Indications for Splinting

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The patient with rheumatoid arthritis presents numerous treatment challenges to the rehabilitation team.3,23 Whether or not to splint is a major decision. A rheumatoid arthritic hand may be splinted for the following reasons: (1) to help decrease inflammation, (2) to rest and support weakened joint structures, (3) to properly position joints, (4) to help minimize joint contractures, or (5) to help improve function through better positioning of the joints.

Controversy, however, still surrounds this subject.6,19 Most agree that splinting has a place, especially in the acute stage, in a total rehabilitation program for the person with rheumatoid arthritis. However, there are few documented or well-established indications for splinting the rheumatoid hand. Therefore, before any splinting program is undertaken for a patient with rheumatoid arthritis, a careful evaluation must be done to determine the feasibility and appropriate ness of splinting. This helps insure that each splint fabricated will then fit the individual needs of the patient. Patients with longstanding rheumatoid arthritis and those taking certain medications, such as cor-ticosteroids, may have thin, delicate skin that bruises easily. In these cases special precautions need to be taken to prevent skin breakdown, and more frequent checks of the splint are necessary.

Alexander,1 Feinberg,910 Gault,16 Mills,24 Partridge,26 Rotstein,27 and Souter29 have advocated a combination of hand splints and rest when the joints are inflamed. During periods of inflammation, the joints are more vulnerable to damage from both internal and external forces. Splinting has been noted to reduce pain and decrease inflammation and muscle spasm, thus reducing stress to the joints and allowing increased motion and function. A study by Zoeckler and Nicholas36 showed that 63% of the patients who responded to their questionnaire found moderate or great relief from pain and morning stiffness by using splints.

Immobilization Splints

Immobilization splints, either for the whole hand or for the wrist, are often recommended for use during acute periods of inflammation. It is suggested that the splints be worn full time except for brief periods of gentle range of motion exercises and to perform necessary self-care tasks. As inflammation subsides, the splints are worn intermittently. The splints should be worn at night for several weeks after resolution of acute inflammation. If bilateral splints are necessary, alternating the use of each splint often seems more reasonable to the patient and leads to better acceptance and compliance. The patient's activities may be gradually increased as tolerated, and joint protection may be taught at this time. In cases where the metacarpophalangeal joints are involved, but the interphalangeal joints are not, a resting splint may be fabricated to include the MP joints while leaving the IP joints free (Fig. 16-2, A). This kind of splint may also be used as an exercise (torque transmission) splint for intrinsic lengthening. For this situation, the metacarpopha-langeal joints are held in full extension to remodel intrinsics. The patient then puts the splint on for short periods of exercise several times during the day.

When positioning an arthritic hand in a wrist and hand immobilization splint, one should keep in mind the pathomechanics of the disease. The tendency, as previously mentioned, is for the metacarpophalangeal joints to sublux palmarly. Therefore the metacar-pophalangeal joints should be held in about 25-30° of flexion to provide palmar support to those joints and surrounding soft tissue (Fig. 16-2, B,C). The proximal interphalangeal joints are then held in approximately

Degree Wrist Extension Splint

Fig. 16-2 A, Wrist neutral, index-small finger MP extension immobilization splint, type 0 (5) B, Wrist extension, index-small finger flexion, thumb CMC radial abduction and MP flexion, IP extension immobilization splint, type 0 (16) C, Wrist neutral, index-small finger flexion, thumb CMC palmar abduction and MP-IP flexion splint, type 0 (16)

A, A resting splint for the wrist and metacarpophalangeal joints. This splint may also be used as an exercise splint for the proximal interphalangeal joints. When used to increase range of motion at the IP joints, the purpose of this splint changes to an index-small finger IP extension and flexion torque transmission splint, type 2 (13). B, An immobilization splint positions wrist and hand during a period of acute inflammation. C, Adapted straps allow easy doffing and donning of immobilization splints.

Fig. 16-2 A, Wrist neutral, index-small finger MP extension immobilization splint, type 0 (5) B, Wrist extension, index-small finger flexion, thumb CMC radial abduction and MP flexion, IP extension immobilization splint, type 0 (16) C, Wrist neutral, index-small finger flexion, thumb CMC palmar abduction and MP-IP flexion splint, type 0 (16)

A, A resting splint for the wrist and metacarpophalangeal joints. This splint may also be used as an exercise splint for the proximal interphalangeal joints. When used to increase range of motion at the IP joints, the purpose of this splint changes to an index-small finger IP extension and flexion torque transmission splint, type 2 (13). B, An immobilization splint positions wrist and hand during a period of acute inflammation. C, Adapted straps allow easy doffing and donning of immobilization splints.

30° of flexion. The wrist should, if possible, be positioned in neutral to 10° of dorsiflexion. Too much dor-siflexion increases pressure in the carpal tunnel and may lead to median nerve symptoms. This is especially significant if there is evidence of flexor tenosynovitis at the wrist, a frequent cause of median nerve compression in rheumatoid arthritis. When the thumb is included in the splint, it should be positioned in palmar abduction or slight radial abduction depending on individual circumstances.

The position for resting a rheumatoid hand is different from the "safe" or "antideformity" position for splinting an injured hand. After injury, the metacarpophalangeal joints are held in 70-90° of flexion with the interphalangeal joints in full extension to protect the collateral ligaments. A rheumatoid hand held in the "antideformity position" could increase palmar subluxation of the MP joints and stiffness of the PIP joints. Metacarpophalangeal and inter-phalangeal joints should be held in only slight flexion in the rheumatoid hand.

Mobilization Splints

Mobilization splints using elastic traction are used to minimize joint contractures, to position joints, or to aid in postoperative positioning. A study of elastic mobilization splinting in 51 nonsurgical rheumatoid arthritic patients done by Convery et al.7,8 and Li-Tsang et al.21 suggested that hand function was not improved and the progression of deformity was not uniformly prevented. They also found that correction of preexisting deformity was not achieved. The authors felt that there was a greater loss of motion than would have been expected if splints had not been used. Others, however, such as Granger,17 Young,35 and Swanson,31 report that a well-designed and properly fitted mobilization splint may help in both preopera-tive and postoperative management. None suggests that an established deformity may be corrected by splinting. Flatt15 stresses the necessity for gentle continuous pull and avoidance of sudden violent force on a joint when any mobilization splinting is used. Forceful manipulation may cause permanent damage to the joints and supporting structures already under stress from the disease process.

Postoperative Splinting

Another important use of splinting is in postoperative management where immobilization, mobilization, restriction, or torque transmission splints, or a combination thereof, may be used. For example, an immobilization splint to position the hand at night may supplement gains made with mobilization splinting. The type of splint design and its accompanying exercise program (Fig. 16-3) are determined by the

Fig. 16-3 Index finger MP extension and flexion torque transmission splint, type 2 (3)

Postoperative exercise programs are important for attaining active range of motion. Secondary immobilization of the index finger IP joints in slight flexion allows the effects of active extrinsic tendon glide to be concentrated on mobilizing the MP joint. (Courtesy Jolene Eastburn, OTR, Scranton, Pa.)

Fig. 16-3 Index finger MP extension and flexion torque transmission splint, type 2 (3)

Postoperative exercise programs are important for attaining active range of motion. Secondary immobilization of the index finger IP joints in slight flexion allows the effects of active extrinsic tendon glide to be concentrated on mobilizing the MP joint. (Courtesy Jolene Eastburn, OTR, Scranton, Pa.)

surgery performed and the status of the patient's soft tissue. Therefore good communication between the therapist and the physician is necessary to design the most effective splint.

Arthroplasty. In the postoperative management of metacarpophalangeal joint replacement arthroplasty, the purposes of elastic traction mobilization splinting are to maintain alignment of the joints and allow guarded motion while the new capsuloligamentous system is forming (Fig. 16-4, A-M).20,22 Outrigger design in postoperative MP arthroplasty splints must be chosen with a thorough understanding of inherent mechanical effect. Because high-profile outriggers require patients to have less volitional strength to flex actively against extension mobilization assists than do low-profile outriggers, patients with weak finger flexion are able to more easily achieve desired active MP flexion range if they are placed in high-profile outrigger splints.4,11-14,18 If finger flexion strength is not an issue, either high- or low-profile outrigger designs are appropriate so long as obligatory extension-radial deviation mobilizing forces are fully achieved. When using low-profile commercial outriggers, be certain that the angle of approach of the extension-radial deviation pull on the index MP joint is fully attained. Many prefabricated outriggers must be reshaped on the radial side to provide the correct angle of force application to the index MP joint. When success of arthroplasty procedures is defined by programmed joint encapsulation, no excuse exists for accepting less than the requisite angle of pull from an outrigger.

Postoperative MP arthroplasty splinting using a regimen that alternates two splints to mobilize the MP

joints first into extension and then into flexion is also becoming more widely practiced. Although these splints possess no moving parts, they are classified as mobilization splints because their purposes are to move the MP joints into extension and flexion.5

Index finger supination mobilization assists may be applied according to one of two general formats. As with outrigger design, choice of a supinator component for the index finger depends on mechanical concepts. A mobilization assist that attaches to the index fingernail and wraps around the distal phalanx to pull the finger into supination affects capsule remodeling while the index finger is in extension. Because this type of "passive" supinator relies on a small moment arm to effect proximal phalanx rotation, the mobilization assist is often inelastic, and is unhooked for exercise sessions (Fig. 16-4, N-O). In contrast, an "active" supinator requires flexion of the index PIP joint to achieve supination of the index finger. With this supinator design, as active PIP flexion increases to 90°, the rotational moment arm on the proximal phalanx lengthens, providing strong rotational torque to the index MP joint. Characterized by a shorter radial outrigger that ends at the level of the PIP joint, an "active" supinator requires very minimal mobilization assist tension because of the long moment arm created upon active PIP flexion (Fig. 16-4, P). If mobilization assist force of an "active" supinator is too aggressive, damaging torque may be applied to the MP joint, resulting in unwarranted attenuation of healing ulnar capsular structures.

When a wrist arthroplasty is done, the goals of the surgery are to provide a stable, pain-free wrist with about a 50° arc of motion. Therefore the wrist is placed in an immobilization splint for 4 to 6 weeks. In some cases a controlled mobilization / restriction splint is used after the removal of the immobilization splint (Fig. 16-5). It is recommended that the patient always wear a wrist immobilization splint for protection when performing heavier tasks.

Tendon reconstruction. Following surgery for correction of a boutonniere deformity, immobilization splinting is used. The length of immobilization depends on the exact nature of the surgery performed. When motion is started, the immobilization splint is usually worn between exercise sessions for a period of time until the soft tissue has stabilized. Mobilization splinting may be introduced as an adjunct to immobilization splinting. The patient may then progress to daytime intermittent mobilization splinting and night immobilization splinting. A long-term splinting and exercise program may be necessary to prevent recurrent deformity.

Tendon ruptures are a frequent complication of rheumatoid disease. Extensor tendons rupture more

Full Index Finger SplintOrfit BoutonniereDynamic Splint For Radial Nerve

Fig. 16-4 A, Index-small finger MP extension and radial deviation mobilization splint, type 1 (5) B, Index-small finger MP extension and radial deviation mobilization splint, type 1 (5) C,D, Index-small finger MP extension and radial deviation, index finger MP supination mobilization splint, type 3 (7) E, Index-ring finger MP extension and radial deviation, index-long finger MP supination mobilization splint, type 3 (8) F, Index-small finger MP extension and radial deviation mobilization splint, type 3 (7) I, Index-small finger MP extension and radial deviation mobilization splint, type 1 (5) J-M, Index-small finger MP extension and radial deviation mobilization splint, type 1 (5) N, Index-small finger MP extension and radial deviation, index finger MP supination mobilization / thumb CMC radial abduction and MP-IP flexion immobilization splint, type 3 (10) O, Index-small finger MP extension and radial deviation, index finger MP supination, thumb CMC radial abduction and MP extension mobilization splint, type 3 (9) P, Index finger MP supination mobilization splint, type 3 (4)

Postoperative mobilization splints for MP joint replacement arthroplasties vary in design. These splints maintain proper alignment of the MP joints and allow guarded motion while a new capsu-loligamentous system is forming. Various outrigger designs permit individual positioning of MP joints into required increments of extension and radial deviation. A, Mobilization assist radial extension may be accomplished through progressively longer rubber bands attached to a stationary radially placed extension outrigger (B) or through adjustable outriggers (C-O). Depending on the extent of surgical repair, flexion mobilization assists may also be directed radially to further reinforce development of a tight radial joint capsule (not shown). A supination outrigger with a Velcro fingernail attachment device, (N) a serpentine supination splint (O), or a two-sling force couple (P) protects the surgical repair to the index or other fingers to minimize pronation deformity. [Courtesy (A,O,P) from Swanson AB, Swanson GG, Leonard J: Postoperative rehabilitation program in flexible implant arthroplasty of the digits. In Hunter JM, et al: Rehabilitation of the hand, ed 2, Mosby, 1984, St. Louis; (C,D) Barbara (Allen) Smith, OTR, Edmond, Okla.; (E) Helen Marx, OTR, CHT, Human Factors Engineering of Phoenix, Wickenburg, Ariz.; (F-I) Jean Claude Rouzaud, Montpellier, France; (J-M) Margareta Persson, PT, Uppsala, Sweden.]

Fig. 16-5 Wrist extension mobilization / wrist radial and ulnar deviation restriction splint, type 0 (1)

A controlled wrist mobilization / restriction splint is used to allow protected wrist motion following removal of the immobilization splints when a wrist arthroplasty has been performed.

Wrist Mobilisation

Fig. 16-5 Wrist extension mobilization / wrist radial and ulnar deviation restriction splint, type 0 (1)

A controlled wrist mobilization / restriction splint is used to allow protected wrist motion following removal of the immobilization splints when a wrist arthroplasty has been performed.

frequently than do the flexor tendons. Tendons rupture through attrition caused by the tendon rubbing on a bony spur, through direct synovial invasion into the tendon, and through pressure of the hypertrophied synovium on the tendons. It is often not possible to do an end-to-end repair of the tendons, since patients often do not seek immediate medical attention after tendon rupture. Also, the condition of soft tissue may be poor. Therefore tendon transfer is frequently undertaken to restore function.

When tendon transfers have been performed for extensor tendon ruptures, immobilization splinting with the metacarpophalangeal joints in extension is used for the first 3 weeks to support the wrist and MP joints while the transfer heals. Later in the rehabilitation program a mobilization splint for extension may be used if the patient cannot obtain adequate extension. A helpful exercise in rehabilitating a patient who has undergone tendon transfer is to tape the inter-phalangeal joints into a claw-like position to transmit torque to the MP joints by isolating the long extensors. The patient then flexes and extends the MP joints with the fingers held in this position (Fig. 16-6). Practice is important, and the patient needs to be aware that several months of rehabilitation may be required to optimize a functional recovery. The number of tendon ruptures and the condition of the soft tissue determine the outcome of tendon transfers.

Splinting to Enhance Function

Functional splints for the person with rheumatoid arthritis help a patient who is having difficulty with daily tasks perform with more ease and safety. From time to time functional splints are used instead of surgery for patients who, for one reason or another, are not surgical candidates. When assessing a patient

Fig. 16-6 Taping exercise has been found helpful after tendon transfer to transmit torque by isolating the long extensors. A, In flexion. B, In extension.

Fig. 16-6 Taping exercise has been found helpful after tendon transfer to transmit torque by isolating the long extensors. A, In flexion. B, In extension.

for a functional splint, it is important to remember that the degree of deformity does not always correlate with loss of function.

Wrist. The wrist is often a source of pain that interferes with a person's functioning. This is usually manifested in decreased grip strength and inability to perform many routine activities. A wrist immobilization splint supports the wrist, often increases grip strength, and allows an improvement in activities of daily living by relieving wrist pain (Fig. 16-7).

Fingers. A common problem seen in rheumatoid arthritis is ulnar deviation of the metacarpophalangeal joints. This may not necessarily cause functional loss and does not routinely require splinting. In some cases, though, a patient may express a need to have a splint to continue with certain activities. Some patients lose dexterity due to inability to effectively position thumb, index, and midfingers for pinch. In these cases, either an immobilization, mobilization, restriction, or torque transmission splint to help position the MP joints may benefit the patient (Fig. 16-8, A-G). The design should fulfill individual patient requirements. The splint should provide palmar support to the metacarpophalangeal joints, since palmar subluxation is often a component of ulnar drift (Fig. 16-8, C,D). Commercial splints are also available

Fig. 16-7 Wrist extension immobilization splint, type 0 (1) A wrist immobilization splint is used to aid function and protect the wrist.

in various designs (Fig. 16-8, E-G). It is unrealistic, however, to expect these splints to correct ulnar deviation of the MP joints. This needs to be explained to the patient before the splint is made.

Immobilization, mobilization, restriction, or torque transmission splints that control unwanted motion at the PIP joints may increase hand function by positioning fingers in more advantageous postures that facilitate hand dexterity and coordination. Although not appropriate for correcting fixed PIP joint deformities, many of these splints are designed to correct PIP joint swan neck or boutonniere deformities that are passively supple (Fig. 16-9, A,D).

It is important to remember that deformities resulting from rheumatoid arthritis are usually insidious in onset, allowing gradual patient adaptation and retention of surprisingly good levels of functional capacity. When corrective splints are applied, they may actually impair hand dexterity rather than improve it due to the sudden postural change of the digits. Both therapist and patient must understand that, if good splint-wearing compliance is to be achieved, a splint must provide bona fide functional improvement, not just cosmetic realignment of joints. A quick functional dexterity test such as the Jebsen Hand Dexterity Test, the Flinn Performance Screening Test, or the Minnesota Rate of Manipulation Test given pre- and post-splint application provides valuable insight into the true usefulness of splints designed to increase function by improving passive joint alignment at the MP and/or PIP joints.

Thumb. When the thumb becomes involved in the rheumatoid process, the function of the hand is often significantly compromised.32 This is especially true with activities requiring fine manipulation. Thumb deformities in rheumatoid arthritis have been classified by Nalebuff.*25

Type I deformity has its origin at the metacar-pophalangeal joint and is characterized by MP joint flexion and IP joint hyperextension. This deformity is further accentuated by normal pinch forces in daily activities. This deformity may be referred to as an extrinsic minus deformity, since there is a loss of extrinsic extensor power at the metacarpophalangeal joint level.

Type II deformity has its origin at the car-pometacarpal joint and is characterized by the flexion at the MP joint and hyperextension at the IP joint. It looks similar to the type I deformity except that adduction of the metacarpophalangeal joint occurs due to contracture of the adductor pollicis.

Type III deformity follows the same pattern as type II except that it is characterized by hyperextension of the MP joint and flexion of the IP joint. This deformity also has metacarpophalangeal joint adduction.

Type IV deformity is the result of stretching or rupture of the ulnar collateral ligament. The proximal phalanx deviates laterally at the MP joint with the

*Nalebuff's thumb deformity classifications are not related to the expanded Splint Classification System's "type" nomenclature.

Extensor Digitorum Communis Test Radial Deviation Mobilization

Fig. 16-8 A,B, Index-small finger MP extension and radial deviation mobilization splint, type 0 (4) C,D, Index-small finger MP flexion and ulnar deviation restriction splint, type 0 (4) E,F, Index-small finger MP ulnar deviation restriction splint, type 0 (4) G, Index-small finger MP ulnar deviation restriction splint, type 1 (5)

A small hand-based MP extension radial deviation splint is helpful in increasing function when ulnar deviation is present. A, Dorsal aspect of splint. B, Volar aspect of splint. C,D, This MP ulnar deviation restriction splint also limits MP flexion. E,F, The innovative hinge on this MP restriction splint allows MP flexion and extension while preventing ulnar deviation. G, This commercially available splint provides MP ulnar deviation restriction. [Courtesy (C,D) KP MacBain, OTR, Vancouver, BC; (E,F) Julie Belkin, OTR, CO, MBA, 3-Point Products, Annapolis, Md.]

Fig. 16-8 A,B, Index-small finger MP extension and radial deviation mobilization splint, type 0 (4) C,D, Index-small finger MP flexion and ulnar deviation restriction splint, type 0 (4) E,F, Index-small finger MP ulnar deviation restriction splint, type 0 (4) G, Index-small finger MP ulnar deviation restriction splint, type 1 (5)

A small hand-based MP extension radial deviation splint is helpful in increasing function when ulnar deviation is present. A, Dorsal aspect of splint. B, Volar aspect of splint. C,D, This MP ulnar deviation restriction splint also limits MP flexion. E,F, The innovative hinge on this MP restriction splint allows MP flexion and extension while preventing ulnar deviation. G, This commercially available splint provides MP ulnar deviation restriction. [Courtesy (C,D) KP MacBain, OTR, Vancouver, BC; (E,F) Julie Belkin, OTR, CO, MBA, 3-Point Products, Annapolis, Md.]

C
D

Fig. 16-9 B, Finger PIP extension restriction splint, type 0 (1); 4 splints @ finger separate; left \\ Finger PIP extension restriction splint, type 0 (1); 4 splints @ finger separate; right D, Small finger PIP extension mobilization splint, type 0 (1)

A,B, Enhancing functional hand use, these splints prevent PIP hyperextension, swan neck deformity at the PIP joints. C,D, A passively supple boutonniere deformity is corrected with this simple, commercially available splint. [Courtesy (A-D) Cindy Garris, OTR, Silver Ring Splint Company, Charlottesville, Va.]

first metacarpal secondarily assuming an adducted position.

In type V deformity, the major deforming factor is an attenuated palmar plate of the metacarpopha-langeal joint. The metacarpophalangeal joint becomes hyperextended and the distal joint assumes a flexed position. Unlike the type III deformity, the metacarpal does not become adducted.

Type VI deformity is distinguished by collapse and loss of bone. Patients with this deformity demonstrate thumbs that are short and often unstable. Although this deformity is specific to the thumb, it is most often associated with similar problems of the other digits.

As in all rheumatoid deformities, these thumb deformities are the results of muscle and tendon imbalance occurring between the joints of the thumb ray. In each case the alteration of posture at one joint influences the posture at adjacent joints.

Splinting may have particular value for the thumb, both for function, by stabilizing the joints, and in postoperative care. In the postoperative phase of thumb reconstruction, extended periods of splinting are necessary to ensure stability for effective pinch.

When the carpometacarpal joint becomes involved, the synovitis stretches out the joint capsule, leading to joint subluxation or dislocation. The metacarpal often assumes an adducted position. Rehabilitation goals at this point are to prevent an adduction contracture and to maintain a functional range of motion. A type 2 thumb CMC immobilization splint may be fabricated to protect and stabilize the CMC joint and maintain the first web space (Fig. 16-10). The thumb MP and wrist are included in this splint as secondary joints. The splint should extend two-thirds up the forearm and distally to the interphalangeal joint crease. The IP joint should be left free to move. A type 1 thumb CMC immobilization splint, where the MP joint is the sole secondary joint, is sometimes made for this problem, but in many cases this proves ineffective. The type 1 splint often does not provide the needed support when the carpometacarpal joint is involved. A type 2 splint that includes the wrist and MP as secondary joints ensures good CMC joint protection while helping to maintain the thumb metacarpal in the corrected position. Patients generally wear this splint during the day when performing functional activities and at night for

Thumb Cmc Palmar Abduction

Fig. 16-10 Thumb CMC palmar abduction immobilization splint, type 2 (3)

This thumb splint protects the carpometacarpal joint, relieves pain, and improves thumb function.

Fig. 16-10 Thumb CMC palmar abduction immobilization splint, type 2 (3)

This thumb splint protects the carpometacarpal joint, relieves pain, and improves thumb function.

positioning. Patients should be instructed to remove the splint several times a day to perform light range of motion exercises.

When the thumb metacarpophalangeal joint is involved, the goals are to prevent the deformity from becoming fixed, to improve function, and to help protect the joint from external forces that could produce further joint damage and deformity. One way to accomplish this is to use a small splint that will protect the metacarpal joint. In this case, neither the carpometacarpal nor the interphalangeal joints need to be immobilized. The exception to this is if there is also deformity or involvement at the adjacent joints. The MP joint may be immobilized with a small aluminum and foam splint or a splint made from thermoplastic (Figs. 16-11, 16-12). Immobilizing the metacarpophalangeal joint often improves function by providing a more stable base for pinching, and protecting the joint from external forces. The interpha-langeal joint also may be controlled with the use of a type 1 thumb immobilization splint of aluminum and foam (Fig. 16-13, A) or thermoplastic, providing both stability and protection of this joint. If IP joint hyperextension is problematic, a type 1 thumb IP extension restriction splint may suffice (Fig. 16-13, B). Continued pinching activities may lead to stretching of the supporting soft tissue, leaving the joint unstable and pinching difficult. If the joint becomes unstable, splinting may improve the patient's functional level.

Fig. 16-11 Thumb MP flexion immobilization splint, type 0 (1)

Designed to support the metacarpophalangeal joint of the thumb, this splint enhances functional use of the thumb.

Fig. 16-11 Thumb MP flexion immobilization splint, type 0 (1)

Designed to support the metacarpophalangeal joint of the thumb, this splint enhances functional use of the thumb.

Immobilization Splint For Writing

Fig. 16-12 A,B, humb MP extension immobilization splint, type 1 (2)

The metacarpophalangeal joint of the thumb is protected in this immobilization splint. A, Dorsal aspect of splint. B, Volar aspect of splint.

Fig. 16-12 A,B, humb MP extension immobilization splint, type 1 (2)

The metacarpophalangeal joint of the thumb is protected in this immobilization splint. A, Dorsal aspect of splint. B, Volar aspect of splint.

Splint Indications
Fig. 16-13 A, Thumb IP extension immobilization splint, type 0 (1) B, Thumb IP extension restriction splint, type 0 (1) Both these splints provide extension stability to the thumb IP joint through either immobilization (A) or restriction (B) of IP joint motion.

for a long time and will need adjustments or replacement from time to time. Because the disease is unpredictable, the patient's needs often change and should be reassessed. Splinting should be only a part of a well-coordinated rehabilitation program.

I CASE STUDY*

The subject is a 62-year-old female who developed rheumatoid arthritis (RA) at the age of 27. Pain and progressive digital instability compelled her to give up her practice as a dental hygienist and begin teaching as a university professor. Over the years, progressive bilateral hand involvement forced the subject to relinquish activities such as playing the piano, typing fluently on a keyboard, manipulating small objects (e.g., jewelry), and grasping large objects unilaterally (e.g., drinking glasses). The subject consulted an experienced hand surgeon, and bilateral reconstructive surgery was recommended to improve hand function and decrease pain. She opted to have the nondominant, left hand reconstructed first (Fig. 16-14).

Prior to surgery, two different splints were fitted to the subject's left thumb to determine which positional splint was most functional (Fig. 16-15, A-D).

Multiple complex deformities of the left thumb and fingers (Table 16-1) required careful preoperative planning to provide the best potential for postoperative hand function (Fig. 16-16, A,B). Surgical procedures to the left digits included arthrodeses, replacement MP arthroplasties, extensor revision and tenotomy, and a capsulodesis (Table 16-2).

Postoperative immobilization of the thumb is maintained for approximately 4 to 6 weeks to ensure good capsular healing and joint stability. During the immobilization period, the patient should be encouraged to perform range of motion of the fingers several times a day to prevent stiffness. After discontinuation of splinting, therapy is directed toward functional use of the thumb. The goal of the therapy program is to obtain a stable, pain-free, functional pinch.

Once a splint has been made, it is necessary to monitor the patient periodically for proper fit and any change in status. When embarking on a functional splinting program for a patient with rheumatoid arthritis, it is important to remember that splinting one area places more stress on adjacent areas. Therefore the patient should be monitored for signs of inflammation in surrounding joints. Because the patient does have a chronic disease, splints are used

TABLE 16-1

Thumb

Index finger Long finger

Ring finger

Small finger

Indications for Surgical Reconstruction, Nondominant Left Hand

MP and IP joint instability

IP joint hyperextension deformity

MP joint subluxation and destruction

MP joint subluxation and destruction

PIP joint extension lag

MP joint subluxation and destruction

PIP joint fixed flexion deformity, joint destruction

DIP joint hyperextension deformity, joint destruction MP joint subluxation and destruction PIP joint fixed flexion deformity, joint destruction DIP joint hyperextension deformity, joint destruction

*The authors express their gratitude to James W. Strickland, MD, and K. E. Gable, EdD, for their invaluable and generous assistance in preparing this case study.

Wrist Flexion Splint

Fig. 16-14 Preoperative thumb and finger deformities resulting from rheumatoid arthritis. A, Left hand. B, Preoperative flexion and C, Preoperative extension of fingers.

Fig. 16-14 Preoperative thumb and finger deformities resulting from rheumatoid arthritis. A, Left hand. B, Preoperative flexion and C, Preoperative extension of fingers.

TABLE 16-2

Thumb

Index finger Long finger

Ring finger Small finger

Surgical Reconstruction Procedures, Nondominant Left Hand

MP arthrodesis

IP flexion capsulodesis

MP replacement arthroplasty

MP replacement arthroplasty

Extensor tendon revision of PIP with tenotomy of terminal extensor tendon MP replacement arthroplasty PIP arthrodesis DIP arthrodesis MP replacement arthroplasty PIP arthrodesis DIP arthrodesis

How Make Your Own Thumb Splints

Fig. 16-15 B, Thumb IP extension restriction splint, type 0 (1) C,D, Thumb IP extension restriction splint, type 1 (2)

B,C, Trials using two separate splint designs, with different type classifications, to restrict IP extension were carried out to determine which design afforded the best function. A, Without splinting, the thumb collapsed into MP flexion and IP hyperextension during pinch, resulting in poor prehension. Subject preferred the type 1 splint design due to the added stabilization (C) and positioning (D) of the thumb MP joint, which allowed the pulp of the thumb to contact objects rather than the ulnar aspect of the thumb IP joint and distal phalanx provided by the type 0 splint design (B).

Fig. 16-15 B, Thumb IP extension restriction splint, type 0 (1) C,D, Thumb IP extension restriction splint, type 1 (2)

B,C, Trials using two separate splint designs, with different type classifications, to restrict IP extension were carried out to determine which design afforded the best function. A, Without splinting, the thumb collapsed into MP flexion and IP hyperextension during pinch, resulting in poor prehension. Subject preferred the type 1 splint design due to the added stabilization (C) and positioning (D) of the thumb MP joint, which allowed the pulp of the thumb to contact objects rather than the ulnar aspect of the thumb IP joint and distal phalanx provided by the type 0 splint design (B).

Fig. 16-16 Preoperative fluoroscans of left fingers (A) and thumb (B).

Fig. 16-17 A, Appearance of left hand following removal of bulky dressing. B, Postoperative fluoroscans of fingers with MP replacement arthroplasties and arthrodesis hardware in ring and small fingers (B) and thumb (C).

Dressing Left Hand

Fig. 16-18 Thumb MP flexion immobilization / IP extension restriction splint, type 0 (2) \\ Long finger PIP extension immobilization splint, type 1 (2) \\ Ring finger IP flexion immobilization splint, type 0 (2) \\ Small finger IP flexion immobilization splint, type 0 (2)

(Radial to ulnar), the thumb splint protects MP arthrodesis and prevents IP extension, to avoid stretching of volar IP capsulodesis, while allowing active and passive IP flexion. Long finger splint prevents PIP motion to allow healing of PIP extensor tendon centralization, with the DIP included as a secondary joint. Ring and small finger splints provide external support at the respective PIP and DIP joints to protect arthrodeses at these joints.

Fig. 16-17 A, Appearance of left hand following removal of bulky dressing. B, Postoperative fluoroscans of fingers with MP replacement arthroplasties and arthrodesis hardware in ring and small fingers (B) and thumb (C).

Therapy was initiated on the 12th postoperative day following removal of the bulky dressing (Fig. 1617, A-C). In addition to exercise, edema control, and implementation of one-handed ADL and vocational compensatory strategies, splinting was an integral part

Fig. 16-18 Thumb MP flexion immobilization / IP extension restriction splint, type 0 (2) \\ Long finger PIP extension immobilization splint, type 1 (2) \\ Ring finger IP flexion immobilization splint, type 0 (2) \\ Small finger IP flexion immobilization splint, type 0 (2)

(Radial to ulnar), the thumb splint protects MP arthrodesis and prevents IP extension, to avoid stretching of volar IP capsulodesis, while allowing active and passive IP flexion. Long finger splint prevents PIP motion to allow healing of PIP extensor tendon centralization, with the DIP included as a secondary joint. Ring and small finger splints provide external support at the respective PIP and DIP joints to protect arthrodeses at these joints.

of the rehabilitation program.* Upon pin and suture removal, and application of edema control digital "socks,"finger and thumb immobilization splints were fitted for continuous wear (Fig. 16-18). Once these digital splints were applied, an index-small finger MP extension and radial deviation, index-ring finger MP supination mobilization splint, type 3 (11) was fitted to influence/control MP joint capsular remodeling (Fig. 16-19, A,B). An additional splint was fabricated for night and as-needed day wear (Fig. 16-20).

Active range of motion was initiated for the long finger PIP joint on the 6th postoperative week. Day and night extension splinting to the long finger continued between exercise sessions to minimize potential development of an extensor lag.

With fluoroscopic confirmation of bone healing, all digital immobilization splints protecting arthrodeses were discontinued at the 8th postoperative week. The index-small finger MP extension and radial deviation, index-ring finger MP supination mobilization splint, type 3 (11) was discontinued at 10 weeks postoperatively. Night splinting and as-needed day splinting, during moderate to heavy hand use, was continued with an index-small finger MP extension mobilization and ulnar deviation restriction splint, type 1 (5) for support and protection of the finger MP joints (Fig. 16-21). Joint protection concepts and techniques were also reviewed with the subject.

»Detailed description of therapy procedures other than the splinting program is not within the scope of this case study.

Finger Mobilization

Fig. 16-19 A,B, Index-small finger MP extension and radial deviation, index-ring finger MP supination mobilization splint, type 3 (11) \\ Thumb MP flexion immobilization / IP extension restriction splint, type 0 (2) \\ Long finger PIP extension immobilization splint, type 1 (2) \\ Ring finger IP flexion immobilization splint, type 0 (2) \\ Small finger IP flexion immobilization splint, type 0 (2)

A, Mobilization assists pull the finger MP joints into extension and radial deviation to control remodeling of MP joint capsules with radial tightening. B, MP supination mobilization assists counteract pronation tendencies of the index, long, and ring fingers following surgery. C, Appearance of hand at 2 1/2 weeks postoperatively. The Velcro loop "buttons" are adhered with cyanoacrylate glue to the fingernails. These allow attachment of the MP supination mobilization assists.

Fig. 16-19 A,B, Index-small finger MP extension and radial deviation, index-ring finger MP supination mobilization splint, type 3 (11) \\ Thumb MP flexion immobilization / IP extension restriction splint, type 0 (2) \\ Long finger PIP extension immobilization splint, type 1 (2) \\ Ring finger IP flexion immobilization splint, type 0 (2) \\ Small finger IP flexion immobilization splint, type 0 (2)

A, Mobilization assists pull the finger MP joints into extension and radial deviation to control remodeling of MP joint capsules with radial tightening. B, MP supination mobilization assists counteract pronation tendencies of the index, long, and ring fingers following surgery. C, Appearance of hand at 2 1/2 weeks postoperatively. The Velcro loop "buttons" are adhered with cyanoacrylate glue to the fingernails. These allow attachment of the MP supination mobilization assists.

Fig. 16-20 Index-small finger MP extension, long finger PIP extension, ring-small finger IP flexion, thumb MP-IP flexion immobilization splint, type 4 (16)

Night and as-needed day immobilization splint protects healing structures and maintains neutral alignment of MP joints. For positioning and stabilization, the wrist, index finger IP joints, long finger DIP joint, and thumb CMC joint are included as secondary joints.

Fig. 16-20 Index-small finger MP extension, long finger PIP extension, ring-small finger IP flexion, thumb MP-IP flexion immobilization splint, type 4 (16)

Night and as-needed day immobilization splint protects healing structures and maintains neutral alignment of MP joints. For positioning and stabilization, the wrist, index finger IP joints, long finger DIP joint, and thumb CMC joint are included as secondary joints.

Fig. 16-21 Index-small finger MP ulnar deviation restriction splint, type 1 (5)

This splint supports the MP joints during functional use.

Fig. 16-21 Index-small finger MP ulnar deviation restriction splint, type 1 (5)

This splint supports the MP joints during functional use.

At the 6th postoperative month, both function and cosmesis were improved considerably (Fig. 16-22, A-D) and the subject reported high outcome satisfaction (Fig. 16-23, A-C) and a desire for surgical reconstruction of her dominant, right hand to be done as soon as possible! Reconstructive surgery of the subject's right hand was accomplished with similar results.

Fig. 16-23 Patient reported high satisfaction with functional and cosmetic outcome. Thumb stability improved for writing tasks (A), types normally with left hand (B) as compared to the single-digit hunt-and-peck method used prior to surgery, holds drinking glass unilaterally with left hand (C), and is able to wear a glove on left hand. All of these activities performed for the first time in more than two decades.

Fig. 16-23 Patient reported high satisfaction with functional and cosmetic outcome. Thumb stability improved for writing tasks (A), types normally with left hand (B) as compared to the single-digit hunt-and-peck method used prior to surgery, holds drinking glass unilaterally with left hand (C), and is able to wear a glove on left hand. All of these activities performed for the first time in more than two decades.

Fig. 16-22 A, Reconstructed left hand at 6th postoperative month with pleasing cosmesis, active finger flexion (B), active finger extension (C), and active thumb flexion (D). (Compare to Fig. 16-14.)

I SUMMARY

Splinting the rheumatoid hand is controversial but may often be beneficial in both medical and surgical management along with a well-planned rehabilitation program. Knowledge of the biomechanics of the disease process, good communication with the physician and other team members, and careful assessment of the patient's individual situation and functional status all help the patient to derive maximum benefit from the splinting program.

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