FUNCTIONAL CAST BRACEFUNCTIONAL CAST BRACE

INTRODUCTIONINTRODUCTION

A closed method of treating fractures based on the belief that continuing function while a fracture is uniting , encourages osteogenesis, promotes the healing of tissues and prevents the development of joint stiffness, thus accelerating rehabilitation

Not merely a technique but constitute a positive attitude towards fracture healing.

CONCEPTCONCEPT

The end to end bone contact is not required for bony union and that rigid immobilization of the fracture fragment and immobilization of the joints above and below a fracture as well as prolonged rest are detrimental to healing.

It accepts that the loss of the anatomical reduction of a fracture is a small price to pay for rapid healing and the restoration of function, without compromising the appearance of the limb by operative scars.

It complements rather than replaces other forms of treatment.

HISTORYHISTORY

1855 – H.H.Smith designed appliance for nonunion proximal femoral fractures.

1910 – Lucas Championniere “ LIFE IS MOTION”.

1926 – Gurd [ # of foot and ankle].1950s – Dehne [# tibia].1963 – Sarmiento began his systemic

study,

THEORETICAL BASISTHEORETICAL BASIS

Elimination of movt at a fracture site is not mandatory for a fracture to unite,

STABILITY – needed1. Reduce the pain2. Maintain alignment3. Prevent deformity.

External bridging callus: situated at distance from the axis of potential movt, it has a greater mechanical advantage than medullary callus, stronger early repair.

Optimal physiological Optimal physiological environmentenvironment

Function in brace provides a milieu wherein metabolic, mechanical, chemical, thermal and electrical factors favorably enhance tissue healing.

Intermittent loading strain in the tissues electrical potentials for bone formation.

Muscle activity increase in circulation supply of nutrient & clearance of waste maintains chemical milieu.

Irritating effect of motion at the # site & deviatoric stains in the surrounding & interposing tissue prolongs the inflammatory response of s.s hyperemia increase in temperature.

M.E streaming potentials through capillary gradients & strain related potentials through tissue deformation enhancement of E.E.

E.E affects chemical reaction in the S.S and has an effect on the rate, quantity and orientation of tissues formation in callus.

Trauma

LimbFunction

Fracture Motion

Vascular Invasion

Thermal Environment Mechanical

Chemical Environment

Electrical EnvironmentTissue

Healing

Interaction of environmental factors

Role of soft tissuesRole of soft tissues

Early stages soft tissues transmit most of the load.

Muscle compartment act as fluid mass surrounded by an elastic container – deep fascia.

Fluids are not compressible and fascia can’t be stretched beyond confines of the cast – HYDRAULIC FORCES.

After initial displacement, pressure and load are transmitted without further deformation.

Muscle contract bulge normally.In FCB muscles are forced inwards

away from the rigid walls and against the central fragments thus causing the fragments to held more firmly.

Hydraulic forces of the soft tissues resist the overlap and angulation until callus forms.

Rotation is resisted by components of the brace and or by tendency of muscle contraction and Jt movt to align the fragments.

SHORTENINGSHORTENING

Braces do not prevent shortening.It is determined at the time of injury by

degree of soft tissue damage.Shortening in closed # does not increase

beyond that that which develops immediately following initial injury.

Movts are elastic no progressive deformity.Control related to fit of brace and extent of

damage

LOAD BEARINGLOAD BEARING

S.T. two major mechanisms for load bearing and provision of stiffness to the limb when encompassed in FCB.

I related to their incompressibility.[ displace under load only until they have filed all the gaps with in the container] important in early post injury period.

II intrinsic strength S.T in tension as they support the bony fragments at their natural attachments.

INDICATIONINDICATION

All middle third shaft fractures and middle 3 rd and lower 3 rd junction fractures in long bones in co-operative patients.

CONTRA-INDICATIONCONTRA-INDICATION

Lack of co-operation by the pt.Bed-ridden & mentally incompetent pts.Deficient sensibility of the limb [D.M with

P.N]When the brace cannot fitted closely and

accurately.Fractures of both bones forearm when

reduction is difficult.Intraarticular fractures.

Galeazzi fracturesMonteggia fracturesProximal half of shaft of femur [tends to

angulate in to varus only used by expert]Isolated # of tibia, fibula tends to cause

varus angulation and to delay in consolidation of #. [ Proximal 1/3]

Time to applyTime to apply

Not at the time of injury. Regular casts, time to correct any

angular or rotational deformity. Compound # es , application to be

delayed. Assess the # , when pain and swelling

subsided1. Minor movts at # site should be pain free2. Any deformity should disappear once D.F

removed

3. Reasonable resistance to telescoping.4. Shortening should not exceed 6.0 mm for

tibia, 1.25 cm for femur.

For # tibia following low energy injury, bracing can be done with in first 2 wks.

High energy injuries with more pain & swelling needs an additional period of 1 or 2 more wks.

For humerus # es , most conditions bracing can be done by 7-10 days time.

Median time of brace removal tibia 18.7 wks, humerus 10 wks.

OPEN FRACTURESOPEN FRACTURES

Does not preclude FCB.Greater degree of soft tissue damage

increased instability of limb needs delay in using FCB.

High degree of soft tissue damage & shortening may require external fixation for sometime before FCB.

RESULTSRESULTS

Shortening encountered in closed tibia fracture rarely exceeds 1 cm. [won’t cause limp].

Angular deformities usually < 5*. Cosmetically and functionally acceptable

for most pts. OA changes doesn’t occur from deformities of such magnititude.

Types of limb segmentsTypes of limb segments

Limb segments with two bones and interosseous membrane surrounded by muscular tissues with lesser amount of fat in sub-cut region.

One limb segment with bulky muscle layer with relatively large sub-cut fat.

First type is inherently stable ,well controlled with FCB.

One bone seg, relatively unstable because of sub cut fat provides lubrication.