New Techniques In The Modification
Of The Milwaukee Brace
By L e R O Y C O O K , C.O.
Snell's A r t i f i c i a l L i m b C o . , N a s h v i l l e , T e n n e s s e e
W i t h an A d d e n d u m B y
P H I L I P B. W I L L I A M S , M . D .
T h e use o f plastics is b y n o w an o l d s t o r y to prosthetists, b u t orthotists
h a v e b e e n s o m e w h a t s l o w e r t o m a k e use o f t h e m in b r a c e s . T h i s article is
i n t e n d e d t o call the attention o f orthotists to the p o s s i b i l i t i e s o f a plastic
l a m i n a t i o n f o r the M i l w a u k e e B r a c e as a j a c k e t f o u n d a t i o n f o r the b r a c e .
Plastic, b e i n g a n o n p o r o u s material, is far s u p e r i o r to leather j a c k e t s
in the sense that there is n o d e t e r i o r a t i o n as often e x p e r i e n c e d in the o l d
m e t h o d . T h e r e is n o b r e a k d o w n v e r t i c a l l y as w a s the c a s e in leather.
C o s m e t i c a l l y , it is c l e a n e r a n d can b e m a d e t o fit m u c h better than leather
a n d the e x t e r i o r m e t a l f r a m e .
T h e Orthotist c a n cut his w o r k time in half b y u s i n g the plastic lamina­
tion.
B a s i c a l l y the n e g a t i v e cast is taken in the usual m a n n e r , h a v i n g the
patient in a vertical p o s i t i o n . B y the use o f o v e r h e a d t r a c t i o n the s p i n e is
p a r t i a l l y straightened, m a k i n g sure the a n t e r i o r s u p e r i o r s p i n e a n d the crest
of the I l i u m are m a r k e d with i n d e l i b l e . T h e cast s h o u l d c o v e r o n e - h a l f o f
the Gluteals, a n d e x t e n d u p w a r d o v e r o n e - h a l f o f the m a n d i b l e a n d o c c i p u t .
T h e i n d e n t a t i o n o v e r the crest s h o u l d b e d e e p l y p r o n o u n c e d . A f t e r the
p o s i t i v e cast is m a d e a n d d r i e d the i n d e n t i o n o v e r the crest o f the I l i u m
s h o u l d b e m o r e p r o n o u n c e d b y s k i v i n g in d e e p e r w i t h a cast k n i f e o r d r a w i n g
k n i f e . A l l b u i l d - u p s f o r n o n p r e s s u r e p o i n t s s h o u l d b e d o n e with plaster in­
stead o f the t r a d i t i o n a l felt as the resin w i l l s o a k in the felt d u r i n g l a m i ­
nation.
T h e a n t e r i o r s u p e r i o r spines a n d the crest o f the I l i u m s h o u l d b e built
u p w i t h plaster s o that n o p r e s s u r e is a c q u i r e d f r o m the j a c k e t w h e n the
traction o f the c h i n a n d o c c i p u t plates are a p p l i e d . T h e i n d e n t a t i o n j u s t o v e r
the crest k e e p s the j a c k e t f r o m s l i p p i n g o v e r the p e l v i s w h e n t r a c t i o n is a p ­
p l i e d . It s h o u l d b e so p l a c e d o n the cast as n o t t o g i v e a n y p r e s s u r e o n the
l o w e r t h o r a x o n the c u r v e d side. T h e side o f the cast o p p o s i t e the a p e x o f
the c u r v e s h o u l d b e b u i l t u p with plaster to m a t c h the afflicted side to g i v e
a m o r e u n i f o r m e x t e r i o r a p p e a r a n c e . T h i s also g i v e s m o r e r o o m f o r the
pressure p a d t o c o r r e c t the S c o l i o s i s w h e n a p p l i e d w i t h vertical t r a c t i o n .
T h e cast is n o w r e a d y f o r a b o u t three c o a t s o f P a r t i n g L a c q u e r w h i c h s h o u l d
b e a l l o w e d to d r y t h o r o u g h l y ( a b o u t o n e d a y ) .
N e x t the patterns f o r the metal strips are m a d e a n d the m e t a l is c u t
a n d bent a n t e r i o r to p o s t e r i o r f r o m the b o t t o m o f the j a c k e t u p a n d o v e r
the crest o f the I l i u m . In these strips, o n e - f o u r t h i n c h h o l e s are d r i l l e d and
s t a g g e r e d a b o u t o n e - h a l f i n c h apart o v e r the crest o f the I l i u m o n l y . T h e s e
o n e - f o u r t h i n c h h o l e s a l l o w resin to run t h r o u g h i n t o the i n d e n t a t i o n o v e r the
crest d u r i n g l a m i n a t i o n . A f t e r the metal is bent and drilled, it is then re­
m o v e d f r o m the cast. A c i r c u m f e r e n c e m e a s u r e m e n t is taken a r o u n d the
t h o r a x , p e l v i s a n d o v e r the crest o f the cast. F r o m these three m e a s u r e m e n t s
a p a p e r pattern is m a d e a n d the first l a y e r o f D a c r o n felt, o n e - f o u r t h i n c h
thick, is made, folded in half and sewed in a seam. By cutting the Dacron
from a pattern the necessary tightness is acquired between cast and Dacron.
The Dacron is then stretched over the cast, the seam being in back where the
jacket is opened, and stapled around the axilla line to the cast. After the
first layer of Dacron is applied to the east, cut six strips of Dacron about
one-and-a-half inches wide and long enough to cover from anterior superior
spine to posterior superior spine. Lay these Dacron strips, three to each
side, into the indentations over the crest of the Ilium. The metal strips
that have been cut and pre-bent are now ready for pre-application to the cast
Next place the metal strips back in place over the Dacron strips, making
sure the one-fourth inch holes are drilled, and apply the second layer of
Dacron felt, using the foregoing process. The metal work is thus between
the interior and exterior surfaces of the lamination.
Figure 1 — S h o w i n g the plastic lamination.
Notice the indentation over the crest inside.
A f t e r t w o D a c r o n s are a p p l i e d , pull
o n three n y l o n s t o c k i n e t t e s sewed
s q u a r e a c r o s s a n d tie off o n the p i p e
inserted into the cast. M a k e a P o l y
Vinyl A l c o h o l b a g long enough to
Figure 2 — T h e plastic jacket and exterior
e x t e n d at least twelve i n c h e s b e y o n d
metal frame showing adjustability o f the
e a c h e n d o f the cast. T h e cast is p u t
Orthosis.
in the v i s e , in an i n v e r t e d p o s i t i o n
and is r e a d y f o r l a m i n a t i o n . M i x e n o u g h resin t o t h o r o u g h l y saturate d e p e n d ­
i n g o n t h e size o f the cast. A m i x t u r e o f 7 0 p e r c e n t 4 1 3 4 t o 3 0 p e r cent 4 1 1 0
will g i v e sufficient flexibility. A d d to this the catalyst a n d c o l o r d e p e n d i n g o n
w h e t h e r N e g r o i d o r C a u c a s i a n . A f t e r s o a k i n g in w e t t o w e l a n d a p p l y i n g
the b a g tied off o v e r the h e a d o f the cast, the p r o m o t e r is a d d e d t o the
resin, a l l o w i n g a b o u t 4 0 m i n u t e s setting t i m e .
T h e r e s i n is p o u r e d in f r o m the b o t t o m o f the i n v e r t e d cast a n d w o r k e d
d o w n i n t o t h e l a y e r s o f m a t e r i a l m a k i n g sure to saturate t h o r o u g h l y o v e r the
crests. A f t e r c o m p l e t e s a t u r a t i o n o f the m a t e r i a l is a c q u i r e d tie the b a g off
at the b o t t o m a n d h o o k u p the c u r r e n t v a c u u m m a c h i n e u s e d in P r o s t h e t i c
laminations o n Hemipelvectomies, hip and shoulder disarticulations, etc. T h e
v a c u u m will s u c k the b a g into the m a t e r i a l a n d the D a c r o n strips o v e r the
crest will b e p u l l e d in p r o n o u n c i n g the i n d e n t a t i o n o n the cast to a m a x i m u m
d e g r e e . A s the v a c u u m p u l l s o u t air the e x c e s s l o o s e n e s s o f the b a g c a n b e
p u l l e d p o s t e r i o r l y in a v e r t i c a l s e a m w h i c h will b e c u t o u t in the p o s t e r i o r
o p e n i n g o f the j a c k e t . T h e v a c u u m c o n t i n u e s to run until the l a m i n a t i o n is
f i r m l y set, t h e n r e l e a s e d a n d the l a m i n a t i o n is a l l o w e d t o c o o l . A f t e r c o o l i n g ,
the Orthotist c a n i m m e d i a t e l y r e m o v e the j a c k e t f r o m the O r t h o s i s b y m e a n s
o f a stryker cast cutter. A f t e r the j a c k e t is r e m o v e d a n d cut t o the d e s i r e d
s h a p e , it is then r e a p p l i e d to the cast a n d the m e t a l w o r k m a y b e g i n .
T h e j a c k e t , in finishing, may he c o v e r e d w i t h thin h o r s e h i d e i n s i d e
a n d t u r n e d o v e r the e d g e s o r left as is. T h e metal strips l a m i n a t e d inside
the j a c k e t serve as a n c h o r p o i n t s for the attachment o f the e x t e r i o r m e t a l
u p r i g h t s . T h e vertical u p r i g h t s are o f stainless steel, m a d e a d j u s t a b l e b y
w e l d i n g a T o n the b a r a n d b e n d i n g o v e r the o v e r l a p p i n g b a r . T h e l o n g
b a r , a n t e r i o r l y , after b e i n g shaped is w e l d e d t o the h o r i z o n t a l b a r u n d e r
the m a n d i b l e . F o m here it passes d o w n w a r d t h r o u g h the bent T o n the l o w e r
bar and a n u m b e r 11! h o l e is drilled in the e n d . T h i s o n e h o l e c o r r e s p o n d s
w i t h a series o f h o l e s n u m b e r 2 9 d r i l l e d a n d t a p p e d in the s h o r t b a r f o r
adjustments v e r t i c a l l y . A s the c h i l d g r o w s , m o r e p r e s s u r e is a p p l i e d t h r o u g h
the m a n d i b l e and o c c i p u t plates. T h e p o s t e r i o r b a r s are m a d e in the s a m e
o r d e r . E a c h b a r is set in a p i e c e o f r e c t a n g u l a r t u b i n g c o r r e s p o n d i n g to the
b a r size u s e d .
r
T h e t w o p o s t e r i o r pieces of t u b i n g are riveted with stainless steel rivets
t h r o u g h the plastic and metal strips laminated i n s i d e . T h e a n t e r i o r t u b i n g
is silver s o l d e r e d to a h o r s e s h o e s h a p e d stainless steel b a r a n d t h e n riveted
on, m a k i n g sure the e n d s o f the bar are d i r e c t l y o v e r the inserted metal strips.
T h e neck p i e c e is m a d e o f three i n d i v i d u a l p i e c e s o f m e t a l . A stainless steel
b a r is p l a c e d d i r e c t l y u n d e r the m a n d i b l e in a h o r i z o n t a l p o s i t i o n . T h i s
b a r s h o u l d b e l o n g e n o u g h t o g i v e a m p l e r o o m o n e a c h s i d e o f the n e c k .
C u t t w o o t h e r b a r s w i t h sufficient l e n g t h t o g i v e adjustment and l a y u p
v e r t i c a l l y . B y u s i n g heat put a twist in the e n d s o f e a c h vertical b a r until
the short e n d c r o s s e s the b o d y of the l o n g e n d . A f t e r twisting the b a r s , w e
h a v e t w o v e r t i c a l b a r s w i t h a three-fourth i n c h h o r i z o n t a l twist o n o n e e n d
of e a c h b a r . O v e r - l a p the h o r i z o n t a l twists o f the vertical b a r s o n the e n d s
o f the h o r i z o n t a l b a r u n d e r the m a n d i b l e , drill t h r o u g h b o t h a n d rivet,
m a k i n g a h i n g e . T h e s e t w o vertical b a r s are n o w slotted. T h e o c c i p u t b a r
is m a d e in the s a m e m a n n e r with a h i n g e o n o n e s i d e o n l y a n d the other
side solid.
Figure 3 — T h e head piece assembly with pos­
terior and anterior hinges.
Figure 4 — T h e complete lateral opening o f
the head assembly on its axis.
Figure 5—Displacing of the anterior
showing metal frame swinging out.
bar
Figure 6 — A n t e r i o r view. The T bar anteriorly
keeping the straps of the pads off the busts.
T h e ends of the o c c i p i t a l b a r extend a n t e r i o r l y d o w n e a c h s i d e of the
neck with the a n t e r i o r bars e x t e n d i n g p o s t e r i o r l y . These liars are o v e r l a p p e d
and are cut l e a v i n g room for future adjustments of the head p i e c e . Two
screws are tapped a n d s c r e w e d in from the inside of the lateral vertical b a r s
of the p o s t e r i o r head piece. The b o d y o f these screws passes t h r o u g h the
slotted e n d s o f the a n t e r i o r vertical b a r s and are s e c u r e d with w i n g n u t s . T h e
h e a d p i e c e is n o w a s s e m b l e d in a three h i n g e affair. The s o l i d side o f the
h e a d p i e c e is left fastened w h i l e the d o u b l e h i n g e d v e r t i c a l b a r s o n the other
s i d e are u n d o n e a n d b o t h v e r t i c a l b a r s s w i n g o u t o n their a x i s l e a v i n g a
c o m p l e t e o p e n i n g o f the h e a d p i e c e laterally.
T h e c h i n and o c c i p u t plates are c u p p e d to fit, p a d d e d w i t h f o a m r u b b e r ,
c o v e r e d w i t h h o r s e h i d e a n d sewn w i t h a b a s e b a l l stitch b y h a n d . A f t e r the
b r a c e is a p p l i e d , the patient m a y easily d i s a s s e m b l e it f o r r e m o v a l . T h e
patient r e m o v e s the w i n g n u t s on the d o u b l e h i n g e d side a l l o w i n g the vertical
b a r s to s w i n g out o n their a x i s l e a v i n g the c o m p l e t e s i d e o f the n e c k p i e c e
o p e n . T h e h e a d a n d n e c k pass laterally t h r o u g h this o p e n i n g as the a n t e r i o r
b a r is p u l l e d u p w a r d out o f its t u b i n g . O n c e the a n t e r i o r b a r is d i s p l a c e d
f r o m its t u b i n g it s w i n g s o n its h i n g e s t o the o p p o s i t e side, t a k i n g w i t h it
the c h i n p i e c e . T h e patient m a y then r e a c h o v e r h i s h e a d as in r e m o v i n g
a sweater a n d pull u p w a r d o n the p o s t e r i o r u p r i g h t s d i s p l a c i n g t h e m f r o m the
t u b i n g . T h e c o m p l e t e metal f r a m e is r e m o v e d intact b y the use o f the s o l i d
side o f the n e c k p i e c e . T h e p o s t e r i o r straps are then u n d o n e a n d the j a c k e t
r e m o v e d . T h e b r a c e is r e a p p l i e d r e v e r s i n g e a c h step.
A m o v e a b l e T b a r w a s f o u n d essential o n the a n t e r i o r u p r i g h t in k e e p i n g
the straps o f the pressure p a d off o f the busts. T h e straps o f the p r e s s u r e p a d
are h e l d in p l a c e b y truss studs, so p l a c e d o n the metal f r a m e that the pressure
p a d m a y b e p l a c e d at the a p e x o f the c u r v e , f u r n i s h i n g the p a d w i t h a m a x i ­
m u m d e g r e e o f c o r r e c t i o n . A sling t y p e c o u n t e r p r e s s u r e p a d is used o n the
o p p o s i t e s i d e u n d e r the axilla. It s h o u l d fit l o o s e l y a n d serve as a c r u t c h and
a m e a n s o f k e e p i n g the patient c e n t e r e d in the b r a c e .
B y u s i n g this m e t h o d , the Orthotist saves h i m s e l f v a l u a b l e t i m e w h i c h
m a y b e utilized f o r other t h i n g s . H e has s a v e d t i m e used in b e n d i n g a n d
c u p p i n g the metal strips in o v e r the crests and m o u l d i n g the leather and
w a i t i n g f o r it t o d r y . T h e finished l a m i n a t e d j a c k e t is n i c e r e x t e r i o r l y a n d
i n t e r i o r l y , has a beller, c l o s e r fit and retains a l o n g e r flexibility than leather
Without c r a c k i n g . T h e plastic jacket m a y also be relieved inside with a sand
c o n e if n e c e s s a r y . A p p r o x i m a t e l y three h o u r s are r e q u i r e d to use this m e t h o d .
W o r k i n g in c l o s e u n i s o n with the D o c t o r and T h e r a p i s t , several o f these
types of b r a c e s h a v e been c l i n i c a l l y c h e c k e d out a n d successfully used at
the Jr. L e a g u e H o m e f o r C r i p p l e d C h i l d r e n at Nashville. T e n n e s s e e .
Figure 7 — P o s t e r i o r view. The pressure pad
at the apex of the curve on a right Scoliosis.
Figure 8 — L a t e r a l view. T h e completeOrthosi
Figure 9 — I n i t i a l fitting and application of
the Orthosis.
Figure 10—Clinical Checkout.
May
7,
1963
M a x i m a l utilization of the Milwaukee type brace for the correction
o f spinal curve problems has been h a m p e r e d in the past b y several
p r o b l e m s . O n e s u c h initial problem h a s b e e n that o f ACquiring an
a d e q u a t e fit o f the pelvic g i r d l e e x p e r i e n c e d with the m o u l d e d leather
process. S i n c e s u c h a p r e c i s e fit has been f o u n d to be a vital part of
the f u n c t i o n o f the d e v i c e , it has been felt that the use o f the plastic
laminate j a c k e t affords a m e t h o d o f faithful r e p r o d u c t i o n o f the cast
contours.
A s e c o n d p r o b l e m , and p r o b a b l y the m o s t i m p o r t a n t c o n s i d e r a ­
t i o n , h a s b e e n o n e o f a s s u r i n g sufficient patient c o m f o r t a n d facility
to e n d u r e the neccssary wearing o f the b r a c e . The use o f the h i n g e d
girdle and neck piece, as d e s c r i b e d a b o v e , has been an i m p o r t a n t
contribution to this a s p e c t . T h i s a l l o w s ease o f e n t r y a n d exit f r o m
the b r a c e for b r i e f periods o f rest a n d f o r p e r s o n a l c a r e , that seem
to please the patients a n d their families, and thereby c o n t r i b u t e to m o r e
intensive c o - o p e r a t i o n o n their p a r t .
T h u s far, the use o f this m o d i f i e d t y p e o f M i l w a u k e e b r a c e h a s
b e e n d e e m e d as effective, if n o t m o r e s o , than the p r e v i o u s t y p e s in
the c o r r e c t i o n o f the d e f o r m e d s p i n e .
Philip B. Williams, M . D .
VRA OFFICIALS RECEIVE H O N O R
AWARDS
S e c r e t a r y A n t h o n y J . C e l e b r e z z e p r e s e n t e d h o n o r a w a r d s this spring
to o u t s t a n d i n g e m p l o y e e s o f the D e p a r t m e n t o f H e a l t h , E d u c a t i o n , a n d W e l ­
fare at the A n n u a l A w a r d s C e r e m o n y . T h e e m p l o y e e s w e r e r e c o g n i z e d f o r
their c o n t r i b u t i o n s to health, e d u c a t i o n , a n d w e l f a r e a n d f o r their a c h i e v e ­
m e n t s in the s e r v i c e o f the D e p a r t m e n t .
J a m e s F . Garrett, P h . D . , Assistant C o m m i s s i o n e r , R e s e a r c h a n d T r a i n ­
ing, Vocational Rehabilitation Administration, Washington, D . C . , received
the D i s t i n g u i s h e d S e r v i c e A w a r d , the h i g h e s t h o n o r c o n f e r r e d b y the Sec­
retary. D r . Garrett w a s o n e o f n i n e s o h o n o r e d .
T h r e e other V o c a t i o n a l R e h a b i l i t a t i o n A d m i n i s t r a t i o n m e m b e r s r e c e i v e d
the S u p e r i o r S e r v i c e A w a r d . T h e y a r e :
Russell J. N . D e a n , C h a i r m a n ,
Washington, D . C .
W i l l i a m M . E s h e l m a n , Assistant
velopment, Washington, D . C .
P o l i c y Planning and Legislation
Chief, D i v i s i o n o f State P r o g r a m
C o r b e t t R e e d y , R e g i o n a l R e p r e s e n t a t i v e , Charlottesville,
Virginia
Staff,
De­