Applied Evidence

MSK injury? Make splinting choices based on the evidence

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Which devices do—and don’t—have evidence to support their use when it comes to injuries like carpal tunnel syndrome, “tennis elbow,” or an ankle sprain? Read on.

PRACTICE RECOMMENDATIONS

› Consider a wrist splint for carpal tunnel syndrome secondary to repetitive motion. B

› Recommend a simple knee sleeve to help patients with osteoarthritis reduce their pain and improve daily function. B

› Use ankle bracing for secondary prevention of a recurrent ankle sprain. A

Strength of recommendation (SOR)

A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series


 

References

About 25% of all outpatient visits to family physicians include musculoskeletal (MSK) complaints.1 Splinting, bracing, or wrapping are used in 25% of these visits.2 The goals of splinting/bracing are multifold: accommodate a correct movement pattern, restrict poor movement patterns, and decrease the use of an injured area to allow for healing.

Splints and braces are generally noncircumferential and are easily put on and taken off. (The terms splints and braces can be used interchangeably.) The devices can be adjusted for swelling and are more comfortable than casts, but have the potential for poor patient adherence, may require frequent adjustment, and can allow for excessive motion.

Making the most of these devices requires an understanding of when the evidence supports (and doesn’t support) their use for particular injuries. In this article, we review the evidence for the use of splints/braces for common upper and lower extremity MSK conditions seen in family practice. We have confined our discussion to readily obtainable, off-the-shelf products. These products come in a variety of sizes and are easily kept on hand, or ordered through a durable medical equipment provider.

Carpal tunnel syndrome

Carpal tunnel syndrome (CTS) is a compression neuropathy of the median nerve at the level of the wrist. It is caused by several different conditions.

Goal of splinting: Minimize wrist movement to decrease any concomitant swelling in the carpal tunnel contributing to the compression. The two different types of orthoses commonly used are a neutral wrist splint (FIGURE 1) and a cock-up wrist splint (20° wrist extension).

Neutral wrist splint

Evidence: A 2003 Cochrane review concluded that short-term symptom relief was achievable with bracing; however, better outcomes were seen with combination therapies (eg, medications, occupational therapy) vs splinting alone.3 A more recent Cochrane review in 2012 found poor or limited evidence that splint use at night was better than no treatment or any other nonsurgical treatment.4 There was also insufficient evidence to recommend one type of splint over another, although several poor-quality studies found neutral splinting to be more beneficial.5

Combination therapy—medication, occupational therapy, and splinting—is better for carpal tunnel syndrome than splinting alone.

A 2016 clinical practice guideline (CPG) from the American Academy of Orthopaedic Surgeons (AAOS) reported strong evidence supporting the use of immobilization.6 (Strong evidence is defined by the AAOS as 2 or more “high” strength studies with consistent findings for the intervention.6) Interestingly, of the 2 studies that AAOS used to make its conclusions,7,8 only the study by Manente et al8 was available at the time of the Cochrane 2012 review, and the Cochrane authors came to a different conclusion. The AAOS CPG does not comment on a specific type of brace.

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