1. Orthotics and Splinting Radomski, Ch 16 and 17 OT 624 Jennifer Boyette, OTR, CHT, CEAS III, PhD

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 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 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  Immobilize for healing  Provide stability and restrict unwanted motion

10. Restore mobility-drop out cast,flexion glove, dynamic ext splint Substitute for weak or absent muscles- MAS, eltoid aide, flexion assist spring, tenodesis splint, WDWHO, ratchet brace Prevent contractures or Modify tone- air splint, ball splint, neoprene thumb loop, wt. bearing splint Purpose of orthosis

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

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

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

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

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

16. 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

17. 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

18. 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

19. 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

20. 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

21. 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

22. 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

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

24. 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, doesn’t restrict fingers  Adjusting pattern  Refitting  Tracing pattern onto material

25. 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

26. 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

27. 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

28. 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

29. 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

31. 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

32. Using Exercise 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

33. 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.  Edema should be decreased ASAP  Strapping or construction of a splint should not constrict venous return

34. 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

35. 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

36. 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)

37. Hand Architecture  Directional Pull of the fingers:  All the fingers, excepting the middle finger (which may flex straight down) cross the palm obliquely from 10-30 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

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

39. 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

40. The Mechanics of Splinting  Principles  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

41. 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

42. 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.

46. 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

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

48. Splinting Lab