Journal of the American Academy of Orthopaedic Surgeons 66 The belief that immobilization of a fracture with the joints above and below it is essential for fracture healing has been ingrained in the minds of the orthopaedic commu- nity for many generations. The popularization of compression- plate fixation by the AO in the 1960s reinforced the belief that rigid immobilization and interfrag- mentary compression constitute the ideal environment for fracture repair. The introduction of functional fracture bracing, also in the 1960s, constituted a radical departure from such traditional practices and beliefs. It freed joints adjacent to the fracture and demonstrated that motion at the fracture site, rather than being detrimental to fracture healing, enhanced osteogenesis. 1-6 It has been documented that there is as much as 4 mm of elastic mo- tion in oblique tibial fractures 2 weeks after the initial insult. 6 After the initial experiences with functional fracture bracing of di- aphyseal tibial fractures, the tech- nique was soon extended to frac- tures of the femoral shaft, the humerus, both bones of the fore- arm, the isolated ulnar shaft, and the distal radius. 5,7,8 The method was also utilized in a small number of patients with tibial condylar frac- tures and tibial nonunions. 5,9 Although early reports suggested that functional bracing could be a viable alternative in the care of frac- tures of both bones of the forearm and femoral shaft fractures, plating and closed intramedullary nailing relegated bracing of those fractures to the few instances in which plat- ing and nailing were not indicated or to areas where the technology of internal fixation was not available. The expanding technology and increased popularity of surgical treatment in fracture management have prompted some to question the role of nonsurgical treatments in the care of long-bone fractures. This article reviews the experience with functional fracture bracing and attempts to place the method of treatment in proper perspective. Diaphyseal Tibial Fractures Functional bracing of tibial fractures was introduced in the early 1960s (Fig. 1). 10 It had been preceded by Dr. Sarmiento is Director, The Arthritis and Joint Replacement Institute, Coral Gables, Fla; and Professor and Chairman Emeritus, Depart- ment of Orthopaedics and Rehabilitation, University of Miami. Dr. Latta is Professor and Director of Research, Department of Orthopaedics and Rehabilitation, University of Miami. Reprint requests: Dr. Sarmiento, The Arthritis and Joint Replacement Institute, HealthSouth Medical Building, Suite 301, 1150 Campo Sano Avenue, Coral Gables, FL 33146. One or more of the authors or the departments with which they are affiliated have received something of value from a commercial or other party related directly or indirectly to the sub- ject of this article. Copyright 1999 by the American Academy of Orthopaedic Surgeons. Abstract Functional bracing is an effective therapeutic modality in the management of selected fractures of the tibia, humerus, and ulna, particularly low-energy injuries. In the case of tibial fractures, it is applicable only to reduced trans- verse fractures and to axially unstable fractures with an acceptable degree of shortening. The rate of union of tibial fractures after functional bracing is approximately 97%. The initial shortening noted with closed tibial fractures rarely increases with weight bearing. Shortening has been reported to be as little as 12 mm in 95% of patients, with angulation of 8 degrees in 90%. Such mini- mal shortening and angulation do not affect functional results. In closed and type I open diaphyseal humeral fractures treated with functional braces, the nonunion rate is approximately 3%. Most of the reported residual angular deformities have been functionally and cosmetically acceptable. For isolated ulnar fractures, the nonunion rate is approximately 2%. Functional fracture bracing is predicated on the premise that motion at the fracture site encourages osteogenesis. The method is applicable only to selected fractures, and it is neces- sary to have a clear understanding of its rationale, indications, and technique. J Am Acad Orthop Surg 1999;7:66-75 Functional Fracture Bracing Augusto Sarmiento, MD, and Loren L. Latta, PhD Augusto Sarmiento, MD, and Loren L. Latta, PhD Vol 7, No 1, January/February 1999 67 use of a below-the-knee functional cast for the treatment of diaphyseal tibial fractures, which was inspired by the patellar tendon bearing pros- thesis used by the below-the-knee amputee. 11 It was extrapolated that a below-the-knee cast, molded much like the patellar tendon bear- ing prosthesis, would stabilize the fracture and prevent shortening by transferring weight-bearing stresses from the floor to the patellar tendon and tibial flares. Clinical and labo- ratory investigations, however, indi- cated that the weight-bearing forces were not concentrated on the patel- lar tendon and tibial flares but were distributed widely throughout the soft tissues surrounding the frac- tured bone. 2,5,12 It was then suspected that main- tenance of limb length was the result of the hydraulic environment created by the compressed water- rich soft tissues surrounding the fractured limb. 2,5,12 This new hy- pothesis, however, did not explain the maintenance of limb length in the position of initial shortening despite the volumetric changes in the injured extremity, as the rigid cast lacks the adjustability to accommodate changes in the girth of the traumatized extremity to maintain the necessary soft-tissue compression. 2,5,12 Subsequent labo- ratory investigations led to the important conclusion that closed diaphyseal tibial fractures do not experience additional shortening beyond that noted at the time of the initial insult and that the local soft-tissue damage determines the degree of initial shortening. 2,5,6,12,13 It was also documented that the motion that takes place between the fragments during function and weight bearing is elastic 2,6,12-14 and beneficial to osteogenesis. 1-6,13 Shortening Tibial shortening after a fracture is not important if it does not exceed 12 mm, as such shortening does not produce a limp or lead to late adverse sequelae (Fig. 2). It represents an inconsequential ana- tomic deviation rather than a com- plication. Correction of shortening in axially unstable fractures by traction/manipulation cannot be maintained during weight bearing by the use of a brace before the development of intrinsic stability at the fracture site. 2,5,12,13 Reports of excessive shortening observed at fracture healing with the use of functional bracing usually included data on patients with axially unsta- ble fractures in whom the initially unacceptable shortening had been corrected by traction before brac- ing. 15-17 Such a practice ignores the basic tenets of functional bracing and leads to unsatisfactory results. Those fractures are best treated with external or internal fixation. 5 As radiographs of open fractures do not always accurately reflect the initial degree of shortening that results from the rupture of the soft- tissue envelope, early functional bracing is best suited for closed fractures and only those that are either intrinsically stable (i.e., reduced transverse fractures) or axially unstable (i.e., oblique, spiral, or comminuted fractures) with acceptable initial shortening. 5,13 Gustilo type I open fractures pro- duced by low-energy trauma with minimal initial shortening can also be braced with the expectation of an acceptable result. Angulation The functional brace does not prevent shortening; it simply assists in maintaining alignment of the fragments. This is accomplished by compressing the soft tissues sur- rounding the fracture and increas- ing the stiffness of the limb segment encompassed within the brace. 2,5,12 Therefore, it is essential that com- pression of the soft tissues be main- tained throughout, particularly while the fragments are still mobile and have not developed sufficient intrinsic stability. A circular cast or brace made of a material that does not accommodate changes in the girth of the extremity (e.g., atrophy or subsidence of swelling during recumbency and its reappearance during dependency of the limb) may not prevent angular deformity. If the brace is applied when the injured limb is still subject to signif- icant volumetric changes, it must be adjustable to maintain the neces- sary compression of the soft tis- sues. 5,6,10,11,13 The presence of an intact fibula predisposes to the development of varus angulation, particularly if the initial radiograph demonstrates varus angulation. Isolated tibial fractures located close to the knee or ankle joints show the greatest varus angulation, particularly if the frac- ture is oblique or spiral and runs from the medial aspect of the tibia proximally to the lateral aspect dis- tally. This particular geometry lacks the benefit of abutment of the angu- lating proximal fragment against Fig. 1 Prefabricated tibial fracture brace permits full range of motion of the knee and ankle joints. Functional Fracture Bracing Journal of the American Academy of Orthopaedic Surgeons 68 the distal one. The comminuted proximal tibial fracture without an associated fibular fracture almost always angulates into varus under weight-bearing conditions. 5 Early recognition of an unac- ceptable angular deformity can be corrected by fibular osteotomy or other surgical means. Angular deformity of less than 8 degrees, particularly varus, which is rarely aesthetically unpleasant and is not associated with late sequelae, is not a complication, simply an anatomic deviation. Valgus deformity of 5 degrees is aesthetically acceptable even in female patients with slight- ly valgus knees. Late osteoarthritis as a direct result of slight angulation or defor- mity after an extra-articular diaphy- seal tibial fracture is extremely rare. 5,18,19 We have not seen an instance in which a tibial fracture healed with less than 10 degrees of residual angulation and osteoarthri- tis developed as a consequence of that deformity. The percentage of tibial fractures treated with func- tional braces that heal with angular deformity of less than 5 degrees compares favorably with that for fractures treated with intramedul- lary nails. 20-22 Technique Diaphyseal tibial fractures treat- ed with functional braces are ini- tially stabilized in long leg casts that hold the knee in almost full extension after appropriate align- ment of the fragments has been achieved. Alignment is obtained by molding the cast over the de- pendent extremity. Oblique, com- minuted, and spiral fractures, in contrast to transverse fractures, rarely require manipulation. Once the acute symptoms have subsided and the patient is able to ambulate with minimal discomfort, the functional brace is applied, and weight bearing is increased as symptoms permit. The brace can be custom-made or prefabricated. In most instances, the brace is applied between the second and fourth postinjury weeks. 10,23,24 Most patients with low-energy- trauma fractures graduate to one crutch or a cane by the end of the sixth week, making it possible for them to carry out most nonstrenu- ous work activities. The Velcro straps of the brace are adjusted by the patient as volumetric changes take place. Instructions concerning brace removal and sock changes for hygienic purposes are given at the end of the first week. Anteroposterior and lateral radio- graphs are obtained to evaluate the alignment of the fracture at that time. If the examination reveals unacceptable positioning of the fragments, the deformity should be manually reduced with reapplica- tion of the cast, or an external fixa- tor or internal fixation should be used. Subsequent follow-up visits are recommended at 3- to 4-week intervals according to the severity of the initial injury and the accom- panying symptoms. Results Most reported series of closed diaphyseal tibial fractures treated with functional braces indicate a nonunion rate of 0% to 3.7%. 5,24 Shortening has averaged about 1 cm. 5,25 In a group of 1,000 closed fractures, the union rate was 98.5%. 13 In the same study, angu- Fig. 2 A, Initial radiograph of a low-energy spiral fracture of the distal tibia and proximal fibula. B, Radiograph obtained through the brace 10 days later. C, Radiograph obtained 1 year after the initial injury. Notice that the initial and final shortening are the same. A B C Augusto Sarmiento, MD, and Loren L. Latta, PhD Vol 7, No 1, January/February 1999 69 lar deformity of less than 8 degrees was recorded in 95% of patients and was 5 degrees or less in 90% of them (Fig. 3). These figures are comparable to those obtained in other series in which intramedul- lary nails were used; in those stud- ies, angulation of 5 degrees was found in 8% to 84% of cases, and nail exchange was necessary in 2% to 28%. 21,22 The average time to union with functional bracing has ranged from 12 to 24 weeks. 5,10,13 Failure to obtain early satisfac- tory alignment between the frag- ments has resulted in abandoning brace treatment for approximately 5% of patients. 13,24 Reported mal- rotation has usually been due to acceptance of deformity at the time of application of the initial above- the-knee cast. A well-molded brace prevents rotary deformity. 2,5,6 Conclusions Functional bracing of closed di- aphyseal tibial fractures requires overnight hospitalization in cases of severe trauma when the extremi- ty may be at risk for development of compartment syndrome. Other- wise, patients are permitted to go home after the application of the stabilizing cast. This compares favorably with intramedullary nail- ing, for which the hospital stay is several days. 15-17,20-22 Anesthesia is used only for transverse, displaced fractures that require manipula- tion. With functional bracing, the complications of infection, residual knee pain, nerve palsy, and broken implants and the need to remove them through secondary surgery are eliminated. Compartment syndromes have not been reported with the use of braces because they are applied long after the initial insult, which is the time when such complications are likely to occur. However, the traction to the extremity usually needed for the insertion of intra- medullary nails and the subse- quent reaming of the medullary canal may increase compartmental pressures and precipitate the clini- cal syndrome. The cost of care is considerably lower compared with surgical treat- ment modalities, particularly if the cost of a second hospitalization for removal of the implant is consid- ered. 13 Return to painless indepen- dent ambulation occurs in a time frame similar to that with closed intramedullary nailing. 17,21,23 Some have reported longer periods of time to union after treatment. However, those authors either delayed the application of the brace or included open fractures in their series. 15-17 Residual knee pain may be seen with intramedullary nailing; nail removal for this reason has been reported in over 50% of patients. 16 The pain may persist even after im- plant removal. 16,17,20 Ninety-five percent of closed tib- ial fractures heal with less than 12 mm of shortening. Shortening of Fig. 3 A, Initial radiographs of a low-energy comminuted fracture associated with a double-segment fibular fracture. B, Radiographs obtained through the brace 2 weeks later. C, Radiographs obtained 11 months later. Notice that there has been no further increase in shortening. A B C Functional Fracture Bracing Journal of the American Academy of Orthopaedic Surgeons 70 that magnitude does not produce a limp or result in late adverse seque- lae. As the initial shortening noted with closed fractures does not increase with graduated weight- bearing ambulation, there is no need to manually regain length in the case of the axially unstable frac- ture if the shortening does not exceed 12 mm. Application of trac- tion to the tibia to correct shorten- ing results in a return to the initial amount of shortening when weight bearing is reinstituted. Therefore, only axially stable fractures (i.e., transverse fractures that are re- duced and stable) and axially unstable fractures (i.e., oblique, comminuted, and spiral fractures) with acceptable initial shortening should be braced. Failure to adhere to these basic tenets of functional bracing leads to complications and unsatisfactory results. 15-17 Angular deformities can be kept below 8 degrees in more than 90% of fractures. Higher degrees of angulation, which would lead to an unsightly deformity, may be corrected with early osteotomy of the fibula or by external or internal fixation. Osteoarthritis due to angu- lar deformities after diaphyseal tib- ial fractures is extremely rare. 5,18,19 Osteoarthritis is rarely a result of an extra-articular tibial fracture that healed with less than 10 degrees of angulation. Polytraumatized patients and those with bilateral tibial fractures are best treated by surgical means, provided appropriate resources are available. Not all tibial diaphyseal fractures should be treated with functional braces. The indications and contraindications for functional bracing are summarized in Table 1. Humeral Shaft Fractures The nonsurgical treatment of di- aphyseal humeral fractures has long been known to render satisfactory results in most instances. According to some, plate fixation and intra- medullary nailing have been associ- ated with a relatively high incidence of complications, such as nonunion, infection, and radial nerve palsy. 26-28 The extension of functional bracing to humeral shaft fractures did not constitute as radical a departure from traditional methods of treat- ment as did tibial fracture bracing. Coaptation splints and hanging casts had been widely used by many surgeons, implicitly indicating acceptance that immobilization of joints above and below the fracture and rigid fixation of fragments were not essential for uneventful healing. Functional bracing does not require hospitalization except in those instances in which the condi- tion of the patient or the extremity calls for a period of observation and those in which the fracture is open and requires either surgical de- bridement or in-hospital antibiotic therapy. Surgical complications, such as infection, peripheral nerve injury, and shoulder impingement, are eliminated. The need for re- moval of intact or failed implants is also avoided. The indications and contraindications for functional bracing are shown in Table 2. Technique Functional bracing of humeral shaft fractures begins with stabi- lization in an above-the-elbow cast or a coaptation splint that holds the elbow in 90 degrees of flexion. A collar and cuff are added. On occa- sion, when the fracture is the result of a low-energy injury and there is minimal swelling of the extremity, the functional brace can be applied at the first orthopaedist-patient contact. 28,29 Otherwise, it is best to Table 1 Functional Bracing of Tibial Fractures Indications 1. Low-energy closed transverse fractures that are either nondisplaced or have been reduced and made axially stable 2. Closed axially unstable fractures (i.e., oblique, spiral, comminuted fractures that demonstrate less than 12 mm of initial shortening) 3. Low-energy closed segmental fractures with minimal displacement between the fragments, with initial shortening of 12 mm or less 4. Grade I open fractures that meet the same criteria as described for the first three categories 5. All of the above, provided angulation is 5 degrees or less after reduction and application of the initial or corrective above-the-knee cast 6. Isolated tibial or fibular fractures that meet the requirements outlined above in patients who have other fractures that do not preclude ambulation with the aid of external support Relative contraindications 1. Selected diaphyseal tibial fractures with an intact fibula 2. Fractures in polytraumatized patients unless other fractures do not preclude ambulation with external support 3. Axially unstable fractures with initial shortening greater than 12 mm where length has been restored by traction unless patients are kept from weight-bearing ambulation for a time sufficient to allow intrinsic stability to develop Augusto Sarmiento, MD, and Loren L. Latta, PhD Vol 7, No 1, January/February 1999 71 use a cast or splint until the acute symptoms and swelling subside. In most instances, the brace is ap- plied approximately 12 days after injury. 30-33 Pendulum exercises are begun the first postinjury day and are continued after the application of the brace to prevent contracture of the shoulder joint. Active elevation and abduction are avoided, as they might produce angular deformity. The collar and cuff are discontin- ued when the elbow reaches full extension but should be used dur- ing recumbency for an additional 2 weeks. During ambulation, the arm hangs at the side of the body and swings normally. The brace must be adjustable and fastened with Velcro straps to maintain con- stant compression of the soft tis- sues and to prevent distal displace- ment of the appliance, which is likely to occur as swelling subsides and atrophy develops (Fig. 4). Radiographic evaluation of the fracture should follow the applica- tion of the brace and be repeated 1 week later and then at 3- to 4- week intervals. Failure to obtain acceptable alignment of the frag- ments calls for abandoning the closed functional treatment mo- dality and beginning use of a dif- ferent strategy. Results Nonunion with functional brac- ing is a rare complication, occur- ring in 1.8% to 3.9% of reported cases. 7,26,29,30,32,33 Nonunion is more common with external fixators, plating, and intramedullary fixa- tion. 26,27,34 Braces are removed on recognition of healing, which takes an average of 8 to 11 weeks. 29,30,32,33 Final mild angulation is com- mon with the use of functional fracture bracing, varus being the most common deformity. Average final angulation has averaged 3 to 9 degrees (Fig. 5). 7,26,29,30,32,33 It is agreed by most that angulation of less than 20 degrees is cosmetically and functionally acceptable. The compression of the soft tissues by the adjustable brace and the dependency of the extremity en- courage the correction of angular deformity. Deformity may be produced by leaning on the elbow, which should, therefore, be avoided. This deformity is more likely to develop in transverse, nondisplaced frac- tures. Rotary deformity has not been frequently reported. We sus- pect that early active use of the flexor and extensor muscles of the elbow results in uncoiling of the malrotated fragments. 5 The loss of the carrying angle of the elbow does not constitute a cosmetic or functional disability (Fig. 6). 5,30 Inferior pseudosubluxation of the glenohumeral joint, which is seen frequently in fractures of the proxi- mal humerus, is easily overcome by active contraction of the biceps and triceps muscles. 5 Acute humeral shaft fractures have a high incidence of associated radial palsy, ranging from 6% to 11%. 5,26,29,30,32,33 Most researchers agree that spontaneous recovery is the rule when the fracture is closed and the palsy appears at the time of the initial insult. 5,26,29,30,32,33 Others recommend early surgical explo- ration if a radial nerve palsy devel- ops after manipulation of the frac- ture. 34 Late palsy usually requires surgical intervention. On permanent discontinuance of the brace, there is frequently limita- tion of motion of the shoulder. However, it improves after return to normal activities. The limitation of shoulder motion has ranged between 0 and 15 degrees. 5,30,31,33,34 Limitation of motion of the elbow is less, ranging from 0 to 10 de- grees. 5,27,29,32,33 Conclusions The vast majority of diaphyseal humeral fractures may be treated successfully with functional braces. The early introduction of function, Fig. 4 Prefabricated humeral fracture brace permits full range of motion of all joints. Table 2 Functional Bracing of Humeral Shaft Fractures Indications 1. Closed diaphyseal fractures without marked distraction between the fragments 2. Closed fractures associated with initial radial nerve palsy similar to those described in the previous category 3. Open fractures without signifi- cant soft-tissue damage Relative contraindications 1. Bilateral humeral fractures 2. Fractures in polytraumatized patients unless they are able to stand erect early and ambulate with external support on the opposite side Functional Fracture Bracing Journal of the American Academy of Orthopaedic Surgeons 72 A B C Fig. 5 A, Initial radiograph of a transverse fracture of the humeral shaft. B, Radiographs obtained 4 weeks later demonstrate early peripheral callus. C, Radiographs obtained 4 months later. The fracture healed with minimal varus angulation. A B C D Fig. 6 A, Initial radiograph of an extra-articular comminuted fracture. B, Radiograph obtained 12 days later, after application of a brace. Anteroposterior (C) and lateral (D) radiographs obtained 4 1 Ú2 months later demonstrate the final residual mild varus angulation. Augusto Sarmiento, MD, and Loren L. Latta, PhD Vol 7, No 1, January/February 1999 73 the dependency of the extremity, and the compression of the soft tis- sues satisfactorily align the frag- ments in most instances. The rate of union is higher than can be obtained with surgical methods, and the residual limitation of motion of the shoulder and elbow is very low. The cost of care is also reduced when compared with sur- gical treatments that require hospi- talization. Isolated Ulnar Fractures Isolated ulnar fractures are infre- quent and are usually the result of a direct blow over the arm. Plate fix- ation has been a common method of treatment. Its popularity proba- bly originated from reports that indicated a high incidence of non- union after the use of an above-the- elbow cast that allegedly failed to immobilize the fragments suffi- ciently to permit healing. How- ever, the complication rate after plating has been relatively high as a result of infection, nonunion, synos- tosis, or nerve injury. 8,25,35,36 Re- ducing the overall incidence of complications is another advantage of functional bracing. The indica- tions and contraindications for functional bracing are shown in Table 3. Technique Initially, the forearm is stabi- lized in an above-the-elbow cast to provide comfort to the patient. It is best to hold the forearm in a re- laxed attitude of supination to sep- arate the two bones as much as possible and to ensure that if a per- manent loss of pronation or supi- nation were to occur, supination would be preserved. Loss of the last degrees of pronation is easily and inconspicuously compensated for by shoulder flexion and rota- tion. A similar inconspicuous com- pensatory mechanism does not exist for loss of supination. If the symptoms are not significant, the functional brace may be applied at the first physician-patient en- counter. The brace extends from below the elbow to the wrist joint and does not immobilize either joint but does limit the last few degrees of pronation or supination (Fig. 7). It should be adjustable to make possi- ble compression of the soft tissues surrounding the fractured bone and to prevent the brace from slid- ing down when the elbow is extended and the swelling has decreased. After application of the brace, which the patient should subsequently be able to remove and reapply, active use of the extremity is encouraged, guided by the degree of discomfort. Results The nonunion rate ranges from 0% to 2%. 5,8,25,35-37 Healing time ranges between 8 and 10 weeks. 5,8,25,35-37 Angular deformity commonly aver- ages 3 to 6 degrees in the mediolateral and anteroposterior planes and rarely exceeds 10 degrees. 5,8 The intrinsic stability of the bone provided by the interosseous membrane and the intact radius precludes major deformity (Fig. 8). 5,8,12,37 The resulting perma- nent limitation of forearm pronation or supination is minimal, averaging 7 degrees. Functional results have been classified as excellent in 89% of patients, good in 8%, and poor in 3%. 5,8,35-37 Conclusions Functional bracing of isolated ulnar fractures renders satisfactory results in the overwhelming ma- jority of instances. The brace does not immobilize joints adjacent to the fracture and permits early active use of the injured extremity. The motion that inevitably takes place at the fracture site encour- ages osteogenesis and is probably responsible for the almost com- plete absence of synostosis. The nonunion rate is low, and the com- plications that may accompany surgery, such as infection, synos- tosis, nerve injury, and refracture, and the need for subsequent sur- gery for implant removal are elim- inated. Fig. 7 Prefabricated brace for isolated ulnar fractures permits motion of all joints. Table 3 Functional Bracing of Isolated Ulnar Fractures Indications 1. Isolated diaphyseal fractures that do not demonstrate displacement between the fragments 2. Type I and II open fractures that meet the criteria described above 3. Fractures that do not have associated dislocation of the proximal radius 4. Bilateral closed isolated ulnar fractures in patients who have not experienced polytrauma Contraindications 1. Open fractures with extensive soft-tissue damage 2. Fractures associated with dislocation of the radial head Functional Fracture Bracing Journal of the American Academy of Orthopaedic Surgeons 74 Summary Functional bracing of fractures of the tibia, humerus, and ulna is a viable therapeutic alternative. In the case of the tibial fracture, the method is applicable almost exclu- sively to closed axially unstable fractures with initial shortening of less than 12 mm and to reduced transverse fractures. For humeral and ulnar fractures, the system has rendered highly satisfactory results in closed as well as selected open fractures. As with other treatment meth- ods, functional bracing has clear indications for its use. Although it is not applicable to all fractures, it has the obvious benefit of not being associated with surgical complica- tions. The union rate is high, com- plications are few, and the cost of care is considerably less than that with surgical management. While anatomic restoration of alignment is frequently sacrificed, the vast majority of the reported residual deformities are functionally and cosmetically acceptable. In the case of the tibial fracture, it is possible to obtain a final short- ening of less than 12 mm and less than 8 degrees of angulation in 95% of patients. If held within those limits, shortening and angulation are not complications, but simply inconsequential anatomic varia- tions. Functional fracture bracing is predicated on the documented fact that motion at the fracture site enhances osteogenesis and that the shortening that takes place initially in the case of tibial fractures remains essentially un- changed after the introduction of graduated weight-bearing ambu- lation. In both the upper and the lower extremities, the soft tissues play a major role in stabilizing the fracture fragments and determin- ing the behavior of the injured parts. Fig. 8 A,Radiograph obtained through a brace a few days after an isolated ulnar fracture. B,Radiograph obtained after healing of the fracture. A B References 1.Goodship AE, Kenwright J: The influ- ence of induced micromovement upon the healing of experimental tibial frac- tures. J Bone Joint Surg Br1985;67: 650-655. 2.Latta LL, Sarmiento A, Tarr RR: The rationale of functional bracing of frac- tures. 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This compares favorably with intramedullary nail- ing, for which the hospital stay is several days. 15-17,20-22 Anesthesia is used only for transverse, displaced fractures that