Thumb Immobilization Splint

References: Coppard, Brenda M. and Helene Lohman, Introduction to Splinting: A Clinical Reasoning & Problem Solving Approach, 2nd Edition, 2001, Mosby, Inc.

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THUMB IMMOBILIZATION SPLINTS

Other Names: Thumb Spica Splint Short or Long Opponens Splint Thumb Gauntlet Splint Purpose: Immobilize, protect, rest, and position one or all of the thumb carpometacarpal (CMC), metacarpophalengeal (MCP), and Interphalengeal (IP ) joints while allowing the other digits to be free. THUMB FUNCTIONAL AND ANATOMICAL CONSIDERATIONS FOR SPLINTING Essential for hand functions: grip, pinch, and fine manipulation - 50 % of overall hand function - Provides stability for grip, pinch, and mobility as the thumb opposes the fingers for fine manipulations. - Sensory input to the tip of the thumb is important for functional grasp and pinch. ANATOMY OF THE THUMB Muscle Actions Nerve Extensor pollicis Thumb IP extension Radial longus Extensor pollicis Thumb MCP Radial brevis extension Abductor pollicis Thumb radial Radial longus abduction Abductor pollicis Thumb palmar Median brevis abduction Adductor pollicis Thumb adduction Ulnar Opponens pollicis Thumb opposition Median The most crucial aspect of the thumb immobilization splint design is the position of the CMC joint. Positioning of the thumb in palmar abduction using the splints thumb post requires adequate abduction of the CMC joint. This position is critical for functional prehension. FEATURES OF THE THUMB IMMBOLIZATION SPLINT - Static splint, no movable parts - Numerous design variations ( volar, dorsal, radial gutter ) - May be hand based or wrist based Parts: Opponens bar, C bar, and Thumb post Opponens bar and C bar position the thumb in some degree of palmar abduction Thumb post immobilizes the MCP only or both the MCP and IP joints. The thumb immobilization splint may do one of the following: 1. Stabilize only the CMC joint 2. Stabilize the CMC and MCP joints 3. Encompass the CMC, MCP, and IP joints Usually the therapist should fabricate a splint that is the most supportive and least restrictive in movement. DIAGNOSTIC INDICATIONS Some specific diagnostic conditions: - Scaphoid fractures - Stable fractures of the proximal phalanx of the 1st metacarpal - tendon transfers - radial or ulnar collateral ligament strains

- MCP joint dislocations - capsular tightness of the MCP and IP joints after trauma - posttraumatic adduction contracture extrinsic flexor or extensor muscle contracture - repair of MCP joint collateral ligaments - flexor pollicis longus (FPL) repair - Rheumatoid Arthritis - uncomplicated EPL repair - Osteoarthritis - congenital adduction deformity of the thumb - de Quervains tenosynovitis - median nerve injuries The therapist should be aware that thumb palmar abduction may be uncomfortable for some persons. Therefore, the thumb may be positioned midway between radial and palmar abduction.

Thumb Immobilization Splint

References: Coppard, Brenda M. and Helene Lohman, Introduction to Splinting: A Clinical Reasoning & Problem Solving Approach, 2nd Edition, 2001, Mosby, Inc.

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Splinting for de Quervains Tenosynovitis De Quervains Tenosynovitis results from repetitive thumb motions and wrist ulnar deviation. It affects the abductor pollicis longus (APL) and the extensor pollicis brevis (EPB) in the first dorsal compartment. - May be recognized by pain over the radial styloid, edema in the first dorsal compartment, and positive results from the FINKELSTEINs Test. Occupations prone for this condition are the following: occupation that involve repetitive wrist deviation and thumb motions home construction tasks of painting, scraping, wall papering, and hammering. Splinting for Rheumatoid Arthritis and Osteoarthritis Rheumatoid arthritis often affects the thumb joints, MCP and CMC joints. Splinting can reduce pain, slow deformity, and stabilize the thumb joints. - Some with RA affecting CMC joint benefits from a hand-based thumb immobilization splint. - If the IP joint is painful and inflamed, the therapist should incorporate the IP joint into the splint. - The person wears this splint constantly for a minimum of 2 to 3 weeks, with removal for hygiene and exercise. - The therapist should be aware that the person may have fragile skin. ( monitor skin breakdown including the ulnar head, Listers tubercle, the radial styloid along the radial border, the CMC joint of the thumb, and the scaphoid and pisiform bones on the volar surface of the wrist) Chapter 5 Fig 5-6 - Padding the splint for comfort to prevent skin irritation may be necessary. - Take note of patients swelling patterns splints should allow enough room for nocturnal swelling - Positioning the thumb in enough palmar abduction for functional activities is important. - Some stabilize the thumb CMC joint alone with a short splint properly molded and positioned. -Material: Thermoplastic material less than 1/8-inch best for small hand splints - Wear splints at night, periodically during the day, and during stressful daily activities - 3 Stages: First stage: involves inflammatory process Goal of splinting: rest the joints and reduce inflammation (wears continuously during periods of inflammation and periodically thereafter for pain control as necessary). Second stage: disease progresses, hand requires mechanical support because joints are less stable and painful with use. (wear for support while doing daily activities and perhaps at night for pain relief). Third stage: pain is usually not a factor but the joints may be grossly deformed and unstable The splint may provide support to increase function during certain activities. Splinting is rarely helpful for the person at night. CMC JOINT OSTEOARTHRITIS a common thumb condition, especially among women over 40. Pain at the base of the thumb interferes with the persons ability to engage in normal functional activities. Precipitating factors: hypermobility, repetitive grasping, pinching (lateral pinch), use of vibratory tools, and a family history of the condition - The dorsal aspect of the CMC joint is stressed by the repetitive pinching and the strong muscle pull of the adductor pollicis muscle and the short intrinsic thumb muscles . ( CMC joint to sublux dorsally and radially: first metacarpal losing extension and becoming adducted, MCP joint hyperextends to accommodate grasp ) - Hand based thumb immobilization or short opponens splint restricting the mobility of thumb joints to decrease pain and inflammation. - Stabilizes the CMC and MCP joints in the maximal amount of palmar abduction for a functional pinch. - Splinting both joints in a thumb post stabilizes the CMC joint in abduction, the base of the MCP deeply situated in the saddle joint: the person should continue to do complete functional tasks. -Material: Thermoplastic material 1/16 inch thin

Thumb Immobilization Splint

References: Coppard, Brenda M. and Helene Lohman, Introduction to Splinting: A Clinical Reasoning & Problem Solving Approach, 2nd Edition, 2001, Mosby, Inc.

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Splinting for Ulnar Collateral Ligament Injury Injury to the UCL/ Gamekeepers Thumb/ Skiers Thumb a common injury that can occur at the MCP joint of the thumb. - The UCL helps stabilize the thumb by resisting radial stresses across the MCP joint. UCL can be injured if the thumb is forcibly abducted or hyperextended ( falling with an outstretched hand with thumb in abduction) - There are Splinting Protocols for each grade of injury. Grades I, II, and III. Grade I injuries involving microscopic tears with no loss of ligament integrity Grade II injuries involve a partial ligament tear, but the overall integrity of the ligament remains intact Grade III injuries involve a completely torn ligament and usually require surgery -If UCL is still in an anatomical position, then a thumb immobilization splint worn consistently will heal the tear. - If patient is with any doubt for the splint, the person should be casted so that ligament protection is ensured. - Protocols for splinting UCL injuries require the thumb to be immobilized in palmar abduction. - Positioning in MCP flexion causes extreme tension on the healing UCL. - SCHULTZ-JOHNSON: Grade II or III UCL tears after surgery can be positioned in MCP joint flexion Injury to the Radial Collateral Ligament/ Golfers Thumb hand-based thumb immobilization splint - The thumb is positioned in maximal comfortable radial deviation at the MCP joint . - The splint helps remove stress to the healing ligament. Splinting for Scaphoid Fractures Fracture of the Scaphoid Bone the second most common wrist fracture. Usually occurs because of a fall on an outstretched hand. - Person has painful wrist movements and tenderness on palpation of the scaphoid anatomical snuffbox between the EPL and EPB. - After the immobilization stage in a cast, hand may be positioned in a forearm-based thumb immobilization splint with the thumb in a position for function (lightly contacts the index and middle finger pads with wrist in neutral). - Splint protects the hand during stressful activities and sleep. FABRICATION OF A THUMB IMMOBILIZATION SPLINT There are many approaches to fabrication of a thumb immobilization splint. (Refer to the photocopy) 1. VOLAR or a DORSAL THUMB SPICA SPLINT 2. RADIAL GUTTER THUMB IMMOBILIZATION PATTERN that excludes the IP joint FABRICATION OF A HAND-BASED THUMB IMMOBILZATION SPLINT These splints are for the following diagnoses: - Low Median Nerve Injury - Osteoarthritis - Ulnar or Radial Collateral Ligament injury of - first web space contracture the MCP joint These diagnoses may require placement of the thumb post in a different degree of abduction, based on protocols. - The IP joint is usually left free for functional movement, unless there is extreme pain in that joint. TECHNICAL TIPS FOR PROPER FIT 1. Before molding the splint, place the persons elbow on a table top, positioned in 90 degrees of flexion and the forearm in a neutral position. Position the thumb and wrist according to diagnostic indications. 2. Monitor joint positions by measuring during and after splint fabrication. The best way to position the thumb in palmar abduction is to have the person lightly touch the thumb tip to the pad of the index or middle finger. For RA, thumb post more comfortable between radial and palmar abduction.

Thumb Immobilization Splint

References: Coppard, Brenda M. and Helene Lohman, Introduction to Splinting: A Clinical Reasoning & Problem Solving Approach, 2nd Edition, 2001, Mosby, Inc.

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3. Follow the natural curves of the longitudinal, distal, and proximal arches. Position the splint area that covers the thenar eminence just proximal to the proximal palmar crease. Be especially careful to check that the index finger has a full flexion because of its close proximity to the opponens bar, C bar, and thumb post. 4. When molding the thumb post, overlap the splinting material into the thumb web space. Be certain that the thumb IP joint remains in extension during molding to facilitate later splint application and removal. Be extremely careful in making adjustments with a heat gun on the thumb post, or the result may be an inappropriate fit. 5. For a thumb immobilization splint that allows IP mobility, make sure the distal end of the thumb post on the volar surface has been rolled to allow full IP flexion. PRECAUTIONS FOR A THUMB IMMOBILIZATION SPLINT - Check for areas of skin pressure over ulnar styloid, the superficial branch of the radial nerve at the radial styloid, and the volar and dorsal surfaces of the thumb MCP joint. - Specific precautions for the molding of the splint include the following: 1. If the thumb post extends too far distally on the volar surface of the IP joint, the result is restriction of the IP joint flexion and a likely area for skin irritation. 2. Because of its close proximity to the opponens bar, C bar, and thumb post, the radial base of the first metacarpal and first web space has a potential for skin irritation. 3. With a radial gutter splint, monitor the splint for a pressure area at the midline of the forearm on the volar and dorsal surfaces. Pull the sides of the forearm through apart if it is too tight. 4. Be careful to fabricate a thumb splint that is supportive and not too constrictive. Constriction results in decreased circulation and possible skin breakdown. Make allowances for edema when fabricating the thumb post. 5. If using a thermoplastic material that has a memory properties (ability of the material to return to its preheated shape, size, and thickness when reheated ), be aware that the material shrinks when cooling. Therefore the thumb post opening must remain large enough for comfortable application and removal of the splint.