Page 22 - Read Online

Page 8 of 11 Patterson et al. Plast Aesthet Res 2022;9:23 https://dx.doi.org/10.20517/2347-9264.2021.117

maturation. Psychological support and social assistance can improve therapy engagement and functional
[70]
outcomes .
Orthotics and bracing to maintain or enhance function, prevent contractures, and prevent
secondary wounds
Orthotics, splints, slings, and other methods of immobilization can provide soft tissue rest, limb segment
support, and joint stabilization to facilitate healing. These interventions are temporary and potentially
harmful if not closely managed. Inappropriate use of or failure to manage orthotics, splints, slings, and other
methods of immobilization can cause dermal, neurologic, and vascular injury, as well as stiffness, infection,
and disability that may ruin function and quality of life. Amputation has been reported after misuse of each
[71]
of these devices .

The duration of use of orthotics is particularly important around joints. Many joints, particularly the elbow,
knee, and ankle, become stiff quickly and may not regain full range of motion despite appropriate physical
or occupational therapy or even after surgical releases. Knee immobilizers should not be used for longer
than 1-2 weeks unless absolutely necessary; a stiff knee will prevent patients from being able to walk
unassisted, climb stairs, or sit in a car or chair comfortably. A knee immobilizer should be exchanged for a
hinged knee brace or no brace at all with the initiation of knee motion as soon as possible in a stepwise
manner to increase motion with therapist aid. Similarly, slings, long arm casts, removable splints, and other
means of immobilizing the elbow should not be used for longer than 1-2 weeks unless absolutely necessary
in order to avoid elbow contracture interfering with activities of daily living such as facial and perineal
hygiene.

Conversely, some orthotics can preserve function by immobilizing certain joints in useful positions. An
ankle foot orthotic (AFO) with the ankle at neutral dorsiflexion (90°) should be used until a non-
ambulatory patient resumes weight bearing to prevent ankle equinus contracture and avoid the need for
delayed gastrocnemius recession, tendoachilles lengthening, or open ankle release to restore ankle range of
motion and normal gait. A walking AFO or CAM boot should be considered in patients with foot drop due
to neurologic or tendon injury to prevent contracture and facilitate gait. Wrist splints should be applied in
the setting of wrist drop due to radial nerve palsy or tendon injury to preserve hand and wrist function.

Cosmesis
Cosmesis is rarely opposed to functional goals. Rather, improved cosmesis is often a secondary outcome of
a successful functional reconstruction: a short, crooked, or contracted limb looks and functions worse than
one that is restored to the appropriate shape and works as it should for interacting with the environment.
Unsightly incisions, skin grafts, discoloration, and other unsatisfactory cosmetic concerns can be addressed
after reconstruction with interventions such as tattoos incorporating incisions, scar revisions, flap
debulking, and other interventions.

CONCLUSION
The orthoplastics multidisciplinary approach to soft tissue management after trauma is a coordinated
pursuit of a reasonable functional outcome with combined skeletal and soft tissue reconstruction and
shared management of postoperative care and rehabilitation. A multidisciplinary approach to a complex
extremity reconstruction should be led by orthopedic and plastic surgeon teams at tertiary or quaternary
trauma centers. Early, thorough debridement and coverage to prevent infection pave the way for subsequent
reconstruction. Skeletal stabilization is a priority and a foundation for soft tissue maintenance or
reconstruction. A prolonged and complex limb salvage pathway may be rife with complications and may
not succeed, leading to disability, destitution, social loss, and mental health impairment. Careful patient