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 splinting. Ray resection with accompanying metacarpal transposition requires protection of the osseous fixation site in addition to protection of the reapproximated transverse inter-

metacarpal ligament.108 Splinting following this procedure is essentially similar to treating an openly reduced and fixated proximal metacarpal fracture with additional attention to the reapproximated transverse intermetacarpal ligament.17

Replantation/Free Tissue Transfer/Transplantation

Splinting programs employed with patients who have undergone replantation, free tissue transfer, or transplantation procedures emphasizes attainment and maintenance of motion in adjacent uninvolved joints and in the replanted segment.* Because of the obligatory immobilization of repaired structures to promote healing, the interval between the initiations of each type of splinting is often several weeks.

Depending on the level of severance, viability status of the replant or transplant, and size of the postoperative dressing, splinting and exercises may be carried out on joints not included in the dressing within the first postoperative week, provided that the mobilization does not stress repaired structures. Initiation of exercises to the replanted/transferred/transplanted part is determined by the particular operative procedures performed and the patient's status as he advances through the requisite physiologic stages of wound healing. It is imperative that splints and exercises appropriately correspond with the healing stages through which the patient progresses (e.g., early active or passive vs. active or passive). Close coordination between surgeon, therapist, and patient is essential, first toward preserving viability of the reat-tached/attached part and later toward achieving maximum patient rehabilitative potential.

With immobilization splints providing external support to internally fixated fractures and healing soft tissue structures, gentle mobilization traction designed according to individual requirements may be initiated. Because of lack of sensation and the potential damaging effect of edema, careful attention must be directed to obtaining a congruous splint fit that does not produce pressure, obstruct venous return, or impair arterial flow. Straps and splint components may be widened to alleviate undue pressure on underlying soft tissue (Fig. 15-30). Splints that apply small areas of three-point pressure or are circumferential in design are contraindicated during the early mobilization of a replanted segment. Careful monitoring of the replant is essential after splint application. An alteration of digital color or increase in edema of the replanted segment necessitates immediate removal of the splint. As the vascular status becomes less tenuous, its sensitivity to pressure decreases, allowing the use of more conventional splint designs.

Fig. 15-29 A, Nonarticular metacarpal splint B, Nonarticular metacarpal splint C, Nonarticular metacarpal splint D, Nonarticular metacarpal splint

A, Along with a well-formed palmar bar supporting the transverse metacarpal arch, the radial and ulnar bars of this splint apply a gentle medially directed force to protect the healing transverse inter-metacarpal ligament. B, As postoperative edema decreases the splint becomes loose and nonsup-portive, necessitating periodic adjustments. C, Fabricating the splint in a thin, flexible thermoplastic material, rather than the standard --inch rigid material, allows the patient to tighten the splint as needed in response to its loosening as edema decreases. D, Another splinting option includes use of a strap or an elastic wrap to provide support to the healing transverse intermetacarpal ligament. This option allows simple yet effective adjustments as edema decreases. Careful attention to fit is necessary to ensure that the transverse metacarpal arch is not flattened or exaggerated once the strap or elastic wrap is secured in place. Since the splint fits circumferentially, it is important to make certain that vascular structures are not compromised.

Amputation

Unfortunately, amputation of portions of a digit or hand may occur after severe injury. From both a psychological and functional standpoint, it is important that all efforts be devoted to rapidly restoring the amputation victim to a productive status.

Splinting a hand that has undergone amputation of a part may be directed toward (1) the maintenance of motion of uninvolved joints, (2) protective splinting to the area of amputation, and (3) functional splinting to improve prehensive patterns.2,103,108 Emphasis is placed on prevention of adhesions and the return of

Fig. 15-30 A, Index-small finger flexion mobilization splint, type 1 (13) B, Wrist neutral immobilization / index-small finger MP extension restriction / index-small finger PIP extension, thumb CMC palmar abduction and MP-IP flexion mobilization splint, type 0 (16) \\ Finger DIP extension immobilization splint, type 0 (1); 4 splints @ finger separate

A, The wristband of this finger flexion splint has been widened to decrease pressure from the splint on the distal forearm. B, Used with the nation's first upper extremity transplant patient, this splint was designed to increase finger IP extension, and thumb palmar abduction and MP-IP flexion. The index-small finger DIPs are immobilized in extension with individual extension immobilization splints. [Courtesy (B) Jewish Hospital, Louisville, Ky.]

Fig. 15-30 A, Index-small finger flexion mobilization splint, type 1 (13) B, Wrist neutral immobilization / index-small finger MP extension restriction / index-small finger PIP extension, thumb CMC palmar abduction and MP-IP flexion mobilization splint, type 0 (16) \\ Finger DIP extension immobilization splint, type 0 (1); 4 splints @ finger separate

A, The wristband of this finger flexion splint has been widened to decrease pressure from the splint on the distal forearm. B, Used with the nation's first upper extremity transplant patient, this splint was designed to increase finger IP extension, and thumb palmar abduction and MP-IP flexion. The index-small finger DIPs are immobilized in extension with individual extension immobilization splints. [Courtesy (B) Jewish Hospital, Louisville, Ky.]

maximum function commensurate with the particular loss. The unnecessary stiffening of unaffected joints after amputation usually reflects a failure to establish motion programs at an early stage. The patient with an amputation is often reluctant to remove bandages and resume motion because of self-consciousness and fear of pain. The upper extremity specialist must be especially supportive, while reinforcing constantly the need to use the extremity and to resume social contacts.

Fingertip amputations are generally the most common kind of amputation seen in the therapy clinic. A tip protector may be needed along with wound management, exercises, and edema control (see Fig. 15-28, A). Stump wrapping to the digit and Silastic molds can improve the final cosmetic appearance and decrease stump hypersensitivity.

Amputation often results in generalized edema of the extremity, increasing the risk of stiffness in the remaining adjacent joints. Splinting therefore may be required to augment exercise programs. In the early postamputation phase, joints in adjacent digits readily respond to uncomplicated traction devices, such as wide rubber bands and glove rubber bands for flexion and three-point fixation splints for extension. Joints proximal to the site of amputation may be more resistant to the establishment and maintenance of good passive and active range of motion, requiring more complicated splints to attain an acceptable level of motion. To encourage early use of the hand in purposeful activity, a temporary splint may be designed to fit over the distal aspect of the remaining digit (Fig. 15-31, A-C). This prevents unintentional bumping of the tender stump and allows more uninhibited use of the hand as healing progresses. These splints are frequently fitted over dressings and should be removed during inactive periods for cleaning and to allow ventilation. Care should be taken to prevent wound maceration from an improper splint-wearing schedule and poor skin hygiene.

The potential for dependence on a protective splint should be acknowledged, and measures taken to gradually wean the patient from the splint as self-confidence increases and area sensitivity decreases. The initiation of a desensitization program is often instrumental in hastening unprotected hand use. Persistent hypersensitivity at the healed site of amputation may indicate unresolved problems such as retained terminal neuromas, and evaluation by a physician should be requested.

Functional splinting of a partially amputated hand permits accomplishment of special occupational tasks (Fig. 15-31). Splint design ranges from relatively simple to extremely complicated, depending on specific anatomic loss and patient requirements. Durability of the splint is often a key factor and may necessitate collaboration with an orthotist.

Individualized, beautifully made cosmetic pros-theses are available for cosmetic coverage of digital, hand, and forearm amputations. Above-elbow and below-elbow amputees require evaluation and training with conventional functional body-powered or electric-powered prostheses.

It is important that an excellent rapport is established with the amputation patient. Initial education

Fig. 15-31 A, Thumb CMC palmar abduction and MP extension mobilization splint, type 0 (2)

B, Thumb MP-IP splint-prosthesis \\ Long finger PIP extension immobilization splint, type 0 (1)

C, Thumb CMC circumduction / [thumb MP-IP flexion fixed] torque transmission splint-prosthesis, type 0 (1) D, Thumb CMC circumduction / [thumb MP-IP flexion fixed] torque transmission splint-prosthesis, type 0 (0) E, [Thumb CMC radial abduction, MP-IP flexion fixed] splint-prosthesis, type 0 (0) F, G, Index finger MP flexion immobilization / [index finger IP flexion, long-small finger flexion fixed] splint-prosthesis, type 0 (1) H, Wrist extension: [finger prosthesis flexion] / wrist flexion: [finger prosthesis extension] torque transmission splint-prosthesis, type 0 (1)

A, This thumb CMC mobilization splint helps prevent joint contracture and loss of thumb motion in a hand that has sustained a partial amputation. B,C, A nonskid thumb pad and simulated thumbnail increase functional prehension for this patient using his prototype thumb splint-prosthesis. Prototypes for prostheses may be fabricated in thermoplastic materials, allowing identification of optimal functional designs. D, This splint-prosthesis simulated a final prosthetic device and allowed the patient to perform daily tasks ensuring the final design would meet the patient's needs. E, Prosthetic thumb post provides a stable surface against which normal fingers can oppose for pinch and grasp activities. F,G, Provision of an adapted gripping surface against which the thumb may oppose allowed this patient to grasp and use a hammer. H, Because this man required splint durability that could not be attained with routine splinting materials, he was referred to an orthotist who specializes in metal hand braces. [Courtesy (A,E) Jolene Eastburn, OTR, Scranton, Pa.; (B-D) J. Robin Janson, MS, OTR, CHT, Indianapolis, Ind.; (F,G) Joan Farrell, OTR, Miami, Fla. (H) Lawrence Czap, OTR, Columbus, Ohio;]

for phantom sensation and nightmares is essential for every patient post-amputation. The loss of a body part is a severe psychological blow, regardless of the level, and the patient must be gently brought to understand the importance of accepting the loss and devoting efforts toward maintaining and restoring maximum function in the remaining hand. See Chapter 23, Splint Prostheses, for additional information.

I USE OF PREFABRICATED COMMERCIAL SPLINTS

The same principles of mechanics, outriggers and mobilization assists, design, construction and fit that define custom-made splints must also be used to analyze prefabricated splints. Application of these principles is unconditionally fundamental to ensuring

the effectiveness and safety of prefabricated splints as treatment modalities. Inattention to these time-honored splinting principles when applying any splint, whether custom or prefabricated, has considerable potential to cause patient harm.

Typically purchased through commercial vendors, prefabricated splints are premolded to "fit" various upper extremity sections/parts. These splints are available in a multiplicity of designs, according to mass-production standard sizes, in a variety of materials including low- and high-temperature thermoplastics, leather, vinyl, fabric, and neoprene. Prefabricated splints may be a splinting source for clinicians who are not proficient at custom splint fabrication and for experienced splint makers; in special circumstances, they may be more cost efficient than custom-fabricated splints. Because of these perceived advantages, prefabricated splints have found widespread use in clinical settings.

Some prefabricated splints permit minor adjustments to achieve better fit. For example, material may be trimmed to clear flexion creases so long as splint fit and structural stability are not sacrificed. Metal stays in many prefabricated wrist immobilization splints do not fit the normal contour of the volar wrist and proximal palm and stays may not bend at the proper angle required for the diagnosis for which the splints are issued. To correct these problems, metal stays may be reformed or replaced with custom-fabricated low-temperature thermoplastic stays to achieve greater contiguous fit and proper wrist angle.

Appropriate selection between a custom and prefabricated splint is predicated on the complexity of patient-specific requirements. For example, prefabricated splints, when properly fitted, may be adequate for the conservative treatment of carpal tunnel syndrome. In contrast, custom-fitted splints are indicated for postoperative splinting of flexor tendon repairs where well-fitting splints that accurately position joints at precise angles are required. When choosing between a custom or prefabricated splint for a shoul der condition, after an analysis of the cost, time, and feasibility of fabrication, a properly fitted prefabricated shoulder splint may be the splint of choice simply because of the large physical mass and inherent strength requisites associated with an adult-size shoulder splint. However, if optimum fit and mechanics cannot be achieved with a prefabricated splint, its use is contraindicated. See Chapter 14, Splints Acting on the Elbow and Shoulder, for further information.

As emphasized in the introduction of this chapter, various splint configurations and designs may be appropriate for any given upper extremity condition. Once a splint's purpose and basic design have been determined, the next sequential phase is splint construction. It is at the construction stage that the pros and cons of custom-fabricated splints versus prefabricated splints may be analyzed as they relate to the patient-specific situation at hand. This is a critical decision as it entails profound consequences that will significantly influence the efficacy of the patient's rehabilitative course.

Deciding whether or not to use a prefabricated splint is dependent on fundamental questions that must be addressed with candor and unbiased analysis: (1) Does a prefabricated splint achieve the same purpose as a custom splint? (2) Does it meet the same standards of mechanics, outriggers and mobilization assists, design, and fit as a custom splint? (3) Will its produced outcome be as clinically effective as that of a custom splint? (4) Does it meet individual patient needs as well as a custom splint? (5) Is it as adjustable as is a custom splint, if adjustments are required? (6) In the long run, will it be as cost-effective as a custom splint? The ability of the patient to achieve maximum rehabilitation potential is always paramount. If the answer is "no" to any of the above questions, then use of a prefabricated splint is inappropriate.

The judicious use of prefabricated splints requires time to study the splints available on the market and to stay current with changing products.50 Preliminary trial fittings with careful attention to detail help separate potentially useful splints from useless contraptions and cost analysis is a must. Prefabs are not indicated for every splinting situation, but they do provide additional choices when they fit properly. Remember, it may take longer to adjust a preformed splint properly than it would take to make and fit a custom splint from scratch, thus negating anticipated cost and time efficacy.

While many prefabricated splints can be stocked in the clinic in various sizes, other prefabricated commercial splints must be rented or purchased through medical supply companies that take care of paperwork (billing, etc.) and send a representative to fit the

Fig. 15-32 A, Elbow extension mobilization splint, type 1 (2) B, Wrist extension mobilization splint, type 0 (1) C, Wrist flexion mobilization splint, type 5 (14)

Not limited to the illustrated examples, prefabricated wrist and elbow splints are available commercially in many designs. Special care is required to achieve correct alignment of joints and proper splint positioning. Splinting principles must be followed in fitting all prefabricated splints. [Courtesy (A,B) DeRoyal/LMB, Powell, Tenn.; (C) Joint Active Systems, Effingham, Ill.]

Fig. 15-32 A, Elbow extension mobilization splint, type 1 (2) B, Wrist extension mobilization splint, type 0 (1) C, Wrist flexion mobilization splint, type 5 (14)

Not limited to the illustrated examples, prefabricated wrist and elbow splints are available commercially in many designs. Special care is required to achieve correct alignment of joints and proper splint positioning. Splinting principles must be followed in fitting all prefabricated splints. [Courtesy (A,B) DeRoyal/LMB, Powell, Tenn.; (C) Joint Active Systems, Effingham, Ill.]

splints. These splints are typically more expensive, including CPMs and complicated mechanized wrist, elbow, and shoulder splints. The bottom line, however, is that patient care is the responsibility of the clinician, not the company representative. When a company representative fits a splint on your patient, it is essential that you, the therapist, evaluate and approve the fit (Fig. 15-32).

As noted above, a prefabricated splint, as with a custom splint, must meet exacting patient requisites according to the specific diagnosis for which it is applied. If a prefabricated splint fails to achieve required parameters, it is not a suitable treatment option regardless of how cost-effective or time saving it may be.

I SUMMARY

One can see that special problems relating to upper extremity injury and disease and the appropriate surgical management of these conditions present somewhat predictable splinting requirements. Although broad generalization with regard to the splinting of these problems may be offered, it is obvious that wide variations occur in the clinical presentation of each problem and its therapeutic approach. Armed with an appreciation of the potential peculiarities of each of these general categories, one must become familiar with the individual circumstances and subsequently initiate the most applicable splinting and exercise program.

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SUGGESTED READING

Brand PW, Hollister A: Clinical mechanics of the hand, Mosby, ed

Green DP, Hotchkiss R, Pederson W: Operative hand surgery, ed

4, London, 1998, Churchill Livingstone.

Mackin EJ, Callahan AD, Osterman AL, et al: Hunter, Mackin & Callahan's rehabilitation of the hand and upper extremity, ed

Omer G, Spinner M, Van Beek A: Management of peripheral nerve problems, ed 2, W. B. Saunders, 1998, Philadelphia.

Strickland JW, ed. The hand, Lippincott-Raven 1998, Philadelphia.

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