Orthosis is the modern word for what used to be called braces or splints.

An orthosis is

a device that is used to protect, support, or improve function of a joint or body

segment. This is achieved by the design and fit of the orthosis.

The term is derived from the "ortho", meaning to straighten. Sciences such as materials

engineering, gait analysis, anatomy and physiology, and psychology contribute to the

work done by orthotists, professionals engaged in the field of orthotics. Individuals who

benefit from a complex orthosis may have an orthopedic condition such as scoliosis or a

fracture or have sustained a physical impairment from a stroke or spinal cord injury, or a

congenital abnormality such as spina bifida or cerebral palsy.

Simpler foot orthoses allow the muscles, tendons and bones of the feet and lower legs to

function at their highest potential. When appropriately prescribed, these orthoses can

decrease pain and increase stability in an unstable joint, along with preventing potential

progression or development of a deformity. Improved quality of life often results from

the application of the principles of orthotics.

Orthotics are medical devices used to support and align the foot while also correcting

foot deformities. Orthotics provide cushion for impact on hard surfaces and relieve the

pressure by providing support behind a problem area such as a callous, bunion or wart. In

addition, orthotics provide support in cases of flatfoot or over-pronation. The three basic

types of orthotics include:

• Soft: Used for temporary cushioning and padding.

 • Semi-flexible: Athletes prefer these because they are permanent; they are more

giving than rigid orthotics and less prone to blisters.

• Rigid: Usually not tolerated by athletes. Most orthopaedic and sports medicine

doctors say athletes should avoid wearing rigid or hard orthotics because they are

unforgiving and may contribute to foot problems.

Types of Orthotics:

• Over-the-counter: These are made from common materials such as silicon,

rubber, or polyethylene. They include felt pads, metatarsal pads, and heel wedges;

the differences are related to durability and cushioning abilities.

• Custom and molded: These are used in circumstances when over-the-counter

types don’t work. Chiropractors, sports medicine and orthopaedic practitioners

can custom-make them based on your specific foot problem.

Uses of Orthotics:

• Runners and joggers wear orthotics to help absorb the shock of impact when their

feet hit the ground while also helping the forefoot with pushoff.

• Sprinters use them to control the movement of their forefoot.

• Cyclists have a limited use for them, and mostly use them to control the internal

and external rotation of the leg.

• Skiers wear them for stabilization of their foot and inhibit motion within t he ski

boot.

• Tennis players use them for lateral support and to absorb shock.
 • Basketball players use them to control the forefoot before jumping and to control

the rear foot while running.

Limits of Orthotics:

• Not useful for all diagnoses;

• Watch out for categorized orthotics that label the patient and take away their

choice;

• Don’t wear hard, rigid orthotics because they can be unforgiving to the feet and

lead to foot problems, such as stress fractures and increased energy consumption

in athletes; and

• The proper shoe selection and fit may eliminate the need altogether for orthotic

devices.

Types of Orthotics

In general, foot care specialists group orthotics into the following categories:

• Functional orthotics are designed to support abnormal foot biomechanics. These

devices, which often are made of supportive plastic polymer materials, prevent

abnormal foot pronation (flattening of the arch) and reduce the impact load from

the ground (shock absorption) while walking or running. Functional orthotics

allow the foot to become a mobile adapter and a rigid lever. They support the rear

foot or subtaylor joints, as well as the midfoot or midtarsal joints. This support

stabilizes the foot and can help prevent repetitive overuse injuries. Functional

orthotics are used to correct many foot deformities.

 • Accommodative orthotics typically feature a soft supportive device that is

designed to relieve mild foot pain and correct minor foot problems. These devices

often are used to correct biomechanical walking problems in young children.

Accommodative orthotics include include splints, gait plates, and night bars

(devices used to hold a child's feet and legs at a proper angle while sleeping) that

promote corrective adjustment for excessive toe-in or toe-out walking. Braces

may be used in infants to correct foot, leg, or hip abnormalities (e.g., metatarsus

adductus, internal or external hip rotation problems

How Does an Orthotic Work?

To explain how orthotics function, it is important to understand the mechanics of

walking. With each step, the vertical axis of the heel ideally should land slightly inverted

to the ground, with an inclination of only a few degrees toward the outside of the heel.

From there, the foot begins to pronate (flatten) and then comes off the ground at the toes

(resuppinates). So, during each step, weight shifts from laterally to medially and back to

laterally. A properly designed orthotic controls how the foot strikes the ground, absorbs

shock, and reduces stress in the foot.

This coordinated motion is a complex process in which many things can go wrong. If a

structural problem is present, the foot can collapse under the body's weight. Over time,

stress on the feet can result in deformities. Running exerts much greater force on the feet

than walking and can lead to more severe injuries, such as sprained ankles, shin splints,

and fractures.
One of the foot's main functions is to absorb shock as the body's weight shifts with each

step. It does this through a complex process in which the arch of the foot flattens slightly.

This absorbs and distributes the weight throughout the entire foot. There are two major

problems that can occur in this mechanism.

The first problem occurs when the arch does not flatten at all. This typically occurs in a

person with a high arch, called a cavus foot. Because the arch does not flatten, it absorbs

shock poorly. Instead of spreading the weight throughout the entire foot, it falls only on

the heel and the base of the toes. This increases stress on the foot, especially the heel.

Furthermore, because the weight is not absorbed well in the foot, it radiates up the leg to

other joints. Over time, this can cause pain in the knees, hips, and lower back.

To correct this condition, an orthotic is used to adjust and even out the contact between

the foot and the ground. This allows the entire foot to support the weight of the body.

Also, extra cushioning can be built into the orthotic so that some of the force does not

reach the foot.

A different problem results when the arch flattens too much. This is known as a planus

or flatfoot. In this condition, the weight distribution on the foot is too far on the medial

side. A flatfoot is unstable and cannot maintain a proper arch. Over time, the weight of

the body on an unstable foot can cause the bones of the foot to become misaligned. This

can lead to the development bunions, hammertoes and other foot deformities, as well as

knee and low back pain.

To address this problem, an orthotic with an increased arch can be prescribed to distribute

the weight laterally. Depending on shape of the foot, the heel of the orthotic can be

slanted to shift the weight more toward the center of the heel.

How Is an Orthotic Made?

While orthotics can be made in several different ways, most physicians prefer to make a

plaster cast of the patient's foot. This is called a negative impression. The cast is sent to

a laboratory with a prescription for recommended modifications. At the lab, a positive

cast is made by pouring plaster into the negative cast. When this dries and is removed, it

forms a perfect reproduction of the bottom of the foot.

Using the physician's recommendations for corrections, the lab technicians custom-mold

an orthotic made of a supportive material that incorporates the necessary adjustments.

The orthotic provides the patient with the support, stability, cushioning, and alignment

necessary to keep the feet, ankles, and lower body comfortable, healthy, and pain-free.

There are four types of orthotics when taking into consideration the structure of building

these devices for the needs of adults and children: Rigid, Soft, Semi-rigid and Orthotics

for Children.

Rigid Orthotics would be used primarily for the function of walking or standing a long

time and may be constructed from plastic or some other form of hard material. The

device normally is made in a type of mold that is in the shape of the patients’ foot and

would encompass their foot when done from the heel to the ball.
Soft Orthotics are used to restore balance, absorb shock and help relieve pain from sore

areas. A soft orthotic as its name states is usually constructed out of a soft, pliable

material. Often an orthotic device of this nature will need to be replaced much more often

than one made of rigid material, but a bonus is that it can be easily adjusted when needed.

This type of orthotic is often used for those who have diabetes or those who have some

form of foot more ‘bulky’ in their formation and hence will take up more space in one’s

shoes when used.

The Semi-rigid orthotic devices are used for those who are involved in sports primarily.

For each athlete and for each sport that athlete is involved in, an individual orthotic is

made of soft material with hard plastic placed in appropriate places to fit that individuals

needs for that sport. For the athlete these types of orthotics allow the tendons to work

more efficiently and allow the athlete to participate in a sport he enjoys without the pain

he would normally experience.

Children who have foot malformations are usually put into a form of orthotic as early as

possible to help clear up any problems when learning how to walk. Children usually need

to have their feet ‘remolded’ and a new set of orthotics made for them once their shoe

size has grown 2 sizes past their original orthotics size. The time needed for a child to

wear an orthotic device is determined by each case and how severe the malformation is.

Once an adult they will usually need to use orthotics for the duration of their lifetime to

help retain their balance and keep them from having foot, ankle and back pains.

A splint is a medical device for the immobilization of limbs or of the spine. It can
be used splints - a device for preventing movement of a joint or holding in
place any part of the body. INDICATIONS:
Temporary immobilization to improve pain and discomfort, decrease blood loss, reduce the risk for fat
emboli and minimize the potential for further neurovascular injury associated with:
• Fractures
• Sprains
• reduced dislocations
• tendon lacerations
• deep lacerations across joints
• painful joints associated with imflammatory disorders

CONTRAINDICATIONS:

MATERIALS:
• Plaster Rolls or sheets
o Strips or rolls of various width made from crinoline-type material impregnated with
plaster which crystallizes or “sets” when water is added
• Prefabricated Splint Rolls (Ortho-Glass)
o Layers of fiberglass between polypropylene padding
• Stockinette
• Cast padding
• Elastic bandages
• Adhesive tape
• Heavy scissors
• Bucket
• Protective sheets or pads to protect patient clothing
• gloves

PATIENT EDUCATION:
• Instructions should be both verbal and written
• Explain and demonstrate the importance of elevation to minimize swelling and decrease pain
• Apply ice bags or cold packs (bags of frozen vegetables also work well) for at least 30 minutes at
a time during the first 24-48 hours after injury to decrease swelling and pain
• Avoid getting the splint wet – some splints may be removable for bathing purposes, otherwise
plastic bags may be placed over the splint to keep it dry while bathing
• Explain signs of infection and vascular compromise, instruct patient to seek help for any concerns
• Instruct patient to return for evaluation of damaged/broken or wet splint
• Discuss follow-up guidelines

PROCEDURE/TECHNIQUE:
• Prepare the patient
o Cover patient with sheet or gown to protect clothing
o Inspect skin for wounds and soft tissue injuries
o Clean, repair and dress wounds as usual prior to splint application
• Padding
o Apply stockinette to extremity to extend several cm beyond edges of plaster, so that it
may be folded back over the edges of the splint after plaster is applied to create a smooth
edge
o Roll on two to three layers of cast padding evenly and smoothly (but not too tight) over
the area to be splinted.
 o Extend the padding out beyond the planned area to be splinted so that it can be folded
back with the stockinette over the edges of plaster to create smooth edges.
o Each turn of the webril/cast padding should overlap the previous by 25-50 % of its width.
o Place extra padding over bony prominences to decrease chance of creating pressure sores
o An alternative to circumferential stockinette and cast padding is to place 2-3 layers of
padding directly over wet plaster, and then apply this webril-lined splint over the area to
be immobilized and secure it with an elastic bandage
• Prepare the plaster splint material
o Ideal length and width of plaster depends on body part to be immobilized in the splint
o Estimate the length by laying the dry splint next to the area to be splinted
o Be generous in estimating length, the ends can always be trimmed or folded back
o Width should be slightly greater than the diameter of the limb to be immobilized
o Cut or tear the splint material to the desired length
o Choose thickness based on body part to be immobilized, patient body habitus, and
desired strength of splint
 Average of 8-12 layers
 Less layers (8-10) for upper extremities
 More layers (12-15) for lower extremities
 More layers may be needed for large patients
o Fill a bucket with cool water, deep enough to immerse the splint material into
 Using cool water decreases the chances of thermal burns, but takes longer for
the splint to dry
• Application of the splint
o Submerge the dry splint material in the bucket of water until bubbling stops
o Remove splint material and gently squeeze out the excess water until plaster is wet and
sloppy
o Smooth out the splint to remove any wrinkles and laminate all layers
o Place the splint over the webril cast padding and smooth it onto the extremity
o An assistant (or a cooperative and willing patient) may be required to hold the splint in
place while you adjust the splint
o Fold back the edges of the stockinette and cast padding over the ends of the splint
o Secure the splint with an elastic bandage
o Place the extremity in the desired position and mold the splint to the contour of the
extremity using the palms of your hand. (Avoid using your fingers to mold in order to
decrease indentations in the plaster which can lead to pressure sores)
o Hold the splint in the desired position until it hardens
• Check and finish the splint
o Check for vascular compromise
o Check for discomfort or pressure points
o Apply tape along the sides of the splint to prevent elastic bandages from rolling or
slipping, (avoid circumferential tape to allow for swelling)
o Provide sling or crutches as needed

**See Diagrams for specific splints

COMPLICATIONS, Prevention & Management:

Compartment Syndrome
• Usually less common in splints than with circumferential casts
• may occur associated with splints from constricting webril (cast padding) or elastic bandages that
cause increased pressure within a closed space on an extremity
 • increased pressure leads to inadequate tissue perfusion and loss of tissue (muscle, vascular and
nerve) function within the compartment.
• Presenting signs and symptoms: (The “5 P’s” are pathognomonic for ischemia: pain, pallor,
paresthesias, paralysis, and pulselessness, but seldom all occur simultaneously, and when they do
– indicate a late finding associated with poor prognosis).
• pain in the extremity
• tenderness over the involved compartment
• significant pain with passive stretching of ischemic muscle tissue
• diminished distal pulses and sensation
• delayed capillary refill, and pale cool skin.

Prevention
• avoid wrapping bandages too tightly or making circumferential splints
• elevate the extremity to decrease swelling
• apply topical cold packs
• no weight bearing
• early (24-48 hour) follow-up for high-risk injuries

Management
• remove all constricting bandages and splint materials
• consider compartment pressure monitoring
• early consultation with orthopedist and/or vascular surgeon for possible fasciotomy

Pressure Sores
• Uncommon with short term splinting
• Can result from stockinette wrinkles, irregular wadding of padding, insufficient padding over bony
prominences or indentions in plaster form using fingers to mold splint
• If suspected, remove the splint materials and check the skin carefully, care for wounds and revise
the splint if necessary

Heat Injury
• can result from drying plaster which produces heat and may cause burns to underlying skin
• To reduce risk for thermal injury, use cool water to wet the splint material and keep splint
thickness less than 12 sheets of plaster

Infection
• More common with open wounds, but may occur with intact skin
• Clean and debride wounds well prior to splint application
• Consider using a removable splint for periodic wound checks

Joint Stiffness
• Expected to some extent after any immobilization of a joint
• Avoid prolonged immobilization if possible

DOCUMENTATION FOR THE MEDICAL RECORD:

• Note the indication for the splint
• Describe any wounds and their location under the splint
• Document the neurovascular exam findings
• Describe the type of splint applied, area immobilized, and materials used to make the splint
• Indicate what follow-up is planned for re-assesment of injury
ITEMS FOR EVALUATION:
• Understands indications for splint
• Knowledge of different materials needed for splinting
• Ability to apply a functional splint which adequately immobilizes the intended part
• Understands potential complications and their prevention and management
• Explains procedure to patient and answers questions
• Proper documentation in the medical record