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