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Immobilisation - ROM brace (knee)

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Indications

Tibial plateau fracture

Ligamentous injuries to knee

Contraindications (absolute in bold)

Open fractures

Neurovascular compromise

Complex fractures

Alternatives

Soft brace (Tubigrip or alternative)

Zimmer splint

Long leg backslab

Open reduction internal fixation

Informed consent

Verbal consent

Less complex non-emergency procedure with low risk of complications

Potential complications

Dermatitis

Abrasions and pressures sores (with risk of infection)

Joint stiffness

Procedural hygiene

Standard precautions

PPE: non-sterile gloves

Area

Seated with feet on a stool

Staff

Procedural clinician and one assistant

Equipment

One range of motion hinged knee brace

Cable ties

Positioning

Patient seated with leg resting in extension on a stool

Assistant supporting weight of leg off bed

Sequence

Remove padding from brace

Apply padding around the thigh and then lower leg (assistant lifting leg)

Slide the brace into position (assistant lifting leg)

Ensure the dials and hinge are at the level of the knee joint

Fasten the Velcro straps (starting closest to the knee and working outward)

Apply hinged knee brace, ensuring hinge is at level of knee joint

Change dial to desired flexion and extension parameter (requires orthopaedic input)

Secure dial with cable ties

Post-procedure care

Orthopaedic discussion

Confirm range of movement settings

Confirm duration of application and whether splint can be removed at any time (e.g. washing)

Obtain weightbearing status

Obtain follow-up

Discharge preparation

Document orthopaedic discussion and follow-up for patient

Consider providing crutches to aid mobility (depending on weightbearing status)

Ensure patient comfort

Advice to return for assessment if increasing pain, numbness or skin colour changes

Discussion

Zimmer splints immobilise without allowing movement at the knee. This risks significant knee stiffness and should not be taken lightly. A hinged range of movement brace immobilises while allowing for a range of flexion and extension. This is important for ligamental injuries where we wish to limit valgus and varus forces, while preventing stiffness. The suggested range of movement depends on the injury.

We suggest Zimmer splints and range on movement hinged braces only be used in discussion with orthopaedics. If the injury is serious enough to need these two orthopaedic appliances, the method of immobilisation, weightbearing status, range of movement and follow-up should be discussed.

Hinged range of movement braces are often less easily available in the emergency department than Zimmer splints. If the ideal splint cannot be provided, we suggest the alternative form of immobilisation should be discussed with orthopaedics.

Peer review

This guideline has been reviewed and approved by the following expert groups:

Emergency Care Institute

Please direct feedback for this procedure to ACI-ECIs@health.nsw.gov.au.

References

NSW Agency for Clinical Innovation. Orthopaedic/musculoskeletal. Sydney: ACI; 2020. Available from https://www.aci.health.nsw.gov.au/networks/eci/clinical/clinical-resources/clinical-tools/orthopaedic-and-musculoskeletal

Roberts JR, Custalow CB, Thomsen TW. Roberts and Hedges’ clinical procedures in emergency medicine and acute care. 7th ed. Philadelphia, PA: Elsevier; 2019.

Dunn RJ, Borland M, O’Brien D (eds.). The emergency medicine manual. Online ed. Tennyson, SA: Venom Publishing; 2019.

Eiff MP, Hatch R. Fracture management for primary care. 3rd ed. Philadelphia PA: Saunders; 2011.

Stracciolini A. Basic techniques for splinting of musculoskeletal injuries In: UpToDate. Waltham (MA): UpToDate. 2019 April 18. Available from: https://www.uptodate.com/contents/basic-techniques-for-splinting-of-musculoskeletal-injuries

Liverpool hospital emergency department: Plaster booklet (2019)

© Agency for Clinical Innovation 2021