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MILWAUKEE BRACE |
The Milwaukee Brace (Figure 3.3) is probably the earliest brace specifically designed to treat scoliosis and has been used world-wide with varied success, however, due to its very uncosmetic appearance, it is being replaced by TLSO braces. It is a corrective spinal orthosis used in the treatment of scoliosis, lordosis, and kyphosis, however it does not have a derotation element incorporated in the brace. This brace consists of a contoured pelvic girdle attached by three uprights to an occipital pad and throat mould of chin piece. Suspended from the uprights are the lumbar and thoracic pads as well as other accessories (shoulder flange, axillary sling, or subclavicular pads). The function of the Milwaukee brace is to redirect spinal growth by stimulating trunk muscle patterns, while three-point pressure systems play a lesser role (Blount et al., 1958).
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Figure 3.3
a) Anterior view of the Milwaukee brace. The chin plate, anterior upright, pelvic girdle, thoracic pad, lumbar pad, posterior upright and pelvic section are represented in the figures as CH, AU, PG, TP, LP, PU and PS. Consists of a thermoplastic (subortholen) pelvic girdle with an anterior aluminium upright that extends vertically to the chin plate. b) Posterior view of the Milwaukee brace. Consists of a thermoplastic (subortholen) pelvic girdle with two posterior aluminium uprights that extend vertically to the occipital plate. In this case, the scoliotic curve is treated with a thoracic pad, which is positioned on the left side of the thoracic curve. The lumbar curve is treated with a lumbar pad, which is positioned on the inside of the pelvic girdle on the right side of the lumbar curve. This Milwaukee brace was designed, fit and delivered to the patient by Grant Wood in Malaga, Spain. |
The pelvic girdle consists of a thermoplastic moulded section with a posterior opening. The trimlines on the pelvic girdle are the following (Blount and Moe, 1980):
1. Anterior superior: is contoured to the inferior border of the tenth rib up to the infrasternal angle.
2. Anterior inferior: approximately follows the inguinal ligament from just above the symphysis pubis to just below the anterior superior iliac spines (ASIS).
3. Lateral superior: contacts the lower margin of the tenth rib.
4. Lateral inferior: 1-1.5cm above the greater trochanter.
5. Posterior superior: extends horizontally from lateral superior margin.
6. Posterior inferior: as low as possible consistent with sitting clearance.
7. Posterior vertical: 2-4cm opening width.
The pelvic girdle provides a distal attachment for the uprights, and provides a foundation for the entire orthosis. The specific function of the pelvic girdle provides reaction points for vertical distraction forces (applied via the uprights), reduction of lordosis and corrective pads. Also, the girdle assists the abdominal musculature in increasing intracavitary pressure.
The head support unit consists of a ring, chin plate, and occipital plate. The ring is made of stainless steel and rectangular, consisting of anterior and posterior adjustments by overlapping lateral bars. The lateral bars have upward and backward angulation of 15 degrees. The ring has anterior hinges, thus, facilitating posterior opening.
The chin plate is symmetrical kidney-shaped and padded as well as horizontal, therefore allowing the patient to rotate their head. The occipital plate is symmetrical butterfly-shaped with a median notch to prevent pressure on the occipital protuberance.
The functions of the head unit are the following (Blount and Moe, 1980):
1. Provides reaction points for vertical distraction forces (applied via the uprights).
2. Positions head and torso.
3. For very high curves, may serve as a lateral reaction point.
4. Serves as attachment for uprights and accessories.
5. Serves as a kinaesthetic reminder and stimulus to the patient to voluntarily raise the chin off the chin plate. This results in elongation of the spine and reduction of scoliotic curve.
The uprights consist of an anterior upright that is aluminium so as to allow X-rays to be taken. It extends vertically from the pelvic girdle to the chin in the midsagittal line. The shape of the anterior upright follows the body contours, however, it flares outward to provide clearance for the thorax.
The posterior uprights extend from the girdle to neck ring following body contours and allowing clearance in the thoracic region with 7-13cm between medial margins of uprights.
The functions of the uprights are the following (Blount and Moe, 1980).
1. Structural connection between pelvic girdle and head unit.
2. Transmit forces between the pelvic girdle and head unit.
3. Provide an attachment for pads and accessories.
The thoracic pad is a L-Shaped, padded aluminium plate that is of concave form. This is secured to the uprights by a transverse strap. The pad is placed on the convex side of the thoracic curve, with the transverse strap extending from the anterior upright to the thoracic pad and continues to contralateral posterior upright. The centre of pressure is at and immediately below the apex of the curve.
The functions of the thoracic pad and strap are the following (Blount and Moe, 1980):
1. Applies a medially, superiorly, and anteriorly directed force to the vertebral column through the ribs.
2. Provides restraint to limit the distance the patient can slump.
3. Serves as a kinaesthetic reminder to voluntarily move away from the pad, therefore reducing the scoliotic curve.
4. Reduces deformity of bulging ribs.
5. Serves as a counterforce to opposing pads.
The lumbar pad consists of a dense pelite that is shaped like an isosceles right-angled triangle. The medial border parallels the spine at the apex of and just below convex side of lumbar curve. The functions of the lumbar pad are to apply anteriorly and medially directed forces to the lumbar spine.
The indications for the Milwaukee brace treatment are (Blount and Moe, 1980):
1. Provides effective correction for mild and moderate curves, up to 40-45 degrees, during the skeletal growth period (contraindicated for mature individuals).
2. More effective for high curves (upper-thoracic and cervical) in comparison with other types of braces.
3. Patients that require less chest restriction and more ventilation and comfort.
1. Anterior superior: is contoured to the inferior border of the tenth rib up to the infrasternal angle.
2. Anterior inferior: approximately follows the inguinal ligament from just above the symphysis pubis to just below the anterior superior iliac spines (ASIS).
3. Lateral superior: contacts the lower margin of the tenth rib.
4. Lateral inferior: 1-1.5cm above the greater trochanter.
5. Posterior superior: extends horizontally from lateral superior margin.
6. Posterior inferior: as low as possible consistent with sitting clearance.
7. Posterior vertical: 2-4cm opening width.
The pelvic girdle provides a distal attachment for the uprights, and provides a foundation for the entire orthosis. The specific function of the pelvic girdle provides reaction points for vertical distraction forces (applied via the uprights), reduction of lordosis and corrective pads. Also, the girdle assists the abdominal musculature in increasing intracavitary pressure.
The head support unit consists of a ring, chin plate, and occipital plate. The ring is made of stainless steel and rectangular, consisting of anterior and posterior adjustments by overlapping lateral bars. The lateral bars have upward and backward angulation of 15 degrees. The ring has anterior hinges, thus, facilitating posterior opening.
The chin plate is symmetrical kidney-shaped and padded as well as horizontal, therefore allowing the patient to rotate their head. The occipital plate is symmetrical butterfly-shaped with a median notch to prevent pressure on the occipital protuberance.
The functions of the head unit are the following (Blount and Moe, 1980):
1. Provides reaction points for vertical distraction forces (applied via the uprights).
2. Positions head and torso.
3. For very high curves, may serve as a lateral reaction point.
4. Serves as attachment for uprights and accessories.
5. Serves as a kinaesthetic reminder and stimulus to the patient to voluntarily raise the chin off the chin plate. This results in elongation of the spine and reduction of scoliotic curve.
The uprights consist of an anterior upright that is aluminium so as to allow X-rays to be taken. It extends vertically from the pelvic girdle to the chin in the midsagittal line. The shape of the anterior upright follows the body contours, however, it flares outward to provide clearance for the thorax.
The posterior uprights extend from the girdle to neck ring following body contours and allowing clearance in the thoracic region with 7-13cm between medial margins of uprights.
The functions of the uprights are the following (Blount and Moe, 1980).
1. Structural connection between pelvic girdle and head unit.
2. Transmit forces between the pelvic girdle and head unit.
3. Provide an attachment for pads and accessories.
The thoracic pad is a L-Shaped, padded aluminium plate that is of concave form. This is secured to the uprights by a transverse strap. The pad is placed on the convex side of the thoracic curve, with the transverse strap extending from the anterior upright to the thoracic pad and continues to contralateral posterior upright. The centre of pressure is at and immediately below the apex of the curve.
The functions of the thoracic pad and strap are the following (Blount and Moe, 1980):
1. Applies a medially, superiorly, and anteriorly directed force to the vertebral column through the ribs.
2. Provides restraint to limit the distance the patient can slump.
3. Serves as a kinaesthetic reminder to voluntarily move away from the pad, therefore reducing the scoliotic curve.
4. Reduces deformity of bulging ribs.
5. Serves as a counterforce to opposing pads.
The lumbar pad consists of a dense pelite that is shaped like an isosceles right-angled triangle. The medial border parallels the spine at the apex of and just below convex side of lumbar curve. The functions of the lumbar pad are to apply anteriorly and medially directed forces to the lumbar spine.
The indications for the Milwaukee brace treatment are (Blount and Moe, 1980):
1. Provides effective correction for mild and moderate curves, up to 40-45 degrees, during the skeletal growth period (contraindicated for mature individuals).
2. More effective for high curves (upper-thoracic and cervical) in comparison with other types of braces.
3. Patients that require less chest restriction and more ventilation and comfort.