10.2 Spinal & Upper Extremity Orthoses
Key Takeaways
- Boston TLSO is indicated for scoliosis curves with an apex at or below T7, whereas Milwaukee CTLSO with a neck ring is required for apex above T7.
- Jewett and CASH hyperextension TLSOs utilize a three-point bending system to restrict sagittal flexion in uncomplicated anterior column compression fractures (T10-L2).
- Halo vest orthoses provide gold-standard maximal cervical immobilization (~90-95%), whereas SOMI orthoses excel at controlling upper cervical flexion (C1-C3) in supine patients.
- Resting hand splints position the upper extremity in the functional intrinsic-plus alignment, while radial nerve splints provide dynamic MCP extension assist for wrist drop.
Spinal & Upper Extremity Orthoses
Spinal orthoses and upper extremity splints are designed to restrict undesirable motion, offload traumatized axial or appendicular structures, stabilize musculoskeletal alignment, and enhance functional capacity. In physical medicine and rehabilitation, prescribing these orthoses requires balancing rigid motion restriction against the physiological risks of muscle atrophy, joint contracture, pressure skin breakdown, and patient non-compliance.
Spinal Orthoses: Scoliosis and Thoracolumbar Trauma
Spinal orthoses are designated according to the anatomical regions they encompass: Cervical (CO), Cervicothoracic (CTO), Thoracolumbosacral (TLSO), and Cervicothoracolumbosacral (CTLSO) orthoses. Their primary biomechanical mechanisms include three-point bending forces, fluid compression of abdominal tissues to offload axial spinal loads, and kinetic motion restriction.
Scoliosis Orthoses
Orthotic management of Adolescent Idiopathic Scoliosis (AIS) aims to halt curve progression during periods of rapid skeletal growth. Orthoses are indicated for progressive scoliotic curves between 25° and 40° Cobb angle in skeletally immature patients (Risser stage 0 to 2).
- Boston TLSO: A custom-molded, rigid thermoplastic thoracolumbosacral orthosis featuring internal corrective pads that exert three-point pressure forces combined with relief voids opposite the curve apex.
- Indication: Scoliotic curves with an apex at or below the seventh thoracic vertebra (T7).
- Wear Protocol: Prescribed for 18 to 23 hours per day until skeletal maturity is reached (Risser stage 4-5 or post-menarche).
- Milwaukee CTLSO: Incorporates a molded pelvic girdle connected by vertical metal uprights to a neck ring with occipital and throat pads.
- Indication: High thoracic scoliotic curves with an apex above T7, or kyphotic deformities (Scheuermann's kyphosis). The neck ring provides the superior three-point bending force necessary to control high thoracic curves that a standard TLSO cannot reach.
- Charleston Night Bender & Providence Orthosis: Hypercorrective nocturnal orthoses designed to be worn exclusively while supine (8 to 10 hours overnight).
- Indication: Single thoracolumbar or flexible lumbar scoliotic curves. The Charleston brace applies aggressive lateral bending forces that overcorrect the spinal curve past neutral, which is tolerated only because the patient is unweighted in the supine position.
Thoracolumbar Spinal Trauma & Compression Fractures
Post-traumatic orthotic management of the thoracolumbar spine depends on fracture stability and the anatomical column involvement (Denis three-column classification).
- Jewett & CASH (Cruciform Anterior Spinal Hyperextension) TLSO: Lightweight, open-frame orthoses utilizing a three-point pressure system comprising two anterior pads (one sternal pad, one pubic pad) exerting posterior force, and one posterior pad (thoracolumbar pad) exerting anterior force.
- Biomechanical Function: Restricts anterior spinal flexion while maintaining the thoracolumbar spine in hyperextension.
- Clinical Indication: Uncomplicated anterior column compression fractures of the thoracolumbar junction (T10 to L2) without posterior element or middle column disruption.
- Contraindication: Unstable burst fractures, three-column injuries, or pedicle/facet fractures, as hyperextension forces can worsen posterior displacement.
- Rigid Custom-Molded TLSO (Bivalve / Total Contact Jacket): Solid plastic shell fabricated from custom body scans or cast impressions.
- Biomechanical Function: Provides total circumferential contact, compressing abdominal contents to decrease axial spinal loading by ~30%, while strictly immobilizing motion across sagittal, frontal, and transverse planes.
- Clinical Indication: Unstable thoracolumbar fractures, burst fractures, post-operative spinal fusion stabilization, and multi-level traumatic spinal injuries.
| Orthosis Type | Anatomical Region | Planes Controlled | Primary Clinical Indication | Special Considerations |
|---|---|---|---|---|
| Boston TLSO | Thoracolumbar (below T7) | Sagittal & Frontal | Scoliosis curve apex T7 or lower | Worn 18-23 hours/day |
| Milwaukee CTLSO | Cervicothoracolumbar | Sagittal, Frontal, Rotational | Scoliosis apex above T7, Scheuermann | Features neck ring with throat pad |
| Jewett / CASH | Thoracolumbar | Sagittal Flexion | Anterior compression fx (T10-L2) | Contraindicated in burst fractures |
| Custom TLSO Jacket | Thoracolumbar | Sagittal, Frontal, Transverse | Burst fractures, post-op fusion | High skin breakdown monitoring |
Cervical Orthoses & Upper Extremity Splints
Cervical Spine Orthoses
The cervical spine is the most mobile spinal segment, requiring progressive structural rigidity based on clinical instability.
- Halo Vest: Gold standard for maximal cervical spine immobilization. Consists of a rigid metal cranial ring fastened to the outer table of the skull via four threaded pins (two anterior pins placed 1 cm superior to the lateral third of the eyebrows; two posterior pins placed 180° opposite), attached via four upright bars to a padded fiberglass body vest.
- Motion Restriction: Restricts ~90-95% of cervical spine flexion, extension, lateral bending, and rotation.
- Indications: Unstable upper cervical spine fractures (C1 ring fractures, unstable C2 hangman's fractures, type II/III odontoid fractures) and post-traumatic cervical dislocations.
- SOMI (Sterno-Occipito-Mandibular Immobilizer): Rigid orthosis featuring a chest plate extending upwards to occipital and mandibular supports.
- Biomechanical Strength: Superior to all other non-invasive orthoses in restricting cervical flexion in the upper cervical spine (C1-C3).
- Special Advantage: Can be easily donned and doffed while the patient remains supine, making it ideal for bedridden trauma patients.
- Philadelphia & Aspen Collars: Semi-rigid foam collars with plastic anterior and posterior reinforcement shells.
- Motion Restriction: Limits ~40-50% of flexion-extension; provides minimal control over cervical rotation or lateral bending.
- Indications: Post-operative soft tissue healing, stable cervical strain, and step-down immobilization.
Upper Extremity Splints
Upper extremity orthoses are classified as static (immobilizing) or dynamic (applying force to permit/assist motion).
- Resting Hand Splint (Functional Hand Splint): A static splint that positions the upper extremity in the "intrinsic-plus" or functional position:
- Joint Positioning: Wrist in 20-30° extension, metacarpophalangeal (MCP) joints in 60-70° flexion, proximal interphalangeal (PIP) and distal interphalangeal (DIP) joints in 0-15° extension (slight flexion), and thumb in palmar abduction/opposition.
- Indications: Preventing flexion contractures in spastic upper limb stroke/TBI, resting acute hand trauma, and managing active rheumatoid arthritis flares.
- Radial Nerve Splint (Dynamic Extension Splint / Cock-Up Extension Splint):
- Biomechanical Design: Holds the wrist in ~30° extension while incorporating rubber bands or dynamic outriggers that passively pull the MCP joints into extension while permitting active finger flexion.
- Indication: Acute radial nerve palsy ("wrist drop"), allowing functional object grasp and release while preventing extensor tendon overstretching.
A 45-year-old male sustains an isolated, stable T12 anterior column compression fracture with 15% height loss following a fall. CT imaging confirms that the middle and posterior spinal columns are fully intact. The spine surgeon requests a lightweight spinal orthosis that restricts trunk flexion while maintaining thoracolumbar extension. Which orthosis is indicated?
A 13-year-old female presents with progressive adolescent idiopathic scoliosis. Radiographs demonstrate a Cobb angle of 34° with the apical vertebra located at the T5 level. Risser grade is 1. Which orthosis is the most appropriate prescription to manage her curve progression?
A 28-year-old male trauma patient in the intensive care unit requires cervical spine immobilization following a stable upper cervical (C2) spinous process fracture. The spine service requests an orthosis that provides superior restriction of upper cervical spine flexion (C1-C3) and can be comfortably donned and doffed while the patient remains supine in bed. Which orthosis best satisfies these criteria?