1. Orthosis and Splinting
Radomski ch 16 and 17
OT 624

2. FOR for splinting and orthosis
Biomechanical-
Uses principles of kinetics and forces acting on the body
Sensory motor FOR-
Used to inhibit or facilitate normal motor responses
Rehabilitation
Facilitates maximal function

3. Defining terms 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
Wrist hinge orthosis

4. Splint
Device for immobilization, restraint, or support of any part of the body.
Usually thought of as more temporary than and orthosis
ASHT splint classification
Static splint
Serial Static splinting
Static Progressive splints
Dynamic Splints

5. Health professionals who deal with splinting and orthotics
OT’s/ COTA’s
CHT’s (can be PT or OT)
CO/ CPO
Dentists
Less common- nurses

6. Orthotic selection What is the clinical or fxl problem?
What are the indications for and goals of splint use?
How will orthosis affect the problem and the client’s function?
Benefits of splint/ orthosis?
Limitations?
Custom made vs. pre-fab vs. No device

7. Splint related factors to consider:
Type
Design
Purpose
Fit
Comfort
Cosmetic appearance
Weight
Cost to purchase vs. fabricate
Ease of care
Durability
Ease of donning and doffing
Effect on unsplinted joints
Effect on function

8. Patient related factors
Clinical status
Functional status
Attitude
Lifestyle
Preference
Occupational roles
Living envio
Working envio
Social support
Issues related to safety and precautions
Ability to understand and follow through
Insurance and financial issues

9. Purpose of orthosis
Support a painful joint- slings, troughs, laptray and splints
Immobilize for healing –dorsal block, buddy strap, figure 8, sh immobilizer
Protect tissues, gun slinger, airplane spl,
Provide stability and Restrict unwanted motion- resting pan splint, dorsal block
Restore mobility-drop out cast,flexion glove, dynamic ext splint
Substitute for weak or absent muscles- MAS, Deltoid aide, flexion assist spring, tenodesis splint, WDWHO, ratchet brace
Prevent contractures or Modify tone- air splint, ball splint, neoprene thumb loop, wt. Bearing splint,

10. Safety precautions for orthosis
Impaired skin integrity
Pain
Swelling
Stiffness
Sensory disturbances
Increased stress on unsplinted joints
Functional limitations

11. Purpose of splints Static Dynamic Rest Prevention of further deformity
Prevention of soft tissue contracture
Substitution for lost motor function
Dynamic
Correction of a deformity
Control of motion
Aid in alignment and wound healing

12. Types of Splints Static splint Drop-out Articulated splints
Self adjusting or elastic components
Static progressive-
Hinges, velcro, turnbuckles
Serial static or casting

13. Purpose of splints Static Dynamic Rest Prevention of further deformity
Prevention of soft tissue contracture
Substitution for lost motor function
Dynamic
Correction of a deformity
Control of motion
Aid in alignment and wound healing

14. Types of Splints Static splint Drop-out Articulated splints
Self adjusting or elastic components
Static progressive-
Hinges, velcro, turnbuckles
Serial static or casting

15. Other considerations for splinting
Compliance
Offer options
Educate about benefits
Provide easy application and removal
Lightweight material
Immobilize only joints being treated
Cosmetically pleasing
Collaborate w/pt. On wearing schedule
Education

16. Anatomical considerations
Landmarks
Distal IP creases
DPC
Proximal palmar crease
Thenar crease
Wrist crease
Styloids, MP joints, IP joints, CMC, IP of Th

17. Anatomy (continued) Arches of the hand Fingers flex toward scaphoid
Longitudinal
Distal transverse
Proximal transverse
Fingers flex toward scaphoid
Functional position of hand
Position of safe immobilization- intrinsic plus position

18. Influence of splinting on tissue
Inflammatory phase- use splint to immobilize and protect
Fibroplastic phase: use splints to mobilize healing tissues while protecting
Maturation phase: low load force may be applied gradually increasing the stress tolerated

19. Tissue Remodeling
Ideal tissue remodeling occurs with gentle elongation of tissues (dynamic and serial splinting/casting)
Total end range time suggests that the amount of increase in PROM of a stiff jt is proportional to the time joint is held at end range (serial static splinting/casting)
Stress relaxation or static progressive stretch therapy

20. Mechanical principles applied to splint design
Increase the area of force application to disperse pressure
Increase the mechanical advantage to reduce pressure and increase comfort
Ensure three points of pressure
Add strength through contouring
Perpendicular traction for dynamic splinting
Acceptable pressure for dynamic splinting
High vs. low profile outriggers

21. Other considerations for splinting
Compliance
Offer options
Educate about benefits
Provide easy application and removal
Lightweight material
Immobilize only joints being treated
Cosmetically pleasing
Collaborate w/pt. On wearing schedule
Education

22. Construction of Hand Splints
Purposes:
Protection
Positioning for function
Immobilization for healing
Restriction of undesired motion
Correction or prevention of deformity
Substitution of absent or weak muscles

23. Construction of a hand splint
Design splint
Select material
Make pattern
Cut splinting material
Heat splinting material
Form splint
Finish edges
Apply straps, padding and attachments
Evaluate the splint for fit and comfort

24. Materials and their properties
Low temperature thermoplastic
High temperature thermoplastics
Metal braces and parts
Soft splints
Properties of materials
Memory
Drapability
Elasticity
Bonding
Self-finishing edges
Time to heat

25. Performance characteristics of materials for splinting
Conformability
Flexibility
Durability
Rigidity
Perforations
Finish, colors, and thickness

26. Pattern Making Tracing the hand Marking landmarks Cutting pattern
Fitting pattern on client
Forearm splint should go 2/3rds up forearm and trough should be ½ around the forearm. Should not restrict DPC if splint goes into hand, but doesn’t restrict fingers
Adjusting pattern
Refitting
Tracing pattern onto material

27. Cutting and molding a splint
Cutting material
Soften material
Mold material on client
Padding if needed prior to molding or after
Adjusting
Reheating vs. spot heating
Strapping
No tourniquet effect
Wider distributes pressure better

28. Dynamic Splinting
Learning Objectives: After this session, the learner will:
Explain the purposes of dynamic hand splinting
Be able to identify the line of pull for muscles and joints in the UE
List common pressure areas with dynamic splints
Fabricate a dynamic flexion or extension splint

29. Purposes of Dynamic Splinting:
Definition- The application of a moving part of a force which remains approximately constant as the part moves.
Purpose: To give MOBILITY to a joint, muscle, tendon, etc... (as opposed to static splinting, which is designed to give STABILITY).
Joint MOBILITY can:
Decrease adhesions
maintain joint function
promote tendon gliding

30. Uses of Dynamic Splints:
Skeletal Substitution
aides in alignment
supports bones and joints
Muscle Balance
paralyzed muscles
divided tendons or muscles (as in tendon transfers)
Joint Motion
preserve or increase joint motion
Rest:
promote wound healing
treat infection
relieve pain

31. Parts of Dynamic Splints
Static Base
Serves as the foundation for the splint, it:
provides alignment
provides the foundation for the outrigger
provides the foundation for a hinge
aides in relaxation of a spastic muscle
allows tissues to adapt to new position
protects a newly repaired structure
provides proximal support
aides in positioning and edema control
Dynamic Component
Can be slings, ratchet, springs, elastic bands, hinge
These features give the splint its MOBILITY

33. Benefits of Dynamic Splinting:
Constant or longer duration of steady tension is more successful than vigorous passive exercise for 20 minutes (especially where contractures are present)
Early motion=more effective healing
increased circulation
decreased edema due to increased pumping of stagnant fluids
increased gliding of tendons
increased flushing of synovial fluids
decreased adhesions
Can be used to introduce exercise more gradually and insure that the patient is doing exercise in good alignment

34. Using Exercise in conjunction with Dynamic Splinting:
Aides in :
Joint excursion
tone of skin
increased circulation
Increased patient confidence by seeing to what degree the hand can be moved safely
Because part is supported proximally, patient can do exercise more independently and more safely
Therapist should instruct patient not to go the the point of pain
Where there is decreased sensation, one must be extremely careful to avoid pressure or push too rapidly
Heat prior to exercise may promote increased movement

35. Medical/ Biomechanical Principles:
Moving muscles must be given an opposing, balance force in order to maintain joint mobility and tendon gliding
Movement prevents joint/muscle atrophy and limits deformity
Joints should never be immobilized needlessly
Where the injury is on the flexor surface, wrist and fingers should be placed in flexion.
Where the injury in on the extensor surface, wrist and fingers should be placed in neutral or resting position.
Position of function should be maintained prior to application of any dynamic splint
Edema should be decreased ASAP
Strapping or construction of a splint should not constrict venous return

36. Edema
Has a high protein content which congeals around the hand structures, joint capsules, collateral ligaments, and other fibrous structures
When these structures are surrounded by edematous fluid, the tissues swell, thicken, and shorten and become and unyielding fibrous tissue
The best program for edema is motion and elevation
Swollen fingers tend to go into hyperextension and the thumb into adduction
Edema is more common in the dorsum of the hand where the skin allows more fluid to accumulate
In the palmar surface of the hand, edema causes the arches to become flattened and hence clients have difficulty making a fist
Splint strapping, when applied too tight, can worsen edema due to decreased blood flow
Edema can also be aided by removal of a splint every two hours and allowing range to the unaffected joints

37. Patient Education: Patients should be educated in:
purpose of the splint
accurate positioning of the splint
what motion or range is being sought
simple anatomy and mechanism of injury / surgical repair
specific wearing instructions that include:
wearing times
placement of splint and strapping
common pressure areas
exercises allowed while in (or out of ) splint (if allowed)

38. Hand Architecture Directional Pull of the fingers:
All the fingers , excepting the middle finger (which may flex straight down) cross the palm obliquely from degrees
Anatomical center of the Hand:
is located at the level of the head of the third metacarpal
To find this point, converge all five fingers at one point with the fingers forming a cone

39. Metacarpophalangeal joints
Metacarpophalangeal joints are the most common site of joint limitations in the hand. Contributing factors might include:
adhesions of the extensor tendons over the dorsum of the hand or of the extensor hood mechanism
thickening of the dorsal capsule of the MP joint
contracture of the collateral ligaments
insufficient skin coverage over the dorsum of the hand
a bony block within the joint

40. Bones Radius Ulna Carpals Thumb Metacarpals Interphalangeal joints
Distal Row
Proximal Row
Thumb
Metacarpals
Interphalangeal joints

41. The Mechanics of Splinting
Principles
Addition of forces
two or more forces acting upon an object may be added and be replaced by a single force which is their sum
Transmissibility of a force
A force acting on a rigid body may be considered to have a point of application anywhere along its line of action
Equilibrium
If the forces and the torque applied to a body add up to zero the body will remain at rest
Action and Reaction
The interaction between two bodies in contact may be represented by two forces equal in magnitude and opposite in direction having the same line of action

42. Friction
the horizontal component of the force applied along the cuff of a dynamic splint when it pulls along the surface of the skin is called friction
Friction is an unreliable force and splints should not be designed to depend upon friction for maintenance of a position. As patients move, slippage of cuffs and splints is bound to occur
Therapists should attempt to reduce friction effects as much as possible
One should assume that skin is essentially frictionless and it should not be depended on during splint design

43. Tension and Compression-
Rubber bands, velcro strapping can have traction effects, the weight of the tension needs to match the weight of the extremity being placed in tension. For example, If a rubber band is too tight or too loose, it will not match the weight of the extremity and hence not have the desired effect
Compression forces are those that squeezed together - A splint with a hinge on it might have this effect if it acts to hold two parts together, but still allows motion

44. Balancing forces
Equilibrium of a splint- all forces should balance out within a dynamic splint if the splint is not to cause problems (such as friction, shearing, pressure areas)
Equilibrium of axial forces- Horizontal forces in a splint must = zero. If a hand presses against a splint and thus cancels out the horizontal force of a rubber band, the horizontal forces can be at equilibrium
Wedging- changes the forces from small to large by changing the distribution of the force over a larger space. This increases the chance of pressure areas if the wedge is not widely distributed over the skin.

45. Common pressure points
MP joints
IP joints
Ulnar styloid
Center of the palm
Any surface on which a finger cuff or traction bar exerts a force
Web space
Dorsal-lateral aspect of the thumb

46. Documentation about splinting
Document why client needs splint
Position that client was splinted in
Instructions you gave client
Follow up needed

47. Splinting Lab