Dorsal Carpal Ganglion DCG

The most common soft tissue tumors of the wrist are ganglions that originate from the dorsal scapholunate ligament.3,45,50 Minor sprains to dorsal wrist capsules or repeated manipulations with the wrists in extension may, in time, cause dorsal ganglions to develop. Gymnasts report wrist ganglia associated with other wrist complaints to be major problems.53 Ganglions may originate either extra-articularly or intra-articularly and the cysts generally involve adjacent tendon sheaths and joint...

Wrist Finger Splints

Some splints include both wrist and digital joints as primary joints. These dual primary purpose splints involve immobilization, mobilization, restriction, or torque transmission of primary proximal joints of the fingers and or thumb in addition to the primary focus wrist joint. Because the expanded SCS groups splints Fig. 13-16 A, Wrist ulnar deviation restriction splint, type 0 (1) B, Wrist flexion restriction splint, type 0 (1) C, Wrist circumduction restriction splint, type 0 (1) D, Wrist...

DeQuervains Disease

DeQuervain's disease is a stenosing tenosynovitis of the extensor pollicis brevis and abductor pollicis longus in the first dorsal compartment. Inflammation of the peritenons of the EPB and APL can be quite debilitating because of their role in thumb function.7 Workers, athletes, and musicians may complain of pain occurring with thumb flexion when the wrist is ulnarly deviated and palmarly flexed. Common examples of sports that involve repetitive hand and wrist motion are bowling and golfing...

Active Exercise

Flexion Block Splint

Active exercise through purposeful activity such as self-care, leisure, work, or sports and individualized exercise routines produces joint motion affected by muscle contraction and resultant tendon excursion. Achievement of a functional level of active motion depends on the presence of adequate muscle strength and passively supple joints (Fig. 15-3). Active range of motion is benefited by correctly implemented passive motion and splinting techniques that are designed to mobilize arthrofibrosed...

Allow for Efficient Construction and

The splint design should also allow for quick, efficient construction. With increasing concern for medical costs, long construction and fit times are, for the most part, inappropriate. Proper design can expedite construction and fit and decrease expense. Because each part that must be bonded or jointed increases the construction time, the incorporation of multiple components into the main body of the splint at the design stage results in improved efficiency. For example, providing contour at...

Allow for Optimum Function of the Extremity

The upper extremity has the unique ability to move freely in a wide range of motions, which allows for the successful accomplishment of a tremendous variety of daily tasks. The segments of the arm and hand function as an open kinematic chain, with each segment of the chain dependent on the segments proximal and distal to it. Compensation by normal segments when injury or disease limits parts of the chain often provides for the continued functional use of the extremity. Because of this adaptive...

Analysis of Splints

FINGER MP, PIP, DIP, THUMB CMC, MP SPLINTS FINGER PIP, THUMB CMC, MP SPLINTS WRIST SPLINTS WRIST, THUMB CMC SPLINTS ELBOW SPLINTS that this chapter will initiate, facilitate, and strengthen sound analytical thinking in regard to splint design and fabrication. On the following pages illustrations of improperly constructed splints are presented and analyzed according to the expanded ASHT Splint Classification System purpose of application, clinical problems, solutions to the problems, and design...

And Shoulder

The wonderful abilities of the hand are intimately related to the function of the shoulder, elbow, and forearm. The extrinsic flexor and extensor tendons of the hand and wrist originate from the forearm bones and or the distal humerus. Without the proper function of the shoulder, elbow, and forearm, one's ability to use the hand in activities of daily living may be severely compromised. Proper rehabilitation of the hand must, therefore, include attention to the status of these more proximal...

Articular Splints

In a study by Neeman and Neeman of the effects of orthokinetic cuffs on a hemiparetic upper extremity, one of three cuffs applied to the subject included a proximally placed cuff to enhance shoulder flexion and abduction and elbow extension.50 Although the effects of the orthokinetic cuff on shoulder motion were not evaluated in their pilot study, the authors reported improvement in active shoulder mobility after a longer duration of treatment. Further, researchers studying the effects of other...

Bone and Cartilage Healing

Unlike the healing by the scar formation of soft tissues, bone is capable of limited regeneration. As with the other tissues, the immediate response to injury includes inflammation and edema with associated bleeding in the marrow cavity and surrounding tissues (Fig. 3-2, A). Within a few days the fibroblas-tic phase of soft tissue healing begins and osteogenic cells from the periosteum and endosteum of the bone begin migration and proliferation at the wound site. These cells lay down callus and...

Casts for Severe Contracture

If the finger is too severely flexed for the cast to be easily removed, the cast could cause shear stress at the dorsum of the proximal interphalangeal joint on replacement. A small cut made along the proximal lateral dorsal surface of the cast may be all that is needed (Fig. 22-4, A) or this can be extended in a U-shape and top flap cut or removed from the cast (Fig. 22-4, B). The cut cast can be secured back on the finger with paper tape. It should be noted that the cast is more secure...

Clinical Solutions

For maximum effectiveness, use a volarly designed splint with separate MP joint finger cuffs with a 90 angle of approach. 2. Add a high-profile outrigger with individual finger cuffs for a 90 angle of approach of the elastic traction to the proximal phalanges to prevent bunching of the fingers when mobilization assists are attached to a single point on the outrigger. 3. Strap placement applies three-point pressure for optimal immobilization of wrist. Fig. 20-3 D, Index-small finger MP flexion...

Consider Individual Patient Factors

The individual requirements of each patient are the most influential factors in determining the ultimate size and configuration of a given splint. After the functional requirements of the splinting program are established, additional individual factors must be addressed How much of the pathologic condition and rehabilitation program does the patient understand, and how much of the program can he intelligently accomplish for himself How accessible is the splinting facility, and how often will he...

Consider the Length of Time the Splint Is to Be Used

In general, the shorter the anticipated need of a splint, the simpler its design, material type, and construction Fig. 8-2 A, Index-long finger extension mobilization splint, type 1 (7) B, Nonarticular thumb distal phalanx splint C,D, Wrist extension immobilization splint, type 0 (1) A,B, Imagination and humor can entice a child to cooperate in the splinting program. C,D, Glow-in-the-dark splinting material (Reveals Nite-Lite , WFR Corporation, Wyckoff, N.J.) improves splint compliance for...

Considerations and Variations

The splint design final can be fabricated in fiberglass or cast-molded in skin colors by local prosthetic companies. A metal or brace-type appearance is avoided as it is undesirable to many patients. The distal splint can be extended in a platform to support flaccid fingers. A wrist-hinge joint can be included, and the splint made to be dorsal (Fig. 23-8). Unconditional routing of the cable helps some patients. Routing the cable around the medial side of the elbow restores pronation in a...

Correlate Physical Properties of the Mobilization Assist with Patient Requirements

Mobilization splinting is dependent upon a series of interrelated variables that describe joint condition, the most important of which include, but are not limited to, time duration, degree of angulation, and end feel. When aligned, these variables form a series of separate but parallel condition continuums, each of which ranges from minor to major level of involvement. Selection of a mobilization assist depends on the amount of joint involvement as it relates to duration of the problem over...

Cubital Tunnel Syndrome

The ulnar nerve is vulnerable to injury at the elbow as it courses under fascia at the medial epicondyle and is tethered by the flexor carpi ulnaris.55 Cubital tunnel syndrome may result from direct trauma, as in being hit on the elbow by a batted ball, or from sustained elbow flexion that compresses the ulnar nerve, as in playing a musical instrument that requires prolonged elbow flexion postures. For musicians, nerve compressions and tendonitis necessitate evaluation of postures, changes in...

Determine the Surface for Splint Application

The decision as to what surface or surfaces of the hand, forearm, or upper arm a splint is to be applied is the next step in the progression through the hierarchy of design principles. This decision is influenced by the interrelationships of anatomic and mechanical factors. Although pressure is usually tolerated better on the anterior surface of the upper extremity, one must be aware that this side makes the greatest contribution to function and sensation. A finger extension mobilization splint...

Dry Heat

Knowledge of splint material properties is important to improving efficiency. Using dry heat alone, some materials, such as Orthoplast, may be heated to malleable stage in a dry heat pan and held for prolonged periods of time at a constant warm temperature, providing splint material that is immediately ready for cutting and fitting throughout the day (Fig. 9-3). Also, when working in environments where water sources are remote or cumbersome (e.g., hospital bedside or surgery), use of dry heat...

E

Early fit cast prosthesis, 608 Economic factors in assessment, 155 design of splint and, 211 Edema compressive dressing and, 102 in contracture, 91-92 force and, 104-105 range of motion and, 105 Edge, smooth, 243-244, 243f-245f Education client, 144b professional, 26 Efficiency, 273-274 Egyptian splint, early, 5f Elastic assist force maintenance of, 203 length of, 200 Elastic-based thermoplastic, 485 Elastic mobilization force, 229-230 Elastic traction mobilization splinting, 605-606, 606f...

Elbow splints

The elbow joint is critical to upper extremity function. Considered a trochoginglymoid joint, the elbow has two articulations, the ulnohumeral joint, a hinge joint, and the radiohumeral and proximal radioulnar joint, an axial rotation joint.26 These two articulations combine to permit two degrees of freedom of motion, flexion-extension and supination-pronation. Without sufficient elbow flexion, the ability to get one's hand to the face and mouth is significantly compromised lack of elbow...

Elbow Splintscontd

Fig. 18-17A Elbow extension mobilization splint, type 0 (1) (Fig. 18-17A) The turnbuckle elbow extension splint is an inelastic mobilization splint used to increase elbow extension. Tension into extension may be increased gradually by positioning or turning the turnbuckle. Materials needed include low-temperature thermoplastic, self-adhesive padding, turnbuckle, two screws with screw posts, two rivets (plastic finger rivets work well), soft wide strapping, Velcro, D-rings.

Exercise and Splinting for Specific Upper Extremity Problems

EXERCISE Passive Exercise Active Exercise Resistive Exercise TORQUE TRANSMISSION SPLINTS TIMING AND TYPE OF EXERCISE COORDINATION OF EXERCISES AND SPLINTING SCHEDULES SPECIAL PROBLEMS ACCORDING TO ANATOMICAL Capsulotomy Capsulectomy Neurovascular Peripheral Nerve Injuries Spinal Cord Nerve Injury Tetraplegia Secondary Procedures Post Tendon Repair Tendon Transfers Soft Tissue Crush, Burn, and Cold Injuries Dupuytren 's Nail Bed Repair Extensive Injuries to Multiple Structures Ray Resection...

Extensive Injuries to Multiple Structures Ray Resection

Splinting post third or fourth digital ray resection without ray transposition is designed to protect the surgical reapproximation of the transverse intermetacarpal ligament of the digits adjacent to the excised metacarpal. Splint buttressing of this ligament reapproximation is accomplished by fitting a nonarticular metacarpal splint (Fig. 15-29) over the site of the ligament and around the remaining metacarpals. Resection of the second or fifth rays generally does not require protective...

Fabrication

Cover working area with disposable drape. Apply a nonsterile surgical glove to the patient's injured hand. Proximal to the glove apply petroleum jelly to prevent adherence of RTV11 silicone rubber to skin and hair followed by prewrap or cotton stockinette (Fig. 17-30). If the foam padding has an adhesive side, remove paper backing. Moleskin is applied to the sticky side of the padding. The adhesive foam padding side will be against the skin and the moleskin side is exposed. The foam-padding...

Finger DIP Splints

Because the DIP joints are also hinge articulations with collateral ligaments and palmar plate stabilization, mechanical principles similar to those of the proximal interphalangeal joints are applicable. From a practical point of view, however, the small area of purchase provided by the distal phalanx makes elaborate mobilization traction techniques less successful in correcting stiffness at this joint. Three-point pressure splints that utilize inelastic traction sometimes prove more effective...

Finger Distal Phalanx Splints

Nonarticular finger distal phalanx splints protect sensitive digital tips, provide pressure to healing nail beds, or reinforce distal phalangeal internal fixation hardware. These splints do not impede DIP joint motion. Pericapsular fibrosis resulting in stiffening of the metacarpophalangeal or interphalangeal joints of the fingers represents the most common disabling problem following hand injury, disease, or surgery. Preventive splints that immobilize or restrict joints in positions least...

Finger Middle Phalanx Splints

Protecting healing structures of finger amputations, nonarticular finger middle phalanx splints (Fig. 11-46) allow early use of remaining finger segments. Fig. 11-45 A, Nonarticular finger proximal phalanx splint. B, Nonarticular index finger proximal phalanx splint A, Two different designs of nonarticular finger proximal phalanx splints protect digital pulley injuries repairs. The splint on the left provides a uniform circumferential pressure around the proximal phalanx, while the splint on...

Finger Mp Pip Dip Thumb Cmc Mp Ip Immobilization

Abduction, flexion, palmar 1 (16) Index-small, thumb abduction, extension Flexion, extension, palmar 1 (16) Index-small, thumb Index-small finger MP flexion and IP extension, thumb CMC palmar abduction 11-38 A-B Index-small finger MP 70 flexion and IP extension, thumb CMC palmar abduction 4-30 A-B Index-small finger flexion, thumb CMC palmar abduction immobilization splint, 8-9 C Index-small finger flexion, thumb CMC palmar abduction immobilization splint, 20-1 2 C Index-small finger flexion,...

Finger PIP Splints

Anatomy of the proximal interphalangeal joint is complex it is important that all those involved in treating PIP joint pathology understand normal and abnormal biomechanics of this joint before embarking on any type of treatment intervention. Although approximately 6 of supination occurs with joint flexion,2 the PIP joint is a hinge joint that allows motion in one plane, extension-flexion. Radial and ulnar collateral ligaments and the palmar plate combine to provide strong articular stability....

Finger Thumb Splints

Finger, thumb splints include the finger MP, PIP, and DIP joints and the thumb CMC, MP, and IP joints as primary joints. The only difference between the splints described in this section and the splints described in the immediately preceding section is the addition of the thumb MP and IP joints to the splints included in this category. All of the concepts discussed above are applicable to splints in this section. Further, splint complexity increases from a minimum total of 13 joints included...

Forearm Splints

Splints may be applied to immobilize, mobilize, restrict, or transmit torque to radioulnar joint motion. Because of the orientation of the rotational axis of the forearm and the problems presented in obtaining a secure mechanical hold from which to base splinting forces, designing and fitting splints to limit or increase supination or pronation range of motion may be a very Fig. 13-21 A,B, Wrist extension index-long finger flexion torque transmission Wrist flexion index-long finger extension...

I

Identification of items or shapes, 153 Identification system for splints, 2627 Iliac crest, 259 Immobilization contracture and, 92-93 of metacarpophalangeal joint, 11 scar remodeling and, 96 Immobilization mobilization splint, 126 Immobilization restriction splint, 345, 347f Immobilization splint design of, 222-223, 223f elbow, 378, 379f finger DIP, 318, 319f MP, 284, 285f MP, PIP, DIP, 295, 296f thumb, 322-323, 323f thumb CMC, 319-322, 322f forearm, 225, 369, 370f ligaments and, 264 in...

Identify Optimum Force Magnitude Parameters

When discussing mobilization assists and the forces they impart, it is important to understand the funda mental differences between a splint designed to substitute for absent or weak active motion and a splint that corrects passive motion limitations. Both of these splints are classified as mobilization splints, but the mobilizing forces employed by each splint differ. A substitution splint is applied to a passively supple joint, requiring a force that is just sufficient to pull or push the...

Identify Secondary Joints

Maximum mechanical benefit of splinting forces may be obtained by controlling joints proximal and or distal to injured or diseased primary joints. Secondary joints are normal or less involved joints that are included in a splint to focus immobilization, mobilization, restriction, or torque transmission forces to primary joints (Fig. 8-17, A). When secondary joints are controlled, dissipation of desired forces at the more mobile secondary joints is avoided. Secondary joints may also be included...

Increase Material Strength by Providing Contour

The time-honored engineering principle of strength through contour is directly applicable to the design and construction of hand splints and is in many instances a concept that is concomitant with the previous consideration of force dissemination and use of leverage. When a large force is placed on a flat, thin piece of material, the counterforce produced by the material is insufficient, and the material bends. If, however, the Fig. 6-31 In a type 1 PIP extension mobilization splint, the force...

Increase Mechanical Advantage

The design and construction of splints should be adapted to include use of favorable force systems. Many splints fail because of patient discomfort or because of fractured components. These problems may result from inattention to the lever systems at play between the splint and the extremity or between individual splint parts. Mechanically, splints are simple machines, levers, that work in equilibrium. Incorporating forces, axis of rotation, moment arms, and resistances, splints are predictable...

L

Laceration, contracture and, 93 Landmark of humerus, 73f Lateral antebrachial cutaneous nerve, 72 Lateral epicondylitis, 471-472, 471f, 472f Latissimus dorsi, 81f, 82 Lengthener, forearm, 610 Leprosy, 20-21 Letterman General Hospital, 10 Levator scapulae muscle, 78, 79f Lever in construction, 244 mechanical advantage and, 164-165 Leverage, 256-257, 259f Lifecasting, 617 Ligament 264f-268f stress and, 262-263 fracture and, 405-406 of hand, 49 inferior glenohumeral, 79f in joint assessment, 146...

Lessons From Hot Feet A Note on Tissue Remodeling

Few persons have contributed more to our understanding of biomechanics and soft tissue response to stress then Dr. Paul Brand. Historically, enlightened physicians and brace makers have, for centuries, advocated slow, gentle tension to effect change in soft tissue, but their opinions were based on individual trial-and-error observations. This lack of organization and scientific validation made their teachings vulnerable to contradictory, opposing practices that prompted harsh manipulation to...

Mallet Finger

Mallet finger, baseball finger, and drop finger are interchangeable colloquial terminology for the most common closed tendon injury in the athletic patient population.1,2,34,35,48 Disruption of the terminal extensor tendon at its insertion may occur when catching a ball (baseball finger) or whenever an excessive external flexion force is applied to the distal inter-phalangeal joint (DIP) while the joint is extended (mallet finger). This injury is frequently seen in athletes who catch or hit...

Mechanical Principles

Fig. 6-12, A-C F x FA R x RA F x 3 0.9 x 2.5 F x 3 2.25 F 0.75 F x 5 0.9 x 2.5 F x 5 2.25 F 0.45 F x 7 0.9 x 2.5 F x 7 2.25 F 0.32 F x 1.5 4(0.5) x 5 F1.5 10 F 6.67 F x 3.75 4(0.5) x 5 F3.75 10 F 2.67 F x 5.75 4 (0.5) x 5 F5.75 10 F 1.74 Fig. 6-21 Torque Force x length T 8 x 1 T 8 inch-ounces Fig. 6-28, A F x 3.5 0.9 x 3 F3.5 2.7 F 0.77 F x FA R x RA F x 9 0.9 x 3 F9 2.7 F 0.3 Patterns for Splinting from Chapters 18 and 21 Articular Nonarticular Joint Segment Shoulder abduction and external...

Mobilization

Index-long finger MP extension mobilization flexion restriction splint, type 1 (3) Index-small finger MP extension, flexion, and ulnar deviation splint, type 0 (4) 11-7 D Long finger MP flexion restriction splint, type 0 (1) 1 7-8 Index-small finger MP flexion restriction splint, type 0 (4) 6-4 B Index-small finger MP flexion and ulnar deviation restriction splint, type 0 (4) 4-15 Index-small finger MP flexion and ulnar deviation restriction splint, type 0 (4) 1 0-4 A Index-small finger MP...

Muscle and Tendon

Diminished or absent active motion in the presence of normal passive articular motion may indicate loss of muscle tendon continuity, impaired contractile capacity, or limitation in tendon glide. The effect is observable in the resting hand when the normal cascading posture of the digits is altered, and pathology is assessed through measurement of active motion of those joints spanned by the involved musculo-tendinous units and through manual muscle testing procedures.35 Again, relating...

Muscle Tendon Tendon

Traditionally, extensor tendon repairs have been treated by immobilizing the wrist and digital joints in extension.81 Problems of adhesions between the repair site and the gliding bed are not as limiting to extensor tendons as they are to flexor tendons because of the relatively long fibroosseous canals through which the flexor tendons course. However, with severe extensor tendon injuries in which periosteum, retinaculum, or soft tissues are involved, adhesions can...

Patterns

SPLINT PATTERN FABRICATION PATTERN MATERIALS AND EQUIPMENT SPECIFIC PATTERNS Metacarpal Shell Metacarpal Wrist Forearm Shell (Dorsal) Metacarpal Wrist Forearm Shell (Volar) Forearm Elbow Humerus Shell CONTIGUOUS ADAPTATIONS OF BASIC PATTERNS Proximal Phalangeal Metacarpal Wrist Forearm Shell Finger Metacarpal Wrist Forearm Shell (Dorsal) Finger Metacarpal Wrist Forearm Shell (Ventral) The transition from the cognitive design process to the actual construction of tangible splint patterns is...

Referral and Interview Information

The information provided in the signed referral and ensuing initial interview is paramount because it directly influences the eventual splint design and subsequent treatment. In addition to the patient's name, age, sex, hand dominance, hospital number, and designation of involved extremity, the referral should include diagnosis, date and circumstances of injury and or onset of medical problem, purpose and timing of splint application, and specific instructions and precautions. The patient...

Replicasting Making Molds of the Hand

General Concepts of Mold Fabrication Matrix Method Using Molding Alginate Brush-On Method Using Silicone Rubber Prepared directly on a subject's hand, a negative mold provides the external frame or shell for a positive reproduction or mold* of the hand in plaster, dental acrylic, or similar casting material. After removal, the negative mold is filled with a liquid material that, through an endogenous heat process, dries and hardens. When this material is completely solid, the negative mold is...

Select Appropriate Design Configuration

The type of outrigger used in a mobilization splint should be reflective of individual patient needs. The number of primary joints being mobilized, their specific range of motions, and the number and positions of secondary joints included in the splint all influence the shape of an outrigger. The purpose of the splint is also important to outrigger design. Is the splint intended to correct joint deformity or to substitute for loss of muscle power Although specific outrigger configurations and...

Skin and Subcutaneous Tissue

Thorough examination of the surface condition and contours of the extremity helps define pathology and influences splint configuration. Closely correlated with neurovascular status, tissue viability, and the inflammatory process are skin color, temperature, texture, and moisture. These should be carefully noted. Alterations from normal extremity size and contour should also be identified, including areas of atrophy, tissue deficit, scarring, local swelling, generalized edema, and abnormal...

Skin Soft Tissue

Adapt for Skin Soft Tissue Alterations Poor fitting splints can jeopardize the healing process by causing further damage through application of unwarranted destructive shear or pressure forces. Splints fitted over portions of an extremity where skin or soft tissue is of questionable viability or where soft tissue defects exist present serious challenges. Depending on specific individual circumstances, avoidance of splinting material around and over problematic areas, including major soft tissue...

Soft Tissue

Although of dissimilar etiologies, extensive soft tissue damage resulting in crush, burn, and frostbite injuries often requires similar conservative treatment. Splinting requirements after these injuries depend on the site and extent of tissue damage. When a major portion of the hand is involved, early use of an anti-deformity or safe position splint (finger MP flexion, IP extension immobilization splint) alternated with exercise facilitates preservation of collateral ligament length by...

Splints Acting on the Fingers

Mobilization Restriction Torque Transmission Splints This chapter follows the expanded ASHT SCS Once articular splints are sorted according to their format by first dividing splints into articular or primary joints, they are divided according to one of nonarticular categories. In the articular cate- four purposes immobilization, mobilization, restric- gory, splints are further grouped according to the tion, or torque transmission. Dual-purpose categories primary joints they influence. Splints...

Thumb IP Splints

Although strong interphalangeal joint motion is valuable to thumb performance, its absence is not critical. In most cases thumb functions are possible if there is a good carpometacarpal joint and perhaps some metacarpophalangeal joint motion. Thumb IP splints are applied to immobilize, mobilize, restrict, or transmit torque to the IP joint. Secondary joints are often incorporated in these splints but are not mandatory. Type 0. Only the distal thumb joint is immobilized in a type 0 thumb IP...

Thumb MP Splints

The middle joint in the important thumb intercalated chain is the metacarpophalangeal joint. At this level, stability is a more important consideration than mobility. A wide discrepancy exists in the amount of thumb metacarpophalangeal motion found in the general population, with flexion ranging from only a few degrees to 90 . It is apparent that the functional sequela of limited or absent metacarpophalangeal motion is negligible if the joint is positioned properly Fig. 12-12 A,B Thumb CMC...

Thumb MP Ulnar Collateral Ligament Tear or Rupture

The metacarpophalangeal joint of the thumb is vulnerable when the thumb is abducted because, in abduction, the MP joint is locked, allowing forces to the distal thumb to be transmitted to the MP joint. Lateral stress with the thumb in abduction stresses the ulnar collateral ligament (UCL).30 Commonly referred to as gamekeeper's thumb or skier's thumb, injuries to the ulnar collateral ligament of the thumb MP joint precipitate MP joint instability. Causative factors include falling with the...

Upper Extremity Assessment and Splinting

EXAMINATIONS CLINICAL EXAMINATION OF THE UPPER EXTREMITY Referral and Interview Information Posture UPPER EXTREMITY ASSESSMENT INSTRUMENTS Activities of Daily Living, Vocation, and Avocation Thorough and unbiased assessment procedures furnish essential foundations for splinting programs by delineating baseline pathology from which splint designs may be created and patient progress and splinting methods may be evaluated. Assessment information also assists in predicting the rehabilitation...

Use Optimum Rotational Force

The mobilization of stiffened joints through traction requires a thorough understanding of the resolution of forces to obtain optimum splint effectiveness. This must be achieved without producing patient frustration or increased tissue damage through joint compression or separation. Theoretically, any force applied to a bony segment to mobilize a joint may be resolved into a pair of concurrent rectangular components acting in definite directions. These two components consist of a rotational...

Work Efficiently

The use of devices or methods that increase the efficiency of the molding time may also be of considerable benefit. Lightly wrapping a warmed, low-temperature, thermal material splint to the patient's hand and forearm with an elastic bandage allows the therapist's full attention to be directed to the positioning of the hand. Strategically applied tape holds Fig. 10-38 Elbow extension restriction splint, type 2 (3) The elbow-locking device restricts elbow joint extension, allowing remodeling of...

Wrist Finger Mp Pip Dip Thumb Cmc Mp Ip Immobilization

Extension, flexion, 0 (16) Index-small, thumb Wrist circumduction, thumb CMC circumduction and MP flexion restriction splint, 17-18 B type 0 (3) Wrist circumduction, thumb CMC circumduction and MP flexion restriction splint, 1 7-18 C type 0 (3) Wrist extension, thumb CMC palmar abduction and MP flexion restriction splint, 9-12 B type 0 (3) Wrist extension, index-small finger MP extension, extension mobilization splint, type 0 (7) Wrist extension, index-small finger MP extension, extension...

Wrist Finger Thumb Splints

Torque Transmission Immobilization Splints Type 2. As noted earlier, the presence of a colon punctuation mark ( ) in a splint's technical name indicates the splint transfers active motion at one or more joints to create passive joint motion at another joint Fig. 13-19 A-C, Wrist radial and ulnar deviation restriction Thumb CMC palmar abduction immobilization splint, type 1 (3) This splint incorporates flexible thermoplastic tubes to restrict wrist deviation and allow active wrist extension,...

View the Past

Palmar Abduction

ELAINE EWING FESS, MS, OTR, FAOTA, CHT The splinting of extremities rendered dysfunctional by injury or disease is not a new concept, and yet *This section originally was published as an article in the Journal of Hand Therapy (JHT), vol 15 2, 2002, with the understanding that it would later appear in Chapter 1 of this third edition of Hand and Upper Extremity Splinting Principles and Methods. Since the JHT publication of this chapter, additional references have been added and some splint...

F

1980 - Fig. 1-14 The Splint Nomenclature Task Force members created the ASHT Splint Classification System at a 1991 meeting in Indianapolis, IN. Members attending were (front row, from left) Lori Klerekoper DeMott, OTR, CHT, Maude Malick, OTR, Janet Bailey, OTR, CHT (task force leader), Karan Gettle, MBA, OTR, CHT, and Ellen Ziegler, MS, OTR, CHT (back row, from left) Cynthia Philips, MA, OTR, CHT, Elaine Fess, MS, OTR, CHT, and Jean Casanova, OTR, CHT (1991 Director, ASHT Clinical Assessment...

Nerve Supply

In considering the nerve supply to the forearm, hand, and wrist, it is important to realize that these nerves are a direct continuation of the brachial plexus and that at least a working knowledge of the multiple ramifications of the plexus is necessary if one is to fully appreciate the more distal motor and sensory contributions of the nerves of the upper extremity. Injuries at either the spinal cord or plexus level or to the major peripheral nerves in the upper extremity result in a...

Finger Thumb CMC Splints Immobilization Splints

Finger, thumb CMC immobilization splints prevent motion of the finger MP, PIP, DIP joints and the thumb CMC joint to rest or to allow healing of soft tissue. The decision of whether to immobilize in an antideformity position or a functional position is key, especially Fig. 11-35 Small finger DIP extension mobilization splint, type 0 (1) To avoid causing injury from shear, splints designed to mobilize the DIP joint must be well stabilized on the finger. Elastic mobilization forces produce soft...

Finger Mp Pip Splints

Finger MP-PIP splints range from simple to complex designs depending on individual patient circumstances. Because MP joints are condyloid in nature and move in multiple planes, and PIP joints are hinge articulations with movement in one plane, proper alignment of these longitudinally situated joints is critical to successful splint application. Further, the combined length of proximal and middle phalanges in finger MP-PIP splints results in longer force arms and greater potential torque on...

Brachial Plexus Mnemonic

Grant Anatomy Brachial Plexus

53-year-old Robert Taylor is a simple memory device for learning the nomenclature and form of the brachial plexus.1 It is not intended to replace formal study of the brachial plexus. The mnemonic Robert Taylor Drinks Coffee Black has been used to recall the nomenclature of the levels of the brachial plexus (proximal to distal) R Rami, T Trunks, D Divisions, C Cords, and B Branches. The rationale for Robert Taylor's age of 53 years is that the structures at each of the levels are in groups of...

Splinting for Work Sports and the Performing Arts

CASE EXAMPLES Musician Worker Athlete Trigger Finger (Stenosing Tenosynovitis) Thumb MP Ulnar Collateral Ligament Tear or Rupture INJURIES CONDITIONS Cubital Tunnel Syndrome Lateral Epicondylitis Medial Epicondylitis Elbow Dislocations Fractures COMMON SHOULDER INJURIES CONDITIONS Humeral Fracture Shoulder Subluxation Dislocation Posterior Subluxation Dislocation Anterior Subluxation Dislocation INSTRUCTIONS FOR SILICONE RUBBER PLAYING CAST FABRICATION Materials Fabrication SUMMARY The upper...

Biologic Basis for Hand and Upper Extremity Splinting

Splints are used to put all or part of the hand at rest so that diseased, injured, or surgically violated tissues can undergo orderly, uninterrupted healing. They are also used to favorably influence tissue healing and minimize the development of restrictive scar tissue, which has a detrimental effect on normal joint and tendon movement. In many clinical situations, there is an appropriate time for the use of immobilizing, mobilizing, restriction, and torque transmission splints to control the...

Humerus Splints

Functional splinting of the humerus following a humerus diaphysis fracture has been an accepted form of treatment for a number of years. While exact percentages vary with individual studies, this technique is associated with a high rate of fracture Fig. 14-19 A, Nonarticular humerus splint Wrist extension mobilization splint, type 0 (1) B, Nonarticular humerus splint Through its circumferential application, a nonarticular humerus splint provides a coaptation force for support of a humerus...

Take into Account Patient Associated Risk Factors

Variables that extend duration of wound healing stages, cause skin or soft tissues to be friable, or pre dispose tissue to scarring or nerve damage must be taken into consideration when designing splints and splint wearing schedules. These variables may include, but are not limited to, therapeutic intervention factors, such as medication or radiation systemic diseases like peripheral vascular disease, poor nutritional status, diabetes mellitus, rheumatoid arthritis, scleroderma, or Raynaud's...

Tissue Remodeling

Section 1 Biologic Basis for Hand and Upper Extremity Splinting TISSUE HEALING INFLAMMATION FIBROPLASIA SCAR MATURATION WOUND CONTRACTURE SPECIFIC TISSUE HEALING Bone and Cartilage Healing Tendon Healing Nerve Healing JOINT STIFFNESS AND TENDON ADHESIONS Joint Stiffness Distal Interphalangeal Joint Contracture Proximal Interphalangeal Joint Extension Contracture Proximal Interphalangeal Joint Flexion Contracture Metacarpophalangeal Joint Extension Contracture Metacarpophalangeal Joint Flexion...

Bone

Occurring at all ages, trauma resulting in upper extremity fractures is prevalent. Fracture of the small bones of the hand is one of the most commonly encountered injuries of the upper extremity.28 Fractures of the distal phalanx occur most frequently, followed by metacarpal, proximal phalangeal, and finally, middle phalangeal fractures.27 The potential functional loss from this kind of injury may be underestimated. Even if fracture healing occurs uneventfully, residual joint stiffness may...

Extremity Spasticity1

SPECIFIC LITERATURE REVIEW SPLINTS USED IN THE CONSERVATIVE TREATMENT OF UE SPASTICITY Articular Splints Shoulder, Elbow Splints Elbow Splints Elbow, Forearm, Wrist, Finger MP, PIP, DIP, Thumb CMC, MP, IP Splints Elbow, Forearm, Wrist, Thumb CMC Splints Forearm, Wrist, Thumb CMC, MP Splints Wrist Splints Wrist, Finger MP, Thumb CMC, MP Splints Wrist, Finger MP, PIP, DIP, Thumb CMC Splints Wrist, Finger MP, PIP, DIP, Thumb CMC, MP, IP Splints Finger MP, PIP, Thumb CMC, MP, IP Splints Finger MP,...

Joint Stiffness

Joint stiffness may result from direct injury or may occur secondarily when afflictions of the skin, fascia, tendon, tendon sheath, muscle, or retinacular Fig. 3-4 Nerve healing. Axonal regeneration following peripheral nerve severance and repair. A, Injury results in degeneration of the axon and myelin distal to the wound and for a short distance proximal to the wound. B, A cell body and proximal stump of the axon enlarge as metabolic activity necessary for regeneration commences. The Schwann...

Tendon Adhesions

Limited excursion may result from direct injury to flexor, extensor, or intrinsic tendons, and the scar resulting from the healing of contiguous tissues may also result in excursion-limiting adhesions to these structures. In particular, fractures of the metacarpals or phalanges, in areas where they have a close anatomic relationship to the digital tendons, may result in the tendons becoming bound in an unyielding fracture callus, which, in addition to reducing the amount of active motion...

Splint Biodynamics

It is important that those involved in the preparation and application of splints have an understanding of what tissues are the limiting factors in the diminished movement of a given joint. Is it periarticular scarring or adherent tendons or a combination of both that prevents joint rotation The injured extremity should be inspected for areas of wounding, edema, inflammation, infection, and the amount of active and passive motion loss. Alterations in joint movement produced by variations in the...

Splinting for Tendon Adhesions

The high propensity for injured tendons to develop excursion-limiting adhesions following repair has resulted in a number of techniques designed to impart a controlled amount of tendon motion at an early stage of tendon healing.92 It is hoped that these methods will favorably modify the quantity, strength, and length of adhesions and permit the maximum recovery of tendon performance. Flexor tendon injuries in the digital canal are particularly prone to the development of adhesions, and programs...

Measurements of Biologic Activity

In an effort to determine the effectiveness of splinting programs in modifying the biologic processes involved in tissue healing and scar formation it is important to measure the response of the affected tissues. Hand performance perhaps can best be determined by serially measuring changes in the active and passive range of motion throughout the course of the splinting program (Fig. 3-14). Brand indicates that torque-angle measurements are more objective for passive range of motion and use...

Soft Tissue Remodeling

Hand upper extremity specialists know from experiential knowledge derived from years of clinical practice that splinting is the most efficacious method currently available for improving joint motion limited by soft tissue contracture and or fibrosis. Unfortunately, a paucity of research studies documenting the efficacy of splinting endeavors exists in current medical literature. Sometimes that which is most evident is the last to be researched formally. While the daily gains of splinting...

Purpose Immobilization Mobilization Restriction Torque Transmission

The fourth element in building an SCS splint name divides articular splints into one of four groups according to the primary objective of the splint immobilization, mobilization, restriction, or torque transmission. Does the splint immobilize, mobilize, restrict motion of, or transmit torque to the primary focus joint(s) By describing intended anatomic joint motion rather than splint component motion, the SCS eliminates past confusion encountered when static splints splints with no moving parts...

Descriptive Phrase

Introduced in the first edition of this book in 1981, the descriptive phrase approach to categorizing splints was the first method to recognize the important role of secondary joints, which are included in splints for mechanical control purposes, but are not the primary target joints of splints.3 An important prelude to the development of the ASHT Splint Classification System (SCS), this method lacked the power, extensiveness, and refinement of the SCS. I ASHT SPLINT CLASSIFICATION SYSTEM (SCS)...

Source of Power

The source of power is another categorical method that divides control splints into those that use internal power and those that provide external power. These splints are often associated with long-term Fig. 4-3 Wrist extension, thumb CMC radial abduction and MP flexion immobilization splint, type 0 (3) Contoured splints are often more comfortable to wear because of increased surface contact of the splint with the extremity. An indication for this splint design includes deQuervain's stenosing...

Purpose of Application

Splints may be designed to prevent deformity by substituting for weak or absent muscle strength, as in peripheral nerve injuries, spinal cord lesions, and neu-romuscular diseases. They may be used to support, protect, or immobilize joints, allowing healing to occur after bone, tendon, vascular, nerve, joint, or soft tissue injury or inflammation. Correction of existing deformity represents another commonly encountered reason for splint application. To achieve full active joint motion potential,...

Boutonniere

Dubbed boutonniere or buttonhole deformity, injury to the extensor tendon central slip is the second most frequently occurring closed tendon injury in athletes. Etiology of this injury involves trauma to the central slip or a sudden forced flexion of the PIP joint, as with a blow to the dorsal middle phalanx that forces PIP flexion as the digit is extended. Boutonniere injuries are more frequently associated with contact sports such as football,34,35 but also occur in nonsports situations....

Sensibility Assessment Instruments

Sensibility relies on neural continuity, impulse transmission, receptor acuity, and cortical perception. Assessment of sensibility may be divided into sudo-motor sympathetic response and the abilities to detect, discriminate, quantify, and recognize stimuli (see Appendix B-9). Moberg's ninhydrin test and the wrinkle test identify areas of disturbance of sweat secretion after peripheral nerve disruption. The involvement of sympathetic fibers in a peripheral nerve injury results in areas of dry...

Consider the Torque Effect

Torque equals the product of the force times the length of the arm on which it acts (T Fi x di). This concept is important in splinting because the amount of pull from a mobilization assist is not equal to the amount of rotational force or torque at the joint. The amount of torque depends on the distance between the joint axis and the point of attachment of the mobilization assist. The torque increases as the distance between the two increases if the applied force is held constant (Fig. 6-21)....

Arches

Support Distal Transverse Arch Splinting

The three skeletal arches of the hand (proximal transverse, distal transverse, and longitudinal) must be taken into consideration in attaining congruous splint fit. The distal transverse or metacarpal arch consists Fig. 10-13 A, Wrist extension immobilization splint, type 0 (1) Pressure over bony prominences may be decreased by avoidance (A), wider area of contact (B), or contoured padding (C). Fig. 10-13 A, Wrist extension immobilization splint, type 0 (1) Pressure over bony prominences may be...

Classification and Nomenclature of Splints and Splint Components

Mechanical Characteristics Source of Power Materials Anatomic Part Descriptive Phrase ASHT SPLINT CLASSIFICATION SYSTEM (SCS) Total Number of Joints Design Options Connector Bar Crossbar Cuff or Strap Deviation Bar Mobilization Assist or Traction Device Finger Cuff Fingernail Attachment Forearm Humerus Bar or Trough Hypothenar Bar Joint Metacarpal Bar Opponens Bar Outrigger Splint Component Integration SUMMARY Good communication, an essential to efficacious patient intervention, is dependent...

Nerve Healing

Fibroblasts Tendon Healing

Injury to peripheral nerves necessitates an entirely different type of tissue healing in that the severed nerve fiber must regenerate distally from the point of injury. The injury results in degeneration of the axon and myelin distal to the wound and, for a short distance, proximal to the wound (Fig. 3-4, A). Schwann cells in the distal stump grow toward the proximal stump, and macrophages clear cellular debris from the distal nerve. The cell body and proximal stump of the axon enlarge as the...

Avoid High Shear Stress

To begin, it is necessary to define a few important terms that describe the material behavior of soft tissues. 1. Force is a vector and therefore has a magnitude, direction, and point of application. It changes the direction and or velocity of objects, and when applied to a surface, forces result in deformation of solid or semisolid substances. 2. Strain is a measure of the deformation of a material. It is defined as a ratio of the change in a reference length (gauge length) to the original...

Medial Epicondylitis

Medial epicondylitis is similar to lateral epicondylitis but involves the muscles originating on the medial epi-condyle of the humerus. Repetitive pronation with wrist flexion often leads to medial epicondylitis. Stress and microtearing to the pronator teres, flexor carpi radialis, flexor digitorum sublimus, and flexor carpi ulnaris occur in pitchers in the acceleration phase of throwing, during tennis serves, hitting a forehand shot, and with golf swings. Gymnasts place stress traction on the...

Functional Patterns

Ergonomics Human Figure Hand

The prehensile function of the hand depends on the integrity of the kinetic chain of bones and joints extending from the wrist to the distal phalanges. Interruptions of the transverse and longitudinal arch systems formed by these structures will always result in instability, deformity, or functional loss at a more proximal or distal level. Similarly, the balanced syn-ergism-antagonism relationship between the long extrinsic muscles and the intrinsic muscles is a requisite for the composite...

General Concepts of Mold Fabrication Precautions

Before starting on any mold-making project, always ask the subject and all others who will be in the immediate area, including staff and patient family members, if they have allergies to any of the products to be used. If someone is allergic to one or more of the materials, the person must leave the area or the project must be discontinued. Although infrequent, allergic reactions to materials range from a mild rash to serious respiratory problems. The work area must be well ventilated, and both...

Resistive Exercise

Splint Wearing Schedule Form

The purpose of resistive exercise is to produce sufficient muscle strength to allow maximum tendon excursion, full joint motion, and the execution of normal daily activities. This may be accomplished through purposeful graded activities and progressive resistive exercises. Strengthening is traditionally divided into isometric, eccentric, and concentric exercises. Emphasis includes improving endurance and or strengthening. Caution is needed in adapting strengthening programs for patients with...

Function Assessment Instruments

Normal Grip Strength Measurements

Hand function reflects the integration of all systems and is measured in terms of handedness tests, grip pinch, coordination and dexterity, and ability to participate in activities of daily living and vocational and avocational tasks. The Waterloo Handedness Questionnaire (WHQ) is a 32-item self-administered questionnaire that has high reliability46,53 and has been shown to be more specific and accurate than the traditional self-report for determining handedness.36,40 Further, when the WHQ is...

Trigger Finger Stenosing Tenosynovitis

Repetitive trauma to the area of the A-1 digital pulley is seen in baseball catchers, gymnasts, weightlifters, workers who employ handled gripping tools such as pliers, and musicians who encounter persistent pressure from holding an instrument.20 Direct pressure from a hard surface applied to the flexor tendon at the Fig. 17-6 Long finger PIP extension and flexion torque transmission splint, type 2 (4) A noninjured digit protects an adjacent digit with a newly healed stable fracture from...

Shoulder Subluxation Dislocation

Complete separation of the articular surfaces by a direct or indirect force results in a dislocation of the glenohumeral joint.47 Dislocation includes a disruption of the ligaments of the joint, while a partial dislocation involves a subluxation of the shoulder joint, the sequela of a sprain. A dislocation may self-reduce, or be reduced by a teammate, coach, trainer, or physi cian. A minimum of 6 weeks is considered necessary for ligaments to mend, with protection that limits shoulder motion,...

Shoulder Anatomy

The shoulder girdle represents the most proximal aspect of the upper extremity. Movements of the scapula in relation to the chest wall as well as movements of the glenohumeral joint profoundly affect one's ability to place the hand in space. Passing through the region of the shoulder girdle are the nerves and vascular structures that supply the entire upper extremity. The clavicle, scapula, and proximal humerus form the bony elements of the shoulder girdle. The clavicle is a doubly curved bone...

Lateral Epicondylitis

Frequently referred to as tennis elbow, rug beater's elbow, or jailer's elbow, lateral epicondylitis is a common condition found in athletes, workers, and musicians. Arising from the humeral lateral epicondyle, the extensor-supinator muscles may be strained or contused through repetitive shear activities that cause microscopic tearing and inflammation at the origin of the common extensor tendon. Gripping an instrument, a piece of sporting equipment, or a tool further aggravates the injury. The...

Wrist Splints

Restricted Extension Elbow

When used to control articular motion, wrist splints affect motion of the multiple carpal joints in a similar manner. They may be used to immobilize, mobilize, restrict motion, or transmit torque. It is important to understand that in order to control digital extrinsic muscle tendon glide, the wrist must be included in the splint. Recommendations and designs for wrist splints are numerous. Much of this is due to the proliferation of upper extremity cumulative trauma cases over the past few...