Orthotics in Pediatric Orthopedics

OrthoticsOrthoses are used to control alignment, facilitate function, and provide protection. They include braces and splints. Often the distinction between braces and splints is poorly defined.

Splints provide static support or positioning and often encompass only half of the limb. They are often worn only part-time.

Braces are usually more elaborate and worn while the child is active. Braces are sometimes divided into passive and active types.

Passive braces are those that simply provide support, such as some scoliosis braces in children with neuromuscular disorders.

Active Braces are those that facilitate function. Such braces may promote active correction, as seen in scoliosis braces that incorporate pads.

Goals

Be realistic about the goals of bracing. Bracing will not correct static deformity or scoliosis. At best, braces prevent progression. Orthotics do not correct physiologic flatfeet or torsional deformity. Although radiographs taken with the orthotics in place may show improvement, this correction is not maintained after the brace is removed. Unbraced radiographs can be made to assess real correction.

Naming Orthoses

The name of the device is determined by which joints are involved. An AFO includes the ankle and foot; a KFO adds the knee; an HKFO includes the hip, knee, and ankle. Special braces are often named by city of origin.

Ordering Orthoses

The prescription should include several components: the extent, material, joint characteristics, and closure types. Order orthoses thoughtfully, as any orthoses is a burden for the child.

Minimizing the Orthotic Burden

Attempt to reduce the burden to the child.

Effectiveness Many orthoses are ineffective and should not be used. Examples include all orthoses for developmental deformities that occur in normal children. These include orthoses for flatfeet, twister cables for torsional problems, or wedges for bowlegs.

Perform the child test For children with neuromuscular problems, orthoses such as AFOs are frequently ordered to improve function. If the brace truly improves function, the child will usually prefer to use the brace. If the brace causes more trouble than benefit, the child will prefer to go without. Make certain the brace is comfortable and fits properly. If the child prefers to go without a comfortable, well-fitting orthosis, it generally means that the brace is a functional liability. In most cases, the unwanted brace should be discontinued.

Minimum duration Duration of bracing is critical to success and acceptance. The effectiveness of bracing to arrest progression of a deformity depends upon two factors: the amount of corrective force applied and the duration this force is applied (based on a 24-hour day). The effectiveness of bracing increases with duration. The psychological and physiological costs also increase with duration. Balancing the benefit and cost is a challenge. Nighttime bracing is least “costly” for the patient because bracing does not interfere with play, is convenient to use, and causes little effect on the child’s self-image. The duration of bracing can vary from full-time (allow an hour free), to nighttime, or part-time. Part-time bracing is commonly ordered for 4-, 8-, or 12-hour periods per day. Negotiate with the child to make certain that the precious free hours coincide with the child’s priorities, such as school or specific athletic or social activities. This will improve compliance.

Minimal length The longer the brace the greater the disability. Extending braces to the pelvis is seldom necessary. Likewise, shoe lifts for leg length inequality may be prescribed that are less than needed to completely level the pelvis. Usually allowing up to 2 cm undercorrection is acceptable to reduce the weight, instability, and unsightly appearance of a higher lift.

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