrumentation with the advent of pedicle screws and
interbody techniques now allow many patients to go with­
out bracing postoperatively. Pedicle screws connect the
anterior load bearing portion of the spine with a posterior
construct by crossing the middle column (Figure  13-9)
and provide better limitation of motion and load sharing
than previous hook/rod constructs. Interbody techniques
place a block of bone between the vertebral bodies, either
through placement by an intraabdominal approach or
with hybrid approaches accessing the disc space from the
posterior part of the spine. The placement of bone in the
middle and anterior columns facilitates healing because of
increased surface area and favorable biomechanical condi­
tions allowing the bone graft to experience compression
forces. A recent randomized trial that assessed the ben­
efit of wearing a lumbar corset for 8 weeks after lumbar
fusion did not find a significant advantage or disadvan­
tage with respect to healing rates or patient comfort.85
A
B
FIGURE 13-8  A, Jewett brace. B, CASH brace.

Chapter 13  Orthoses for Spinal Dysfunction
381
Today, postoperative bracing is reserved for patients who
feel more comfortable with support (a lumbar corset) or
those with poor bone quality or technical issues leading to
concerns about healing or the stabilization provided by the
instrumentation.
Patients with acute low back pain may find the additional
support and postural reminder of a lumbar corset helpful
for pain reduction. Lumbar corsets are generally semirigid
or flexible braces (see Figure 13-9A). Their function is to
reduce gross trunk motion and increase intracavitary pres­
sure in the abdomen by transmitting a three-point pressure
system to the lumbar spine. They are designed to support
the trunk in a neutral sagittal alignment and provide a kin­
esthetic reminder to limit motion. The lumbar corset has
little resistance to gross body motion during sitting and
standing.86 Typically, the anterior borders of the lumbosa­
cral corset are superior to the symphysis pubis and infe­
rior to the xiphoid process. The posterior borders extend
between the sacrococcygeal junction of the pelvis and the
inferior angle of the scapulae; some may incorporate shoul­
der straps. The Chairback Orthosis (see Figure 13-9B) is an
LS corset with both a thoracic and a pelvic band connected
by two paraspinal bars for optimized sagittal control. A pair
of lateral bars can also be added for improved coronal con­
trol (the Knight orthosis).
The literature on the effectiveness of the corset is conflict­
ing. In 2001, a systematic review of randomized and non­
randomized controlled trials demonstrated no evidence that
spinal orthoses are effective in the prevention or management
of low back pain.87 An orthosis should be used in conjunction
with a rehabilitation program focused on core strengthening
and stabilization in these patients.
Spinal orthoses have been found to have a decondition­
ing effect on the paraspinal muscles and trunk stabilizers.
Electromyographic studies have found conflicting results,
with some demonstrating a significant reduction in muscle
activity in the brace and others finding either unchanged or
increased activity.83,88 An exercise regimen should be main­
tained when the clinical situation allows, and the orthosis
should be discontinued as soon as possible.
SCOLIOSIS
Scoliosis is a general term that refers to a three-dimensional
spinal deformity characterized by coronal displacement of
vertebral bodies away from the axis of gravity combined with
abnormal vertebral rotation. There are many types of scolio­
sis as well as many etiologies. In current times, the only type
of scoliosis that is typically and frequently managed with spi­
nal orthoses is the idiopathic curve. Adolescent idiopathic
scoliosis (AIS) refers to a curvature and rotational deformity
of the spine that develops with growth. It can occur in the
upper thoracic, thoracic, thoracolumbar, or lumbar spine or
some combination of these. There is often a primary curve
(the curve with abnormal growth) and a compensatory curve,
which is a second region of the spine curving in the opposite
direction to the primary curve to keep the head centered over
the pelvis. The age of the child, growth remaining, and curve
pattern all have implications for prognosis.
Prevalence and Natural History
Idiopathic scoliosis has been studied and documented for
many years and maintains a consistent prevalence of approxi­
mately 1% to 2% of school-age children.89–91 Ninety percent
A
B
FIGURE 13-9  A, Lumbar corset. B, Chairback orthosis.

382
Section II  Orthoses in Rehabilitation
of children have adolescent onset curves, although this figure
may be falsely elevated because younger children are not rou­
tinely evaluated.92 The prevalence of curves that do not require
treatment (<20 degrees) is 20 to 30 per 1000, the prevalence of
moderate curves amenable to bracing (20 to 30 degrees) is 3 to
5 per 1000, and the prevalence of large curves likely to go on
to surgical management is 2 to 3 per 1000 people.91 The prev­
alence of curves is greater in females, particularly with respect
to curves over 20 degrees (6.4 F:1 M).93 The single right tho­
racic curve is the most prevalent pattern.94 The most important
determinants of the likelihood of progression are those that
reflect skeletal maturity: age, menarchal status, and the pres­
ence of mature growth centers on radiographs of the pelvis
(Risser sign) or hand. The likelihood of progression deter­
mines the need for treatment; those at highest risk are those
with a younger age at diagnosis, a curve that appears before
the onset of menstruation, a double curve pattern, and a
curve that is documented to change more than 5 degrees on
serial radiographs taken at 6-month intervals. Curve mag­
nitude and rotation are both correlated with increased pro­
gression rates.95 This is the basis for the recommendation that
curves greater than 50 degrees in a growing child be treated
surgically.
Biomechanics
Curves progress when buckling loads change during growth,
along with other hormonal and developmental factors.
A straight, flexible column fixed at the base and free at the
other end subjected to axial forces will buckle, which in
the spine results in a combination of curvature and rota­
tion. The loads at which these processes occur are related
to length and rigidity of the spine. The adolescent growth
spurt results in a significant increase in spinal length and
may result in increased flexibility as well, which contrib­
utes to the drastic increases in curve progression com­
monly observed during adolescent years. As the curve
progresses, a feed-forward cycle is created. With curve
progression, the spine is subjected to increasingly abnor­
mal force vectors and deviates further from the normal
anatomic alignment at which it is best equipped to resist
such loading. Braces used for scoliosis are designed to
interrupt this feed-forward cycle.
There are three primary mechanisms by which an ortho­
sis exerts forces on a developing spine: end point control,
curve correction, and transverse loading.96 End point con­
trol is the ability of the orthosis to constrain the spine. An
example of end-point control is the neck ring at the proximal
end of the Milwaukee brace, which can control the position
of the upper thoracic spine relative to the pelvis. Curve cor­
rection has the greatest effect because it stiffens the spine and
reduces the curve, which in turn decreases the load on the
spine and slows the rate of deformation. Transverse loading
at the apex is the primary mode of correction within modern
orthoses, but begins to lose efficacy as the curves get larger.97
It is important to note that brace treatment often does not sig­
nificantly correct the curve that exists but rather prevents it
from increasing in size during growth. Some degree of curve
correction should be achieved within the brace (ideally 50%
or more) because the curve will regress back to its initial mag­
nitude once the brace is removed. 98,99 The overall concept is
to halt curve progression.
Evaluation
The first step in evaluating a child with a spinal curvature
is a thorough orthopedic history including age, growth pat­
terns, family history of spinal problems, the age the curve
was discovered, and any treatment that has been used to date.
The primary goal of an orthosis in treating a scoliotic defor­
mity is to control remaining spinal growth so that the spine
reaches maturity with an acceptable curvature. There is no
role for using an orthosis to prevent scoliosis and the abil­
ity of an orthosis to make a curvature ultimately smaller is
limited.100–102 Scoliosis progresses as the spine grows, so an
adolescent at the end of spinal growth has very little risk of
progression, and there is no role for bracing a curve that has
already reached a size where surgery is indicated.103 Therefore
it is critical to identify children with scoliosis at the early
stages. A national screening program has been adopted in
many countries for this purpose.
Physical examination and radiographs are used to mea­
sure the size, flexibility, and effects of each spinal curvature.
The Scoliosis Research Society has adopted a set of terms and
definitions to describe scoliosis as well as to describe the mul­
titude of spinal conditions that can lead to scoliosis. Curves
can be described either by etiology of the structural changes
(Box 13-2) or by the spinal level of the anatomical apex of
the curve. In a cervical scoliosis, the apex of the curve is at
or between the vertebral body of C1 and C6. In a cervicotho­
racic curve, the apex is at C7, C8, or T1. A thoracic curve has
an apex at or between T2 and T11. A thoracolumbar curve
reaches its apex at the T12 or L1 vertebral body. A lumbar
curve occurs at L2, L3, or L4, whereas a lumbosacral curve
reaches its apex at L5 or S1. Numerous descriptive terms are
also used in the diagnosis, evaluation, and management of
scoliosis (Table  13-2). These standards and definitions are
used throughout this chapter.
Scoliosis can also be described by etiology. A child or ado­
lescent who develops scoliosis after relatively typical growth
and development is diagnosed as having idiopathic scoliosis.
An individual who develops scoliosis as a secondary com­
plication of nervous system or muscle disease is described
as having neuromuscular scoliosis. Clinical examination
includes an assessment of the patient's posture, noting any
asymmetry in trunk alignment, shoulder height, scapular
prominence, and pelvic rotation. Special attention is paid to
the degree of thoracic kyphosis and lumbar lordosis, and any
tendency toward trunk shift to the right or left (spinal decom­
pensation) (Figure 13-10). The Adams forward bending test
assesses the rotation of each curve by the degree of promi­
nence over the apices, and the patient can be flexed laterally
while bent forward to assess the degree of curve flexibility
(Figure  13-11). Complete neurological, skin, and cardiac
examinations are then performed.
The timing of orthotic treatment is an important deter­
minant of efficacy. Principles have remained the same
regardless of the orthosis used. First, treatment should

Chapter 13  Orthoses for Spinal Dysfunction
383
IDIOPATHIC
Infantile (0-3 years)
Resolving
Progressive
Juvenile (3-10 years)
Adolescent (older than 10 years) Neuropathic
NEUROMUSCULAR
Upper motor neuron
Cerebral palsy
Spinocerebellar degeneration
Friedreich's ataxia
Charcot-Marie-Tooth disease
Roussy-Lévy disease
Syringomyelia
Spinal cord tumor
Spinal cord trauma
Other
Lower motor neuron
Poliomyelitis
Other viral myelitides
Trauma
Spinal muscular atrophy
Werdnig-Hoffmann disease
Kugelberg-Welander disease
Myelomeningocele (paralytic)
Dysautonomia (Riley-Day syndrome)
Other
Myopathic
Arthrogryposis
Muscular dystrophy
Duchenne's (pseudohypertrophy)
Limb-girdle
Fiber-type disproportion
Congenital hypotonia
Myotonic dystrophica
Other
BOX 13-2  Classification System for Idiopathic and Neuromuscular Structural Scoliosis
TABLE 13-2  Glossary and Definitions of Terms in Scoliosis
Term
Definition
Adolescent scoliosis
Spinal curvature presenting at or about the onset of puberty and before maturity
Adult scoliosis
Spinal curvature that develops after skeletal maturity
Angle of thoracic
The angle between the horizontal plane and inclination plane across the posterior rib cage at the greatest
prominence of a rib hump, assessed with the trunk flexed 90 degrees at the hips
Apical vertebra
The most rotated vertebra in a curve; the most deviated vertebra from the vertical axis of the patient
Body alignment
1. Alignment of the midpoint of the occiput over the sacrum in the same vertical plane as the shoulders over
the hips
2. In radiography, when the sum of the angular deviations of the spine in one direction is equal to that in the
opposite direction (also described as balance or compensation)
Café au lait spots
Light-brown, irregular areas of skin pigmentation; if they are sufficient in number and have smooth margins,
they suggest neurofibromatosis
Cobb angle or method
On radiograph, the uppermost and lowermost vertebrae in the curve are identified; a perpendicular line
(curve measurement) is drawn from the transverse axes of these vertebrae, and the angle formed at their
intersection (Cobb angle) measures the severity of the curve; if vertebral end plates are poorly visualized,
a line through the bottom or top of the pedicles can be used
Compensatory curve
A curve, which can be structural, above or below the major curve that tends to maintain normal body alignment
Congenital scoliosis
Scoliosis due to congenitally anomalous vertebral development
Double major scoliosis
Scoliosis with two structural curves
Double thoracic curves
Two structural curves within the thoracic spine
End vertebra
1. Uppermost vertebra of a curve, the superior surface of which tilts maximally toward the concavity
of the curve
2. The most caudal vertebra, the inferior surface of which tilts maximally toward the concavity of the curve
Fractional curve
Compensatory curve that is incomplete because it returns to the erect; its only horizontal vertebra is its
caudad or cephalad one
Full curve
Curve in which the only horizontal vertebra is at the apex
(Continued)

384
Section II  Orthoses in Rehabilitation
be initiated before skeletal maturity when there is growth
remaining because bracing is only effective in a growing
child; curves less than 20 degrees are generally observed,
but once a curve is greater than 20 degrees and/or demon­
strates significant progression bracing is initiated. Second,
the brace should be worn full time, which was defined
by Blount104 as 23 hours per day and recently confirmed
by metaanalysis of available studies.105 Third, the brace
should be worn until skeletal maturity. Lastly, there should
be a weaning period accompanied by a rehabilitation pro­
gram to rebuild muscle strength once skeletal maturity is
reached.
Term
Definition
Gibbus
Sharply angular kyphos
Hyperkyphosis
Sagittal alignment of the thoracic spine in which more than the normal amount of kyphosis is present (a kyphos)
Hypokyphosis
Sagittal alignment of the thoracic spine in which less than the normal amount of kyphosis is present but
not so severe as to be lordotic
Hysterical scoliosis
Nonstructural deformity of the spine that develops as a manifestation of a conversion reaction
Idiopathic scoliosis
Structural spinal curvature for which no cause is established
Iliac epiphysis or apophysis
Epiphysis along the wing of an ilium
Inclinometer
Instrument used to measure the angle of thoracic inclination or rib hump
Infantile scoliosis
Spinal curvature that develops during the first 3 years of life
Juvenile scoliosis
Spinal curvature that develops between the skeletal age of 3 years and the onset of puberty (10 years)
Kyphos
Change in alignment of a segment of the spine in the sagittal plane that increases the posterior convex
angulation; an abnormally increased kyphosis
Kyphoscoliosis
Spine with scoliosis and a true hyperkyphosis; a rotatory deformity with only apparent kyphosis should
not be described by this term
Kyphosing scoliosis
Scoliosis with marked rotation such that lateral bending of the rotated spine mimics kyphosis
Lordoscoliosis
Scoliosis associated with an abnormal anterior angulation in the sagittal plane
Major curve
Term used to designate the largest structural curve
Minor curve
Term used to refer to the smallest curve, which is always more flexible than the major curve
Nonstructural curve
Curve that has no structural component and that corrects or overcorrects on recumbent side-bending radiographs
Pelvic obliquity
Deviation of the pelvis from the horizontal in the frontal plane; fixed pelvic obliquities can be attributable
to contractures either above or below the pelvis
Primary curve
First or earliest of several curves to appear, if identifiable
Risser sign
Rating system used to indicate skeletal maturity, based on degree of ossification of the iliac epiphysis
Rotational prominence
In the forward-bending position, the thoracic prominence on one side is usually due to vertebral rotation,
causing rib prominence; in the lumbar spine, the prominence is usually due to rotation of the lumbar vertebrae
Skeletal age (bone age)
Age obtained by comparing an anteroposterior radiograph of the left hand and wrist with the standards
of Greulich and Pyle's atlas
Structural curve
Segment of the spine with a lateral curvature that lacks normal flexibility; radiographically, it is identified by
the complete lack of a curve on a supine film or by the failure to demonstrate complete segmental mobility
on supine side-bending films
Vertebral end plates
Superior and inferior plates of cortical bone of the vertebral body adjacent to the intervertebral disc
Vertebral growth plate
Cartilaginous surface covering the top and bottom of a vertebral body, which is responsible for linear
growth of the vertebra
Vertebral ring apophyses
Most reliable index of vertebral immaturity, seen best in lateral radiographs or in the lumbar region in
side-bending anteroposterior views
TABLE 13-2  Glossary and Definitions of Terms in Scoliosis—cont'd

Chapter 13  Orthoses for Spinal Dysfunction
385
Types of Braces
Milwaukee Brace
In 1944 the Milwaukee brace was developed by Blount and
Schmidt. The Milwaukee brace, a cervicothoracolumbosacral
orthosis (CTLSO), was initially employed as a postoperative
modality but soon found a more important role. Since 1954
it has been used in the nonoperative treatment of idiopathic
scoliosis.106 The brace consists of a pelvic section, which helps
reduce lumbar lordosis, and an attached “superstructure.” The
superstructure consists of three metal uprights that are attached
to a neck ring superiorly. It provides an end point of control to
make the spine structurally more rigid, better aligned, and pro­
vide a means of attachment for the spinal pads (Figure 13-12).
This style is considered a full-time brace and should be worn
23 hours each day. The initial design incorporated distraction;
however, this has since been modified due to problems with
malocclusion of the jaw. Subsequent to the Milwaukee brace,
various low-profile TLSOs have been introduced. Most of
these spinal orthoses are named for the city in which they were
developed (e.g., Boston brace, Miami orthosis, Wilmington
brace, Lyon brace). These spinal orthoses share one character­
istic: All control the alignment of the thoracolumbosacral spine
but have no superstructure. The Milwaukee brace is mentioned
here primarily for historical significance. It remains the most
effective brace for upper thoracic curves but requires a dedi­
cated patient and family for compliance.
Boston Thoracolumbosacral Orthosis
In 1972, Hall created a more low-profile, modular TLSO
known as the Boston brace in response to patient concerns
about the bulkiness and neck ring of the Milwaukee brace.107
Watts and Hall108 reported on the Boston brace in 1977. The
Boston is a rigid underarm TLSO that has become the most
prevalent form of orthosis used, with various modifications.
The original Boston brace consisted of multiple modules that
were fabricated in different sizes and could be combined to
provide a custom-fitted brace that did not require as much
time or expertise on the part of the orthotist.107 Several stud­
ies have demonstrated equivalent results with the use of
the Boston brace or its related products compared with the
Milwaukee brace, with the possible exception of use for high
thoracic curves.98,99,109–111 Boston braces are popular due to
their low-profile and partially open design, which is comfort­
able and well-tolerated.
FIGURE 13-10  Trunk shift.
FIGURE 13-11  Adams forward bend test.

386
Section II  Orthoses in Rehabilitation
Charleston Nighttime Brace
The Charleston Nighttime brace was created in 1979 by Reed
and Hooper.107 This orthosis is manufactured so that curve is
maximally corrected while the patient sleeps; the correction
is so significant that an upright position is not comfortable.112
Price and colleagues112 reported on the prevention of progres­
sion of curvature in 66% of patients with curves less than 49
degrees and significant growth remaining. One compara­
tive study between the Boston and the Charleston orthoses
showed the Boston orthosis to be more effective in all curve
patterns but the Charleston orthosis to have equal efficacy in
25- to 35-degree single thoracolumbar or lumbar curves.113
The theoretical advantages to the Charleston orthosis in
terms of body image and socialization issues are intuitive, but
have not been shown in rigorous studies; likewise, compli­
ance problems are similar to those of other braces.
SpineCor
Traditionally, corrective spinal orthoses used in the treatment
of adolescent and juvenile scoliosis have been rigid or semi­
rigid devices. Rigid orthoses have been shown to be effective for
some patients with adolescent idiopathic scoliosis (AIS) but are
associated with drawbacks related to cosmesis and physical dis­
comfort, which create a barrier to adequate patient compliance.
In the early 1990s, Coillard and Rivard developed the SpineCor
brace. The SpineCor brace is a dynamic bracing system that
uses nonrigid, harness-like bands to apply corrective forces to
the patient's torso. The components of the brace include a pel­
vic base, two thigh bands, two crotch bands, a cotton bolero,
and four corrective elastic bands that may be arranged in a
number of different configurations, depending on the specific
deformity being treated. The pelvic base is a belt that includes
three pieces of soft thermoplastic material. Fitting patients with
the brace is done in a systematic fashion using supplementary
computer software and a training course is offered to providers
for education on proper fitting technique.
Coillard and Rivard, the developers of the SpineCor brace,
published the initial clinical results in 2003.114 They reported
on the treatment results of 195 patients between 6 and 14 years
of age with idiopathic scoliosis curves between 15 and 50
degrees and Risser stages 0 to 3. Success in their study was
defined as either a correction or stabilization of ± 5 degrees or
more. Failure was defined as worsening of the curve by more
than 5 degrees. The authors found that, at 2 years of follow-
up, there was an overall correction of greater than 5 degrees in
55% of patients, curve stabilization in 38%, and worsening by
greater than 5 degrees in 7% of patients. This equates to 93%
success at 2 years. At 4 years of follow-up, the probability of suc­
cess was 0.88 to 0.92. Coillard and Rivard published results of
the same prospective cohort again in 2007 using the Scoliosis
Research Society scoliosis research inclusion criteria.115 One-
hundred-seventy patients were included in the study. The
authors reported that successful treatment was achieved in
59.4% of patients at the time of brace discontinuation with
22.9% requiring fusion during the treatment period and 1.2%
of patients with curves exceeding 45 degrees at maturity. These
initial results reported by the developers of the SpineCor brace
were promising; however, further study by independent inves­
tigators have yielded some conflicting results.
Weiss and Weiss116 published the results of a small study
which compared treatment with a SpineCor brace with TLSO
bracing. The authors compared 12 SpineCor patients with 15
TLSO patients and found that the SpineCor patients, with a
starting Cobb angle of 21 degrees, progressed an average of 10
degrees after 21 months of treatment versus 0.2 degrees in the
TLSO patients who had a starting Cobb angle of 33 degrees.
Wong and colleagues117 compared 22 SpineCor patients with
21 TLSO patients and demonstrated that only 68% of SpineCor
patients maintained curve progression of less than or equal to
5 degrees compared with 95% of TLSO patients. Gammon and
colleagues118 compared 35 patients treated with a TLSO with
32 patients treated with the SpineCor brace and found no sig­
nificant differences between the two outcomes with respect to
progression of less than or equal to 5 degrees (60% in TLSO
and 53% in SpineCor) or success in avoiding curve progres­
sion past 45 degrees (80% in TLSO and 72% in SpineCor).
An important aspect of any brace is the degree of phys­
ical comfort and cosmetic considerations. As is true with
the literature regarding the efficacy of the SpineCor brace
versus TLSO bracing, the literature addressing the impact
of the SpineCor brace on comfort and cosmesis is scant. In
their 2008 study comparing the SpineCor brace with TLSO
FIGURE 13-12  Milwaukee brace.

Chapter 13  Orthoses for Spinal Dysfunction
387
bracing, Wong and colleagues117 administered a questionnaire
at 3, 9, and 18 months of treatment to gain information about
patient acceptance of her brace. The only significant dif­
ferences noted were problems with toileting (greater in the
SpineCor group) and donning/doffing the orthosis (greater
in the TLSO group).
ORTHOTIC PRESCRIPTION
An orthosis should initially improve the magnitude of
the curve.119 An orthosis that provides some correction
theoretically decreases the load on the developing verte­
brae, increasing the likelihood of long-term control of the
deformity.120 Over time the orthosis should be ­capable of
­preventing curve ­progression for long periods, frequently
until the patient reaches skeletal maturity. Finally, an
orthosis should be designed to be well tolerated and allow
normal social and physical development; even then, com­
pliance with brace wear is a significant issue for adoles­
cents.121–124 The effectiveness of an orthosis has been shown
to be directly related to time spent in the brace, so the
patient's willingness to wear the brace is of utmost impor­
tance.105,113,125–127 “Smart braces” that measure compliance
have demonstrated that even the most apparently compli­
ant patient spends much less time in the brace than actu­
ally prescribed.122,124,128–131
The prescribing physician should specify the particular
requirements for the orthosis based on the deformity, the
goals of treatment, and his or her assessment of the likelihood
for compliance. The exact type of brace, generally CTLSO or
TLSO, with specifications of thoracic pad placement, lum­
bar pad placement, need for axillary slings, anterior gussets,
trochanteric extensions, kyphosis pads, and the like depends
on the type of deformity being treated. Each pad requires a
specified location, medial-lateral orientation, and placement
instructions. The choice between a CTLSO and TLSO is dic­
tated by the location of the curve, with high thoracic curves
most effectively treated by the former. A TLSO has a much
lower profile and is therefore more socially acceptable. The
orthosis may be prefabricated and adjusted to fit, or custom
molded for patients who require additional adaptability.
The time in the orthosis is slowly increased over several
weeks and then assessed both physically and radiographically
by the prescribing physician. Specific pressure point relief
and corrective pad adjustments may be required periodically
because these patients are in a period of rapid spinal growth.
For the youngest patients, multiple braces may be required
before growth concludes.
Complications
Complications with scoliosis orthoses are generally mild from
a physical standpoint. Compression of abdominal viscera
can result in increased intragastric pressure, leading to gas­
troesophageal reflux and, potentially, esophagitis.132 Mild to
moderate decreases in kidney function and lung volumes have
been described, but neither has been found to have significant
long-term consequences.133,134 Brace treatment in adolescence
has been found to produce psychological disturbances that are
measurable into adult life.135,136 Finally, the successful use of
bracing requires a supportive, constructive family and a simi­
lar relationship between the physician and the adolescent.
Future Directions
The key to scoliosis treatment is to identify which children are
likely to develop curve progression, avoiding treating those
with curves that will remain in the 25- to 35-degree range
through their growth and therefore not require any interven­
tion. Epidemiological studies and skeletal maturity indicators
have traditionally been used for this purpose and continue to
be refined.89,103,137–139 Recently, genes that control the growth
of scoliotic curves have been identified.140–143 With this new
information in combination with traditional methods, it may
become possible to predict which children will develop sig­
nificant curves with a high degree of certainty. Surgical treat­
ments that harness asymmetrical growth in the spine are also
becoming available.144–152 This combination of techniques
may allow intervention before bracing becomes necessary.
SUMMARY
Spinal orthoses are used to treat patients with a variety of spinal
disorders ranging from low back pain to complex spine trauma
and deformity. Selection of the appropriate orthosis for a spe­
cific patient is based on many factors such as the indication for
bracing and its severity, the age and body habitus of the patient,
the willingness and ability to commit to a potentially long and
difficult treatment course, and weighing the risks and benefits
of orthotic treatment against other treatment modalities. These
challenging treatment decisions are best managed by a multidis­
ciplinary team comprised of the treating physician, the ortho­
tist, the physical and occupational therapists, and the patient
and his or her personal support network. Frequent follow-up
and close communication between all members of the treat­
ment team is essential to ensure thorough patient and family
education,to ensure adequate fit of the orthosis, to evaluate for
treatment efficacy, to monitor for complications, and to provide
psychosocial support to the patient. Adequately addressing all
of the issues surrounding orthotic treatment of spinal disease
requires a thorough understanding of the natural history of the
pathology being treated, the indications for bracing and use of
specific braces, the mechanism of action of the orthosis, poten­
tial outcomes of the treatment, and potential complications
and methods to minimize them. Comparative studies, long-
term outcome analysis, and biomechanical studies have helped
promote understanding of and appropriate and effective use
of spinal orthoses. Despite the large body of knowledge about
these topics, there are still many unknowns surrounding spinal
orthoses and their role in treating disorders of the spine. This
chapter provides a brief overview of basic functional anatomy
of the spine, the fundamentals of spine trauma and scoliosis,
the various types of braces and their mechanisms of action and
indications, and the potential complications. The ability to use
spinal orthoses safely and effectively requires a comprehensive
understanding of these topics.

388
Section II  Orthoses in Rehabilitation
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