Chapter 111 Evaluation of Splinting DR. LARSON:I am hopeful that our discussion this afternoon will be as lively as it was this morning and we will open it with the subject of the evaluation of splinting. This is n'either radical nor conservative management SO there is much latitude for discussion by orthopedists and rheumatologists alike. I hope we will bring out the need to understand more about why we are splinting, how much to splint and what is accomplished by this technic. A. General Comments DR. SAVILL:Evaluation of splinting in' rheumatoid arthritis presents difficulties. Conflicting views are held by physicians of experience. It is not only a question as to whether immobilization is or is not of value but whether or not it is actually dangerous. It is unlikely that one view is correct and another is incorrect. The complexities of the problem are due to the n'ature of a disease arising at any age, presenting systemic and local manifestations of varying severity and widely differing patterns of joint involvement. Advanced destruction may be present in some joints, yet in the same individual at other sites can be found early involvement of joint and tendon synovium. In the hand gross deformity may exist with no radiographic evidence of cartilage destruction or bone erosion'. There can be no hard and fast rule regarding splinting in such a disease. Every patient and every joint require careful evaluation. Patridge and Duthie* have s h a m that absolute bed rest and joint fixation by casting for 4 weeks can be safely employed resulting in relief of pain, reduction of disease activity and an over-all tendency toward increase in joint motion. Because of this finding, together with evidence indicating that joints may be affected adversely by motion and weight bearing during exacerbation of the disease, there may well be a place for periods of bed rest and splinting at these times. Corrective splinting, as the words imply, corrects deformity. This is accomplished mainly by the use of serial plaster shells and is particularly applicable to the knee joint. Functional static bracing maintains correction achieved by rest or serial correction. Plaster of Paris can be used but lighter materials are preferable. We now pass into the province of the orthotist. Braces can be used to stabilize the elbow, wrist, thumb and knee. A long leg brace with pretibial shell of polyester resin is particularly useful for unstable deformities at the knee. Functional dynamic bracing is mainly used for the hands. Well-constructed braces can hold a deformed hand in better position, may prevent development of gross fixed deformity and improve function by dynamic assistance. Hand *Patridge, R. W. H. and Duthie, J. J. R.: Controlled trial of the effect of complete immobilization of the joints in rheumatoid arthritis. Ann. Rheum. Dis. 22:91, 1963. 585 586 ORTHOPEDIC MEASURES I N RHEUMATOID ARTHRITIS braces are expensive, must be expertly made and require skillful fitting. Regular maintenance and modification are essential. The place for functional dynamic bracing in rheumatoid arthritis has still to be determined. In my view the dangers of immobilization in rheumatoid arthritis have been exaggerated. I do not believe that immobilization even of a severely affected joint for periods of 8 to 12 weeks must necessarily do harm. It is important, however, that the splinted joint should always be comfortable. This requires skillful application. Rheumatoid knees with valgus or varus deformities resulting from gross destruction of lateral or medial tibial tuberosities may be immobilized up to 12 weeks and possibly longer following high tibial osteotomy and still rapidly regain range and even increase of motion. Paradoxically, a rheumatoid knee immobilized for as long as this after reconstructive hip surgery will almost certainly lose range of movement. This also applies to combined shoulder and elbow fixation, but splint fixation of an elbow following wrist arthrodesis does not as a rule cause reduotion in elbow function. These are problems difficult to understand but serve to emphasize the importance of careful assessment in every case. A guiding principle in the management of a patient suffering from rheumatoid arthritis is that joint deformity should not be permitted to develop. We are all familiar with the deformities that can occur at all joints and yet we continue to watch their development. Prevention may be tedious and time consuming, calling also for a high degree of patient cooperation, but it is fundamental. When deformities are widespread, corrective splinting, functional static bracing, functional dynamic bracing and surgical procedures hemme more difficult and less rewarding. To summarize, therefore, I suggest that splinting in rheumatoid arthritis should be applied as follows: 1. Rest splinting: to relieve pain and encourage local and systemic remission of disease. 2. Corrective splinting: to correct deformity by serial methods. 3. Functional static bracing: to maintain Correction' by joint stabilization, thereby facilitating function of the limb as a whole. 4.Functional dynamic bracing: to maintain correction by stabilization and to assist movements by elastic, spring or motorized elements. Whatever value each of these measures may or may not possess, it is important that nomenclature should be standardized. B. Aims of Splinting DR.RHINELANDER: The aims of splinting can be given in a few sentences and are largely subjective, depending on the individual who gives them. I have decided, therefore, to discuss splinting of a specific joint which presents a major problem in rheumatoid arthritis and to test my personal aims of splinting against some of the methods employed. The immediate aims of splinting in rheumatoid arthritis are twofold: (1) to alleviate the patient's discomfort and ( 2 ) to prevent, or to correct and maintain correction of, a joint deformity. The accomplishment of one means the EVALUATION OF SPLINTING 587 accomplishment of the other. A secondary aim of splinting is to facilitate whatever ancillary treatment or activity may be indicated for the patient, such as physical therapy or ambulation. Restoration of maximum fun'ction is the ultimate goal. To illustrate application of these aims let us consider a flexion deformity of the knee. An effective and well-known method of splinting is the use of serial plaster casts which are bivalved soon after each application to produce removable shells. Experience has demonstrated that instead of making a new set of shells every week or so, as the deformity diminishes, it is both more convenient and more efficient to use a single set of shells which is rendered adjustable by incorporation of hinges. Figure 2 shows three types of hinge as used in pairs in order to obviate the necessity of making serial casts. The type which is most frequently useful (the middle one in' the illustration) consists of a strip of malleable steel, the center segment of which has been twisted through 90". One of these strip-hinges is fastened by rivets to each side of the posterior plaster shell, spanning the region of the joint. The plaster is then cut transverseIy behind the knee opposite the apex of the hinge. The strip-hinges are adjusted by means of a bracemaker's bending irons. The shells are held in place on the leg by webbing straps and buckles. They are removed daily for range of motion exercises. This is most important with any type of support used for a rheumatoid joint. I must emphasize that whenever one of these casts is adjusted to accommodate the increased extension of a knee that has gained, one must take up only the slack which has accrued since the last adjustment. The criterion for maximum permissible adjustment into further extension is that, when the posterior she11 is firmly in place on the leg, the patient's heel can still be lifted out of the shell very slightly. (If, on the other hand, the heel be maintained against the back of the cast by any degree of force whatever, pressure n'ecrosis of the skin will develop; the knee joint itself will be subject to strain and will cease in the further relaxation which these shells engender. ) The adjustability of plaster shells or splints of this type makes them more compatible with the aims of splinting as a whole than are serial casts. Special details of applying, cutting, drying and padding these splints are important. They have not changed since I described them in 1945.' After the flexion deformity of the knee has been corrected as fully as possibIe, the use of splinting does not cease-as too often seems to be the point of view. Protective measures for the joint must long be continued in order that correction be maintained. The plaster shells are still used at night but a suitable leg brace is required when the patient walks. If correction of the knee deformity has been complete, a simple light brace with fixed knee is to be preferred.+ The patient removes the whole brace for ORhinelander, F. W. and Ropes, M. W.: Adjustable casts in the treatment of joint deformities. J. Bone &Joint Surg. 27:311, 1945. fRhinelander, F. W.: The effectiveness of splinting and bracing on rheumatoid arthritis. Arth. & Rheumat. 2:270, 1959. 588 Fig. 2.-Three of serial casts. ORTHOPEDIC MEASURES IN RHEUMATOID ARTHRITIS types of hinges used in pairs in order to eliminate the necessity essential exercises once or twice a day. At all other times the knee is held straight because there is no hinge to unlock and allow the knee to bend up again. For the chronic rheumatoid knee which is very resistant to final full correction walking may sometimes be permitted while there is still slight residual flexion deformity. (This should not exceed 15" or the leverage forces are too great.) Whenever any flexion deformity be present, the brace should be adjustable at the knee-just as the plaster splints are adjustable-so that it can accept the flexion' deformity and still support all parts of the leg when the knee is locked. This adjustment is provided by a two-jointed knee hinge as illustrated in figure 3. The upper joint allows knee motion and has a standard lock: the lower joint, which is secured by means of a Phillips-head screw, allows the adjustment from a slightly flexed to a straight position as indicated. In summary, then, I have attempted to elucidate my concepts of the aims of splinting in rheumatoid arthritis as applied to the knee. Of course, other joints require different types of apparatus but the aims remain the same: to relieve pain, to prevent or reduce joint deformity and to preserve or enhance whatever therapeutic gain has been achieved by the overall treatment. Any method of splinting should facilitate carrying out the patient's total program of day-to-day rehabilitation. DR.LARSON: There remain' a good many questions on the subject of splinting even though our aims are quite clear. How long do we use them? What 589 CVALUATION OF SPLINTING Fig. 3.-Two-jointed hinge for adjustable knee brace. does it lead to in the future as far as the total management is concerned? However, first we will hear a discussion on the evaluation of end results of splinting. C . Evaluation of End Results DR. RAY: Most of what I have to say is a repetition. In the past evaluation of braces has been empirical-do they work or do they fiat work-as opposed to scientific. Is it possible to evaluate such devices scientifically? The answer depends on what one means by “scientific.” In essence the scientific approach consists first of classification of available information on a given subject (we are still a long way from a satisfactory classification’) and agreement concerning terminology; next comes definition of the problem or problems to be solved; the third step is to work out a method for solving the problem, the experiment, and finally, critical evaluation of the results to determine their reliability and the possibility of future predictability. 590 ORTHOPEDIC MEASURES IN RHEUMATOID ARTHRITIS When it comes to applying the foregoing approach to a clinical problem such as bracing, one encounters major difficulties. In the laboratory one essential feature of ihe third step, the experiment, is to establish controls; in the clinic it is frequently impossible to control the many-almost infinite-number of variables. Another feature of the laboratory experiment is objective quantitation of the results but in many clinical situations great difficulty is encountered in quantitating end results since there is nothing specific one can measure. For example it has been suggested that the time required to perform some particular function may be used as a measureable entity. However, this has limited usefulness in evaluating the results of splinting since in many cases it does not represent the purpose behind the device. It has been suggested that joint motion be used to evaluate splints. However, this, too, is limited in application and beyond the purpose of many devices. For the most part one is reduced to nonquantitative terms to describe clinical results such as excellent, good, fair or poor and here the problem is one of a standard of reference. Do we take a foundry worker or an office worker as our standard? In the case of women do we use a housewife or a ballet dancer as our standard? It was suggested earlier today that we use the patient as a standard of reference. Under these circumstances a different set of terms must be used. One speaks of improvement, no improvement, or progressive deterioration but this raises the question of the predictability of the course of the disease in any given individual. It has been said that rheumatoid arthritis can be most unpredictable even when one follows the patient for a long time. We have spoken about the evaluation of the patient. Evaluation of the patient and the effectiveness of splints and braces is further complicated by the fact that their application usually coincides with other procedure such as medication, physical therapy and possibly surgery all of which must be taken into account. It is equally important to evaluate the effectiveness of a brace or splint in reference to its purpose. Dr. Savill and Dr. Rhinelander pointed out that one purpose of such devices is to relieve pain and inflammation in an affected joint by immobilization. In a sense this should be easy to evaluate. You just ask the patient! However, evaluation of pain is seldom that simple. There are many variables such as the pain threshold, psychologic and racial factors, fatigue, etc. In subjective terms it may be possible to say that a patient is or is not improved but to express relief of pain in quantitative terms for comparative purposes is just about impossible. Correction of deformity is another purpose behind spIinting and bracing. One can say that a flexion deformity of the knee through the use of a brace has been corrected but now that the knee is extended, is there any flexion left in' the joint? The brace may have succeeded in its original purpose only to leave the problem still further complicated. Evaluating prevention of deformity is even more difficult. It seems to be pretty well agreed that it is not possible to prevent a deformity in a patient with severe active rheumatoid arthritis by splinting alone, but is it possible in the less severely involved case? Again, we encounter the problem of controlled 591 EVALUATION OF SPLINTING clinical studies. Who is to say that if a deformity does not progress, a brace or splint is responsible for the lack of progression? Another purpose of braces and splints is to provide function. Here again it is difficult to evaluate end results. We can say that an extensor-assist splint enables the patient to extend his fingers but this is not a quantitative result, and in terms of predictability it is dependent on a host of variables including the initial deformity, range of motion and activity of the disease. Is it possible to evaluate end results in terms of the activities of daily living and whether the device aids in accomplishing these? This raises the question of patient acceptance. A perfectly designed device may accomplish its designated purpose but if the patient does not use it, it may be of little value; and patient acceptance can be difficult to determine. Many patients are more diplomatic than honest! In addition to evaluation of braces and splints in reference to their various purposes, evaluation of the device itself is essential. A splint, brace or cast can hide a lot of deformity and its purpose may not be realized just because of poor design. There are well designed and badly designed braces! It is possible to evaluate devices scientifically---one can quote the work of Norton and Brown' on back braces as an example--but it is not easy. In summary then, evaluation of braces in the treatment of patients with rheumatoid arthritis must take into account the status of the patient and activity of the disease, as well as any ancillary treatment the patient is receiving, the specific purpose the brace is intended to serve and the actual design and construction of the brace itself. GENERAL DISCUSSION DR. LARSON: You have made it clear that in the use of splints we must be somewhat careful about our objectives. If you have a deformity measured in degrees and it is corrected a number of degrees, it is a mechanical problem. If we talk in terms of prophylaxis, however, this is quite something else because you have predicted that there was going to be a deformity. This brings up an important point. Does anyone here know of an evaluation taking place now in the objective measurement of the accomplishment of braces, whatever the objective be? DR. RAE:The Committee on Prosthetics Research and Development is ha\7ing a meeting this week and a half day will be devoted to the question of evaluation of orthopedic devices. They are attempting to establish criteria by which they can be evaluated much the way prostheses have been evaluated in the past. DR. ROSENGARTEN: At the New York University Medical Center we have attempted to apply academic principles in a prospective study to evaluate splinting procedures, splints, the materials and methods involved, and their effects on patients with rheumatoid disease. We are attempting to establish *Norton, P. L. and Brown, T.: The immobilizing efficiency of back braces. J. Bone & Joint Surg. 39-A: 111, 1957. 592 ORTHOPEDIC MEASURES IN RHEUMATOID ARTHRITIS a clear picture of the actual role of splinting in the therapeutic regimen. We have evolved our own splint nomenclature so that we have a common ground for discussion with others engaged in similar studies, and are trying to establish criteria for “when” and “how long’ to splint at the various stages of the disease and for the selection of appropriate splint materials and their evaluation. We use essentially the same evaluation procedures for function and anatomic position as does Dr. Preston: activities of daily living, range of motion, muscle strength, photographs, tracings of the hands, testing at the start of the study and at periodic intervals thereafter. We study patients with bilateral involvement, especially those with hand and/or wrist involvement, but we splint only one side. We try to keep all other therapeutic procedures similar on both sides and splint the most disabled side. If the disability is essentially the same bilaterally, we splint the dominant side. We decide on our objective in splinting, make the splint and reevaluate the patient and splint periodically. With some patients we have multiple objectives to be achieved that can not be obtained with one splint. Thus, we may make one splint to aid the patient in performing his daytime activities and have him use another one during his sleep to keep the involved part in a more optimal position. Essentially, we are trying to evaluate our criteria over a period of five or six years so that we may make more specific recommendations as to the type of splints to be used with other therapeutic modalities in the varying types cf disabdlity observed in patients with rheumatoid disease. DR. MCEWEN:If the objective is achieved, the goal is upgraded to a slightly better one, but there is always a stated objective on record and the patient is followed in terms of the progress being made in achieving that specific aim. DR. NICHOLSON: In correcting knee flexion deformity it must be borne in mind that the knee is not a hinge joint. The tibia glides around the femoral condyles as though they were the axle and the tibia the spoke of a wheel. Knee flexion deformity of 45” or greater, if of a month or more duration, can not be straightened by a wedged, hinged or turn buckle cast without possible compression of the femural condyles since there is posterior displacement of the tibia. It has, therefore, been our practice with children in this classification’ to apply a modified Russell traction, using the sling under the upper tibia to pull it forward while exerting a pull on the lower leg. In resistant knees we use a threaded wire introduced just proximal to the distal epiphysis of the tibia and fibula. In severely resistant knees we modify the traction with a second threaded pin’ through the proximal tibia just distal to the proximal epiphysis. A direct lift is placed on this pin by means of a separate weight. The distal pin, thereby, pulls in line with the tibia, distracting the joint, while the proximal pin corrects the posteriorly subluxated knee. In heavy patients a Thomas leg splint with a Peierson attachment is used to support the thigh and lower leg. I believe splints should be used as soon as inflammation or pain in the joint is recognized. All splints should be accompanied by muscle setting exercises, EVALUATION OF SPLINTING 593 particularly for the extensor muscles. Splints should be of the bivalved type and made directly on the leg which is first covered with a thin coat of vaseline. If the splint is removed directly upon setting and put aside for 24 hours, it will dry hard and strong and need not be more than 3 to 6 layers of plaster in thickness. The thickness depends upon the size of the patient. When furl extension of a knee is desired, a right angle position of the ankle and a neutral position of the foot must be obtained. A brace must be used for ambulation'. The exercises must continue, at this time, for flexors as weil as extensors. The early exercise is against gravity alone. Resistant exercises are not started until knee motion is from 0" to YO". The importance of exercises can not be overemphasized, since exercise not only prevents atrophy of muscle. but decalcification of bone. Evidence has been given as to the importance of joint motion to cartilage nutrition. Cartilage is nourished by joint fluid and its nutrition is dependent upon compression and relaxation. This can be compared to the ablility of a sponge to take up water. When wedge casts are used for knee contractures, it is important to hinge the cast, first, a b o ~ ethe femoral condyles as the knee joint motion depends upon' the tibia1 gliding forward in an arch around the femoral condyles. The patient is placed prone for the wedging so that the weight of the lower leg opens the space provided for the wedge. This diminishes leverage of the tibia1 tuberosities against the condyles of the femur which occurs with the patient in a supine position when the heel is lifted to promote extension of the knee. DR. LARSON:You have mentioned an interesting point in that there is a limitation to when one can use splinting and when one has to proceed to something else such as skeletal traction. DR. FERGUSON: We are interested that a school of thought as exemplified by Grokoest and associates* has grown among pediatricians which holds that there is no point in keeping children with rheumatoid arthritis at rest and that they should be allowed to run around. In fact it is stated that if you put them in' casts the joints will immediately fuse. We have looked up 100 cases of juvenile rheumatoid arthritis we have treated over the past 10 years. It was not a perfect study as we did not start many of these children years ago. However, they had had bivalved casts and exercises along with it and had been kept on bed rest while their disease was in the active stage in their joints. We found no fused joints. There were 7 children with same residual disease but the average duration of the disease was 2 and 8/12 years. Two children under pediatric care who contracted chickenpox while on cortisone had died. Residual deformities remained only in those who began their disease with either finger or toe joints rather than major joints. They had marked systemic involvement but the joints in general were excellent. There were another 15 in' whom we noticed some residual disease in terms of synovial thickening but the parents were unaware that there was anything wrong except in these 7 previously-mentioned cases. "Grokoest, A. W., Synder, A. I. and Schlaeger, R.: Juvenile Rheumatoid Arthritis. Boston, Little, Brown and Co., 1962. 594 ORTHOPEDIC MEASURES IN RHEUMATOID ARTHRITIS DR. RAE: We find, particularly in the upper extremity, we accomplish the objective of even the appearance of the brace being acceptable but even' so it takes a considerable amount of skill to get the patient to wear it and to continue to wear it over a period of time. I think many of us have had the experience of putting splints on and finding that the patient uses them only for a short time. DR.RAY: The aim in making a splint should be to make it as simple as possible to accomplish its purpose. We have a little splint that is made in Ann Arbor to prevent ulnar drift of the hand which is not difficult to make. DR. LARSON: Has anyone here followed a group long enough to be able to say that they have prevented ulnar drift? DR.RAY: It is difficult to say you have prevented it when they have not yet had it. There are a lot of rheumatoid arthritis patients who do not have ulnar drift but it would be difficult to determine that the patient would have it if you had not splinted. DR. MCEWEN:We are aided in making such a determination by the fact that rheumatoid arthritis is characterized by an extraordinary degree of symmetry of involvement. If you are testing a splint or brace, you just splint one side. The other side will serve, roughly, as a guide as to what course the disease is taking. DR.RAY: Another problem which arises when a patient who has been prescribed a splint develops ulnar drift in spite of it is the contention by the man who designed the splint that the patient did not wear it. Unfortunately, the patient is not always the best source of information on this question. Social service department personnel often find the patients who claim to wear their prostheses have them, in fact, sitting in their closets. DR.MCEWEN:I guess we will have to add a lie dectector test to our criteria! DR. RHINELANDER:It is not justified to divorce the splinting from physical therapy in an evaluation because each answers to the other to get the best results. They must both be used. It would be incomplete to try to evaluate splinting without carrying out physical therapy simultaneously. DR. LARSON: It is true that those using splints employ other modalities of therapy at the same time. We are trying to explore whether we can in any way separate these factors to learn which, if either, have any real benefit and, if so, how much. DR.KENRICK:If we have a patient who is unable to walk due to a painful knee and weak quadriceps, and with the added support of the cast is able to walk during the time needed to strengthen the quadriceps, this certainly provides a criteria by which to determine the value of the cast. Generally, we use casting or splinting to provide added support for a specific period of time. I do not think it is realistic to use the opposite (unsplinted) hand or knee as a guide to evaluate splinting. We have splinted hands quite differently on the same patien't to fulfill different needs. We always put casts on the weaker of the two legs in the hope that it will become stronger. Sometimes we can get a patient to the point of ambulation without splinting the second leg. EVALUATION OF SPLINTING 595 With reference to Dr. Rhinelander's mention of hinging joints I think the idea of casting started with wedging casts in the United States and then went into disrepute. It was picked up in England and has now returried as a new type of cast. DR. LARSON: There is no doubt that if someone cannot walk without a splint and can with one, this is a pretty obvious criterion. DR. SAVILL:I am horrified to hear that someone believes that wedging splints or plasters came back to the States from England. We have not used them for decades. DR. KENRICK:I am sorry. I believe it was started as wedging casting in the United States and was further developed in England into the new Gypsona type of serial casting-it has returned as serial casting, not wedging. DR.LARSON: When a patient is seen, it must be determined whether a splint is necessary for a deformity, for example, of the knee joint. What do you use as a criteria to tell you when you might indicate splinting and, if so, what type? When do you conclude that there is no longer a need for such splinting? DR. ILL: I have fairly strong feelings about this. We should, first, clarify the difference between splints, casts and rest casts. As Dr. Nicholson mentioned, I prefer that those patients who begin to show acute knees be given rest and rest casts for the time they are in the acute phase, also immediately on' any tendency toward flexion contraction. I think rest casts are invaIuabIe for certain periods to prevent further contraction and to promote extension. We use a great many serial casts for correction of knee flexion contraction quite successfully, depending upon how early treatment is begun. We are not satisfied with an ultimate 5 " )10" or 15" contraction but then put them in' braces. We insist on going to a fuII correction for good mechanical weight-bearing angle which can be tolerated, with outstretch at the knee, before the patient is allowed up. During this period the majority of them can, through their corrective exercises, develop sufficient musculature so that they can stand and balance with crutches and without braces. DR. LARSON: Do you think there is a limit on the amount of deformity that would preclude using rest casts? DR. HILL: This is quite difficult in a contraction beyond 45".If we can, in some of these, we try to develop their musculature to some extent in bed or in the p o l and may, through a partial correction of this deformity, take them half-way to the point where they can go in a rest cast. Subsequently, through manipulation of the cast we finish the job. DR.ROBINSON: I agree very much with what Dr. Hill said. We use a great deal of plaster splinting. During the active stage of the disease we use rest casts to prevent deformity. If there is early deformity, we employ serial casting. When' we get flexion deformities that have been present for months or even a year or more, we often find that only a few degrees of extension can be achieved, perhaps only 10" or 15", with the use of serial casts. Usually, we decide that that situation probably requires an orthopedic approach. 596 ORTHOPEDIC MEASURES IN RHEUMATOID ARTHRITIS We find certain patients who are never in risk of developing deformities. (They have something like a cystic rheumatoid arthritis.) Other patients get flexion deformities of the knee 1-ery easily. With the latter group, once having corrected a flexion deformity of the knee, there is a tendency for this to recur when the disease becomes active again. With those patients we prescribe resting splints which they are taught how to use. One last point is that if we find that the patient is not wearing the rest splint it is usually because it needs a small change or correction. Certainly, many of the patients must use their rest splints because frequently they wear out and have to be replaced. DR. LARSON: Do you ever send a patient directly to the orthopedist, bypassing splinting and physical therapy? DR. ROBINSON:We sometimes do. We certainly go very quickly to the orthopedic surgeon where we think it is irreversible. DR. FRIED:I would like to cite the experience we have had at the National In'stitutes of Health with a splinting program of the knee and wrist we have carried on for the past 7 years. One of our first patients with a knee flexion contracture about 7 years ago was started on conservative exercise therapy: active exercises, stretching, etc. We failed because it was severe. The orthopedic surgeon was called in and he performed a hamstring tenotomy and capsuloplasty and achieved a substantial correction. Then Dr. Jonas Kellgren came to NIH as a visiting scientist. He asked if we used plaster splints to correct knee flexion deformities and we said we had had no experienke with them. He showed us the procedure and since then we have corrected at least 300 to 400 knee flexion contractures by the use of serial plaster casts. Among the very important questions is what kind of patient do you have? How old is he? If the patient is a heavy SO year old, correction of the contracture is difficult. How many degrees is the flexion deformity? We have corrected up to 65". How long has it persisted? Obviously, if you have a recent knee flexion' contracture, you will correct it relatively easily. The most difficult we had to correct had been in existence 5 years. By a peculiar coincidence the one patient who was SO years old and obese had had a 65" flexion contracture for 5 years. Now let me point out that we neyer go directly to plaster casts. We always use conservative physical therapy first. This case was very difficult and it took about 3 months to correct the flexion contracture. In relating our experiences to a visiting Polish surgeon he said, "But I could do this in' a single operation." Well, perhaps the patient does not want that single operation and the risks inherent in open surgery. At any rate our experience has been most gratifying. We never try to make a great gain. We are happy with 3" or 4" or 5" per cast. Every case is treated individually. If it yields nicely, we gain a little more. If it is difficult to make even a small gain, we leave the patient in plaster for several days. Interestingly enough, when the plaster is removed the patient usually has a new range which represents a gain in extension. We EVALUATION OF SPLINTING 597 do not try this on an outpatient basis and, also, we have never had a significant problem with skin, nerves or blood vessels as a result of being extremely careful and observant. DR. MCEWEN:May I ask a question? Sixty-five degrees divided by 4 is about 16. That is 16 casts at what interval? DR. FRIED: Three to 4 days. DR. RAY:Have you compared traction with serial casts as a method for correcting a deformity? DR. FRIED: I should have mentioned that we use traction while applying the cast. It is manual traction' during the application of the plaster to achieve whatever distraction of the joint you can. DR. LARSON: Does anyone use wedging plaster where you forcefully bend the plaster out? DR.NICHOLSON: I think there is a place for it. There is one thing about using wedge casts; you have to have your wedging above the condyles. Otherwise, you do a lot of harm getting subluxation in the knee. I am interested in' what the lateral x-ray would be of that 65" flexion contracture that was relieved in 3 months. DR. RAY:We have used wedge casts where we believed the joint was irretrievably damaged and we simply wanted to get it to ankylose in a position of function. DR.MCEWEN:I understand, Dr. Savill, that in Edinburgh you think that any forceful procedure-such as traction-is really working against what it is hoped to accomplish; that it is less useful than the application of serial cast because the very fact that force is applied tends to make the muscles resist the pull. Is that correct? DR.SAVILL:Yes. When we do serial corrections, we do not completely encircle the limb. The patient is prone and the plaster is applied directly to the skin with no wool or protection of any nature, The plaster is carefully molded to the skin, behind the malleoli, so that there is no pressure on any bony prominence. Cuffs are then placed in position above and below the knee. Within about 5 days, if you split the distal cuff, you can lift the heel out of the shell and that is an expression of the correction that has been obtained by rest with no force or traction whatever. We then apply another cast and so on. Each time the cast is changed you get fewer degrees of correction. Very often we use these cask because we know that both knees are pretty badly disorganized and that one will have to be arthrodesed. We perform an arthrodesis on the joint that does n'ot respond to serial correction as well as the other and leave the best one as a functional joint. DR. FRIED: I did not mean to infer that of the 350 knees we have applied this technic to we have achieved full correction in every one. We attempt to get the correction to 8" to 10" thinking this is important for function. We have not succeeded in doing this in every case, we have failed .in at least 4, but we have a good percentage. DR. HILL:What follow-up did you have on those patients with residual contracture? What has happened to them 5 years later? We have extensive follow-ups. Almost a11 of them will have some DR. FRIED: 59s ORTHOPEDIC MEASURES I N RHEUMATOID ARTHRITIS residual contracture. You almost never get them down to normal. They may have from 5" to 8" of flexion. We follow as many of these patients as we can. We impress upon them the constant tendency to recurrence and give them a plaster cast which fits them in the degree of correction with which they are sent home. We often urge that they wear these casts all night if the tendency to contracture is severe or an hour or so a day if it is slight. Sometimes they have slipped back. We have had some patients return with total recurrence. How much cooperation we got from such patients in their use of the plaster cast at home I do not know. DR. ROTSTEIN: Would Dr. S a d comment on the following? We have been using the method of splinting learned from Dr. Duthie. You stated that in the serial splints you put the cuff above and below the knee rather than using a cuff at the knee. I found it more difficult to obtain good results in the first 2 casts the first 10 days using that method. We use progressive splinting every 5 days for a series of 4 or 5 casts. We found that a better result was obtained by putting the middle cuff at the knee and not using any wedge pressure but by keeping the advantage gained when the splint was originally applied. DR. SAVILL:That well may be true. If the splint is cuffed above and below the knee the patient can move more easily than if there is a cuff over the patella. The cuffs have to be very carefully applied and well molded, particularly around the heel. There must be absolutely no padding, not even a layer of gauze, as that means the plaster is loose. I think Dr. Duthie does not put a band around the knee because he feels very strongly that the patient's knee must be comfortable throughout this period of correction'. DR. MAYNE:I feel something like the devil's advocate here. I am not too enthusiastic about splints. The longer I work with patients, the fewer splints 1 use. I think they are inconvenient. We used to say that the bushes in front of the hospital were full of them. A plumber or an electrician with spondylitis will not wear a Taylor or a Baker brace even' though he should. I do think that a Taylor brace or a Swaim cast or similar appliances are effective. But it seems to me that splints and braces are something like hernia trusses. There are thousands of them but none are as satisfactory as I would like. I am not convinced that the ulnar-drift splints actually correct the hands. This is merely a personal impression. Many of our patients have multiple joint involvement. We cannot put splints on multiple joints without having our patients look like the Tin Woodman of Oz. I think some splinting is not only inconvenient but possibly dangerous. With the use of intra-articular steroids and careful physical therapy for flares of joint disease I think there is little use for casts. However, a full cast left in place for a month or so has been used to treat such flares, which proves primarily, I believe, the advantages of rest for the joint. For chronic joint involvement, but where there is more than 45" of joint EVALUATION OF SPLINTING 599 range, I think that, as Dr. Hill mentioned, we can achieve more by operation than by applying a cast. I remember one man who had, following a sydovectomy, a 10” contracture of the knee (that last 10” is the hardest to correct). He entered the hospital on a Saturday afternoon and I carefully explained to him that, although we would start working on his knee in the Physical Therapy Department on Monday, it would be difficult to get much done on’ Saturday afternoon or Sunday. When I came in Monday, his knee was straight for the first time in 2 years. I asked him how this occurred and he said, “Well, you told me I just had to keep my leg straight as possible if I wanted to straighten it so I tied my feet together with my bathrobe belt and propped my heels on a pillow and left it that way ever since.” He was unusual in his endurance but it paid off. DR. LARSQN: It is clear that there is a wide latitude in the criteria that we use today for splinting. Are there any closing remarks? DR. SAVILL:I would like to refer briefly to my opening remarks about the importance of standardizing nomenclature. I suggest that we might look upon splinting in rheumatoid arthritis as consisting of four phases: rest splinting, corrective splintin’g, functional static bracing and functional dynamic bracing. I think most of us who have worked in arthritis centers where patients are well selected, and the splints are properly applied and maintained have little doubt that rest splinting, corrective splinting and functional static bracing are all of value. The main question uppermost in our minds is whether or not functional dynamic bracing, particularly for the hand, is valuable. I do not know the an’swer at the moment. I feel it is not of much value as a prophylactic measure. For years I used it in the postoperative phase of hand surgery employing the braces for 3 months and discontinuing them when the position had become stabilized. At Rancho Los Amigos Hospital there is a wonderful opportunity to evaluate functional dynamic bracing. I think there are few places in the United States where dynamic braces are made more expertly. DR. RHINELANDER: The problem of maintaining range of motion after splinting has been mention’ed. This is part of your objective. If you have a joint which is fairly acute, you can expect to get full correction. In a chronic joint you do not expect to obtain full correction. Sometimes it is more desirable to get the joint straight so that the patient can walk with a straight leg and sacrifice range. Then you must go to more forcible methods. I think there is a problem with the definition of “wedging.” It does not mean that you apply force. It simply means that you take up slack. In a club foot, where force would also cause skin necrosis, wedging is commonly used. Wedging, therefore, does not imply forcible correction. Serial casts observe exactly the same principle as wedging-you simply take up the slack. Hinged casts, which I prefer because they save putting on so many serial casts, apply the same principle. 600 ORTHOPEDIC MEASURES I N RHEUMATOID ARTHRITIS As a last resort, I think skeletal traction may be used to try to get a joint straight; but if you must resort to that, the chances of obtaining gocd motion are very slim in comparison with what you can expect from allowing the joint to extend by itself in removable splints. As a \.cry last resort you use surgery. D R . RAY: There is frequently more than one way to accomplish one's purpose. In the use of traction I think that many times one can correct a deformity with serial casts or correcti1.e splinting but often, if traction is properly applied, it can accomplish the same purpose more quickly. I am speaking now of the type of traction which utilizes sponge rubber traction straps that are removed when the patient is sent to physical therapy. But we have had patients with flexion deformities of the hips that go beyond 90" and knee flexion deformities where they are getting pressure sores lying in bed. In order to get them out of these positions and ambulatory again we use traction to great advantage as part of the overall therapy program. I think it has a place in the armory of the physician dealing with these problems. DR.LARSON: So far, then, it is clear that traction and splinting, etc. are not used solely by themselves when they are used and we can profitably continue this discussion along with the subject to be discussed in the next section on therapeutic exercises.