1. UPPER EXTREMITY ORTHOSIS (STATIC AND DYNAMIC)
Aila Nica J. Bandong, PTRP
University of the Philippines Manila
College of Allied Medical Professions
PT 150: Orthotics and Prosthetics

2. Learning Objectives
At the end of the session the students should be able to:
determine the classification used for upper extremity orthoses
determine diagnostic indications for upper extremity orthoses
determine the components and functions of upper extremity orthoses
discuss several static splints
describe dynamic splints
enumerate the purposes for prescribing dynamic splints
determine physiologic considerations in dynamic splints
determine the basic components and functions of dynamic splints
discuss several dynamic splints

3. Orthosis Clinic Team Orthotist Physician Social worker Psychologist
Patient
Physical Therapist
Occupational Therapist

4. Scope of Practice Occupational Therapy Hand Rehabilitation
Maximize residual function of the patient who has had surgery to, or an injury or the disease of the upper extremity
Physical Therapy
RA Section 16
Assess the need to use assistive device and train patients as called for
Train patients to become functionally independent

5. Orthosis vs. Splint?

6. Characteristics of Thermoplasts
HANDLING
PERFORMANCE

7. Handling Characteristics
Memory
Drapability
Elasticity
Bonding
Self-finishing edges
Heating time
Working time
Shrinkage

8. Performance Characteristics
Conformability
Flexibility
Durability
Rigidity
Moisture Permeability and Air Exchange
Finish
Colors
Thickness

9. Upper Extremity Orthosis Classification
Type
Static
Dynamic
Region
Volar or Dorsal
Joints crossed
* Finger / thumb splint
* Wrist Splint
* Wrist Hand Orthosis
(WHO )
* Elbow (WHO)
* Shoulder (Elbow- WHO)
Function
Flexion
Extension
Abduction
Adduction
Rotation

10. STATIC SPLINTS

11. Purpose of Splinting: STATIC
Immobilize or support
Help prevent deformity
Prevent soft-tissue contracture
Allow attachment of assistive devices
Block a segment

12. Basic Components C-Bar Connector bar Crossbar Cuff or strap
Deviation bar
and pan
Forearm trough
Anatomic bars
Thumb post
Thumb trough
Blocks

13. Basic Components : C-bar

14. Basic Components: Connector bar

15. Basic Components: Cross bar

16. Basic Components: Cuff or Strap

17. Basic Components: Deviation bar

18. Basic Components: Pan and Thumb trough

19. Basic Components: Forearm trough

20. Basic Components: Anatomic Bars
Hypothenar Bar
Metacarpal Bar
Lumbrical Bar
Opponens Bar

21. Basic Components: Thumb Post

22. Basic Components: Blocks

23. Name the components Lumbrical Bar Metacarpal bar Deviation Bar
Forearm trough
Metacarpal bar
Deviation
Bar

24. Upper Extremity Orthosis
Finger and thumb Orthosis
DIP
PIP
Hand Orthosis
Volar or dorsal hand orthosis
Universal Cuff
WHO
Cock - up splint
Resting hand splint
Thumb spica
Antispasticity splints

25. Diagnostic Indications
Fractures
Tendon injuries
Crush injuries
Amputation
Arthritis
Carpal tunnel release
Arthroplasty
Tendon transfer
Tumor excision
Reconstruction of congenital defects
Overuse syndromes
Cumulative trauma disorders

26. Treatment Goals Prevent or decrease edema Assist in tissue healing
Relieve pain
Allow relaxation
Prevent, misuse, disuse and overuse of muscles
Avoid joint jamming or injury
Redevelop motor & sensory function

27. Finger Orthosis ( DIP ) Type Region Function Static Volar
Static or dynamic
Region
Volar or dorsal
Joint crossed
Function
Static Volar
DIP Extension Splint

28. Finger Orthosis ( PIP )
Static Three point orthosis for boutonniere deformity

31. Hand Orthosis Type Region Function Static Dorsal Hand Orthosis
With an MP
Block

32. Hand Orthosis
Universal Cuff

33. Wrist Cock-Up Splint (WHO)
Maintain the wrist in the neutral or mildly extended position
Immmobilizes the wrist while allowing full MCP flexion and thumb mobility

34. Wrist Cock-Up Splint (WHO)
Contraindications:
Active MCP synovitis
Joint inflammation resulting to volar subluxation and ulnar deviation
Disadvantages:
Interferes with tactile sensibility on the palmar surface of the hand
Dorsal strap can impede lymphatic flow

35. Dorsal Wrist Cock-Up Splint
Stronger mechanical support of wrist and freeing up some of the palmar surface for sensory input
Distributes pressure over the larger dorsal wrist surface area
Better tolerated by edematous hand

36. Suggested Wearing Schedule
Hand Condition/
Suggested Wearing Schedule
Position
NERVE COMPRESSION
Carpal Tunnel Syndrome
(median nerve compression)
Carpal Tunnel Release Surgery
Radial Nerve Palsy
Wrist extensor tendinitis
Acute flare up stage: 4 to 6 weeks continuously worn except for cleaning/hygiene and ROM exercises
Gradually decreases in duration with some doctors recommending nighttime wear only
1 week post-surgery, fitting may commence
Wearing schedule that applies during sleep. Strenuous activities, and for support throughout the healing phase
Wrist kept in functional position and the splint should substitute for the loss of the radial nerve by placing the wrist in extension
Continuous wearing followed by gradual weaning of the splint
Volar, dorsal, or ulnar gutter splint with the wrist in a neutral position
Volar splint with the wrist in a neutral or slightly extended position
Volar or dorsal with wrist in 0 to 30 degrees in extension
Volar with degrees of wrist extension

37. Suggested Wearing Schedule
Hand Condition
Suggested Wearing Schedule
Position
FRACTURES
Colle’s fracture
(closed reduction)
Indicated following removal of the cast and healing of fracture
Discontinue use as soon as possible to allow functional hand movement
Volar with maximum passive extension that the patient can tolerate- usually up to 30 degrees
RHEUMATOID ARTHRITIS
Periods of swelling and joint inflammation
Worn continuously with established periods for ROM exercises between splint wearing schedule
Volar, in extension up to 30 degrees based on patient tolerance
OTHER
Reflex Sympathetic Dystrophy
Wrist joint synovitis or tenosynovitis
Nighttime wearing
Worn during acute flare ups
Volar, in extension as tolerated by patient
Volar, o to 15 degrees in extension

38. Resting Hand Splint (WHO)
Immobilize to reduce symptom
Position in functional alignment
Retard further deformity

39. Resting Hand Splints (WHO)
Forearm through
C-bar
Pan
Thumb through

40. Suggested Wearing Schedule
Hand Condition
Suggested Wearing Schedule
Position
RHEUMATOID ARTHRITIS
Acute Exacerbation
Fitted to maintain as close to a functional (midpoint) position as possible until exacerbation is over
Removed for hygiene and exercise purposes
Worn during the day and at nighttime as needed
WRIST: neutral or degrees extension depending on patient tolerance
MCP: degrees flexion and 5-10 degrees ulnar deviation
THUMB: position of comfort in between radial and palmar abduction
TRAUMA
Crush injuries of the hand
Fitted after the injury to reduce pain, edema, and swelling and to provide rest to injured tissues
Worn at nighttime and worn as needed
WRIST: extension of 0 to 30 degrees
MCP: degrees of flexion
PIPs and DIPs: full extension
THUMB: palmar abduction and extension
BURNS
Dorsal or Volar hand burns
Worn after the burn injury until healing begins and removed for dressing changes, hygiene, and exercise
WRIST: Volar or circumferential burn degrees of extension; Dorsal burn neutral position
MCP: degrees of flexion
DIPs: full extension

41. Special Considerations
For burns: make adjustments as bandage bulk changes
Preventing infection: when open wound has exudates, clean splints with warm soapy water, hydrogen peroxide, or rubbing alcohol
Patients in the ICU: use sterile materials; follow protocol of the facility
RA patients benefit from thin thermoplast
( less than 1/8 inch )

42. Thumb Spica Splint (WHO)
Help stabilize CMC, MCP and IP joints
Thumb Post
Volar
Dorsal
Radial
Gutter
Opponens Bar

43. Suggested Wearing Schedule
Hand Condition
Suggested Wearing Schedule
Position
SOFT TISSUE INFLAMMATION
de Quervain’s tenosynovitis
Acute flare-up: worn continuously with removal for hygiene and exercise
IP joint included only if pain is present with IP flexion and resisted IP extension
Long Forearm-based or Radial ulnar gutter splint:
WRIST: 15 degrees of extension
THUMB CMC: palmar abduction 40-45degrees
THUMB MCP: 5 to 10 degrees of flexion
If with inflamed tendons, the the thumb CMC joint is sometimes positioned in radial abduction and extension instead of palmar abduction
RHEUMATOID ARTHRITIS
Periods of pain and inflammation in the thumb joint
Worn continuously with removal for hygiene and exercise
Wearing schedule is adjusted according to the patient’s pain and inflammation levels
Long Forearm-based thumb spica splint
WRIST: degrees of extension
THUMB CMC: palmar abduction 45 degrees; or midway between radial and palmar abduction depending on patient’s tolerance
THUMB MCP: if included, 5 degrees of flexion
TRAUMATIC INJURIES OF THE THUMB
Gamekeeper’s thumb
Worn continuously for 3 to 4 weeks with removal for hygiene
Short opponens splint
MCP: joint immobilized and the thumb CMC joint palmarly abducted 25 to 30 degrees

44. EVIDENCE IN PRACTICE
A review of studies conducted by Oldfield and Felson (2008) regarding the effects of wrist orthotic device use on pain and functionality in patients with RA reveal that the splints improved wrist pain and functionality without compromising dexterity

45. Antispasticity Splints
Platform design
Volar based platform
Dorsal based platform
Finger and thumb position
Finger spreader
Cones

46. Upper Extremity Orthosis
Static Dorsal Elbow Orthosis

47. Upper Extremity Orthosis
Balanced
Forearm
Orthosis
Forearm trough
Elbow dial
Distal arm
Proximal
bearing
Rocker Assembly
Distal bearing
Bracket

48. Upper Extremity Orthosis
Humeral Fracture Brace
Shoulder slings

49. Upper Extremity Orthosis
Airplane Splints

50. DYNAMIC SPLINTS

51. Purpose of Splinting: DYNAMIC
To substitute for loss of motor function
To correct an existing deformity
Provide controlled directional movement
Aid in fracture alignment and wound healing

52. Physiologic Considerations
Too great stretch
Fatigued
injury
Failure
Too little stretch
Atrophy and weaken
Skin, tendons, ligaments, and joint capsules will shorten in the absence of habitual tensile forces
Enough stretch
Three degrees of gain in ROM per week, with a range of 1-10 deg, is acceptable (Cummings et al 1992 )
High intensity short term stretching actually promotes stiffness
The client should sense tension in the tissues but feel no pain

53. Guidelines for Dynamic Splinting
Hepburn, 1987
The stretch should not be perceived as a “stretching” force until at least 1 hour has passed
Client should remain comfortable with the orthosis for up to 12 hours
After removal, the client should feel no more than a stiffness or mild ache

54. Basic Components Outrigger Dynamic Assist Finger cuff
Reinforcement bar
Fingernail attachments
Phalangeal bar/finger pan

55. Basic Components: Outrigger

56. Basic Components: Dynamic Assist
Springwire finger coils
Elastic bands
Springwire knuckle bender

57. Basic Components: Finger Cuff

58. Basic Components: Reinforcement Bar

59. Basic Components: Phalangeal Bar/Finger Pan

60. Basic Components: Fingernail Attachments
hooks
Contoured finger hooks

61. Dynamic Splints Dynamic finger extension splint
Dynamic wrist extension splint
Tenodesis training
Dynamic ulnar nerve splint
Capener
Anti-microstomial splint

62. Dynamic Finger Extension Splint
Dynamic radial nerve splint
Objectives:
Immobilize the wrist in functional position
Passively extend the MCP to 0
Permit full active MCP flexion and unrestricted IP motion
Indications:
Paralysis of wrist, MCP, Finger extensors
Advantages:
Relatively has a less obtrusive shape as compared to the outrigger design
The hand can be slipped through a loose sleeve with the orthosis on

63. Finger Cuff
Dynamic Springwire Assist
Dorsal Forearm Trough

64. Dynamic Wrist Extension Splint
Objectives:
Passively extends the wrist while allowing wrist flexion
To prevent contracture of unopposed, innervated wrist flexors
Indication:
Weak or paralyzed wrist extensors

65. Metatarsal Bar
Dynamic Springwire Knucklebender Assist
Volar Forearm Trough

66. Tenodesis Training Splint
Rehabilitation Institute of Chicago
Objectives:
To train tenodesis grasp
To promote a strong tripod pinch with wrist extension
Allows finger opening with wrist flexion
Indication:
C6 quadriplegia with grade 3 strength of wrist extensors

67. Finger Cuff
Thumb Spica
Dynamic Elastic Band Assist
Forearm Cuff

68. Dynamic Ulnar Nerve Splint
Dynamic anti-claw deformity splint, Wynn Perry Splint
Objectives
To passively flex the 4th and 5th MCP’s
To prevent shortening of the MCP Collateral ligaments
To promote active IP flexion
Indication
Ulnar nerve lesion

69. Lumbrical Bar
Metacarpal Bar
Dynamic Springwire Knucklebender Assist

70. Capener Splint Dynamic spring wire splint for PIP extension
Objectives:
To passively extend the PIP
Allows active IP flexion
Provide stability to PIP
Promote restabilization of lateral bands and prevent rupture of the central slip
Advantage
“no, profile” minimizing its visual presence
Indications
- PIP flexion contracture
- PIP dorsal dislocation
- Volar plate injury
- Flexor tendon repair with resulting PIP flexion contracture
- Partial or complete tear of the collateral ligament
- Boutonniere deformity

71. Dynamic Springwire Finger Coil Assist
Thermoplast

72. Anti-microstomial Splint
Objectives:
To apply stretch to tissues surrounding the oral cavity while permitting speech
To prevent contractures of lip and buccal tissues that may lead to limitation in oral opening
Indications:
Facial and perioral burns
Wearing regimen
Continuously worn
Taken off only for cleaning
Precaution
The commisures(corners) of the lips are prone to skin breakdown with improper fit and tension of the splint

73. General Precautions
Be aware of and make adjustments for pressure areas
Check for presence of edema
Timing
Compliance
Skin reactions

74. THANK YOU FOR LISTENING!!!
ANY QUESTIONS?