Pediatric Orthotics and Braces

Posted by Nurse Linda in Life After Paralysis on December 31, 2021 # Health

Young girl using a wheelchair in a classroom settingBraces and orthotics are words that are often interchanged. A brace is a device that holds or supports something in place, including a body part. An orthotic is a medical device for preventing or facilitating movement in an arm, leg, or spine. The word orthotic sounds so much more severe than a brace, but these words are practically interchangeable in health care. Orthotic is the medical term; a brace is an earlier term. Usually, the use of brace or orthotic in the name of medical equipment is consistent with the time it was invented. Earlier developed equipment has the name brace, which has not been updated. Later developed equipment is orthotics.

Pediatric orthotics and braces are used for different purposes. An orthotic or brace may be used to hold a body part in place, move a body part back into alignment, or assist with functional activities. Becoming familiar with the types of orthotics used helps to understand their importance. Use of the least restrictive device is usually the best choice.

There are a variety of placement braces for extremities to hold limbs in place. These may be prefabricated and fitted to your child, or they are custom-made. Their job is to hold the body part in an anatomical position at rest.

A common use of braces is to ensure that bones are aligned, and that additional injury does not occur. Starting with more common braces, slings are used to gently support a limb that needs to be immobilized to protect some part of the extremity. Examples are holding an arm close to the body when the area is strained or for immobilization in a cast. Shoulder supports are used to help protect the shoulder joint if arm muscles are challenged.

In scoliosis or spinal injuries, an orthotic is used to hold the torso in place to avoid further bending of the spine vertebrae or prevent movement in the boney vertebrae from rubbing against the spinal cord. A Thoracic Lumbar Sacral Orthotic (TLSO) is a casing that conforms to the torso from shoulder blades to hips, sometimes higher and/or lower. An opening is usually over the abdomen for expansion and contraction of the abdomen. These can be made of plaster or hard plastic that is molded to the body. In the case of a child, the orthotic will need to be remade due to growth. Plaster TLSOs are often used if the orthotic is used for the long term because they can be easily switched for growth. Molded TLSOs is used if the child or teen will be at a stable height or weight for a while. Plastic TLSOs have small holes to allow for some air circulation. A t-shirt is generally worn beneath this orthotic.

There are several other types of orthotics that are used in specific scoliosis situations. These orthotics are called braces because they were developed before the term orthotic became common in medical use. The Boston Brace applies gentle pressure to the spine's outer curve, allowing the spinal vertebrae to align in the center. A Wilmington Brace is a TLSO that does the same. The Cheneau Brace selectively applies pressure for de-rotation where needed but does not affect the rib cage.

If a child has spine surgery for any issue that requires immobilization of the cervical area of the spine, a Halo brace may be used. This consists of a metal band that surrounds the head. Screws are placed in the skull bone-not into the brain-for stability with a shoulder and upper chest harness. Rods connect the headpiece to the shoulder apparatus for complete immobilization of the neck.

Developmental Dysplasia of the Hip can be diagnosed at birth or later. It is due to muscles that are not strong enough to hold the hip into the ball and socket joint or an issue within the hip joint. For infants, a soft splint called a Pavlick harness is used. It creates just enough pressure to hold the ball in the socket joint until the muscles develop to take over the job. The Rhino cruiser is used in older children as it is flexible enough for walking.

For hip injury or repair in children, a spica cast may be used. This is a plaster cast that is formed around the waist and down the leg on one or both sides of the body to hold the hip immobile until healed. An opening in the groin allows for toileting or diaper. Since the legs are spread apart, mobility is accommodated by an adult-sized wheelchair.

Reciprocating Gait Orthoses (RGO) is a hip, knee, ankle, and foot device used for walking by children with neurological injury or disease. These are individually made or can be adapted to your child. A waist or hip support with metal rods aligns with the leg, articulating at the hip, knee, and ankle. Support surrounds the thigh and calf. Often support extends to the bottom of the foot. Some will use the articulations closed for total leg support others will use the RGOs articulations open if minimal support is needed. Crutches are often used for additional support and balance.

There are many inserts to wear in shoes, depending on the situation. These can help internal foot rotation, external rotation, and insteps. The UCBL shoe insert is used if the foot is flexible. A supportive tie or Velcro closing shoe will help with these devices to hold them in place.

An ankle-foot orthotic (AFO) supports the foot and ankle joint, keeping it in alignment. This is a manufactured or custom item that fits along the back of the leg and under the foot. It is generally plastic. A Velcro band at the top holds the orthotic in place on the leg with a supportive shoe to hold the foot end.

To prevent foot drop when not using muscles, such as from lying in bed, pressure dispersing boots can be obtained. This is great for those with sensation issues. Children with sensation may opt for high top athletic shoes for ankle support. For foot drop treatment, an AFO or an ankle cuff with laces that attach to a shoelace holds the foot up to prevent tripping. The ankle needs to be somewhat stable to use either of these devices.

Casting has been mentioned in many of the situations above. It is a good alternative to expensive devices when your child will need it only temporarily or if your child will outgrow the orthotic before treatment is completed. Because of quick growth spurts, casts are a more effective option for children. They can be reapplied when one cast becomes too snug.

A cast may be used as a brace for a one-time event like a broken bone or used long-term. They can be used as orthotics. Treatment of tone (spasticity) or contractures may be done using serial casting. This is performed to slowly elongate a muscle back into function. Muscles are arranged in the body for pulling or pushing. The pulling muscles are just a bit stronger than pushing muscles. When tone is active, muscles tend to move the limb toward the body. Range of motion exercises and anatomical positioning will help reduce tone, but often tone can become overpowering.

As tone takes over, contractures or shortening of the muscle can occur. In some cases, the use of casts can gently extend the muscle back to its usual length. This is done by application of a cast just a tiny bit more than how far the muscle stretches. The cast is typically formed to the body, dried and then bivalved or cut in half. Half of the cast is then applied and secured with an ace wrap. This allows the ability to check the skin and for bathing. A new cast is applied in a few weeks, again just a bit longer. This keeps occurring until the muscle is back to full length. The process does take time but with little discomfort because it is so slow. There are manufactured braces that can do the same by releasing the joint area of the brace over time.

If your child uses an orthotic, there are some tips for your awareness.

Know if the orthotic or brace can be removed and what the restrictions are if it is removed. Some orthotics can be off when the child is positioned in bed; many others cannot. Sometimes there might be an on/off schedule.

With any orthotic or brace, check the skin frequently, especially when new. An orthotics or brace is meticulously fitted to your child. However, people, especially children, like to move around. Rubbing, friction injuries and even skin pressure injuries can occur.

Look at your child’s extremities. Make sure their circulation is good. Swelling or edema in an orthotic or brace can become constrictive. Look for pigmentation color changes and feel for a cooler temperature to the extremity. That means circulation may be restricted.

Think about hygiene. If the orthotic or brace cannot be removed, they do tend to stink because of body odor and a build-up of sloughing skin. Clean the body all around the area of a non-removable. Be careful with casted orthotics, especially in the diaper area, as waste on the cast can make it soggy needing to be changed. Plastic tape can be used around the toileting opening to prevent moisture from entering the plaster but check the skin area to ensure breakdown does not occur.

Encourage your child. Wearing an orthotic or brace can be a challenge in becoming accustomed to the device. Actively talk about the purpose of the device so they can understand the importance of using it. Some individuals will make a device for your child with a modified version for their favorite doll or superhero. Many products come in colors or patterns that are attractive to children. Nurse Linda

Linda Schultz is a leader, teacher, and provider of rehabilitation nursing for over 30 years. In fact, Nurse Linda worked closely with Christopher Reeve on his recovery and has been advocating for the Reeve Foundation ever since.

In our community, Nurse Linda is a blogger where she focuses on contributing functional advice, providing the "how-to" on integrating various healthcare improvements into daily life, and answering your specific questions. Read her blogs here.

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