Splinting Lily

Age related changes/medical conditions

cognition

cardiovascular/hematological

digestive/metabolic/endocrine

genitourinary

skin functions

neuromuskuloskeletal

sensory functions

Considerations of orthotic in short term setting

prevent secondary conditions

monitor recovery

optimize positioning

forward info to discharge setting

Considerations of orthotic in long term setting

choose safe materials for clients with cognitive impairment or restricted mobility

train team members to monitor skin integrity

Considerations of orthotic in community based setting

provide pictures and written instructions for use and care

provide contact information in case questions arise

orthoses typically enable functional participation

orthoses must be versatile and durable

For older adults, keep the design...

simple for easy donning/doffing

For older adults, you can label the orthosis with

name

left/right

hand/foot

landmarks for proper positioning

Written and oral instructions should be provided which include...

application

wearing schedule

precautions

Goals of pediatric orthoses for positioning

mobilize joints

reduce contractures

provide stability

rest

proper alignment

Goals of pediatric orthoses for function

enable existing function to continue

improve existing function

substitute for weak or absent muscles

augment benefits of therapy

Goals of pediatric orthoses for hygiene

improve or prevent hygiene problem

Goals of pediatric orthoses for protection

keep child safe

prevent undesired behaviors

Fabrication considerations for children

different proportions

they're constantly growing

parent/caregiver education

Foundational movement patterns are set within the first...

2-3 years

Approaches to pediatric orthoses fabrication

engage child in the process

frequently monitor for physical growth and psychosocial development

caregiver engagement

safety

prepare the child

custom designs

material selection

pattern making

time

padding and strapping

Wearing schedule should align with ______

purpose

Purpose/goals of orthoses for arthritis

manage pain

improve function

joint protection

Fabrication considerations for orthoses for arthritis

pressure areas

joint alignment

Wearing schedules for orthoses for arthritis

patient and condition specific

Precautions for orthoses for arthritis

do no harm

Purpose/goals of orthoses for fractures

immobilize for healing

Fabrication considerations of orthoses for fractures

fluctuation in edema

anticipate potential pressure ares

Wearing schedules for orthoses for fractures

condition and protocol specific

Precautions for orthoses for fractures

do no harm

Purpose/goals of orthoses for extensor tendons injuries

position and protect healing tendon

prevent scarring

Fabrication considerations for orthoses for extensor tendons injures

allowing as much movement without compromising healing structure

Wearing schedules for orthoses for extensor tendons injures

condition/patient and protocol specific

Precautions for orthoses for extensor tendons injures

follow healing protocol

Purpose/goals of orthoses for flexor tendon injuries

position and protect healing tendons

prevent scarring

Fabrication considerations for orthoses for flexor tendon injuries

allowing as much movement without compromising healing structure

Wearing schedules for orthoses for flexor tendon injuries

condition/patient and protocol specific

Precautions for orthoses for flexor tendon injuries

following healing protocol

Intrinsic plus/Antideformity position

MCP flexion 50-80

PIP extension

DIP extension

Wrist extension 15-20

Thumb abducted with IP extended

Intrinsic plus/Antideformity position is considered safe to immobilize for...

long periods of time without developing hand stiffness/contractures

Advantages of prefabricated orthoses

time efficient for therapists

immediate feedback

lightweight

sportier look

some have soft material

supports and allows movement

may be more sensitive on scars/skin

less pressure over bony prominences

Disadvantages of prefabricated orthoses

compromised joint position

may be less supportive

may allow for more mobility

dont conform

difficult to fit

does not address all conditions

difficult and expensive to stock

Low temperature thermoplastic materials (LTT)

softens between 130-180 degrees

High temperature thermoplastic materials

softens above 250 degrees

How do you choose which material?

patient population

diagnosis

therapists preference/familiarity

availability

client factors

Material content and properties

memory

drapability

elasticity

bonding

self-finishing edges

conformability

flexibility

durability

perforation

finish

color

thickness

Examples of tools and resources

scissors

splint pan

grease pencils

contact cement

velcro hook/pile

d-rings

outriggers

Finishing touches

padding

avoid pressure areas

finish edges

reinforcement

Types of padding

moleskin

molestick

polycushion

sticky-back T-foam

Assure that MD prescription for OT intervention provides clear info of...

diagnoses

purpose

involved body part

duration of orthosis wear

The MD prescription will guide your...

plans for orthosis fabrication and the education you provide to your client/patient

Factors that may influence adherence to home program

client understanding of medical necessity

social support

valued/necessary life roles/tasks performed while wearing orthosis

Considerations: cognitive status

attention

memory

problem solving abilities

performance analysis

Considerations: health literacy needs

demonstration

written information

pictures/graphics

writing directly on orthosis

Use ______ _______ for client to demo understanding

teach back

Guiding questions for wearing schedule

purpose

compliant

medical contraindications/precautions

patient tolerance of orthosis

assitance needed to don/doff

Clear instructions for orthosis care

avoid heat sources

cleaning procedures

keep away from pets

Precautions during orthosis fabrication and fitting

fragile skin

impaired sensation

fluctuating edema

impaired vision

Skin checking: darker skin tones

feel for changes in temp over boney prominences

watch for change in texture

watch for change in color

Change in texture in darker skin tones

smoother or shinier can indicate lack of blood flow

bogginess can indicate wound below surface

Skin checking: lighter skin tones

watch for redness around bony prominences and borders of orthosis

Areas of redness should not last more than...

15 minutes after removal

Stage 1 pressure injury: assessing dark skin tones

no visible blanching in response to pressure

redness may not be visible

Deep tissue pressure injury: assessing dark skin tones

may not be easily visualized

assess for pain and changes in skin temp

Inflammation: assessing dark skin tones

recently resolves areas of inflammation may appear darker

compare affected area with non-affected skin for temp, color, shine, tautness, pitting edema and pressure

Ecchymoses (bruising): assessing dark skin tones

bruised areas may appear darker and may be tender when palmated

Finger gutter orthosis can be used to treat

PIP and DIP fractures/sprain

contractures

mallet finger

tendon laceration

Considerations for finger gutter fabrication

know where injury is

MCP creases should be clear to allow for full ROM

changes in edema may require orthosis modifications

Volar wrist orthosis can be used to treat

carpal tunnel

radial nerve palsy

wrist sprain/fracture

RA exacerbation

drop wrist

Considerations for volar wrist fabrication

condition will guide wrist angle

allow for full thumb ROM

radial and ulnar styloids are potential pressure points

orthosis should not limit hand function

Short opponens can be used to treat

skiers thumb

gamekeepers thumb

golfers thumb

thumb CMC osteoarthritis

Considerations for short opponens fabrication

thump IP joint is typically left free

allow for full wrist ROM

thumb is typically in palmar abduction

Resting hand can be used to treat

RA exacerbation

burns

crash injuries

complex regional pain syndrome

acquired brain injury

radial nerve injury

Considerations for resting hand fabrication

position of joints will vary depending on clients condition and goals of treatment

lots of joint included means lots of potential pressure areas

Long opponens can be used to treat

dequervain tenosynovitis

thumb CMC osteoarthiritis

RA exacerbation

tendonitis

scaphoid fracture

Considerations for long opponens fabrication

thumb IP joint is typically left free

thumb is typically in palmar abduction

radial and ulnar styloids are potential pressure areas

Standardized outcome measures

DASH/QuickDASH

COPM

Patient Related Wrist Evaluation (PRWE)

Moberg Pick-up Test

Jebsen-Taylor Hand Function Test

Provocative Tests

techniques that reproduce specific symptoms

Top-down approach

occupational performance analysis

client-centered frame of reference

Bottom up

evaluate pathology

attempt to connect impairments in body functions/structures to performance difficulties

How are the arches of the hand related to function?

balance stability and mobility, allowing the palm to cup, grip objects of various shapes, and execute fine motor skills

Features of the snuff box

extensor pollicis longus

abductor pollicis longus

extensor pollicis brevis

You dont want to over immobilize the snuff box because...

you want to preserve movement and function where you can

When possible it can be really helpful to compare...

both sides

Wrist joint

ulna, radius and 8 carpal bones

pronation/supination

ligament support

Finger and thumb joints (palmar surface)

thick

immobile

hairless

sensory

Finger and thumb joints (dorsal surface)

thin

mobile

edema accumulates

Shoulder complex

high mobility at cost of stability

scapulohumeral rhythm

Elbow joint

2 degrees of freedom

ligament support

*considerations during splinting

Following surgery, the targets of orthosis intervention are to...

protect nerve computation

reduce edema

control pain

Factors that determine the duration of immobilization for nerve conditions

operative procedure

location of nerve

amount of nerve movement

concomitant procedures

patient/surgeon related factors

A nerve repair is typically immobilized for up to _ _______ compared to nerve transfers/grafts

3 weeks

Nerve regeneration is approximately _____ per day

1 mm

Sometimes its takes up to ________ for initiation of regeneration

one month

Ulnar nerve dermatome

Median nerve dermatome

Radial nerve dermatome

Potential causes of radial nerve injury

saturday night palsy

honeymoon palsy

crutch palsy

humeral fracture

entrapment at elbow

elbow fracture

entrapment at wrist

Symptoms of radial nerve injury (axilla)

weakness

tingling and numbness from back of arm to hand

Symptoms of radial nerve injury (spiral groove)

weakening of brachioradialis

interferes with ability to bend wrist back and straighten fingers

Symptoms of radial nerve injury (posterior interosseous nerve)

muscle weakness

inability to extend ones fingers

Purpose/goals of orthotic intervention for radial nerve conditions

position for healing, comfort and function

facilitate extension

Fabrication considerations for orthotic intervention for radial nerve conditions

lack of motor control

posting to assist fabrication

provide "just right" tension

Wearing schedules/functional considerations for orthotic intervention for radial nerve conditions

static for comfort and positioning

dynamic for functioning

Precautions for orthotic intervention for radial nerve conditions

dorsal pressure areas

decreased sensation

client centered wear schedules

Potential causes of ulnar nerve injury

fracture at medial epicondyle

fracture of olecranon process

compression at epicondylar groove

compression at wrist

Froment's sign

thumb IP flexion during lateral pinch attempt.