Immobilisation - ROM brace (knee)
Tibial plateau fracture
Ligamentous injuries to knee
Contraindications (absolute in bold)
Soft brace (Tubigrip or alternative)
Long leg backslab
Open reduction internal fixation
Less complex non-emergency procedure with low risk of complications
Abrasions and pressures sores (with risk of infection)
PPE: non-sterile gloves
Seated with feet on a stool
Procedural clinician and one assistant
One range of motion hinged knee brace
Patient seated with leg resting in extension on a stool
Assistant supporting weight of leg off bed
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
Confirm range of movement settings
Confirm duration of application and whether splint can be removed at any time (e.g. washing)
Obtain weightbearing status
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
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.
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.
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)