I appreciate Dr. Ring's comments, which I answer in the following manner: Aware of the success of JBJS Supplements dealing with Surgical Techniques, I asked the Editor-in-Chief if there was room in the journal for the description of the non-surgical technique of functional bracing of fractures. His response was a positive one. He stated that the most appropriate way to do it was by having a publication based on an old article of mine, which approximately a year ago JBJS had called "A Classic"(1). After submitting a draft I was asked to expand the narrative by briefly discussing and illustrating the clinical work that had preceded the concept of tibial fracture bracing(2). I was given instructions as to the length of the manuscript and the number of illustrations. Subsequently, I was requested to expand even further by briefly discussing and illustrating my later applications of the concept of functional fracture bracing. I gladly accepted the request. However, because of the need to remain within a certain number of pages and illustrations, I chose to limit the discussion to fractures of the humeral and ulnar shaft, as well as Colles' fractures. In doing so, I excluded the functional bracing of tibial nonunions and other conditions where the indications for bracing are limited, such as femoral fractures and fractures of both bones of the forearm.

I trust the above background will satisfy Dr. Ring's criticisms concerning the lack of control studies, and references to his and other authors' work. However, in a large number of previous publications, I have discussed, as carefully as I could, indications, contraindications, and complications.

I appreciate Dr. Ring's observations concerning the likely mechanism through which humeral braces works. I concede that the extrapolations we have advanced, though supported by laboratory studies, may lack, in some aspects, true scientific validity. However, long clinical evidence has strongly suggested that the resulting compression of the soft tissues and the controlled motion at the fracture site, play a major role in attaining healing with acceptable angular deformities. Methods of treatment of fractures used in antiquity resulted in union in most cases, as demonstrated by the scarcity of nonunions in retrieved specimens. There is much we do not know about fracture healing; therefore the wisest explanation was somewhat facetiously given by the famed British orthopaedist, Alan Apley, who when asked, "Why do broken bones heal?" He responded, "Because they are broken".

It pleases me to hear Dr. Ring categorize himself as "a strong advocate for the measured use of operative treatment and a proponent of functional bracing of humerus fractures in particular"(3). I was aware of his views from reading his publications on the subject at hand. He is a refreshing voice in a time when the surgical treatment of virtually all fractures seems to be the party line.

References:

1. Sarmiento A. A functional below-knee brace for tibial fractures. J Bone Joint Surg Am. 1970;52:295-311.

2. Sarmiento A. A Functional below-knee cast for tibial fractures. J Bone Joint Surg Am. 1967;49:855-875.

3. Sarmiento A. A functional below-the-knee brace for tibial fractures: A report on its use in one hundred and thirty-five cases. J Bone Joint Surg Am. 2007;89:157-169. [Letter to The Editor] J Bone Joint Surg Am. epub 19 Sep 2007. http://www.ejbjs.org/cgi/eletters/89/2_suppl_2/157.

To The Editor:

As a strong advocate for the measured use of operative treatment and a proponent of functional bracing of humerus fractures in particular, I was delighted to see Dr. Sarmiento expertly describe his techniques in The Journal. However, I must point out important limitations in the article that temper the conclusions that can be drawn from the data.

The author does not address the lack of controls in studies of functional bracing (does the brace really do anything, or are we just observing nature's healing powers. Sometimes my patients remove the brace or don't wear it properly and they usually do very well in spite of that).

The author's references do not sufficiently cite publication other than his own. In particular, he states that the level of the diaphyseal humerus fracture is unimportant and as evidence cites himself four times, while failing to note that two groups of investigators have noted trouble with oblique proximal third fractures of the diaphyhseal humerus, albeit in uncontrolled and underpowered studies.(1-3)

Dr. Sarmiento also attributes the failures of bracing to the patient without scientific evidence supporting this accusation.

I do believe that this important subject should be presented in a balanced way that uses the principles of evidence based medicine.

The author did not receive any outside funding or grants in support of his research for or preparation of this work. Neither he nor a member of his immediate family received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the author, or a member of his immediate family, is affiliated or associated .

References:

1. Toivanen JA, Nieminen J, Laine HJ, et al. Functional treatment of closed humeral shaft fractures. Int Orthop 2005;29(1):10-3.

2. Ring D, Chin K, Taghinia AH, Jupiter JB. Nonunion after functional brace treatment of diaphyseal humerus fractures. J Trauma. 2007 May;62(5):1157-8.

3. Rutgers M, Ring D. Treatment of diaphyseal fractures of the humerus using a functional brace. J Orthop Trauma. 2006 Oct;20(9):597-601.