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FUNCTIONAL CAST BRACE

INTRODUCTION
A closed method of treating fractures based on the belief that continuing function while a fracture is uniting , encourages osteogenesis, promotes the healing of tissues and prevents the development of joint stiffness, thus accelerating rehabilitation y Not merely a technique but constitute a positive attitude towards fracture healing.
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CONCEPT
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The end to end bone contact is not required for bony union and that rigid immobilization of the fracture fragment and immobilization of the joints above and below a fracture as well as prolonged rest are detrimental to healing.

FUNCTIONAL CAST BRACE It accepts that the loss of the anatomical reduction of a fracture is a small price to pay for rapid healing and the restoration of function, without compromising the appearance of the limb by operative scars. y It complements rather than replaces other forms of treatment.
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HISTORY
1855 H.H.Smith designed appliance for nonunion proximal femoral fractures. y 1910 Lucas Championniere LIFE IS MOTION. y 1926 Gurd [ # of foot and ankle]. y 1950s Dehne [# tibia]. y 1963 Sarmiento began his systemic study,
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THEORETICAL BASIS
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Elimination of movt at a fracture site is not mandatory for a fracture to unite, STABILITY needed Reduce the pain Maintain alignment Prevent deformity.

External bridging callus: situated at distance from the axis of potential movt, it has a greater mechanical advantage than medullary callus, stronger early repair.

Optimal physiological environment


Function in brace provides a milieu wherein metabolic, mechanical, chemical, thermal and electrical factors favorably enhance tissue healing. y Intermittent loading strain in the tissues electrical potentials for bone formation. y Muscle activity increase in circulation supply of nutrient & clearance of waste maintains chemical milieu.
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Irritating effect of motion at the # site & deviatoric stains in the surrounding & interposing tissue prolongs the inflammatory response of s.s hyperemia increase in temperature. y M.E streaming potentials through capillary gradients & strain related potentials through tissue deformation enhancement of E.E.
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E.E affects chemical reaction in the S.S and has an effect on the rate, quantity and orientation of tissues formation in callus.

Interaction of environmental factors

Trauma
Limb Function Fracture Motion

Thermal Environment

Mechanical

Vascular Invasion

Chemical Environment

Tissue Healing

Electrical Environment

Role of soft tissues


Early stages soft tissues transmit most of the load. y Muscle compartment act as fluid mass surrounded by an elastic container deep fascia. y Fluids are not compressible and fascia cant be stretched beyond confines of the cast HYDRAULIC FORCES. y After initial displacement, pressure and load are transmitted without further deformation.
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Muscle contract bulge normally. y In FCB muscles are forced inwards away from the rigid walls and against the central fragments thus causing the fragments to held more firmly.
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Hydraulic forces of the soft tissues resist the overlap and angulation until callus forms. y Rotation is resisted by components of the brace and or by tendency of muscle contraction and Jt movt to align the fragments.
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SHORTENING
Braces do not prevent shortening. y It is determined at the time of injury by degree of soft tissue damage. y Shortening in closed # does not increase beyond that that which develops immediately following initial injury. y Movts are elastic no progressive deformity. y Control related to fit of brace and extent of damage
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LOAD BEARING
S.T. two major mechanisms for load bearing and provision of stiffness to the limb when encompassed in FCB. y I related to their incompressibility.[ displace under load only until they have filed all the gaps with in the container] important in early post injury period. y II intrinsic strength S.T in tension as they support the bony fragments at their natural attachments.
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INDICATION
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All middle third shaft fractures and middle 3 rd and lower 3 rd junction fractures in long bones in co-operative patients.

CONTRACONTRA-INDICATION
Lack of co-operation by the pt. Bed-ridden & mentally incompetent pts. Deficient sensibility of the limb [D.M with P.N] y When the brace cannot fitted closely and accurately. y Fractures of both bones forearm when reduction is difficult. y Intraarticular fractures.
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Galeazzi fractures y Monteggia fractures y Proximal half of shaft of femur [tends to angulate in to varus only used by expert] y Isolated # of tibia, fibula tends to cause varus angulation and to delay in consolidation of #. [ Proximal 1/3]
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Time to apply
y y y y 1. 2.

Not at the time of injury. Regular casts, time to correct any angular or rotational deformity. Compound # es , application to be delayed. Assess the # , when pain and swelling subsided Minor movts at # site should be pain free Any deformity should disappear once D.F removed

3. Reasonable resistance to telescoping. 4. Shortening should not exceed 6.0 mm for tibia, 1.25 cm for femur.

For # tibia following low energy injury, bracing can be done with in first 2 wks. y High energy injuries with more pain & swelling needs an additional period of 1 or 2 more wks. y For humerus # es , most conditions bracing can be done by 7-10 days time. y Median time of brace removal tibia 18.7 wks, humerus 10 wks.
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OPEN
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FRACTURES

Does not preclude FCB. y Greater degree of soft tissue damage increased instability of limb needs delay in using FCB. y High degree of soft tissue damage & shortening may require external fixation for sometime before FCB.

RESULTS
Shortening encountered in closed tibia fracture rarely exceeds 1 cm. [wont cause limp]. y Angular deformities usually < 5*. y Cosmetically and functionally acceptable for most pts. OA changes doesnt occur from deformities of such magnititude.
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Types of limb segments


Limb segments with two bones and interosseous membrane surrounded by muscular tissues with lesser amount of fat in sub-cut region. y One limb segment with bulky muscle layer with relatively large sub-cut fat. y First type is inherently stable ,well controlled with FCB. y One bone seg, relatively unstable because of sub cut fat provides lubrication.
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