Clinical Geriatrics

An orthosis is an orthopedic appliance or apparatus used to support, align, prevent, or correct deformities, or to improve the function of movable parts of the body.1 (In contrast, an assistive device is more specifically a device like a walker, wheelchair, cane, or crutches used to compensate for a physical limitation.2) With improvements in trauma care, more victims of catastrophic events are surviving to live with disabilities.3 Life expectancy is increasing, so increasing numbers of older adults are facing their later years with disabling sequelae of disease or trauma. Along with this rise in persons coping with disabilities, the number, technical complexity, and availability of orthoses for various indications has increased dramatically. Consequently, geriatricians may have considerable confusion about both when to prescribe particular devices and which specialist to employ for recommendations. This brief review seeks to clarify the evaluation for and prescription of common orthoses, and to provide recommendations for both timing and direction of referrals for specialty input.

CLASSIFICATION
Orthoses are most often classified and named according to the part of the musculoskeletal system they are designed to assist. Two kinds of support may be provided: support that allows some (often limited) movement of the limb or body part (functional orthosis), and support that restricts movement in the limb or body part (a splint or brace). In this review, we cover both functional orthoses and splints for each region of the musculoskeletal system, from head to foot.

HEAD AND NECK ORTHOSES
There are few orthoses for the head, and most are simple protective devices (helmets). These protective devices are only employed when there is a significant risk of repeated head injury from falls due to uncontrolled seizures (a very rare situation).

Supportive devices for the cervical spine are employed primarily after surgery or trauma. Immobilization is no longer recommended in simple sprains or strains. Although immobilization and support may afford some pain relief, recovery time is extended due to disuse weakness of the cervical musculature.4 Collars and halos that allow little or no movement are available, as are collars made of more flexible, softer materials that allow a great deal of movement. Soft collars do not offer much real support and are not necessary in most cases; however, they can provide some local warmth and a tactile reminder for the patient to be gentle to a traumatically or surgically injured neck. Hard collars should only be employed in the short term following trauma—usually only for time between initial presentation, radiologic evaluation, and definitive treatment. As soon as it is safe and practical, spinal evaluation should be completed and the collar removed, or definitive management instituted. Careful attention to all pressure points (especially occipital) for skin breakdown is important with these cervical supports.

UPPER-EXTREMITY ORTHOSES
Orthoses for the extremities are practically named based on the particular limb portions supported. For upper-extremity orthoses, WHO is a Wrist Hand Orthosis, EO is an Elbow Orthosis, SEO and SEWO are Shoulder Elbow or Shoulder Elbow Wrist Orthosis, respectively (Figures 1-3). Orthoses that are supportive (and only immobilizing) are classified as static. If it is built to allow limited or enhanced function, it is called dynamic. Static upper-extremity orthoses have a variety of applications in older patients. After surgical joint repair or replacement, they may serve to immobilize the repaired area to allow healing. In repetitive motion disorders such as carpal tunnel syndrome, static orthoses are often applied to discourage inflammation and promote healing (when worn, especially at night, these may indeed be all the treatment required for these injuries) (Figure 3).