Splinting, Orthoses, and Casting for Occupational Therapy Students: OT 460B

Learning Objectives At the end of this session, the learner will: 1. Review Anatomy of the Hand and Forearm 2. Identify and Explain the four phases of prehension 3. List and explain the purposes of splinting, casting and orthotic devices. 4. Describe types of splints, casts, and/or orthoses and their implications for use 5. Fabricate two splints cast with minimal supervision (after a demonstration)

Frames-of-References for Splinting Biomechanical Uses principles of kinetics and forces acting on the body Sensory motor Used to inhibit or facilitate normal motor responses Rehabilitation Facilitates maximal function

Definitions Orthosis Any medical device applied to or around a body segment to address physical impairment or disability Brace and support are terms used for an orthosis A force system designed to control, correct, or compensate for a bone deformity, deforming forces, or forces absent from the body Refers to a permanent device to replace or substitute for loss of muscle function

Definition of Splint Device for immobilization, restraint, or support of any part of the body Usually thought of as more temporary than an orthosis American Society of Hand Therapists (ASHT) Splint classification: Static splint Static progressive splints Dynamic splints

Anatomy of the forearm and hand Bones: 27 Bones- carpals, metacarpals and phalanges 8 carpals arranged in two rows: radial to ulnar in proximal row= scaphoid, lunate, triquetrum and pisiform radial to ulnar in distal row= trapezium, trapezoid, capitate, and hamate Wrist Flexion/Ext and RDUD occur at the radiocarpal and midcarpal joint

Anatomy of the forearm and hand Arches: Transverse Arch- comprised of the heads of the metacarpals it is always oblique Longitudinal Arch- follows the long lines of the metacarpal and carpal bones alone a slightly oblique line along the third finger Proximal Transverse Arch- comprised of the carpal bones and the annular ligament

Anatomy of the forearm and hand Palmar skin is tight, irregular and has several creases that create contour Wrist crease Thenar crease Distal Palmar Crease Palmar digital Crease PIP crease DIP crease

Anatomy of the forearm and hand Joints of the Wrist and Hand Radiocarpal Carpometacarpal Metacarpophalangeal Proximal Interphalangeal Distal Interphalangeal

Anatomy of the forearm and hand Position of Rest in the wrist and hand: midway between pronation and supination wrist is 12 to 20 degrees of extension phalanges are slightly flexed thumb is in partial opposition and forward

Anatomy of the forearm and hand Position of function: wrist in 20-35 degrees of extension normal transverse arch thumb in abduction and opposition and lined up with pads of other fingers PIP jts are flexed 45 to 60 degrees Wrist must be stable to be able to use hands

Four Phases of Prehension Reach client must have functional range in all proximal joints of forearm client must be able to stabilize proximal arm and trunk during reach client must have adequate strength to maintain position and accomplish as motion

Four Phases of Prehension Prehension Patterns (Grasp, Pinch, Hook) Pinch: Tip Pinch Palmar, 3-Jaw, Tripod Pinch Lateral Pinch

Four Phases of Prehension Grasp Cylindrical palm serves as an opposition platform for flexed fingers used to hold hand rails, tools and sports equipment the grip of the 4th and 5th fingers stabilizes the grasp need some degree of thumb abduction to get the object into the palm typically, wrist is in extension

Four Phases of Prehension Ball palm acts as a platform with all five fingers around a spherical object wrist is stabilized in dorsiflexion (extension) Hook accomplished by flexion of the fingers without the use of the thumb metacarpals and wrist joints are in neutral Used to carry objects by a handle

Four Phases of Prehension Carry Gravity- acts upon us as we carry objects Balance- proprioception is necessary to carry objects Inertia- is the resistance of objects to movement Stability- of proximal joints is necessary when carrying objects Leverage- changes during progression of an activity Release usually achieved by extension of digits

Purposes of Splinting, Orthotics, and Casting: Splinting and Orthotics are used for the following purposes: Protection- prevention of injury, or used with decreased sensation Immobilization- used during the recovery stage of an injury Support- used to prevent injury or joint deformities

Purposes of Splinting, Orthotics, and Casting: Splinting and Orthotics are used for the following purposes: Positioning- used to prevent edema, promote functional position, or prevent deformities. Can also be used to help weak muscles. Correction- used to correct a deformity or stretch out a contracture (c-splint)

Purposes of Splinting, Orthotics, and Casting Splinting and Orthotics are used for the following purposes: Function- may facilitate function (ulnar drift splint) or substitute for lost function (wrist drop splint) Modify tone- spasticity splints actually fatigue muscles out until they relax

Purposes of Splinting, Orthotics, and Casting Casting is used for the following purposes: Immobilization- done during the healing phase of a bone, joint, ligament, or tendonous structure Protection, positioning and support during the healing phase Correction -deformities can be gradually corrected through serial casting

Splint Evaluation Criteria: Need Design Mechanics Construction Fit

Orthotic Selection Consider the following: What is the clinical or functional problem? What are the indications for and goals of splint use? How ill orthosis affect the problem and the client’s function? What are the benefits of the splint/orthosis? What are the limitations of the splint/orthosis? Should the splint be custom made or pre-fabricated?

Classification of Splints: Forearm based, hand based; or finger based Volar or Dorsal placement Rigid (i.e... thermoplastic, plaster) or Soft (neoprene, velfoam, leather)

Types of static splints, orthoses and casts Resting Pan Cock-up Thumb Spica Ulnar drift splint C-Bar splint Gutter splints Boutonniere and Swan-Neck splints

Types of static splints, orthoses and casts Slings AFO BFO/ Mobile Arm Support, Deltoid Aide, Swedish Aide, Lapboard, positioning wedge etc.....

Types of static splints, orthoses and casts Immobilization casts Serial Casts Drop-out casts

Fabrication principles Requirements of a Well Designed Splint Maintains arches, should contour to the skin Maintains axis of motion Permits balanced function of unaffected muscles (i.e.. does not immobilize whole extremity just to splint the finger) Allows maximal mobility while providing optimal stability

Fabrication Principles Requirements of a Well Designed Splint Frees palmar surface of the hand and digits for the greatest amount of sensory perception Places minimal stretch on joints or muscles in a more prolonged period, rather than going for a quick correction Increases surface area to distribute pressure by using padding Follows contours of the normal hand and forearm

General Precautions for Splints Splints should be designed for individuals and systematically re-evaluated for fit Splints should be worn intermittently Splints should be worn for as long of a duration as they are functional Avoid tight circling around the extremities with the strapping, there should be no blanched areas where circulation is decreased

General Precautions for Splints Avoid making the forearm too long or too short as this provides inadequate leverage (generally go 2/3rds of the forearm) The palmar piece should fit the metacarpal transverse arch to avoid blocking MP motion Avoid positions of hyperextension. The IP joints of digits should be flexed about 15-25 degrees.

General Precautions for Splints Forearm shaft of the splint should be designed as a trough. The sides should come up midway on the sides of the forearm An exercise program should be used in conjunction with splinting wherever possible

Patient Compliance To ensure pt. compliance and efficient use of splints the splints should be: simple in design as comfortable as possible lightweight easy to put on and take off as cosmetically pleasing as possible free of pressure areas readily adjustable

Materials Overview Materials need to be evaluated for the following properties: stretchability drapability rebound elastic memory

Materials Overview High Temperature Materials: Nyloplex Royalte Kydex Moderate Temperature Materials: High Impact vinyl

Materials Overview Low Temperature Materials: Orthoplast Synergy Ezeform San-Splint Aquaplast

Materials Overview Low Temperature Materials (continued) Polyform Kay-Splint SOS-Plastazote No-Heat or Layered Materials Plaster of Paris Fiberglass casting

Splinting Supplies Equipment Tools Heat pan/ hydrocallator Heat gun Sewing machine Tools Scissors for material such as velcro Sharp scissors for cutting splinting materials Curved scissors for cutting splinting materials Leather punch

Splinting Supplies Tools (continued) Wire snips Utility Knife Needle nosed pliers Tongs Wire bender

Splinting Supplies Materials other than splinting material Paper towels or tissue for making patterns Towels for drying splinting materials before application Stockinette- to apply beneath the splint Velcro, Velfoam, strapping materials etc.... Lining materials, moleskin

Splinting Supplies Materials other than splinting material fishing line and leather for outrigger splints adhesive and solvent to clean material in prep for glueing safety pins and rubber bands for dynamic splints cold spray

Patient education regarding splints, orthosis, and casts Pt. education should consist of the following: the purpose of the splint the correct method of application the need for regular review and ongoing evaluation of the client and their splint the importance of checking the skin for pressure areas

Patient Education Patient Education Should consist of the following: the importance of understanding that the splint should not cause pain that splints should be worn according to the prescribed schedule that clients must still perform their therapy programs

Now You Do It! Divide up into pairs: One person makes a thumb spica splint (a.k.a. Thumb palmar abduction immobilization splint or short or long opponens splint or thumb gauntlet splint) One person makes a flexor tendon dynamic splint