Past
Trainees and trained Consultants in Orthopaedics and Trauma have been using knee splints in one form or other for millennia. The first use of splinting was described in The Edwin Smith Papyrus, discovered in 1862 outside of Luxor, Egypt. It is the oldest known medical text, a copy of an earlier text from around 3,000 BC, in the history of civilization. The discovery of splints around broken bones in mummified remains from Egyptian tombs confirms the advanced nature of the management of these injuries. The craft of simple splintage of the injured limb survived to 300 BC when Hippocrates in ancient Greece appeared to have had the knowledge of the contents of the Edwin Smith Papyrus and its teachings and used them as the basis for their writings.
By 980-1037 AD “Ibn Sina” or “Avicenna”, a renowned Persian physician, made contributions to various aspects of science influencing not only Persian medicine, but later also medical sciences in Europe. Avicenna’s prominent medical compendium entitled Al-Qanun-fi-al-Tibb (The Canon (or Law) of Medicine) was the standard textbook of medical education in the West until the 16th century. The Canon is composed of five volumes. Bone fractures and dislocations are the main topics of focus in the fourth volume in the chapter entitled Al-Jabr, “orthopaedics”. This chapter is divided into three parts. In the first part, Avicenna initially generally describes Al-Khala dislocation and then specifically discusses ways to diagnose and manage dislocations in 15 bones of the upper and lower extremities. In this he describes the use of splints1.
The demands of treating the many wounded and sick during military conflicts have put great pressure on doctors in every age. The unique difficulties and situations of wartime medicine, however, have in the past led to important medical advancements. This led to the next advances in splinting. This was splinting with either skin or skeletal traction. One of the best known was the splint Hugh Owen Thomas devised for treating femoral injuries in 18752. During the First World War, its use was shown to dramatically reduce the mortality of ballistic femoral fractures.
Present
There are three more recent advances on the development of the post-traumatic splint relevant to the bracing of knees that are highly important. That in the immediate period after knee injury the joint frequently requires a period of rest has been previously recognised. The first advance is that we realise the knee joint injury should not be splinted in the early and late periods after injury as secondary complications such as arthrofibrosis and osteoarthritis can occur.
The second advance in our understanding is that off loading one of the four compartments of the knee can offer a strategic advantage for healing or symptom management. Braces to achieve this have been developed for the immediate and early post-operative periods and others for the late post-traumatic or operative period.
The final third advance is the recognition that an injured knee may lack some of the biomechanical and physiological properties of the uninjured knee.
The Richards Splint
Post-traumatic injuries of the knee are often transported from the accident site to the Accident and Emergency department in the simple gutter, Richards or cricket bat splints used for millennia and still used today. The splinting avoids movements of the injured joint and so reduces pain. Rest, ice compression and elevation are the stalwarts of the management of swelling following injury. A splint allows the limb to rest before rehabilitation. See Figure 1.
The Range of Motion Brace
At some point, depending on the knee injury, mobilisation of the joint needs to be recommenced. We know from the brilliant research of Professor Robert Salter, of the Toronto Hospital for Sick Children3, that continuous passive motion of the knee encourages cartilage healing and the prevention of adhesions. The development of knee splints that unlock to allow a controlled range of motion was the obvious new step in knee splint design. See Figure 2.
The Ligament Knee Bracing
Knees with a Posterior Cruciate Ligament (PCL) injury demand early mobilisation with different stabilising requirements and range limitations from those with Anterior Cruciate Ligament (ACL) injury, medial or lateral collateral ligament injury. There are braces that are designed to control each of these movements with the ability to limit range while protecting from recurrent ligament injury. The bracing requirements for medial collateral (MCL) and lateral collateral ligament (LCL) injury tends to be less and these tend to be the less expensive braces. See Figure 3.
Offloading Knee Braces
We have learnt from the effects of displacement osteotomy that offloading a weight-bearing joint can encourage fibrocartilage to form4. We also know now that offloading an arthritic compartment with a biomechanical brace5 can have significant improvement of the symptoms of knee osteoarthritis6. Many offloading knee braces have been designed to offload the medial or lateral tibiofemoral compartments. Some are for the immediate and early post-operative period and others for improving the symptoms of unicompartmental knee osteoarthritis. See Figure 4.
The effective but simple Knee Sleeve
Finally, research has demonstrated the loss of the proprioceptive function (position sense) of a joint through rupture of the ACL. Similarly, research has also demonstrated that the use of a simple sleeve support can restore some of this proprioceptive function for periods of up to two years from injury or reconstruction7. The use of a sleeve allows athletes to return to top level sport sooner and more safely following ACL reconstruction and rehabilitation. See Figure 5.
Future
The future in knee supports and bracing is in advanced materials and understanding of the biomechanics of the knee.
Compliance and benefit depend on your patients receiving the correct brace for the correct indication. Get to know the braces on the market. Your manufacturer’s rep will be happy to demonstrate each of the types of brace available for the condition you indicate. All the manufacturers should show you how to measure your patient for the well-fitting brace.
Finally, with some of the advanced sports braces one little sentence directed by you to your patient may make the difference between patient satisfaction and recommendation of your skills to other people or dissatisfaction: “break it in by wearing it for an hour on the first day, two hours on the second day and three hours on the third day…”
References:
- Shrafkandi A. Al-Qanun-fi-al-Tibb (The Canon of Medicine) by Avicenna [in Persian] Tehran: Soroush Press; 1991.
- Thomas HO. Diseases of the Hip, Knee, and Ankle Joints with their deformities. Treated by a new and efficient method, (enforced, uninterrupted, and prolonged rest.) Liverpool: T. Dobb & Co, 1875.
- Salter RB, Simmonds DF, Malcolm BW, Rumble EJ, MacMichael D, Clements ND. The biological effect of continuous passive motion on the healing of full-thickness defects in articular cartilage. An experimental investigation in the rabbit. J Bone Joint Surg Am. 1980;62(8):1232-51.
- Jung WH, Takeuchi R, Chun CW, Lee JS, Ha JH, Kim JH, Jeong JH. Second-look arthroscopic assessment of cartilage regeneration after medial opening-wedge high tibial osteotomy. Arthroscopy. 2014 Jan;30(1):72-9.
- Zhang W, Moskowitz RW, Nuki G, Abramson S, Altman RD, Arden N, Bierma-Zeinstra S, Brandt KD, Croft P, Doherty M, Dougados M, Hochberg M, Hunter DJ, Kwoh K, Lohmander LS, Tugwell P. OARSI recommendations for the management of hip and knee osteoarthritis, Part II: OARSI evidence-based, expert consensus guidelines. Osteoarthritis Cartilage. 2008 Feb;16(2):137-62.
- McAlindon TE, Bannuru RR, Sullivan MC, Arden NK, Berenbaum F, Bierma-Zeinstra SM, Hawker GA, Henrotin Y, Hunter DJ, Kawaguchi H, Kwoh K, Lohmander S, Rannou F, Roos EM, Underwood M. OARSI guidelines for the non-surgical management of knee osteoarthritis. Osteoarthritis Cartilage. 2014 Mar;22(3):363-88.
- Beynnon BD, Good L, Risberg MA. The effect of bracing on proprioception of knees with anterior cruciate ligament injury. J Orthop Sports Phys Ther. 2002 Jan;32(1):11-5.
