Splinting the Pediatric Patient

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Joni Armstrong, OTR, CHT*

Chapter Outline

IDEAS TO AID IN SPLINT CONSTRUCTION MATERIALS SELECTION

HOW TO IMPROVE THE LIKELIHOOD THAT A SPLINT

WILL BE WORN IDEAS TO AID IN SPLINT DESIGN IDEAS TO PREVENT UNWANTED SPLINT REMOVAL

ARTICULAR SPLINTS Thumb Splints Wrist Splints Forearm Splints Elbow Splints OTHER

Splints with Grasp Assist SUMMARY

Splinting in the pediatric population can occur as early as the neonatal intensive care unit and may persist into adulthood for those who continue to be challenged by abnormal tone. Review of the literature finds very little objective research in the area of pediatric splinting.1 This is probably due to difficulty finding a sufficient number of children in a given area who have a similar diagnosis with a comparable clinical picture on which to do a comparative study. Because of this and the resulting unfamiliarity of pedi-atric therapists with splinting options available, splinting is perhaps an underused form of treatment in the field of pediatrics. Although not a replacement for other forms of therapy, it can be a valuable adjunct to other therapeutic techniques.

This chapter focuses primarily on splinting for children who have developmental disabilities with subsequent difficulties in hand function. Although the splints discussed in this chapter have been observed

*All figures in this chapter courtesy Joni Armstrong, OTR, CHT, Bemidji, Minn.

to be clinically effective, lack of conclusive research and the variety of opinions specifically regarding splinting of the spastic hand mean that splint appropriateness must be evaluated on an individual basis and carefully monitored for effectiveness.

The overall goal of splinting in the pediatric population is to maximize hand function. This can be achieved through splint use with the following goals: (1) provide protection and support to weak muscles and joints, (2) provide proximal support and stability for improved distal function, (3) normalize muscle tone, (4) provide positioning of a joint, which then allows overall limb use and improved body movement and function, (5) compensate for muscle imbalance, (6) substitute for muscles that are not functional, (7) increase joint range of motion, (8) improve joint alignment, (9) decrease edema, (10) prevent or correct deformities, (11) make skin care and hygiene tasks easier, and (12) assist in task performance.

When selecting a splint for a pediatric patient, consider not only the problems associated with the upper extremity but also the strengths. Make certain that strengths are not eliminated with the problem's solution. Because most children with developmental disabilities have experienced the problems since birth, they have learned compensation techniques that allow them to use their hand quite functionally. Unless function is evaluated through observation, it can be easy to eliminate this functional use by splinting to fix another problem. Examples of this might be splinting the thumb in a position of palmar abduction and therefore preventing the functional use of the lateral pinch; or splinting a child's hand in functional position to prevent contracture formation, but using a splint that is too heavy for the child to wave his hand in greeting.

Problem areas seldom occur in isolation with the pediatric hand. Typically, several problems occur simultaneously. In splint selection, one needs to prioritize the problems, and then decide if all of these can be addressed at the same time in the same splint or if focus on one problem should be delayed in favor of initially focusing on another. Often a variety of splints with varying wearing schedules are an option to address more than one goal. Consideration of splints that are designed to increase function for performance of a specific task may also be warranted and these splints would only be worn during that task performance time.

As with adult hand splinting, there are many pedi-atric splinting options available to address the specific goals. A table of common pediatric problem areas describes splinting options presented in this chapter (Table 18-1). Selection varies with each patient's needs, caregiver compliance and preference, and therapist familiarity.

Compliance with the basic splinting principles described in this book for fabrication and fit of an adult splint is also recommended when fabricating pediatric splints; however, additional points also need to be considered for pediatric splinting success. Skin integrity of a child is often less than in an adult, so precautions need to be taken during the fabrication process and in monitoring to avoid burns and skin breakdown. This is particularly true for children who are underweight with little subcutaneous fat tissue. Splint monitoring by a responsible adult is very important as children often don't or can't complain of pain or discomfort. This is especially important if there is an accompanying sensory deficit. Children characteristically grow at a very rapid rate, so splints need to be monitored for appropriate fit and may frequently need replacing as they are outgrown. With the hopefully active lifestyle of children, splints may tend to wear out rapidly and this may necessitate replacement more often than with adults. Due to a high activity level and lack of mature judgment, damage to pedi-atric splints is not infrequent. Excuses given are similar to those for the question, "What happened to your homework?" such as "My dog ate it," and "It fell out the bus window." As many children realize the importance of a splint, sometimes a reluctance to report damage that might "be their fault" is seen. This can result in not wearing the splint, improper application, or pressure areas.

In pediatrics, abnormal muscle tone is commonly the problem that therapists try to address. As a positioning change is made in one joint with abnormal tone or decreased range of motion, that change will most likely affect an adjacent joint as a way of compensation. An example of this would be as wrist extension is increased, increased finger flexion is also observed. Therefore, it may be necessary to compromise the ideal position of the splint (splint at less than maximum range) of one joint in order to avoid increased stresses on adjacent joints resulting in decreased function. Make certain that a splint does not prevent hand use that was previously achieved. Is an important action being taken away to gain something else? Which is more important?

I IDEAS TO AID IN SPLINT CONSTRUCTION

Pediatric splinting can be fun but also really quite challenging, due to a number of factors including increased muscle tone, presence of primitive reflexes, splint size, short attention span, and lack of ability or desire to cooperate.

If the child being splinted has a significant amount of hypertonicity or behaviors that make splint fabrication difficult, it is recommended that another person be available to assist, not with the actual splint fabrication, but with positioning and distracting of the child. It is not recommended that a parent, teacher, or caregiver assist in the actual fabrication because their focus tends to be on control of the child with resulting fingerprints and pressure in the portion of the splint being held rather than the desired contour. However, their assistance in holding, positioning, and comforting the child can be of great value. Although a toy may be nice to occupy the child during the splinting process, it is not recommended that the child hold articles in the opposite hand due to the frequent overflow of tone to the hand being splinted which may make positioning difficult. Wrapping the forearm piece with elastic wrap or exercise band cooled in a refrigerator or freezer is also an option when an extra hand is needed. Quick cooling with cold spray is often helpful if positioning is difficult to hold due to behavior or spasticity. When another experienced therapist or aide is available to assist in fabrication, this situation is ideal.

TABLE 18-1

Common Pediatric Problems and Associated Splinting Options

Elbow Splints Problem: Elbow Flexion

TABLE 18-1

Elbow Splints Problem: Elbow Flexion

ESCS

Common Name

Elbow extension mobilization splint, type 0 (1)

*Elbow extension (volar) Elbow extension (circumferential) Elbow extension (bivalve) Air splint

Turnbuckle elbow extension

Elbow extension mobilization splint, type 0 (1)

*Orthokinetic cuff

Forearm Splints Problem: Limited Supination

ESCS

Common Name

Forearm supination, wrist extension, thumb CMC palmar abduction mobilization splint, type 0 (3)

*Long serpentine (proximal neoprene strap)

Forearm supination, wrist extension, thumb CMC radial abduction and MP extension mobilization splint, type 0 (4)

*Long neoprene thumb abduction with serpentine strap

Elbow flexion, forearm supination, wrist extension mobilization splint, type 0 (3)

Long arm (positioned in elbow flexion and forearm supination)

Wrist Splints Problem: Wrist Flexion

ESCS

Common Name

Wrist extension, index-small finger extension, thumb CMC palmar abduction and MP-IP extension mobilization splint, type 0 (16)

*Resting hand (used serially if contractures have formed)

Wrist extension mobilization splint, type 0 (1)

*Radial bar wrist cock-up (volar)

Radial bar wrist cock-up (dorsal)

Wrist cock-up (thumb hole)

Wrist cock-up (palmar support only)

Wrist cock-up (circumferential thumb hole)

Long neoprene (volar or dorsal stay)

Wrist extension, thumb CMC radial abduction and MP extension mobilization splint, type 0 (3)

*Long neoprene thumb abduction (volar or dorsal stay)

Forearm supination, wrist extension, thumb CMC palmar abduction mobilization splint, type 0 (3)

Long serpentine (for mild hypertonicity)

Wrist extension, index, ring-small finger MP abduction, index-small finger extension, thumb CMC palmar abduction and MP-IP extension mobilization splint, type 0 (16)

Antispasticity

Wrist extension mobilization splint, type 0 (1)

*Orthokinetic cuff

Problem: Wrist Ulnar Deviation

ESCS

Common Name

Wrist extension mobilization / wrist ulnar deviation restriction splint, type 0 (1)

Ulnar gutter

Wrist cock-up with ulnar support

Wrist extension, thumb CMC radial abduction and MP extension mobilization / wrist ulnar deviation restriction splint, type 0 (3)

Long neoprene thumb abduction with ulnar gutter insert

Problem: Wrist Radial Deviation

ESCS

Common Name

Wrist extension, thumb CMC palmar abduction and MP extension / wrist radial deviation restriction splint, type 0 (3)

Long thumb spica Long thumb opponens

Wrist extension, thumb CMC palmar abduction mobilization / wrist radial deviation restriction splint, type 0 (2)

Dorsal radial bar wrist cock-up with thumb C-bar

TABLE 18-1

Common Pediatric Problems and Associated Splinting Options—cont'd

Hand Splints Problem: Thumb-in-Palm Positioning

TABLE 18-1

Hand Splints Problem: Thumb-in-Palm Positioning

ESCS

Common Name

Thumb CMC radial abduction and MP extension mobilization splint, type 0 (2)

*Neoprene thumb abduction Short thumb opponens Short thumb spica

Thumb CMC radial abduction mobilization splint, type 0 (1)

*Thumb loop

Wrist extension, thumb CMC radial abduction and MP extension mobilization splint, type 0 (3)

Long thumb opponens

Long thumb spica

Wrist cock-up with thumb loop

Wrist extension, thumb CMC palmar abduction mobilization splint, type 0 (2)

Serpentine (short)

Thumb CMC palmar abduction mobilization splint, type 0 (1)

Thumb c-bar

Forearm supination, wrist extension, thumb CMC palmar abduction mobilization splint, type 0 (3)

Serpentine

Forearm supination, wrist extension, thumb CMC palmar abduction and MP-IP extension mobilization splint, type 0 (5)

Serpentine with thumb piece

Problem: Hand Fisting

ESCS

Common Name

Wrist extension, index, ring-small finger MP abduction, index-small finger extension, thumb CMC radial abduction and MP-IP extension mobilization splint, type 0 (16)

Antispasticity ball

Antispasticity (dorsal) with finger pan (volar) *Resting hand (can add finger spacers)

Wrist extension, index-small finger MP extension mobilization splint, type 0 (5)

MacKinnon

Index-small finger extension, thumb CMC radial abduction and MP-IP extension mobilization splint, type 0 (15)

Cone

Problem: Difficulty Weight Bearing

ESCS

Common Name

Wrist extension, index-small finger MP extension and IP flexion, thumb CMC radial abduction and MP-IP extension mobilization splint, type 0 (16)

*Weight bearing

Elbow extension mobilization splint, type 0 (1)

Elbow extension *Elbow air (water wings)

Problem: Inability to Maintain Grasp

ESCS

Common Name

Wrist extension mobilization splint, type 0 (1)

*Wrist cock-up

*Neoprene grasp assist

Thumb CMC radial abduction and MP extension mobilization splint, type 0 (2)

*Thumb abduction with sewn neoprene grasp assist Neoprene thumb abduction with sewn elastic pocket

Problem: Difficulty with Finger Isolation for Task Performance

ESCS

Common Name

Wrist extension, index finger MP flexion and IP extension, thumb CMC radial abduction and MP extension mobilization splint, type 0 (6)

*Long thumb opponens with index finger extension

*Long or short neoprene thumb abduction with index finger included

'Indicates this author's favorites.

'Indicates this author's favorites.

If hypertonicity is one of the challenges, it may be beneficial to decrease the tone through gentle passive range of motion exercises, massage, or neutral warmth application prior to splint fabrication. These techniques may also be helpful for use prior to splint application.

Awareness of the presence of primitive reflexes is important because they may be elicited by a change in body position. Positioning to elicit or inhibit the

I MATERIALS SELECTION

Upper Extremity Hypertonia

Fig. 18-1 A-E, Demonstrating and playing with dolls or toys that have been fit with splints will instill a positive introduction to children before application of splints to the actual pediatric arm.

reflex assists in splint fabrication. For example, a child who exhibits a strong asymmetrical tonic neck reflex will exhibit extension in the upper extremity with his head turned to that side, decreasing the flexor tone in that extremity. If the head is turned to the opposite side, strong flexion can be seen in the extremity, making splint fabrication difficult.

When a child is frightened or uncertain about allowing a splint to be fabricated on his hand, allowing that child to play with scraps of the splinting material so he can see how it feels will often make him feel more at ease. Another technique is to have the child assist while making a splint on her doll or stuffed toy. A doll or toy that the therapist has wearing splints may also be helpful (Fig. 18-1).

I MATERIALS SELECTION

A variety of materials are available for use in pediatric splinting. Some of the most commonly used and those recommended in this text include low-temperature thermoplastics, neoprene, elastomers, elastic wraps,

Fig. 18-1 A-E, Demonstrating and playing with dolls or toys that have been fit with splints will instill a positive introduction to children before application of splints to the actual pediatric arm.

and a variety of strapping materials. Selection of thermoplastics varies with each therapist and each child splinted. A variety of thermoplastics are available with pros and cons for the use of each.

Rubber-based thermoplastics work well with the pediatric population because they allow a great deal of control. They can be worked aggressively and have a high resistance to fingerprinting and stretch. Memory is fairly good if reforming or serial splinting is necessary. This material does need to be worked somewhat and held in place to maintain conformabil-ity. It is not as durable as some of the other splinting materials, so it may need reinforcement to prevent stress fractures. Rubber-based thermoplastics are a good choice for children who have a great deal of spas-ticity or who demonstrate behaviors that are not conducive to splinting. It is also a good choice for larger splints. Rubber-based thermoplastics are probably the easiest material to work with for beginning splinters.

Plastic-based thermoplastics are good material choices if a great deal of conformability is desired, especially for very small splints. It stretches easily and is not resistant to fingerprints. This material has very little memory, so it is not a good choice for serial splinting. Working time is short, which may or may not be an advantage. It is quite rigid when hard. Due to the high degree of stretch, the tendency to stick to itself, and little resistance to fingerprinting, it is difficult to use with children who have a high degree of spasticity or behaviors that are not conducive to splinting. It is typically a difficult material for beginning splinters.

Elastic-based thermoplastics are excellent choices for serial splinting due to their high degree of memory. Conformability is similar to that of rubber-based and is resistant to stretch and fingerprinting. Although rigidity is not high, this material is durable and will typically hold up to hard use. Working time is long, which may or may not be an advantage. It is not recommended to cool this material with cold spray because the top layer cools more quickly than the bottom, resulting in a twisting of the material. It can also lose some contour if removed from the hand and cooled quickly under cold water or if removed before cooling is complete.

Rubber-plastic-based thermoplastics are splinting materials that balance control and conformability. They self-edge nicely with some resistance to stretch and fingerprinting. These are a good choice for settings that see a variety of patient types, but only carry one type of splinting material. These materials may not have the desired control for children with a high degree of spasticity.

In the ideal situation, it is nice to carry an example of each of the four types of thermoplastics described above and use them to best meet patient needs. However, in many settings (particularly school-based therapists), the budget will allow purchase of only one type of thermoplastic. In this situation, the author recommends a thermoplastic that is primarily rubber-based because it will allow for the control needed when working with hands that have a high degree of spasticity, a shorter working time for impatient patients, and the memory that would allow for reforming or serial splinting situations. Opinions may vary among therapists and their respective experience. Using the material with which the therapist is the most comfortable is often best.

Neoprene is a fabric-covered synthetic rubber sheet, which provides a semidynamic stretch and good conformability in splint fabrication. It is available in Lycra or rubber-backed and some are available in a loop surface that is sensitive to Velcro hooks. It can be found in a variety of color choices depending on the source. A variety of thicknesses are also available. One may choose a thicker neoprene if more assistance or support is desired. A thicker neoprene sometimes works well in providing just enough resistance in a circumferential elbow splint to prevent self-abusive behavior. The Lycra-backed type will make splint application easier and may be more comfortable for wear, while the rubber-backed type prevents slipping and can be used to stabilize objects or a part of the hand. In addition to its other qualities, neoprene also maintains hand warmth, which can assist in decreasing spasticity, and is useful for splinting hands that have a cold hypersensitivity.

Elastomer is a silicone-based putty that conforms exceptionally well. They are used in pediatric splinting for thumb positioning or finger spacers. They also work well for scar softening and help to decrease scar hypersensitivity. Many types are available through splinting product catalogs. The putty types with a gel catalyst or the 50/50 mix are probably the easiest to work with because they can be mixed in the hand and varied in stiffness by adding more or less catalyst.

Because of the need for frequent small splint sizes, additional but inexpensive tools are sometimes valuable to have. After a splint has been fabricated, one is often hesitant to use a large heat gun to soften and smooth a small area because there is risk with such tiny splints of losing the entire contour and form. A smaller heat gun, such as the Ultratorch, works nicely to touch up small areas, but if one is not available, a turkey baster or eyedropper can be used to apply hot water directly to hard-to-reach places (Fig. 18-2, A). A pen, pencil, small dowel, or chopstick (the author's favorite is a laminated chopstick) is sometimes a helpful tool to use in smoothing out tiny areas that are smaller than the end of the therapist's finger (Fig.

Splint Wearing Schedule FormSplint Wearing Schedule Form
Fig. 18-2 A, A turkey baster, eye dropper, or Ultratorch are tools applicable to spot heating a small area on a pediatric splint. B, This chopstick can be maneuvered to smooth out hard to access areas. C, Tiny curves can be cut with small manicure scissors.

tic can also be doubled; however, this is often not recommended because it significantly increases the weight of the splint.

I HOW TO IMPROVE THE LIKELIHOOD THAT A SPLINT WILL BE WORN

Whenever possible, ask the parent, caregiver, and teaching staff for their assistance in planning the wearing schedule. It is important to try to make the wearing schedule compatible with the child's typical routine and the caregiver's schedule. This consultation allows caregivers to know that the therapist has respect for their opinions and time, allows the therapist an opportunity to stress the reason and importance of splint use, and helps the therapist plan a wearing schedule that is appropriate for the child, as well as being possible for caregiver compliance.

In an alternate-care or school setting, plan where the splint may be kept during nonuse times to ensure compliance with the wearing schedule and prevent splint loss (e.g., in a backpack or wheelchair bag in school or in a bag that attaches with Velcro to the bed, crib, or isolette at home or in a hospital or institutional setting). Mark all splints with the child's name and the hand to which it is applied to assist in proper application and decrease the chance of its being lost. Sometimes including the wearing schedule or the therapist's phone number is also helpful.

The hand therapist's version of Murphy's Law is, "If a splint can be applied incorrectly, it will be." Anything that gives added information about splint application improves the likelihood that the splint will be applied correctly. A photograph of the splint on the hand along with the application instructions is helpful especially if there will be a variety of people applying the splint. If splint parts or straps are removable, the part or strap and the spot to which it is applied can be numbered or marked with a picture to ensure proper application following removal.

I IDEAS TO AID IN SPLINT DESIGN

18-2, B). Small, curved fingernail scissors can be used to cut tiny curves (Fig. 18-2, C).

Because many children tend to have very active lifestyles, pediatric splints may require reinforcement to prevent early stress fractures in thermoplastics. Particularly, splints on hands with a great deal of spas-ticity may require reinforcement. Any technique that increases contour increases material strength. Contoured reinforcing bars or posts can be easily added to increase the strength of a splint. The thermoplas-

The more input the patient has into the planning and design of a splint, the more likely that he or she will comply with splint use. With that in mind, it is desirable to ask a patient's opinion about design choices that do not alter the basic goal and purpose of the splint.

Allow the child a choice of thermoplastic, neo-prene, or Velcro color if this is available in your facility. This is the ideal, although highly unlikely, pediatric splinting situation. Most facilities will not have the budget for all these options so the following ideas using a neutral-colored thermoplastic might be considered. Apply decorative ribbon available in many designs at fabric stores to the straps. This ribbon is easily stitched on with a sewing machine (Fig. 18-3, A). Pictures can be drawn on the splint either before or after fabrication with permanent markers. The therapist or patient can do this. It can be done on the thermoplastic as a fine motor therapy activity prior to making the splint with resulting enthusiasm for fabrication and subsequent use. "Strap Pals" can be made out of thermoplastic by coloring a picture onto a scrap with permanent markers, cutting it out, then attaching it to the strap with self-adhesive Velcro hook. Designs can be traced with carbon paper onto the thermoplastic from a coloring book or children's book.

A variety of other items can be used for splint decoration. Take caution that the child will not remove and accidentally swallow these. Baby barrettes can be applied to the strap. Fabric paints can be used by the therapist or the patient to draw pictures or write a name on the straps. Material designs can be appliqued onto the straps or orthokinetic cuffs with an iron-on adhesive. They can be finished by sewing with a close zigzag stitch or edged with fabric paints. Shoelaces are available in a variety of colors and designs and can be used to secure a splint. "Bow Biters" or shoelace charms can also be added for decoration. Stickers applied to the splint are an easy option that most

Easy Draw For Extremity

Fig. 18-3 A, Wrist extension mobilization splint, type 0 (1). B, Wrist extension mobilization splint, type 0 (1) A, Decorative ribbon added to straps, drawings, or (B,C) strap critters with movable eyes enhancing the appearance of splints will increase the child's acceptance to their new splint. D, Covering the splint with a sock puppet can be a great fun project for the child and will have the added benefit of warmth.

Fig. 18-3 A, Wrist extension mobilization splint, type 0 (1). B, Wrist extension mobilization splint, type 0 (1) A, Decorative ribbon added to straps, drawings, or (B,C) strap critters with movable eyes enhancing the appearance of splints will increase the child's acceptance to their new splint. D, Covering the splint with a sock puppet can be a great fun project for the child and will have the added benefit of warmth.

children enjoy. "Strap Critters" can be made out of felt; add movable eyes and Velcro hook, and attach them to the splint straps (Fig. 18-3,B,C). These can also easily be used as a reward for doing well in therapy and provide a small change that can encourage continued splint use. For older individuals, decorative lapel pins can be used on the strap as long as they are attached only through the first layer of the velfoam strapping or the back is covered with moleskin to prevent pressure. Sock puppets can be made out of tube socks for a fun splint covering and are great to use when mittens don't fit over the splint (Fig. 18-3, D). Splint covers may also be sewn out of polar fleece with Velcro closure, for use when splints do not fit under mittens.

Sometimes just the way a splint is described can encourage wearing compliance. For example, describing a neoprene splint as a "scuba diver's glove" or "the kind of glove Batman wears" can make a child feel like this splint is something that's "really cool" and fun to wear.

To facilitate independence in splint application and removal, especially for patients who are bilaterally involved, simple strapping adaptations can be made. Lengthening the ends of the straps, allowing them to overlap where there is no Velcro, makes them easier to grasp. Adding a thumb loop or cutting a hole in the strap so that the thumb can be inserted and used to pull the strap is helpful when functional pinch is not present. Consider the line of pull of the strap. Is it easier to apply and remove from one direction than the other? Using their teeth instead of hand grasp for applying and removing straps is frequently a good option for patients (often the one chosen or discovered by patients).

I IDEAS TO PREVENT UNWANTED SPLINT REMOVAL

Each therapist has treated those "little Houdinis" who are able to get out of any splint applied; they are the ultimate challenge to one's problem-solving skills. Since splints are not effective if not worn, adaptations to the conventional strapping techniques may need to be made. Reinforcing a Velfoam strap with Velcro loop makes it harder to remove and also increases the strap life. Riveting straps makes removal more difficult and ensures that straps will not be lost or applied incorrectly. A D-ring strap that wraps over the top of itself is more difficult to remove than the standard Velcro strap. Shoelaces for attachment rather than Velcro straps are often more challenging for removal. The shoelace can also be sewn onto the end of the strap and brought through the D-ring for added reinforcement or sewn onto the strap and then tied after the

Velcro has been fastened. "Bow Biters," little plastic critters that tie on the lace and then clamp down on the bow after it is tied, can also be used to secure the lace, therefore making removal more difficult (Fig. 184, A,B). Luggage locks work as fasteners even if they are not locked; it is difficult for little hands to push down the button and pull it out at the same time with one hand. Decorative "Friendship Bracelets" that have a push down/pull out type of fastener can be sewn onto the strap and hooked after the Velcro has been fastened, adding decoration and making the strap difficult to remove (Fig. 18-4, C,D). Swivel snaps and rings (available on key chains or at hardware stores) are nearly impossible to remove with one hand and secure the splint nicely. Metal C-rings with screw closures, available at hardware stores, take more time to apply but are very difficult for little hands to remove. Placing an elasticized stockinette or the cuff of a decorative sock over the splint or splint strap also makes removal more difficult. A strip of Dycem or rubber-backed neoprene placed inside the splint can prevent distal migration or help to keep a thumb in place.

In one case study, a female patient at an institution for severely and profoundly handicapped adults demonstrated hand positioning of wrist and finger flexion due to spasticity that was so severe it made palmar hygiene difficult, which made splinting a necessity. However, this patient was not fond of splints and went to extreme measures to remove and/or destroy them. The typical splints fabricated out of a rubber-based thermoplastic with Velcro and webbing D-ring strapping were literally eaten one small piece at a time. After a great deal of trial and error, splints fabricated out of elastic-based thermoplastic (because of its durability) with leather D-ring straps and luggage locks were successful.

The following are a variety of pediatric splints with directions for patterns and fabrication as well as a variety of adaptations for each splint. Reference can be made to Table 18-1 for assistance in splint selection. Splinting equipment previously described in this book is needed for fabrication of most thermoplastic splints. A sewing machine with a very sharp size 11 or 14 stretch needle, or a needle and thread for hand sewing, is necessary for fabrication of most neoprene splints. An alternative method to sewing neoprene is to use commercially available products, such as neoprene glue, iron-on seam tape, and iron-on Velcro hook and loop, for creating custom neoprene splints without having to sew a single stitch.5,8

Detailed fabrication instructions for 15 splints that are commonly used with pediatric patients are presented in the next section of this chapter. Each splint is named according to the ESCS; its colloquial name is identified; pattern, construction, and fit details are

Fig. 18-4 A, Wrist, extension, thumb CMC palmar abduction and MP extension mobilization splint, type 0 (3) B, Wrist extension, thumb CMC palmar abduction and MP extension mobilization splint, type 0 (3) C, Wrist extension mobilization splint, type 0 (1) D, Wrist extension, thumb CMC radial abduction and MP extension mobilization splint, type 0 (3)

Children are great escape artists when it comes to removing splints. A creative therapist may add (A,B) shoelaces with Bow Biters (C,D) push down/pull out type fasteners to secure the straps in place.

Fig. 18-4 A, Wrist, extension, thumb CMC palmar abduction and MP extension mobilization splint, type 0 (3) B, Wrist extension, thumb CMC palmar abduction and MP extension mobilization splint, type 0 (3) C, Wrist extension mobilization splint, type 0 (1) D, Wrist extension, thumb CMC radial abduction and MP extension mobilization splint, type 0 (3)

Children are great escape artists when it comes to removing splints. A creative therapist may add (A,B) shoelaces with Bow Biters (C,D) push down/pull out type fasteners to secure the straps in place.

provided; and common variations of the splint are illustrated. The 15 splints are organized according to the Splint Sequence Ranking Index (SSRI), in which the most proximal primary joint or segment influenced by the splint defines its entry position in the SSRI. Presence of more distal primary joints in the splint further refines the splint's ranking order.

Ranking categories for these splints include thumb, wrist, wrist-thumb, wrist fingers thumb, forearm wrist thumb, elbow, and elbow wrist fingers. Description of various grasp assists is included at the end of the fabrication section of this chapter. Appendix F contains larger-scale versions of all the patterns illustrated in this chapter.

I ARTICULAR SPLINTS

Thumb Splints

Thumb CMC

Fig. 18-5A Thumb CMC radial abduction mobilization splint, type 0 (1) Fig. 18-5B Thumb CMC radial abduction mobilization splint, type 0 (1)

Thumb CMC, MP

Fig. 18-5D Thumb CMC radial abduction and MP extension mobilization splint, type 0 (2)

Opponens Writing Splint

(Fig. 18-5A,B) A "thumb loop splint" brings the thumb into radial abduction. These splints are typically used with patients who have mild to moderate tone pulling the thumb into the palm but these splints usually do not provide enough support for individuals with high tone.

Materials needed include neoprene - to - inch thick, depending on the size of the patient, and Velcro.

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Responses

  • tove
    What is the purpose of a serpentine splint?
    3 years ago
  • jonna
    How to apply splints to pediatric patients?
    2 years ago
  • cornelia
    How to splint a peditric elbow?
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  • Maria Wright
    How to determine wearing schedule for hand splints?
    8 months ago
  • Claudio
    Can you use sagar splint on pediatric patients?
    7 months ago
  • jesse wright
    When to splint hypermobile elbow pediatric?
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    How to make paediatric splints?
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    How to do a pediatric thumb spica splint?
    5 months ago
  • jürgen
    How long to wear splint to provide stretch to upper extremity?
    4 months ago
  • Jaakko
    How to splint hand pediatric?
    3 months ago
  • Mikki
    Which pediatric splint is best for children who fist?
    2 months ago
  • monica salminen
    How to make splints in pediatrics?
    2 months ago

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