Tech & Fab

Airplane Splint

burns, especially axilla

Dynamic splint

Moving parts are included, utilized to increase passive ROM, assist weak motions or substitute for lost motion

Scaphoid fracture Gamekeeper's or skier's thumb (first MC fracture with bony avulsion of UCL) Boxer's fracture/MC of fourth and/or fifth digit

Name three common hand fractures that a hand therapist would treat and manage with an orthosis.

Digits and elbow

Name two potential areas of friction force in a typical wrist immobilization orthosis.

Duran dorsal protection splint

Flexor tendon injuryRadial nerve palsytendinitis/tenosynovitiswrist fracture

Thumb CMC Immobilization Orthosis (HFO)

Give an example of an immobilization orthosis that would allow increased functional use of the hand.

Volar Wrist/Thumb Immobilization Orthosis (WHFO) Wrist 0-20 ext, 0 deviations, thumb between rad and palm abd, MP 10 flex, IP free Distal strap (radial dorsal web), middle strap (proximal to dorsal crease), proximal strap (fitted around arm), and a small strap across the trap doo Smooth and slightly flare borders, make sure bony prominences are clear, and make sure it is comfortable for the patient

Give two examples of immobilization orthosis for a wrist fracture. Include proper positioning, proper strap placement, and important considerations.

Temporal Dimension

Home as routines and order Home as the past, present, and future

Defining Home

Home is a relationship created between an individual and their environment. A house is a dwelling place, whereas home is a relationship between individual and setting. This distinguishes physical living spaces (houses and apartments) from homes.

Visual Analog Scale (VAS) or Numerical Rating Scale (NRS)

How can pain be measured?

Silicone gel dressing applied under the orthosis may prevent formation of excessive scar tissue. The silicone can assist in desensitizing a hypersensitive scar and overall assist in remodeling dense, thick, ropelike scars.

How can scar management be integrated into an orthosis used to protect a tendon repair?

As borders to inhibit or create certain movements

How can the creases of the hand be used during the orthotic fabrication process?

Opponens splint

Median Nerve Injury

thumb posterior splint

Median Nerve Injury

C bar splint

Median Nerve Injury Used to maintain web space No joint stabilization

What is the difference between a mobilization orthosis and a restrictive orthosis?

Mobilization orthoses allow movement and rely on actual cell growth due to tension. Restrictive limit a specific aspect of joint mobility

Volar splint

with the wrist in a neutral carpal tunnel release surgery radial nerve palsytendinitis/tenosynovitisrheumatoid arthritiswrist fracture

Drapability

§ Ability of the thermoplastic to conform without assistance

Conformability

§ Ability of the thermoplastic to contour to anatomy § Beneficial when an intimate fit is required

Memory

§ Ability of the thermoplastic to regain original shape following heating

§ Extrinsic Muscles

§ Act on the hand, but originate outside of the hand § Ex. Flexor pollicis longus

Static progressive splint

§ Apply low-load prolonged-stretch to soft tissue via advancing static positioning to increase PROM § Gradual stretch § Option for compliant motivated patient

Putting it All Together

§ Considerations for splint/orthotic fabrication § Which region(s) of the anatomy require intervention? § What is the objective of the intervention? - Protection after injury, Immobilization, etc. § What qualities are required of the thermoplastic? -Drapability, perforation, rigidity, etc. § Which thermoplastic will you choose?

§ Intrinsic Muscles

§ Contained entirely within the hand § Ex. Opponens pollicis

Prefabricated Finger Splints-> Static Progressive Finger Extension Splint

§ Designed to offer low, prolonged stretch to the PIP joint to encourage extension § Often able to be adjusted by a medically compliant client under guidance from the therapist/MD.

Prefabricated Finger Splints ->Spring Finger Extension Splint

§ Designed to treat a variety of diagnoses § Indicated for the involvement of PIP tightness § Indicated for PIP joint limitations of 45 degrees or less § Dorsal pad distributes pressure evenly across the PIP

Overview of Splint Fabrication

§ Determine - splint and pattern § Decide - material and how to select § Prepare - material § Apply - patient § Finish - trimming, edge finishing, strapping § Assess - fit, make necessary modifications § Instruct - care and wearing schedule

History of Splinting & Orthotics

§ Evidence of orthotics in ancient Egypt § Wars produced largest advancements § Significant improvement within the last 50 years

Perforation Benefits

§ Increased airflow § Reduced skin maceration § Lighter orthotic § Increased client satisfaction

Precut Splint Blanks with Perforation

§ Increased airflow § Reduced weight § Beneficial for those with moisture/ dampness under the splint (ie. dressing drainage, etc.) § Available in various thermoplastics

Precut Splint Blanks

§ Increased efficiency with fabrication -Reduced time cutting, sizing and fitting § Preselected materials appropriate for anatomy and splint type § Helpful for beginners

Sheet Fabrication

§ Increased flexibility in design -Helpful for the fabrication of nontraditional or specific splinting designs § Often more cost efficient than pre-cut splint blanks

Selection Considerations

§ Intrinsic vs extrinsic muscular involvement § Objective of the splint: safety? Immobilization? § Client preference, comfort, and/or compliance

Anatomical Review of Hand

§ Longitudinal Arch § Transverse Metacarpal § Oblique Arches § Anatomy > Arches § Arches > Function § Remember! Splinting must support, not alter normal anatomy

-Within normal limits. -Within functional limits. -Hypermobility that requires further treatment.

•An OT practitioner is assessing the range of motion of an individual who actively demonstrates internal rotation of the shoulder to 70 degrees. The practitioner would MOST likely document this measurement as:

Mobile Arm Supports- MAS

is a shoulder elbow orthosis that supports the weight of the arm and provides assistance to the shoulder and elbow motions through a linkage of bearings joints. Using gravitational forces and occasionally tension from rubber bands or springs to substitute for or supplement loss of strength in shoulder and elbow musculature Mounted on wheelchairs and comprised of forearm trough and optional pivoting and tilting of the proximal arm. Patient Population: M.S., Polio, Guillain-Barre, Amyotrophic lateral sclerosis Specific evaluation for deltoids, elbow flexors, and external rotators most important for function of MAS

ulnar gutter splint

median nerve compression(CTS)

FOREARM BASED SPLINTING PART 2

FOREARM BASED SPLINTING PART 2

Ulnar Fracture

Also called "night stick fracture" Involves distal 2/3 of ulna Applied first week of fracture Orthotic Indications: Angulation less than or equal to 10 degrees Distal 2/3 of ulna

Fracture Orthosis Contraindications

Angulation or deformity is greater than orthosis can correct for Soft tissue loss Instable phase of healing Insensate, dysvascular, neruological patient Polymer sensitivity Open fractures Intra-articular or close to it Non Compliant patients

Commonly Seen Orthotic UE Pathologies

Carpal Tunnel Syndrome Rheumatoid Arthritis Post CVA/SCI Swan Neck/Boutanniere Deformity

Static Shoulder Elbow Orthosis

Commonly seen for support of a painful shoulder or traumatized brachial plexus-injured limb for long term use as opposed to simple sling. The coupling between the forearm trough and the iliac cap can be customized to permit a variety of motions for the glenohumeral joint. Common examples include: "gunslinger," forearm trough, or shoulder abduction orthosis. Patient Population: Brachial Plexus injury Painful or subluxing glenohumeral joint Intrinsic plus hand and wrist C7-8 Spared Can have a an WHO extension is weak hand/wrist

Static Elbow Orthosis

Designed for reducing soft tissue contractures. Must be custom designed and custom fabricated with cuffs and straps. Application of low magnitude, long duration forces is preferable for reducing contractures. Contracture reduction should be done slowly and incrementally in a therapeutic setting. Patient Populations: Can result from trauma or disease Largest population affected is SCI who depend on full ROM of the elbow to propel a wheel chair or bring the hand to the face

Wresting Wrist hand orthosis

Designed to maintain the arches of the hand, keep the thumb abducted and flexed, and maintain the wrist in a functional position (30 degrees) Most often used to preserve the hand architecture but also used to reduce hypertonicity by abducting the fingers Also used to alleviate wrist or hand pain by immobilizing the muscles and tissues and suitable for preventing loss of motion after acute trauma. Patient Populations: CVA, hemiplegia, SCI, traumatic injury Either volar or palmar design to accommodate for patient needs

Shoulder Elbow Wrist Orthosis

Frequently prescribed to protect soft tissues or to prevent contractures of soft tissues or to correct an existing deformity. Can be utilized for static placement or designed to allow for maximum mobility. These orthoses also known as a shoulder stabilizer or airplane orthosis. Patient Populations: Post rotator cuff repairs Anteroposterior capsular repairs Postmanipulation Axillary burns

Ulnar Fracture Orthosis

Full elbow and wrist motion made available to patient Usually flare distal aspect for wrist motion and proximal aspect if patient has a lot of soft tissue Usually provides compression of the majority of the forearm with adjustable straps for increased compression Makes use of interosseus membrane of forearm

Casting for UE Orthosis

Goal is to get hand in functional position Align wrist with third MCP for "neutral" alignment Position thumb for prehension directly under index finger Thumb can be casted separately or included in cast of arm and hand all together Indicate bony prominences with indelible pencil and include bicipital mark (where forearm touches bicep when arm flexed) to indicate proximal trim line.

Hand Orthosis Attachments

MCP Extension Stop: Used for intrinsic weakness of the hand to prevent MCP hyperextension. MCP stop placed just proximal to the IP joints. Used for median and radial nerve injury causing weakening of the transverse arch Thumb Adduction stop: Positions thumb in opposition and maintains thumb web space leaving the hand in a functional position for use. Allows IP flexion of the thumb and flexion of the second MCP joint.

Hand Orthosis

Maintains palmar arch and web space Useful for acute intervention in a painful hand or when thumb contracture is threatening. Used to position the thumb in opposition, leaving the hand in functional position for use. Several different attachments for therapeutic uses to achieve patient specific goals.

Static Hand Orthosis

Maintains the functional position of the hand and prevents development of deformities . Serves as a vehicle for other therapeutic attachments Patient Population: Patients with weakness or paralysis of the hand intrinsic musculature and strong wrist extensors Without this orthosis these patients are at risk for developing flat hand with the thumb carpometacarpal joint in extension The C7 neurosegmental level quadriplegic exhibits this weakness

Post-Operative Care

Post operative orthoses used in conjunction post surgery to facilitate proper healing Usually will involve continued soft tissue compression and selective positioning Can incorporate ROM dial locks for therapeutic purposes to prevent or allow physician specified movements.

Humeral Fracture

Primarily used for fractures of the mid shaft and distal 1/3 of humerus Usually applied after 2nd week post fracture Indications for use: Less than or equal to 30 degrees varus angulation Less than or equal to 20 degrees A/P Less than or equal to 25 mm of shortening

Upper Limb Fracture Orthosis

Primary fracture orthoses for Humerus and Ulna Provides micro-motion (increased osteo-genesis), easier donning and doffing than casts, improved hygiene, adjustability for swelling, adjustability in limb positioning, Maintain limb mobility, and most importantly total contact and soft tissue compression Requires several follow up visits to ensure optimal fit and function

Inflammation, proliferative, remodeling

What are the three stages of tissue healing?

•Factors to Consider when selecting orthosis

-Diagnosis (evidence) -Age -Medical Complications -Goals -Orthotic Design -Occupational Performance -Ability to follow orthotic instructions (client or caregiver) -Independence with regimen -Comfort -Environment

1/16 1.8 mm

-Half the weight of 1/8 3.2 mm splinting material -Easy to cut when cold -Idea for pediatrics, finger splints, and hand-based splints

3/16 4.8 mm

-Maximum Rigidity -idea for body jackets, abnormal tone splints, lower extremity splints, and fracture braces

Creases of the hand

-Palmar Creases § Distal (transverse) § Proximal (transverse) -Additional Landmarks § Thenar eminence § Hypothenar eminence - Splint Borders § Palmar - Proximal to distal crease § Dorsal - Midpoint of creases

Functional Upper Limb Orthosis

Protects and assists weak musculature to perform selective tasks Often uses internal or external power sources to achieve increased functionality of upper limb Often used for patient populations with long standing limitations who would benefit from increased function of hand through use of orthoses

Key Components of the Upper Limb

Shoulder: Positioning and support critical Elbow: Emphasis on flexion Wrist: Achieve most optimal placement and ROM Fingers: Proper positioning for patient goals Thumb: Primary emphasis for prehension and grasp

3/32 2.4mm

-lightweight w/ moderate support -minimizes bulkiness -perfect for a wide range of static and dynamic splints or progressive splints where less weight is desired (i.e arthritis, thumb, hand, wrist, and small area splints.)

Static WHO

Supports the wrist joint, maintains the functional architecture of the hand, and prevents wrist-hand deformities . Patient Populations: Severe weakness or paralysis of the wrist and hand musculature. Prevention of contractures or deformities Often used for post CVA or C1-5 Quadriplegics with zero wrist extensors and an intrinsic minus hand

Hand Orthosis Attachments

Thumb post: Used for Absence of active opposition and thumb flexion or a flail thumb with no volitional control that needs complete positioning and placement. Positions thumb for prehension and grasp. IP extension assist: Used for assisting opening of the fingers to aid in grasp and release. Used for weakness of the intrinsic muscles of the hand with adequate finger flexion.

Problems w/ Upper Extremity Orthosis

Upper extremity orthoses some of the most difficult for compliance Many patient lack the ability to self don orthoses and require additional assistance Cosmesis is a big concern as many upper extremity orthoses are bulky and cumbersome High functionality and mobility of the hand make UE orthoses hard to keep in desired position Upper extremity orthoses often require patience and practice in order to achieve patients goals If the orthoses help a patient achieve their goals, compliance increases exponentially

Colle's Fracture

Usually involves a fall on outstretched hand (females>males) Involves distal 20 mm of radius Orthosis applied second week after fracture Orthosis positioned so that elbow is bent slightly and wrist is ulnarly deviated

Functional Wrist Hand Orthosis- Wrist Driven WHO:

"Flexor hinge WHO" Dynamic prehension orthosis for transferring power from the wrist extensors to the fingers. Active wrist extension provides grasp, and gravity assisted wrist flexion enables the patient to open the hand. The proximal and distal IP joints of fingers 2 and 3 are immobilized along with the carpometacarpal and MCP joints of the thumb. An adjustable actuating lever system at the wrist joint allows the user to fine-tune the wrist joint angle at which prehension occurs. Patient Populations: Paralysis or severe weakness of the hand Wrist extensor strength must be 3+ with functional proximal strength Indicated for SCI C5 and some C6 return or C6, C7 levels

Case Study #1: Mrs. K Thumb Spica § 62 year-old female § Recently started kayaking, 3-4 hrs./day, several times per week § Diagnosis: -Thumb MP joint ligament strain § Physician ordered a forearmbased thumb spica § Actions: - Select thermoplastic and splint base design (ie. precut, preformed, etc.)

- Tips to Fabrication: § Use children's craft foam to create durable reusable patterns § Easy to test on the client's anatomy prior to cutting thermoplastics § May also use padding at the thumb IP or MP to protect skin integrity

1/12 2.0 mm

-lightweight with moderate support -Easy to cut when cold -idea for pediatrics, finger, hand-based splints and other areas requiring lightweight support

Static progressive splint

-provides a constant static force, adjusted serially as tissues lengthen -Often used with contractures in order to elongate affected tissues -ex: pt with TBI causing severe flexor tone -ex: pt recovering from burns -reliable cts w/ normal muscle tone may make more rapid progress b/c they can tailor the adjustment to their own pace and tolerance. -canNOT be used for ct with abnormal tone or ct who is unreliable.

Thumb Spica Splint

-stabilizes and supports CMC joint, IP joint free, includes wrist -provides rest to pt who has pain or edema in thumb Used with diagnosis of RA, sprains, wrist instabilities and surgical repair, DeQuervain's tenosynovitis, Skier's/Gamekeeper's thumb -splint should be worn: during activities that may require extra support; activities that include repetitive movements; at night to provide a functional resting splint

1/8 3.2mm

-traditional thickness that provides stability and firm support -well suited for positioning and holding joints, aiding abnormal tone, contractures, and fracture bracing.

Custom Made orthosis (Process)

1.Trace the pattern 2.Cut out pattern 3.Ensure pattern fit on client's extremity 4.Trace pattern onto thermoplastic sheet 5.Score a square/rectangle on the thermoplastic material around the pattern 6.Soften the material in the splinting pan 7.Remove material with a spatula

Process for Custom-Made Orthosis (cont'd)

9. Cut the pattern using sharp scissors 10. Reheat material 11. Position the client optimally 12. Remove material and drape and form onto patient 13. Make adjustments using heat gun or reheating in splint pan 14. Apply strapping (heat adhesive backing of Velcro for increased bond) 15. Finish the edges by heating with heat gun and smoothing 16. Reinforce if necessary

Functional Wrist Hand Orthosis- Ratchet wrist-hand orthosis

: Enables the patient to grasp and release objects using external power Power is manually controlled and substitutes for finger flexor and extensor muscles that are less than grade 3 A __________ system is used so that the hand can be closed in discrete increments . Pinch is achieved by applying force on the proximal end of the ________ bar or by using the patients own chine, other arm, or battery power to flex the fingers to form 3 jaw chuck. Patient Populations: SCI with weak or no hand or wrist extension, C5 quadriplegics Patient should have grade 2shoulder flexion, abduction, external/internal rotation.

Flail arm splint

Brachial Plexus Injury (BPI)

Boutenniere Deformity

Consists of PIP flexion and DIP hyperextension Ruptured Central Slip Subluxed Lateral Band PIP flexion caused by extensor tendon DIP extension caused by shortening of extensor tendon Can use finger orthoses to encourage PIP extension and prohibit DIP hyperextension (Oval 8)

Protection and support for conditions and injuries

Chapter 7 What is the purpose of a hand based orthosis? Give examples of the appropriate diagnosis and functional goals for hand based orthosis Dorsal/Ulnar/Radial MCP/PIP/DIP Immobilization Orthosis MCP, PIP, or middle phalanx fx, MCP capsulectomy, or sagittal band injury or repairs Immobilize proximal phalanges and metacarpals of IF and MF to allow healing and/or protection of involved structures Thumb MP Immobilization Orthosis UCL injury, RCL injury, TM or CMC jt arthritis, MP jt arthritis, MP jt arthroplasty, MP jt dorsal dislocation Immobilize thumb MP jt to allow for healing of involved structures. Rest painful and/or inflamed MP jt Thumb Abduction Immobilization Orthosis Median nerve injury or postoperative contracture release Prevent soft tissue contracture of first web space as a result of median nerve injury or disease Thumb CMC Immobilization Orthosis TM jt arthritis, lax or subluxed ™ jt, UCL or RCL injury, low median nerve injury Immobilize thumb CMC and MP joints to allow healing, rest, and/or protection of involved structures

Static Orthosis

Classified as therapeutic orthoses For support and positioning of weak or paralyzed upper extremities Used to prevent contractures and further deformity Can also serve as a platform for other therapeutic attachments Classified into levels of involvement: WHO: Wrist-hand orthosis HdO: Hand orthosis EO: Elbow orthosis SEWO: Shoulder-elbow-wrist orthosis SEO: Shoulder-elbow orthosis

Ulnar Nerve Splint

dynamically flexes the MP joints of the ring and little finger to allow functional use of the hand Ulnar Nerve Injury

A circumferential design for immobilization Immobilization orthosis including two-thirds of the length of the forearm

Describe a minimum of two design choices for orthotic management of a distal radius fracture.

OA is referred to as degenerative joint disease and more common in weight bearing joints (hips, knees, feet, and spine). It may affect only one side of the body or one part of the body such as the hands or one thumb. RA is an autoimmune and inflammatory disease of synovial joints. Early onset in shoulders, wrists, and knees, but then involve other joints of UE and LE.

Describe the general difference between OA and RA.

Resistance to stretch is the degree to which heated material is able to counteract being stretched or pulled, giving the therapist valuable information on how much handling the material can tolerate.

Describe the term resistance to stretch and how this relates to the different types of thermoplastic materials.

Base managed by wrist immobilization orthosis with wrist in neutral and MCP free. Worn for 3-4 weeks. Shaft managed by radial/ulnar forearm-based wrist/digit immobilization with wrist extension MCP of 60-70, PIP free, and with or without taping buddy. Worn for 3-4 weeks. Neck managed by radial/ulnar hand-based digit immobilization orthosis with MCP of 60-70, PIP/DIP free.

Describe the three common locations a metacarpal bone tends to fracture and the proper orthotic management and position for each fracture.

Inflammatory: immediate response Proliferative: fibroblasts start the production of collagen fibers, low tendon tensile strength Remodeling/maturation: tendon gains more tensile strength Inflammatory phase - This phase begins at the time of injury and lasts up to four days. It includes clotting of platelets and constriction of blood vessels to stop blood loss, in addition to the arrival of white blood cells to kill bacteria and naturally clean the wound site. Proliferative phase - This phase begins about three days after injury and overlaps with the inflammatory phase. It involves cells called fibroblasts that help to produce new collagen, create new blood vessels, and repair the avascular epithelial tissue. Remodeling phase - This phase can continue for six months to one year after injury. Collagen continues to increase and the tissue begins to contract with the help of fibroblasts, both of which add strength to the new tissue. Excessive collagen can cause scar tissue formation.

Describe the three phases of wound healing and how they impact the healing tendon.

Longitudinal, transverse, spiral, linear, and/or comminuted fractures to the hand, fingers, wrists, elbows, radius, and/or ulna

Describe the upper extremity fractures hand therapists commonly treat.

DIP Immobilization Orthosis

Describe the various orthoses that may be used to address a mallet finger or injury in zone I.

Padding on straps or padding on aspects of orthoses

Describe two techniques for accommodating bony prominences.

Doing, Being, Belonging, Becoming

Doing: Observable elements of occupation Being: Sense of personal existence Belonging: Being a part of groups, communities, and places; something bigger than oneself. Becoming: Change, development, and transformation (Wilcock & Hocking, 2015)

Occupational Dimension

Ease of doing things Meaningful occupations A place of doing, being, belonging, and becoming

Elbow

Elbow flexion remains the biggest importance in regards to movement and stabilization Extension usually aided by gravity Constant positioning in extension increases tension on shoulder joint Elbow flexion imperative for positioning of wrist and hand.

Rest and support weaken structures Reduce pain and inflammation of joints Position the involved joints as close to proper alignment as possible Help prevent, minimize, and/or retard joint deformity Provide external support to improve functional use of the hand Position healing structures appropriately after postoperative procedures

Explain the general goals and precautions for the use of orthoses in the arthritic upper extremity.

Shoulder

In the normal shoulder, the articulating surfaces of the humerus and glenoid provide minimal stability of the shoulder The contact area between the two articulating surfaces is relatively small, with only 25-30% of the humeral head in contact with the glenoid surface in most anatomical positions Due to a lack of bony stability, it relies mostly on capsular, ligamentous, and dynamic muscular activity for constraint (resist joint translation)

Fingers

Increased finger range of motion directly proportional to increased functionality and independence For dynamic orthoses, control over the 2nd and 3rd finger remain primary target for grasp and prehension The MP joints are the most important for and function as they contribute 77% of total arc of finger flexion as it is a diathroidal joint contributing to ab/adduction, critical for prehension. PIP joints are of importance as they produce 85% of intrinsic digital flexion and contribute 20% to the overall arc of finger motion. (Arc from 45-90 deg provides normal function relatively)

Rheumatoid Arthritis

Inflammation of wrist, usually accompanied by Carpal Tunnel and thenar atrophy Boutonniere/swan neck deformity and ulnar deviation commonly seen Orthotic Goals: Decrease pain and swelling Maintain joint mobility/prevent deformity Position MCPs in 25 deg flexion, PIPs slight flexion Wrist in neutral or 10 to 15 deg flexion

Person-Environment Transactions: The Heart of the Home

Interaction between a person and his or her environment is dynamic and changing Person-environment connection can only be understood when examined as a unified system The environment is much more than the physical environment; includes personal, social, cultural, and political aspects Transactions are both observable and unobservable

Carpal Tunnel Syndrome

Main cause is compression of median nerve Main objective is to position wrist in neutral but preferably slight extension (approx 30 degrees) to get pressure off of median nerve Static low profile wrist supports often used to position wrist accordingly Usually accompanied by hypertrophied thenar eminence Assessment: Phalen Manuever (praying hands) Tinnel Sign (tapping on palmar side of wrist)

Post CVA/SCI

Main objective is to position to prevent contractures and prevent wrist and finger flexion due to high tone Usually involves a static volar resting hand orthosis Can incorporate ROM dial lock to gradually increase ROM if contractures/tightness already present Prefabricated models often involve modifications for personalization and optimized use

Serial Static Fabrication Goals

Maintain arches § Contour to skin § Maintain motion (if indicated) § Permit balanced function of unaffected muscles § Allow maximal mobility with optimal stability § Allows for freedom of digits § Minimal stretch for a longer period rather than quick correction § Larger surface area to distribute pressure following the normal contours of the hand and arm

Swan Neck Deformity

PIP hyperextension and DIP flexion Stretching of Palmar Plate Lateral band Dorsal Shifting Ruptured Superficialis Tendon, lateral sides of phalanx Can use finger orthoses to prevent PIP hyperextension and/or DIP flexion

Hand Burns: (Resting Hand Splint )

OT's do not splint in functional position Position in intrinsic-plus (clam digger) or antideformity position · Positioning may vary, depending on surface of hand burned · Goal of position to prevent deformity by keeping collateral ligaments of the MCPs, volar plates of IPs, along /c wrist capsule and ligaments from shortening · Dorsal skin of hand will maintain length in the antideformity position · Thumb web space is vulnerable to remodeling in a shortened form in presence of inflammation and in situation in which tension of the structure is absent

Describe the importance of the antideformity position.

Once therapy begins, you won't need to counteract tissue tightness and ti prevents deformity to facilitate return to function.

Social Dimension

Others in home Family, visitors, neighbours, social network Relationships Social activities

Process

P- Pattern creation R- Refine pattern O- Options for materials C- Cut and Heat E- Evaluate fit while molding S- Strapping and components S- Survey completed orthosis

Thumb Extension Splint

Radial Nerve Palsy

Dimensions of HOme

Physical Personal Social Temporal Occupational Societal

Societal Dimension

Political and economic conditions that influence the resources and control that people have over their homes: Government policies Standards, building codes Renting Funding and guidelines for services

MCP Extension Mobilization Orthosis (WHFO) (Common Name: Dynamic MCP Extension Splint)

Primary Functions: Provide low-load, prolonged extension mobilization force to MCP joints to facilitate lengthening of tissue. Passively support MCP joints in extension while allowing active digital flexion

Antideformity Position

Purpose: often used to place the hand in position to maintain a tension/distraction of anatomic structures to avoid contracture and promote function Positions of Antideformity splint: · Wrist 30 to 40* of extension · Thumb MP 40 to 45* of palmar abduction · Thumb IP joint full extension · MCPs 70 to 90* flexion · PIPs and DIPs in full extension

Personal Dimension

Safety and security Privacy Control, freedom, and independence Identity and connectedness

No, wait. Swelling could cause too much pressure resulting in nerve or blood flow compromisation.

Should a patient be placed immediately into a digit mobilization orthosis 2 days after wrist fracture repair if he or she presents with swollen and stiff fingers? Why or why not?

Because some conditions like diabetes can inhibit healing, patients might be allergic to some materials, and medical problems can mimic or contribute to UE conditions.

Why is it important to take a medical history?

What are the three basic mobilization orthoses and how do they differ from each other?

Static progressive: tension, removable for hygiene Dynamic: Less time with tension, removable for hygiene and at night Serial static: like casts, non-removable

To prevent excessive pressure/discomfort and be more well-molded

Why should orthoses be fabricated as long and wide as possible?

Physical Dimension

Structure, services, and facilities Space Ambient conditions Location of home

Successful Static Splinting Hand Based Splint Fabrication, Part 3

Successful Static Splinting Hand Based Splint Fabrication, Part 3

Silver rings Splint

Swan Neck Deformity

Ulnar Deviation Splint

Ulnar Drift

Wrist

Wrist positioning key for achieving therapeutic goals Neutral positioning or 30 degrees extension is optimal for static orthoses Wrist flexion very imperative for prehension and grasp with dynamic orthoses

Carpal Tunnel Syndrome Splint (typing on computer)

Wrist splint positioned 0-15 degrees extension

Upper Limb Components

Upper limb orthoses are more widely accepted by a patient if the therapeutic purpose is well defined or the orthosis provides a desired function that cannot be accomplished otherwise Therapeutic orthoses tend to be optimized for specific purposes or activities. Often these purposes are divided into static and dynamic purposes. Orthoses are even further divided into therapeutic or functional purposes.

What is EBP and how does it relate to orthotic interventions?

Using clinically relative evidence to support/choose interventions.

Age, medical conditions, nutrition/lifestyle

What factors may negatively influence a patient's ability to heal?

Describes orthoses by body parts, movements, and specifics Ex. SO without joint custom = shoulder orthosis static custom (not prefabricated)

What is an L-Code?

Pattern creation Refine pattern Options for materials Cut and heat Evaluate fit while molding Strapping and components Survey completed orthosis

What is the PROCESS of orthotic fabrication?

Orthotic application. Others discussed were pain control, principles of joint protection teaching, exercise, dynamic stability training, thermal modalities, nonsteroidal anti-inflammatory medications, and corticosteroid injections

What is the conservative orthotic management of the first CMC OA? What are the choices described in this chapter?

High = high vertical outriggers Low = low, close to the surface outriggers

What is the difference between a high- and low-profile design?

So it heals properly

What is the importance of properly positioning the joint acutely?

Wrist and hand extension restriction orthosis. IP joints are in full extension when possible.

What is the most common orthosis used for flexor tendon rehabilitation and how can this be altered to address a developing PIP flexion contracture?

90 degrees. Do regular checks for the angle Give an example of compressive stress and how it relates to an orthotic application. Straps of the orthotic. They need to only come into light contact with the skin to prevent compression.

What is the optimal angle of force application and how can a therapist ensure this is maintained in an orthosis?

A radial head fracture, coronoid fracture, and dislocation of the humeroulnar joint

What is the terrible triad?

Age, injury, motivation, location, and goals

What must a clinician take into consideration when choosing the most appropriate orthosis for a patient?

Heat guns, hole punches

What other tools are helpful to have in the clinic for orthotic fabrication?

The thumb is positioned in mid palmar and radial abduction to preserve the first web space.

What position should the thumb MP be placed in after a skier's injury? Why is this position so important?

Bony prominences, nerves, blood flow, and what signs to look for on these subjects

What precautions must a therapist educate a patient to be aware of when dispensing these devices?

Frequent, regular inspections for adjustments due to their fragile skin and slow healing.

What precautions should be stressed when dispensing an orthosis for a patient with diabetes and rheumatoid arthritis?

Proliferative?

What stage of wound healing is most often treated with immobilization?

Breaks, external fixation repairs, overuse, protection

What types of injuries are most appropriate for an Immobilization orthosis?

Purpose, type, desired joint position, goal, and wearing schedule

What, ideally, needs to be included in a physician referral?

Long use, over bony places, sweating, elderly

When is using padding or lining material appropriate in an orthosis?

Case Study #2: Mrs. Q Volar or Dorsal Wrist Cock-Up § 42 year-old female, legal assistant § Typing at a computer/office work daily § Diagnosis: - Numbness and tingling, productivity suffering due to need for frequent breaks due to discomfort § Increased discomfort upon waking, patient preferred more conservative treatment before considering surgery § Physician ordered a wrist cock-up splint § Actions: -Select thermoplastic and splint base design (ie. precut, preformed, etc)

Volar and/or Dorsal Wrist Cock-Up Case Study #2: Mrs. Q § Determine the approach to splint fabrication for this client § Which approach would you choose? § Why?

WEEK 2 FABRICATION PROCESS

WEEK 2 FABRICATION PROCESS

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What are the best ways to stay abreast of the new component systems available?

Conformity, weight, and perforation. Too high of conformity may not be the best choice if joint swelling fluctuates so more rigid options are best for this population. Orthoses should be lightweight. A highly perforated material may irritate the fragile skin.

What are the considerations for material choice in this patient population and why is it so important?

Less error when cutting

Why is having a good pair of scissors so important with orthotic fabrication?

Give an example of each. Immobilization is used more for postoperative management whereas mobilization is used for pain management, rest, and preventing deformities

What are the general indications for use of immobilization and mobilization orthoses in both populations?

Numbness, paresthesias, burning, motor control changes, and/or pain

What are the signs of nerve irritation?

Pyramid of Progressive Force?

What are the theories behind early passive mobilization (EPM) and early active mobilization (EAM) in flexor and extensor tendon repair management?

Home as place

Space is a neutral physical dimension that lacks meaning. Places are spaces that have been transformed into places of meaning through human events and interaction. Places hold memories of personal experiences. Three elements in transforming space to place: Use of an environment Familiarity with the environment Emotional attachment and ownership of the environment

Tenodesis splint

Spinal Cord c6-c7

Summary

The dimensions of home provide a picture of the complex, and personal environment of home, within which the home modification process occurs. Understanding the experience of home is important Influences home modification decision making When dimensions of home are not valued or understood, negative outcomes can occur Provide modifications and solutions that benefit the client and enhance their experience of home

Understanding the Experience of Home: Culture

The experience of home is tied to its cultural context. Culture shapes each dimension of home. Occupational therapists need to be culturally responsive in their practice.

Thermoplastics

Thickness § Conformity § Drapability § Memory § Resistance to Stretch § Perforation

Thumb

Thumb is top priority for prehension as it provides 40% of overall hand function in uninjured patient. (50% in injured) The ability to grasp is the pinnacle of importance in regards to the thumb Positioning, functionality, and optimization of web space are the top concerns

Distal transverse, proximal transverse, and longitudinal

What are the three arches in the hand?

longitudinal arch hand

begins at the wrist and runs the length of the metacarpal and phalanges for each digit

Humeral Fx orthoses

usually come pre-fabricated but also require trimming and modifications to individualize for patients. Regular follow ups for tightening and cleaning mandatory Fitting protocol: 25 mm inferior to axilla medially 15 mm proximal to medial epicondyle Immediately distal to acromion Proximal to lateral epicondyle Allows for full ROM

Functional Elbow Orthosis- Functional EO's

usually incorporate an elastic device with a locking mechanism to assist elbow flexion with multiple angular lock points. The user initiates elbow flexion with residual musculature or using body mechanics . The elastic device (i.e. spiral spring) assists the flexion until one of the flexion stops is reaches. A release on the stop permits the elbow either to advance to a new greater angle or fall back into extension Patient Populations: Selective loss of elbow flexion secondary to a brachial plexus injury or congenital defect Bilateral applications may be more successful than unilateral (so no dominance)

Serial Static Goals

§ Maintain arches § Contour to skin § Maintain motion (if indicated) § Permit balanced function of unaffected muscles § Allow maximal mobility with optimal stability § Allows for freedom of digits § Minimal stretch for a longer period rather than quick correction § Larger surface area to distribute pressure following the normal contours of the hand and arm

Prefabricated Finger Splints Oval-8 Splint

§ May also be used for trigger finger to rest the tendon § Also frequently prescribed for mallet finger - Occurs when the distal IP flexes and requires assistance with extension

Prefabricated Finger Splints-> Sizing and Placing a Spring Finger Extension Splint

§ Measure from the distal palmar crease to the DIP crease of the palm. § When placing the finger extension splint, do not extend the PIP in question immediately § Measure to determine

Static Splint

§ Most common splint type § No moving parts § Used to support, immobilize, rest, protect, reduce pain and/or prevent muscle shortening or contracture

Aquaplast - T

§ Often preferred by pediatric clients due to color offerings and ability to accommodate § Multiple thickness and perforation options § Thermoplastic with the most 'memory

Finger Gutter Splint

§ Often used for protection of an injured finge r § and prevent flexion Blocks the PIP and DIP joints to keep the finger immobile § Variations in splint design

MP Blocking Splint Design

§ Often used to treat trigger finger § Blocks the MP joint from performing flexion, while allowing free flexion of the IP joint of the digit.

Serial Static Splint

§ Position soft tissue toward the end of available range to increase tissue length § Low-load prolonged stretch solution (Increases ROM) § No movable parts

Preformed Splints

§ Previously molded and sized to client based on a size chart § Easily adjustable and reshaped via heat if needed § Various thermoplastics available

Dynamic splint

§ Static base onto which resilient components (rubber bands, springs, elastic cord) are attached § Increases PROM § Augments AROM by assisting joint through the range § Accommodates for decreased ROM

Polyform

§ The most conforming thermoplastic currently available § Often used for very detailed and/or small anatomical surfaces

Remember:

· Closely monitor pt. and make adjustments as necessary to splint · Splinting pt. /c excessive edema avoid forcing wrist & hand joints into the ideal position. This can cause ischemia from damaged capillaries Edema reduction: · serial splinting may be necessary as ROM is gained to splint toward ideal position · Serial resting hand splints should conform to pt, not attempt to conform pt. to the splint · Accommodate for bandages covering burn sites by proximally forming the pan for MCP flexion · Initial splint provision should be applied /c gauze/wraps rather than straps to reduce risk of compromising circulation · Splints should be removed for exercise, hygiene, and appropriate functional tasks on adult pts.

Emergent Phase

· First 48 to 72 post burn hrs. · During this time frame, dorsal edema occurs and encourages wrist flexion MCP joint hyperextension, and IP joint flexion · Static splinting is initiated during phase to support hand and maintain length of vulnerable structures

Dorsal and volar burns:

· MCPs in 70 to 90* flexion · PIP jts and DIP jts full extension · Palmary abduct thumb to index and middle fingers /c the thumb IP jt extended

Additional intervention for pts /c RA include education on:

· Mgmt. of inflammation · Jt. protection · Muscle strengthening · ROM maintenance · Pain mgmt. reduction techniques · Pts in late stages /c skeletal collapse and deformity may benefit from support of a splint during activities and at nighttime (Biese 2002)

**Remember:

· Thumb web space at risk for developing adduction contracture after burn injury · Palmar abduction of thumb is position of choice for CMC jt. to prevent contracture · Pts may not initially tolerate jt positions · When tolerable splint can be adjusted more closely to ideal position · Stages of burn recovery (emergent, acute, skin grafting, and rehabilitation) should be considered when splinting

Positioning to counteract the forces of edema includes:

· Wrist 15 to 20* extension · MCP jts 60 to 70* flexion · PIP and DIP jts full extension · Thumb positioned midway between palmar and radial abduction /c IP jt slightly flexed

Typical joint placement for RA positions:

· Wrist in 10* of extension (not typical 30*) · Thumb positioned midway between radial and palmar abduction or palmar abduction depending on comfort · MCP joints 35 to 45* of flexion · PIP and DIP joints slight flexion

Functional position (Resting Hand Splint)

· Wrist in 20 to 30* of extension · Thumb in 45* of palmar abduction · MCP joints in 35 to 45* of flexion · PIP and DIP joints in slight flexion

Antideformity position for palmar or circumferential burn: (resting hand Splint)

· Wrist in 30 to 40* of extension and neutral (0*)

Acute and Chronic Rheumatoid Arthritis:

· during periods of acute inflammation and pain requiring support, rest and immobilization · Biomechanical rationale for splinting acutely inflamed joints: reduce pain by relieving stress & muscle spasms · This position may not prevent deformity

With upper extremity orthoses, our main goals usually revolve around...

• Maintain or maximize functionality of the upper limbs • Prevent deformity or contractures • Improve positioning or range of motion of upper limbs • Allow protection and positioning for proper healing and recovery • Improve mobility and quality of life

-Passive flexion at each joint and total the numbers. -Distance from the fingertip to the distal palmar crease with the hand in a fist. -Active flexion at each joint and total the measurements. -Distance between the tip of the thumb and the tip of the fourth finger.

•A method that an OT practitioner can use to document total finger flexion without recording the measurement in degrees would be to measure the:

-Apply the stimuli beginning at the little finger and progress toward the thumb. -Test the thumb area first, then progress toward the little finger. -Present test stimuli in an organized pattern to improve reliability during retesting. -Allow the individual unlimited time to respond.

•An OT practitioner is evaluating two-point discrimination in an individual with median nerve injury. The MOST appropriate procedure is to:

-Check the alignment of the goniometer. -Use a larger goniometer. -Use a smaller goniometer. -Attempt to force the individual's arm further into flexion.

•An OT practitioner measures an individual's elbow PROM three times, and gets three different measurements, varying by up to 10 degrees. The BEST action for the therapist to take is to:

-Good (4) -Fair (3) -Fair minus (3-) -Poor plus (2+)

•An individual is able to complete the full range of shoulder flexion while in a side-lying position during an evaluation. However, against gravity, the individual is not quite able to achieve 75% of the range for shoulder flexion. This muscle should be graded as:

-Mallet deformity. -Boutonniere deformity. -Subluxation deformity. -Swan neck deformity.

•An individual's PIP joint appears flexed, and the DIP joint appears hyperextended. The OT can BEST document this condition as a:

Finger based orthotics

•DIP Immobilization Orthosis •PIP Immobilization Orthosis •Thumb IP Immobilization Orthosis

Considerations

•Fit orthotic 30-60 minutes after pain medication is taken •Skin integrity- cover with stockinet if at risk for burns •Determine best position for clients with hypertonicity and contractures prior to fitting •Educate patient during trial wear time in the clinic. Education includes: Purpose of orthosis, how to don and doff, what to expect and watch for, proper care/cleaning of orthosis, and wear time/schedule •Take pictures with cell phone of proper fit

Examination

•Include subjective and objective information •Standardized and non-standardized testing • •Assessments- DASH, pain scale, volumeter, monofilament, MMT, ROM, dynamometer, pinch gauge

Thumb IP Immobilization (Common Diagnosis)

•Mallet •Distal phalanx fx •Crush injury to distal phalanx •Nail bed injury and repair •Partial tip amputation •IP sprain •IP OA

DIP Immobilization (common Diagnosis)

•Mallet Finger •Distal Phalanx fx •Partial fingertip amputation •Crush injury to distal phalanx •Nail bed injury and repair •DIP OA

Common Splinting Precautions

•Preexisting skin problems •-Bony prominences •-Friction •-Pressure spots

Goals

•See Table 6-1 • 1.Identify problems 2.Prioritize problems 3.Establish short and long-term goals (integrate client's goals if possible)

Referral

•Should Include: - Purpose - Type - Desired joint positions - Goal - Wearing Schedule Disclaimer: This is ideal; however, some information may be missing. If in doubt, contact the physician for further information.

Selecting the Orthosis

•Use clinical reasoning based on evidence based practice and a frame of reference- Ask: What is the goal? •How would the function and fit of a pre-fabricated orthosis compare with a custom-made orthosis? -Soft pre-fabricated vs. LTT custom-made -Consider the person, task, and environment

Wear Schedule

•What does the evidence say? •Light tension over long period of time •Number of hours per day •Time of day (day vs. night) •Static vs. dynamic during sleep •Verbal and written instructions •Teach back method •Measuring follow through

-elbow -mid-forearm -palmar crease -carpal tunnel

•When assessing an individual who is suspected of having carpal tunnel syndrome, the OT tests for Tinel's sign by gently tapping the median nerve at the level of the:

PIP Immobilization (Common Diagnosis)

•Zones III and IV extensor tendon injury •Boutonniere deformity •PIP sprain •PIP intra-articular fx •PIP OA •PIP Arthroplasty •