Shoulder Splints

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Because of its inherent complexity and size, splinting the shoulder is one of the more challenging splinting endeavors clinicians may encounter. The shoulder is a composite of four articulations that work together in a complex symphony to provide three degrees of freedom of motion in multiple planes. The four joints of the shoulder include the glenohumeral joint, the sternoclavicular joint, the acromioclavicular joint, and the scapulothoracic joint.24 Positioning of the shoulder following injury or surgery depends on the injury, the reparative procedure performed, and surgeon preference.

Clinicians have a wide range of shoulder splint design options from which to choose, ranging from custom-fabricated splints to commercially available splints. Deciding whether to make a shoulder splint or to apply a prefabricated splint involves careful consideration of numerous factors including patient, staff, and third-party reimbursement variables. Unfortunately, some custom-designed shoulder splints are time-consuming to fabricate and they often require the assistance of a second person to obtain a proper fit. In today's therapy world, not only is this not practical, but it often is not possible in some clinics! With an increasing number of commercial shoulder splints on the market, some clinicians seem to be gradually moving away from making custom-fitted shoulder splints. Interestingly, a defining element of this trend involves purpose of splint application, in that most shoulder immobilization splints continue to be custom fabricated to exactingly meet individual patient needs. In contrast, lack of an easily constructed and adjusted shoulder mobilization splint design may be intimidating to some clinicians, insidiously shrinking acceptance criteria in favor of less efficacious but quicker and easier shoulder mobilization splinting solutions. This unfortunate situation, however, is rectified with a simple, adjustable shoulder mobilization splint devised by McClure and Flowers25 (see section on shoulder mobilization splints).

Sometimes a prefabricated shoulder splint may be the splint of choice. If a commercially manufactured splint is used, it must satisfy all of the principles (mechanics, outriggers and mobilization assists, design, construction, and fit) discussed earlier in this book. There is never any excuse for an improperly fitting or poorly functioning splint, whether custom or commercially made.

When fitting shoulder splints, care should be taken to avoid overstretching of the brachial plexus and to avoid pressure over the radial nerve. Wounds involving both bone and soft tissue require innovative splinting solutions. For example, humeral fractures are commonly associated with radial nerve injuries.* In complex cases such as these, splinting must satisfy multiple purposes including immobilizing the humeral fracture and providing splintage for the associated radial nerve palsy.

A clinical hint that is applicable to fitting most shoulder splints is as follows: To prevent a patient from assuming an adverse scoliotic spinal posture from supporting the weight of his arm in a shoulder splint, design the splint so that its inferior-lateral border includes the upper portion of the patient's iliac crest. This stabilizes the splint on the hip, allowing an upright and comfortable posture. Poor spinal posture is not a problem with bilateral shoulder splints because arm weight is balanced evenly. Other clinical hints for fitting shoulder splints include putting the patient in a side lying or supine position to make efficient use of gravitational forces as the splint material is applied, and using elastic wraps to secure the distal portion of the splint to free the therapist's hands for fitting more proximal portions of the shoulder splint.

Immobilization Splints

Shoulder immobilization splints prevent movement of the shoulder in predefined planes of motion according to injury-specific and/or surgery-specific requisites. Many shoulder immobilization splints include

multiple secondary joint levels, allowing arm weight to be dispersed over a larger area, thus providing greater comfort than would splints that incorporate only the shoulder and humerus. The majority of these splints incorporate the elbow, forearm, and wrist as secondary joints to improve splint mechanics. For example, if the elbow is not included in a shoulder splint, control of shoulder external and internal rotation is difficult if not impossible, and destructive pressure on the distal portion of the humerus occurs as the forearm and hand are allowed to assume a dangerous, edema producing, dependent position at rest. As each successive, more distal joint is incorporated into the design of a shoulder splint, control of shoulder joint position and splint comfort increase. While finger and thumb joints frequently are free of splint material, inclusion of the wrist as a secondary joint is an important consideration in shoulder splint design. Leaving the wrist free allows better hand function but the trade-off that must seriously be considered is the potentially injurious dependent position of the hand at rest that is allowed. As a solution, a removable wrist immobilization splint may be used— removed to allow for hand use and donned for comfort and protection.

Incorporating the shoulder and elbow as primary joints, shoulder, elbow immobilization splints may be used postoperatively to protect healing tissues after procedures such as arthroplasty, acromioplasty, Bankart repair, rotator cuff repair, and tendon trans-fers.7 For postoperative rotator cuff repairs, shoulder position is dependent on the specific repair and surgeon preference. The shoulder may be positioned in abduction for a period of time to protect the repair or the arm may be positioned at the patient's side in a sling or shoulder immobilization splint.8,31 Debate continues regarding optimum postoperative treatment for rotator cuff repairs. For example, in a study by Watson, it was found that the results of splinting the shoulder in abduction did not enhance the outcome of rotator cuff repairs and that after 5 weeks splinted shoulders were often stiff with winging scapulas.31

Close communication with referring physicians is mandatory when working with postoperative shoulder repairs. Cookbook approaches to splinting protocols are inappropriate in this arena. Various positioning splint designs are available to clinicians and many factors must be considered to appropriately correlate splint design with individual patient needs. Determining variables include, but are not limited to, injury and amount of damage, surgical procedures, physician preferences, patient requirements, and third-party payer criteria.

Type 1. Type 1 shoulder immobilization splints include the elbow as a secondary joint in addition to the primary shoulder joint (Fig. 14-14, A). These splints may be used to immobilize the shoulder in abduction or adduction and/or shoulder external or internal rotation. Inclusion of the elbow in a flexed posture allows control of shoulder rotation positioning.

Type 3. Type 3 shoulder immobilization splints incorporate one primary joint, the shoulder, and three secondary joint levels, the elbow, forearm, and wrist (Figs. 14-14, B, 14-15). The shoulder may be positioned in abduction or adduction, and in external or internal rotation, or combinations thereof, depending on patient-specific requirements. These splints are used to immobilize shoulders in precisely defined attitudes. Inclusion of the elbow, forearm, and wrist as secondary joint levels reinforces shoulder immobilization forces.

Mobilization Splints

Mobilization of a passively supple shoulder requires, at a minimum, force sufficient to abduct, extend, flex, or rotate this proximal upper extremity joint that is both complex in structure and large in size. No other upper extremity joint requires force levels of this magnitude to simply move the joint through its normal passive range of motion. Splinting the complex gleno-humeral, sternoclavicular, acromioclavicular and scapulothoracic joint composite requires incorporation of more secondary joints than are typically employed in splints designed to mobilize more distal, smaller, upper extremity joints. Inclusion of these secondary joints allows improved purchase, stabilization, and torque to be applied to achieve specific shoulder positions. Mobilization splints may be used in the conservative treatment of stiff or frozen shoulders, or for postoperative shoulder procedures such as manipulation or capsulectomies. These mobilization splints maintain or increase shoulder passive range of motion through application of low-load prolonged tension on associated soft tissues.19,25 While most shoulder mobilization splints mechanically function using three-point pressure systems, some specialized mobilization splints work through two-point systems, applying coaptation forces. Examples of two-point pressure splints may be found in some of the splints that minimize or passively correct shoulder subluxation. Classified as articular shoulder coaptation mobilization splints, these splints apply opposing, longitudinally directed forces that approximate the humerus and glenoid fossa.

Type 1. Shoulder mobilization splints, type 1 include one secondary joint, the elbow, in addition to the primary shoulder joint (Fig. 14-16).

Joint Immobilization Splint

Fig. 14-14 A, Shoulder abduction and neutral rotation immobilization splint, type 1 (2) B, Shoulder abduction and external rotation immobilization splint, type 3 (4)

A, A foam pillow with straps immobilizes the shoulder in abduction and neutral rotation. B, Colloquially known as the "airplane" or "Statue of Liberty" splint, this shoulder abduction and external rotation immobilization splint is used during the initial period of rest following tendon transfer surgery to restore shoulder abduction and/or external rotation. With the initiation of exercises, the splint's purpose changes and it is serially adjusted to allow gradual mobilization of the shoulder into adduction and internal rotation while active abduction and external rotation exercises are performed within the limit of the splint. With the change in purpose, the splint is renamed a shoulder adduction and internal rotation mobilization / restriction splint, type 3 (4).

Fig. 14-14 A, Shoulder abduction and neutral rotation immobilization splint, type 1 (2) B, Shoulder abduction and external rotation immobilization splint, type 3 (4)

A, A foam pillow with straps immobilizes the shoulder in abduction and neutral rotation. B, Colloquially known as the "airplane" or "Statue of Liberty" splint, this shoulder abduction and external rotation immobilization splint is used during the initial period of rest following tendon transfer surgery to restore shoulder abduction and/or external rotation. With the initiation of exercises, the splint's purpose changes and it is serially adjusted to allow gradual mobilization of the shoulder into adduction and internal rotation while active abduction and external rotation exercises are performed within the limit of the splint. With the change in purpose, the splint is renamed a shoulder adduction and internal rotation mobilization / restriction splint, type 3 (4).

Internal Splinting

Fig. 14-15 A, Shoulder external rotation immobilization splint, type 3 (4) B, Shoulder external rotation immobilization splint, type 3 (4) C,D, Shoulder flexion and internal rotation immobilization splint, type 3 (4)

Colloquially labeled "gunslinger" splints, these shoulder splints incorporate the elbow, forearm, and wrist as secondary joints. Attaining correct shoulder position is more easily accomplished when these three distal joints are included in shoulder splints. The wide torso portion of the splint improves patient comfort. A dual-purpose connector bar spans the distance between the torso base and the distal splint, providing the support needed to immobilize the entire extremity and controlling shoulder and forearm positions. Strapping placed anteriorly (A) and laterally (B-D) allows removal of the torso splint sections. [Courtesy (A,B) Sally Poole, MA, OTR, CHT, Dobbs Ferry, N.Y.; (C,D) Lin Beribak, OTR/L, CHT, Chicago, Ill.]

Fig. 14-15 A, Shoulder external rotation immobilization splint, type 3 (4) B, Shoulder external rotation immobilization splint, type 3 (4) C,D, Shoulder flexion and internal rotation immobilization splint, type 3 (4)

Colloquially labeled "gunslinger" splints, these shoulder splints incorporate the elbow, forearm, and wrist as secondary joints. Attaining correct shoulder position is more easily accomplished when these three distal joints are included in shoulder splints. The wide torso portion of the splint improves patient comfort. A dual-purpose connector bar spans the distance between the torso base and the distal splint, providing the support needed to immobilize the entire extremity and controlling shoulder and forearm positions. Strapping placed anteriorly (A) and laterally (B-D) allows removal of the torso splint sections. [Courtesy (A,B) Sally Poole, MA, OTR, CHT, Dobbs Ferry, N.Y.; (C,D) Lin Beribak, OTR/L, CHT, Chicago, Ill.]

Type 3. In addition to the primary shoulder joint, three secondary joints—elbow, forearm, and wrist— are included in shoulder mobilization splints, type 3. Incorporating three secondary joint levels increases mechanical advantage, improving shoulder positioning, splint stability, and patient comfort. Type 3 shoulder mobilization splints may be fitted to improve shoulder abduction or adduction and/or shoulder external or internal rotation.

As noted earlier in this chapter, mobilization splints are used with much greater frequency to treat joints distal to the shoulder. Custom-fabricated shoulder mobilization splints are less accepted by clinicians due to the perceived and actual degree of difficulty of fabricating these splints. Rectifying this unfortunate situation, McClure and Flowers advocate the use of a simply constructed, easy-to-adjust splint capable of effectively mobilizing the shoulder into whatever

Coaptation Splint

Fig. 14-16 A-C, Shoulder coaptation mobilization splint, type 1 (2) \\ Small finger MP flexion mobilization splint, type 0 (1) A-C, An articular coaptation mobilization splint is used with a brachial plexus injury to minimize subluxation of the humerus while permitting function. A,B, A hand-based MP flexion mobilization splint increases small finger MP flexion motion. C, Posterior view of harness design. (Courtesy Carol Hierman, OTR, CHT, Cedar Grove, N.C., and Elisha Denny, PTA, OTA, Pittsboro, N.C. © UNC Hand Rehabilitation Center, Chapel Hill, N.C.)

Fig. 14-16 A-C, Shoulder coaptation mobilization splint, type 1 (2) \\ Small finger MP flexion mobilization splint, type 0 (1) A-C, An articular coaptation mobilization splint is used with a brachial plexus injury to minimize subluxation of the humerus while permitting function. A,B, A hand-based MP flexion mobilization splint increases small finger MP flexion motion. C, Posterior view of harness design. (Courtesy Carol Hierman, OTR, CHT, Cedar Grove, N.C., and Elisha Denny, PTA, OTA, Pittsboro, N.C. © UNC Hand Rehabilitation Center, Chapel Hill, N.C.)

altitude is required (Fig. 14-17, A).25 With a design predicated on efficiency, the McClure-Flowers splint essentially is a wrist immobilization splint attached to a torso-base component via a dowel rod or other kind of connector bar. Serial adjustments of this splint are accomplished by simply changing the length and/or position of the connector dowel rod (Fig. 14-17, B). Once the beauty of this minimalistic design is fully understood and appreciated, all sorts of adaptations come to mind. For example, incorporation of specialized thermoplastic "change-out cups" that hold the ends of the dowel rod make alterations even easier. Trustworthy patients who are unable to return to the clinic for frequent adjustments may be given a series of different-length dowels and taught to change the dowel connector bar as shoulder range of motion improves. Further, by cutting the dowel in half and inserting an appropriate-size spring between the two cut ends of the dowel, elastic traction rather than inelastic traction may be applied to the shoulder. Application of a thermoplastic collar around the dowel-spring-dowel unit stabilizes and reinforces the connector bar, creating a spring-loaded dowel. Wound care and axilla hygiene are also easy with this remarkable splint design. Flowers notes that compliance may be a problem with this splint due to its inherent bulk, but when compared to other type 3 splints, this design is streamlined.

The application of splinting low-load, prolonged gentle tension to remodel contracted soft tissues is a fundamental concept to hand/upper extremity specialists but, for various reasons, in clinical practice these concepts have not been applied in their entirety to the shoulder. Lack of an efficacious splint design and the fact that shoulder treatment has been almost exclusively "manual therapy, electrotherapy, active exercises, and various forms of passive stretching"25 have delayed clinical acceptance of splinting to remodel stiffened or frozen shoulders. With a simple shoulder mobilization splint design, there no longer is an excuse for therapists to avoid making custom shoulder mobilization splints. Easier shoulder splint fabrication also means that research studies may be initiated to identify the most efficacious methods for mobilizing stiff shoulder joints. Just as forceful manual manipulation of digital joints is now considered harmful and passé, so too may these nonsplinting shoulder mobilization techniques become in the future! Further, questions regarding duration of shoulder splint wearing times may be put to rest through research studies that compare continuous, or nearly continuous, splint wear to short duration, 2-3 times a day, wear.

More complicated type 3 shoulder mobilization splint designs are available, providing a range of options from which clinicians may coordinate appropriate shoulder mobilization splints with patients' individual needs (Fig. 14-17, C-E).

Type 7. Type 7 shoulder mobilization splints include the primary shoulder joint and seven

Types Splints For Shoulder

Fig. 14-17 A, Shoulder abduction and external rotation mobilization splint, type 3 (4) B, Shoulder abduction and external rotation mobilization splint, type 3 (4) C, Shoulder abduction and neutral rotation mobilization splint, type 3 (4); right \\ Shoulder abduction and neutral rotation mobilization splint, type 3 (4); left D, Shoulder abduction and external rotation mobilization splint, type 3 (4) E, Shoulder flexion mobilization splint, type 3 (4)

Custom (A-C) and prefabricated (D,E) type 3 splint designs for shoulder mobilization. A,B, Shoulder abduction and external rotation may be increased through lengthening of the connector bar in a custom-fabricated splint based on the design by McClure and Flowers. C, Bilateral "airplane" splints are worn for scar remodeling after burn injury. D,E, Prefabricated splints require the patient to be supine during the application of a low-load tension to the shoulder. [Courtesy (C) Indiana University School of Health and Rehabilitation Sciences Department of Occupational Therapy, Indianapolis, Ind.; (D,E) Dynasplint Systems, Inc., Severna Park, Md.]

Fig. 14-17 A, Shoulder abduction and external rotation mobilization splint, type 3 (4) B, Shoulder abduction and external rotation mobilization splint, type 3 (4) C, Shoulder abduction and neutral rotation mobilization splint, type 3 (4); right \\ Shoulder abduction and neutral rotation mobilization splint, type 3 (4); left D, Shoulder abduction and external rotation mobilization splint, type 3 (4) E, Shoulder flexion mobilization splint, type 3 (4)

Custom (A-C) and prefabricated (D,E) type 3 splint designs for shoulder mobilization. A,B, Shoulder abduction and external rotation may be increased through lengthening of the connector bar in a custom-fabricated splint based on the design by McClure and Flowers. C, Bilateral "airplane" splints are worn for scar remodeling after burn injury. D,E, Prefabricated splints require the patient to be supine during the application of a low-load tension to the shoulder. [Courtesy (C) Indiana University School of Health and Rehabilitation Sciences Department of Occupational Therapy, Indianapolis, Ind.; (D,E) Dynasplint Systems, Inc., Severna Park, Md.]

Wrist Joint Mobilization
D
Dynasplint Severna Park
E

For legend see opposite page.

secondary joint levels including elbow, forearm, wrist, finger MP-PIP, and thumb CMC-MP joints. Type 7 splints may be custom fitted or they may be obtained through commercial sources (Fig. 14-18). Inclusion of digital joints to enhance splint comfort may be optional in some commercial type 7 splints.

Mobilization/Restriction Splints

Shoulder mobilization / restriction splints are designed to limit a specific range of shoulder motion to protect healing tissue structures while simultaneously mobilizing other shoulder motions. These splints are often used to rehabilitate postoperative tendon transfers done to provide shoulder external rotation and abduction. Tendon transfer procedures usually require that postoperative exercises be performed within a specific range while shoulder range of motion is gradually increased.7,17 To accomplish this, an adjustable shoulder mobilization/restriction splint allows incremental increases in adduction and internal rotation. Adjustable, prefabricated shoulder restriction splints are commercially available in adult sizes; however, children may require custom-fabricated splints in order to achieve a proper fit.7 When designing a shoulder mobilization/restriction splint that will be periodically adjusted to change the angle of motion restriction, use of screw rivets rather than bonding of adjacent surfaces to join the humeral portion of the splint to the torso-base portion of the splint will save therapist time and effort during the adjustment process. If this is not done, frequent adjustments of solid splint bonds may result in a stretched-out and weakened splint that may require replacement.

Movilizaciones Activas Hombro

Fig. 14-18 A, Shoulder abduction and external rotation mobilization splint, type 7 (14) B, Shoulder abduction and external rotation mobilization splint, type 7 (14)

These prefabricated splint designs allow adjustments to be made in varying degrees of shoulder abduction and external rotation. Inclusion of hand joints is for patient comfort. Commercial splints may provide the heavy durability needed to mobilize the large and complex shoulder composite joint. [Courtesy (A) DJ Orthopedics Inc., Vista, Calif.; (B) Joint Active Systems, Inc., Effingham, Ill.]

Fig. 14-18 A, Shoulder abduction and external rotation mobilization splint, type 7 (14) B, Shoulder abduction and external rotation mobilization splint, type 7 (14)

These prefabricated splint designs allow adjustments to be made in varying degrees of shoulder abduction and external rotation. Inclusion of hand joints is for patient comfort. Commercial splints may provide the heavy durability needed to mobilize the large and complex shoulder composite joint. [Courtesy (A) DJ Orthopedics Inc., Vista, Calif.; (B) Joint Active Systems, Inc., Effingham, Ill.]

Type 3. Shoulder mobilization / restriction splints include three secondary joint levels; the elbow, forearm, and wrist improve splint stability and positioning of the shoulder.

Torque Transmission Splints

Shoulder torque transmission splints are designed to transfer moment to joints external to the splints themselves. These splints transfer moment longitudinally and proximally to the shoulder joint through control of one or more distal secondary joint(s). Single-purpose torque transmission splints have a minimum of one secondary joint level. These splints are often referred to as "exercise" splints because they are used to maintain or increase motion in conjunction with functional upper extremity use.

Type 1. Type 1 shoulder torque transmission splints incorporate one distal secondary joint, the elbow, in addition to the primary joint, the shoulder. By controlling the elbow secondarily, unwanted elbow substitution patterns that incorrectly compensate for shoulder motion may be eliminated. Further, specific shoulder motions including but not limited to internal and/or external rotation may be encouraged by controlling the elbow to transmit active moment to the shoulder joint to improve shoulder motion or to remodel soft tissue. Although many shoulder torque transmission splints, type 1 (2) are used as exercise splints, these splints may also be used over time to remodel soft tissues about the shoulder joint. A word of caution: Care must be taken to ensure that elbow joint motion is not compromised through the requisite secondary immobilization or restriction of the elbow.

I NONARTICULAR HUMERUS SPLINTS

Nonarticular splints do not cross joints or affect joint motion. They often are used to protect healing fractures as in the case of humeral fractures. Circumferential or bivalve designed nonarticular humerus splints employ two-point coaptation forces to support humeral fractures. Constriction of blood or venous flow at the distal edge of the nonarticular humerus splint should be monitored due to its circumferential nature.

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Responses

  • andreas brandt
    What is gun slinger splint?
    3 years ago
  • yolanda
    How to fabricate a shoulder splint for dynamic splinting?
    1 year ago

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