OTA 206 - CH.19 Splinting

Purpose of Splinting

• To protect, support, and immobilize joints to permit healing

• To position and maintain the integrity of arches, ligaments, structures, and joints

• To correct a deformity or prevent further deformity (ulnar drift)

• To substitute for weak or absent muscle function caused by neuromuscular disease or spinal cord injury

• To maximize ROM and prevent contractures

• To increase ADL independence (attached to device/tool= walker orthosis)

• To exercise

• To enhance positioning and functional performance in patients with abnormal tone

Bones

• Radius

• Ulna

• Carpal bones

• Phalanges

Bony Prominences:

The styloid process of ulna, head of the thenar metacarpal

Alignment

Capitate is the center of the wrist

Combined movement of hand, wrist, and forearm =

allows for a variety of movements needed for various activities.

When each finger flexes, they converge towards the center of the wrist =

capitate

When flexed together,

they contact the palm parallel to each other.

Longitudinal Arch

• Follows the lines of the Carpal and Metacarpal bones of the 3rd finger

• Flexion and extension of the fingers occurs along this arch

Proximal Transverse Arch

• Bony, fixed arch formed by the proximal row of the carpals and annular ligaments (carpal tunnel)

• Within this arch- includes nerves, blood supply, and forms fulcrum for finger flexors

Distal Transverse Arch (Metacarpal Arch)

• Across metacarpal heads (knuckles)

• Important for dexterity and functional hand use

• Mobility of this arch is critical for hand functioning

• A splint must be formed to preserve this arch to ensure maximal functional use of the hand while the splint is on or off. 

Dual obliquity

• Natural non-parallel lines from 2nd to 5th metacarpal. 

  • Hand in functional position is higher on radial side because radial side fingers are longer than ulnar side fingers

Creases

• Skin folds can act as guides when fabricating and fitting splints

• Creases indicate an axis of movement for the joint

Creases Includes:

• wrist

• distal palmar

• proximal palmar

• thenar

• creases at each finger joint (palmar digital, PIP, DIP)

Dorsal skin of hand is

fine, supple, and mobile to allow free movement of fingers in flexion and extension

Palmar skin is

tough, thicker, and inelastic to protect underlying structures and prevent slippage with grasping items.

Radial nerve

• Extensor / Supinator muscles on dorsal radial side of hand

• “Wrist drop”

Medial nerve

• Supply flexor / pronator muscles thenar group, 1st / 2nd lumbricals

• Thenar eminence + digits 2+3

• “Ape Hand”

• “Hand of Benediction"

Ulnar nerve

• Intrinsic muscles of the hand focusing on ulnar side

• “Claw hand”

Tenodesis

• Orthopedic observation of passive hand grasp and release mechanism affected by wrist extension and flexion

  • Caused by attachment of finger tendons to the bones and the passive tension created by two-joint muscles used to produce movement 

  • Moving the wrist in extension will cause the fingers to flex 

  • Moving the wrist in flexion will cause the fingers to extend.

(1) Static Splint - Fabricated

• No moving parts and used to immobilize

• Generally used to place the hand in a functional position 

  • Protect weakened muscles from overstretching or keep functioning muscles from contracting

  • Support the hand for resting or healing

  • Prevent or correct a deformity

(1) Static Splint - Pre-fabricated

• Can be ordered through a medical supply company

• Can customize and fit certain parts 

(2) Dynamic

• Generally have a static base and one or more moving parts.

• Allows for mobility in certain directions and controls the degree and direction

• Correct or prevent a deformity, such as tightening joints or muscles

• Prevent weakened muscles from overstretching

• Assist in strengthening weak muscles or tendons

• Prepare for surgical procedures, such as increasing ROM

• Position or protect areas following burn debridement, skin graft, or other surgical procedures

Tenodesis splint

used by patients with no or very limited active hand movement (C6 SPI) Thermoplastic Tenodesis splint

Splinting material

• Low-temperature thermoplastics 

• Material selected by moldability, drapability, elasticity, memory, self-bonding, etc.

  • Aquaplast

• Sockinette

Straps

• Velcro with self-adhesive backing and soft strapping

• Typically strapped at three points

Padding

Moleskin or other padding for bony prominences if necessary

Wrist Cock-Up Splint

• Use to support and/or position the wrist on the volar surface

• Wrist is positioned in about 15 degrees of extension

• Dx: wrist injuries/fx, median nerve compression injuries, spasticity/deformity, CTS, arthritis, CP

DR.Cuma

• Drop - Radial

• Claw - Ulnar

• Medial - Ape

Radial nerve injury

• “Wrist drop”

• Dynaamic wrist extension splint or volar splint

Ulnar nerve injury

• “Claw hand”

• MCP dorsal blocking splint (counteracts hyperext. Of MCPs and flexion of PIPs)

• Most commonly affects digits 4 & 5

Medial nerve injury

• “Ape Hand” - thenar wasting

• C-bar or short opponens splint (thumb spica)

Resting hand splint

• Common for tendonitis, contractures, rheumatoid arthritis, carpal tunnel syndrome, flaccid CVA

• Can be mitt or webbed style 

• Maintains the arches of hand and integrity of structures

  • Wrist at 10-20 degrees extension

  • Slight flexion of finger joints

  • Thumb midway between opposition and abduction, thumb pad towards the index finger

Thumb spica (Short opponens splint)

• Used to immobilize the thumb and/or wrist while allowing other digits to move freely

• Provides support for thumb injuries, gamekeeper’s thumb, osteoarthritis, de Quervain’s syndrome, or fractures of the scaphoid, lunate, or first metacarpal. 

Different silver ring splints

• Boutonniere deformity

• Swan-neck deformity

Precautions

• It is important to give verbal and written instructions to patients when issuing splints

  • Consider cognition, perception, maturity, and education level 

• Make sure the client can don and doff splint- if not make sure you complete caregiver education!

• Splints can be cleaned with warm water, mild soap or alcohol. 

• Never leave the splint in a hot area (melt)

(Precautions - Skin Integrity) When splints are initially issued the area should be checked every half hour to watch for any red marks from pressure or skin irritation

• If the client noticed red marks or irritation, they need to contact the OT practitioner ASAP for modification

• Advise the client to discontinue wear until follow up 

Stockinette, powder, or cornstarch can be used to help absorb excess moisture.

Excess moisture can lead to skin breakdown and infections

Depending on the type of splint and purpose, splints will have different wear schedules

• Ranging from all day, at night, during certain activities, off/on specific hours

• Usually best to start with 1-2 hours and progress tolerance

• OTA should recommend building up tolerance over the first few days

• Discuss with your OTR!

Resting Hand Splints

• RHS splints hold hand and wrist in functional position, but do not allow for movement or activity

• Typically recommended wearing during sleeping or rest times. 

• Recommended to secure straps as tight as a watchband

How many arches are there?

three

The creases are important as they indicate

where the axes of motion for the joints occurs.

the three arches:

• Longitudinal arch

• Proximal transverse arch

• Distal transverse arch

• Creases at each finger joint.

the proximal crease is associated with MCP flexion of digit

two and three

distal crease is associated with flexion of the digits

three, four, and five

Opposition of the thumb is the basis of all prehension patterns. Therefore, if this area is to be included in the splint this digit is positioned this way to allow

grasp and prehension

The functional position of the hand involves

• 20 to 30 degrees of wrist extension

• thumb abducted and opposed to the pad of the middle finger

• MCPs flexed to approximately 30 degrees

• IPs in 45 degrees of flexion

Resting position

• 10-20 degrees of wrist extension

• slight flexion of all finger joints

• thumb midway between opposition and abduction

• thumb pad towards the index finger

another name for the Position of Safe Immobilization

Safe Positioning

Safe Positioning

• 10 to 30 degrees wrist extension

• MCP flexed

• IP full extension

Current classification system

Expanded Splint Classification System (ESCS)

How does the ESCS classify

• immobilization

• mobilization

• restriction

• torque transmission

older classifications

• static

• dynamic

• static progressive

Examples of why we splint:

• To protect, support, or immobilize joints to permit healing after inflammation or injury to the tendons, bones joint, soft tissue, or vascular/nerve supply.

• To position and maintain alignment you keep integrity of the arches, ligamentous structures and joint relationships.

• To correct deformity or to prevent further deformity.

• To substitute for weak and absent muscle function

• To maximize ROM

• To increase ADL independence

• To exercise

Examples of how we splint:

• An arthritis resting mitt, which immobilizes the MP and wrist joints (of an inflamed arthritic hand), permits IP movement to all for function.

• An adjustable outrigger on an orthosis ensures alignment of the MP joints after surgical replacement.

• An ulnar drift positioning orthosis is used to align the fingers of a client with RA in a neutral position. In the early stages of the disease the orthosis acts to prevent the rapid progression of the deformity. Later on, it positions the digits for more effective functional use.

• A radial nerve orthosis amplifies the strength of the tendonesis action for the client who cannot actively extend the wrist or fingers. With active finger flexion the wrist is passively extended, thus functionally increasing prehensile strength.

• A dorsal blocking orthosis assists flexion yet blocks extension to decrease stress and stretch on the surgical repair side while permitting tendon excursion.

• It is easier for the client, for example, to have an orthosis attached to a razor to allow him/her to hold it or use a walker orthosis to compensate for weakness or sensory loss.

• mobilization or torque transmission orthoses that either assist or strengthens the client’s own active motion, depending on the direction of pull of the orthosis.

bony prominences:

• radial styloid

• ulnar styloid

• pisiform

• metacarpal heads

• base of the thumb’s metacarpal

• olecranon process

• radial head

• epicondyles

We can avoid pressure in these areas by

• trimming material to avoid them or

• flaring the splint material or

• creating a bubble in the splint material over the prominence.

what can be placed over the prominence before creating the splint

self-stick circle of closed-cell padding

The volar splint can be good due to the high amount of padding on the volar surface. Dorsal is better when we

want to preserve tactile input and functional contact with the volar surface of the hand.

Client should periodically check their skin directly after removing the splint and look for

redness

Visual inspection is extremely important for those clients with

reduced sensation or impaired sensation as they may not be able to otherwise sense these problems.

Forearm based splints should be ____ of the length of the forearm

2/3

the splint should cover about ___ of the circumference of the arm

1/2

________ all edges so they are rounded

flare or pad

The better the fit the more the pressure is

evenly distributed

Client’s need to realize that if the splint gets too hot from being left in a closed car, window sill, etc it can

Melt

At the client’s next visit you should have them show you they can

position it correctly, perform skin checks

What are the 6 steps to making a splint

1. pattern making

2. pattern fitting

3. thermoplastic cutting

4. molding

5. strapping

6. home instruction