Practical Considerations In The Fitting, Use And Care Of Corrective And Supportive Braces
Albert E. Corfman, Jr. *
Orthopedics is defined as all work pertaining or related to the prevention or correction of physical deformities. Or, as a noted anthropologist explains it, "The specialty known as Orthopedics deals, in some degree, with bodily difficulties due to man's imperfect adaptation to an erect posture and to a biped mode of progression."
It might be well to explain the bracemaker's part in orthopedics. A bracemaker who has completed his training and has successfully passed his examinations becomes a Certified Orthotist. He then is a member of the team of physician, physiotherapist, and orthotist who work together for the betterment of the handicapped patient. The physician is directly responsible for all decisions and treatment. The orthotist, in turn, is responsible to the physician and must, accordingly, follow his directions explicitly as to bracing the patient.
There can be no over-all specifications for braces. Each case is unique and must be treated as such. Braces are made for each individual patient to accomplish exact requirements. A brace which does not fit or accomplish precisely what the doctor prescribes can frequently hinder a patient's progress rather than help him.
The bracemaker must make the patient's appliance perform the functions for which it is intended. The brace must be fit carefully as to contour, alignment and location of mechanical parts corresponding to anatomical land marks and joints. The brace should be strong, yet light as possible, neat in appearance and easy to manage. Particular care should be extended by the bracemaker to familiarize the patient with the proper manner in which the brace should be worn for best results as well as proper care and maintenance.
Braces are generally classified as either supportive or corrective-supportive in the case of fractures and weaknesses which require additional strength, and corrective when a deformity either exists or appears likely to occur. A brace alone can not correct a fixed deformity, especially in an older patient. However, proper bracing can frequently arrest an old deformity and prevent it from progressing. Young patients can usually tolerate correction more readily and early bracing can sometimes eliminate subsequent surgery. On many occa sions, corrective surgery followed by bracing has proven satisfactory.
Supportive bracing for leg fractures is generally effective. A light cast is usually made over the patient's leg covering the fracture area where support (
Fig. 1a
) is required. The cast is then removed from the patient, filled with plaster and allowed to harden. Then the outer, or original, cast is removed leaving a positive model of the leg. Leather is soaked and molded over the cast and allowed to dry giving a legging, or cuff (
Fig. 1b
), which corresponds perfectly to the patient's leg. This legging is attached in position on the brace (
Fig. 1c
) and secured to the patient with lacing. The brace can be made to extend well up under the ischial tuberosity so that in standing or walking less pressure is exerted downward through the leg thus further helping to protect the fracture. The knee joints can be equipped with locks which will hold the leg rigid while bearing weight, and can be released to allow the patient to flex his knee in sitting. The locks can be removed when the patient has recovered sufficiently to walk with normal motion of his knee. Provisions can be made at the ankle joint to allow as much, or as little, ankle motion as indicated.
In some instances where extremely tight hamstrings result from long confinement in a cast carried in knee flexion, the patient is sometimes unable to straighten his knee despite treatments of heat and massage. An attachment can be added to the leg brace just under the knee consisting of serrated discs (
Fig. 2
) which fit closely together and are secured with screws. The screws can be loosened from time to time and the discs rotated slightly to progressively straighten the knee as the hamstrings relax.
Leg braces are constructed of steel or aluminum. Steel is heavy but affords strength and durability. Aluminum has the advantage of being light but is somewhat weaker and is more subject to wear. The material selected for a brace depends on the weight of the patient and the type of work in which he is engaged. A big man performing heavy work will exert tremendous strain on a brace. A strong steel brace heavily banded with double locks might be indicated. On the other hand, a slight patient who will be seated most of the time will be able to manage with a much lighter single lock brace. It is interesting to note that a brace equipped with locks on both knee joints, although sometimes somewhat more difficult to manipulate, affords much more stability than a single lock which subjects the brace to torsion or twist due to one knee joint being held rigid while the other attempts to function as a free joint.
Oftentimes corrections of various natures are needed. Leg braces can be made with spring type ankle joints to counteract toe drop conditions due to tight heel cords. This type of ankle joint will give the patient normal ankle motion, yet prevent him from dragging his toes and scuffing his shoes. The stretching action working on the tight heel cord is also beneficial. Sometimes the doctor will prescribe a brace of the adjustable "toe up" type to be worn at night which is used in conjunction with the walking brace to consolidate gains made on the heel cord through the day.
Shoe wedges and ankle straps sewn to the shoes are attached to prevent ankles from turning inward and outward. It should be noted that when wedges are employed, they should be attached between the stirrup and the shoe rather than on the base of the shoe heel as it is desired to tilt only the foot and not the complete brace. Shoe buildups and extensions are required when one leg is shorter than the other and there is no hope of equalizing the length of the legs.
Knock knee, bow leg, flexed and hyperextended knees are controlled with braces equipped with pull straps and pads which oppose the deformities. Internal or external rotations of the leg through the hip joint are corrected with the addition of a pelvic band joined to the leg brace with a hip joint either free or the lock type as prescribed. The pelvic band lends additional stability and enables the leg to be held in proper position. Another simple arrangement to oppose leg rotation is the so called "twister" which consists of elastic webbing which is sewn to the forepart of the shoe, then spiraled either clockwise or counter-clockwise as the correction requires, around the leg and joined to a light webbing pelvic belt. The "twister" is particularly effective with children's leg rotations which can be held with mild correction.
Tibial torsion, evidenced by a rotation of the knee inward with the foot turned inside the normal line of progression, is corrected by offsetting the ankle joints of the leg brace with the inside joint carried forward in relation to the outside joint and aligned with as much outer rotation (
Fig. 3
) as necessary to bring the knee back into normal position and remedy the twist in the tibia.
When man assumed the erect posture he took a lot upon himself and put an awful strain on his back. Because of man's massive super structure, a tremendous burden is placed on the thin line or vertebrae relied on for support when he stands or walks. Then, when muscle weakness, softening of the spine, or constant poor posture prevail, man's already overworked spine becomes even more vulnerable to trouble.
A normal person's back, from hips to head, consists of three gentle basic curves (
Fig. 4a
) which compensate for each other and are needed for balance. These are the lumbar curve forward, the dorsal curve backward, and the cervical curve forward. The keystone, or most important area of the back is the lumbo-sacral angle or the angle at which the sacrum and pelvis is related to the lumbar spine. This angle is important because of the effects it has on the spine above. For example, if the pelvis is tilted forward due to tight hip flexors, an exaggerated curve in the lumbar region is required for balance. Acute spinal curves can cause discomfort and possible injuries such as pinching of nerves, displacement of discs, and actual wear on the edges of the vertebrae.
Corrective types of backbraces (
Fig. 4b
) are designed to oppose spinal deformities such as lordosis (commonly recognized as extreme sway back), kyphosis (
Fig. 4c
) (humpback), and scoliosis (
Fig. 4d
) (lateral curvature of the spine resulting in a pelvic tilt which causes the illusion of one leg being shorter than the other).
In most cases of corrective back bracing, a three point principle is in effect. It is necessary to direct pressure above and below the curvature or deviation, while a counter pressure is exerted in the opposite direction between the first two. As an example, in the lordosis deformity, pressure is directed with a pelvic band against the sacro-lumbar area and with a dorsal band across the lower thoracic region while a corset front presses against the abdomen (
Fig. 5
) tending to straighten the forward lumbar curvature.
Lateral deformities of the spine are also corrected with the three point principle (
Fig. 6
) or by vertical traction coupled with lateral pressure exerted against the curvature. In this type of bracing the hips are held securely and traction is applied either under the arms or to the occipital region of the head and under the chin. An adjustable pressure pad or pull strap arrangement is used to supplement the traction and to oppose the lateral deformity.
Supportive back braces are used in fractures, compressed vertebrae, disc displacements and spinal fusions. There are any number of different backbraces, but the two most frequently used are the Taylor and the Knight or "chairback" brace. The "chairback" brace (
Fig. 7
) used for low back conditions is usually about 10 inches to 12 inches long and consists of a pelvic band, two back bars, two side bars and a dorsal band making the appearance of the brace somewhat similar to the back of a chair. It is held in position with a corset front.
The Taylor (
Fig. 8
) brace supports the thoracic or dorsal spine as well as the lumbar and consists of a pelvic band and two long uprights on either side of the spine extending well up to the shoulders. It is held in position with an apron front and shoulder straps.
Back braces sometimes have a tendency to work up higher on the back than is good for either support or comfort. If this happens, peroneal straps may be added to hold the brace down securely in the proper position.
The metal framework of these braces is usually of aluminum which keeps the weight of the brace to a minimum and still affords sufficient strength. The inside of the brace is covered with felt padding and horsehide. and the outside with elk or calf hide which makes the appearance of the brace neater and protects clothing from metal wear against the back of chairs. The fronts, or aprons of braces are made of various types of corset material or merely canvas.
Back support can also be attained with orthopedic corsets and belts such as sacro-iliac belts, lumbo-sacral and lumbo dorsal corsets depending upon how much support is required. These types of supports have ample take up for adjustment and are reinforced with bones or stays for rigidity.
Neck or cervical supports and braces are many and varied as to the purpose in mind. The simplest type of mild traction and support is the Schanz, or felt, collar, which is merely a wedge-shaped piece of thin white felt five to six feet in length, about five inches in width at one end tapering to two inches at the other.
This is wrapped around the neck starting with the narrow end and is held in place with straps.
Another simple type of neck support is the duck collar which is made of leather and lined with felt and goes around the neck supporting under the chin and the occipital area, and is strapped in position.
When active traction is desired, a turnbuckle arrangement mounted to chest, back, chin and occipital pieces (
Fig. 9
) is often used, called the Forrester collar. The proper amount of traction may he attained by lengthening the turn buckles. It should be kept in mind when applying neck supports that the chin should be carried fairly low with most of the pressure under the occipital area to give maximum traction. Forcing the chin too high actually compresses the cervical vertebrae rather than extending them.
Braces properly fitted and used intelligently, will protect weak muscles as they grow stronger, keep an arm or leg from growing out of shape, and enable the patient to perform all sorts of functions he could never manage without a brace. However, bracing is also expensive, so certain precautions in the way of brace care and maintenance should be observed so that additional expenses can be held to a minimum. It pays to give a brace the very best treatment and attention. Patients should, under no conditions, attempt adjustments to their braces themselves. However, there are many things they can do to keep their braces in good working order.
There is a constant tax on brace joints and locks. Besides the wear and tear of use, lint and dust have a way of gathering on braces, especially in the moving parts, and causing damage by clogging. Keeping a brace free from dirt is all important.
The oil can is the leg brace wearer's best friend. A drop or two of oil on the joints periodically will keep them working smoothly and freely without annoying squeaks and rusting. Excess oil should always be wiped off to prevent soiling of clothing.
Children's leg braces are usually of the extension type so that the brace may be lengthened from time to time to keep pace with the child's growth. It is important to keep all screws tight at all times to prevent weakening of the brace. It is a good idea to have on hand screws of the right size in the event any become worn or lost. Some patients have found keeping a small kit of essential parts and tools handy is good insurance. Ordinarily, however, a few extra screws, a screw driver, shoe laces and some foam rubber to insert in pressure areas which might develop, will see them through emergencies until they can contact their brace man.
Shoes worn on braces must be watched carefully. Heels sometimes are allowed to wear down so that the metal framework touches the ground. Even a slight wearing of the heel may alter the position of the brace and throw knee and hip out of line. If soles and heels are wedged or elevated, they should be kept exactly as prescribed, otherwise the corrective measures will be lost.
The leatherwork on a brace is most apt to deteriorate quickly. Perspiration and moisture are hard on leather. Saddle soap used as directed is the standard treatment. Dry cleaning agents are to be avoided as they tend to dry and crack leather and may prove harmful to the patient. Coating inside leather with liquid nylon or other non-toxic leather preservatives will prolong the life of the leather.
If all visible leatherwork is cleaned and polished, and shoes kept shined and in good repair, the whole brace will make a better appearance and improve the patient's psychological outlook toward wearing his brace.
(Editor's Note: The illustrations are by
the author
.)
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