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

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

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

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 5680 Section 16 Assess the need to use assistive device and train patients as called for Train patients to become functionally independent

Orthosis vs. Splint?

Characteristics of Thermoplasts HANDLING PERFORMANCE

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

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

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

STATIC SPLINTS

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

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

Basic Components : C-bar

Basic Components: Connector bar

Basic Components: Cross bar

Basic Components: Cuff or Strap

Basic Components: Deviation bar

Basic Components: Pan and Thumb trough

Basic Components: Forearm trough

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

Basic Components: Thumb Post

Basic Components: Blocks

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

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

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

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

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

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

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

Hand Orthosis Universal Cuff

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

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

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

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 20-30 degrees of wrist extension

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

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

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

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 20-30 degrees extension depending on patient tolerance MCP: 15-20 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: 60-80 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 30-40 degrees of extension; Dorsal burn neutral position MCP: 70-90 degrees of flexion DIPs: full extension

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 )

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

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: 20-30 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

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

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

Upper Extremity Orthosis Static Dorsal Elbow Orthosis

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

Upper Extremity Orthosis Humeral Fracture Brace Shoulder slings

Upper Extremity Orthosis Airplane Splints

DYNAMIC SPLINTS

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

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

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

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

Basic Components: Outrigger

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

Basic Components: Finger Cuff

Basic Components: Reinforcement Bar

Basic Components: Phalangeal Bar/Finger Pan

Basic Components: Fingernail Attachments hooks Contoured finger hooks

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

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

Finger Cuff Dynamic Springwire Assist Dorsal Forearm Trough

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

Metatarsal Bar Dynamic Springwire Knucklebender Assist Volar Forearm Trough

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

Finger Cuff Thumb Spica Dynamic Elastic Band Assist Forearm Cuff

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

Lumbrical Bar Metacarpal Bar Dynamic Springwire Knucklebender Assist

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

Dynamic Springwire Finger Coil Assist Thermoplast

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

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

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