Radomski, Ch 16 and 17

OT 624

Orthotics and
Splinting

Jennifer Boyette, OTR, CHT, CEAS III, PhD

FOR for splinting and orthosis
 Biomechanical-
 Uses principles of kinetics and forces
acting on the body
 Sensory motor FOR-
 Used to inhibit or facilitate normal motor
responses
 Rehabilitation
 Facilitates maximal function
Defining terms
 Orthosis-
 Any device applied to or around a body
segment to address physical impairment or
disability
 Brace and support are terms used for an
orthosis
 A force system designed to control, correct, or
compensate for a bone deformity, deforming
forces, or forces absent from the body
 Refers to a permanent device to replace or
substitute for loss of muscle function
 Wrist hinge orthosis
Splint
 Device for immobilization, restraint,
or support of any part of the body.
 Usually thought of as more
temporary than and orthosis
 ASHT splint classification
 Static splint
 Serial Static splinting
 Static Progressive splints
 Dynamic Splints
Health professionals who
deal with splinting and
orthotics
 OT’s/ COTA’s
 CHT’s (can be PT or OT)
 CO/CPO
 Dentists
 Less common- nurses
Orthotic selection
 What is the clinical or fxl problem?
 What are the indications for and goals of
splint use?
 How will orthosis affect the problem and
the client’s function?
 Benefits of splint/orthosis?
 Limitations?
 Custom made vs. pre-fab vs. no device
Splint related factors to
consider:
 Type  Cost to purchase
 Design vs. fabricate
 Ease of care
 Purpose
 Durability
 Fit
 Ease of donning
 Comfort and doffing
 Cosmetic  Effect on
appearance unsplinted joints
 Weight  Effect on function
Patient-related factors
 Clinical status  Social support
 Functional status  Issues related to
 Attitude safety and
 Lifestyle precautions
 Ability to
 Preference
understand and
 Occupational roles
follow through
 Living envio  Insurance and
 Working envio financial issues
 Purpose of orthosis
 Support a painful joint
 Immobilize for healing
 Provide stability and restrict unwanted
motion
 Purpose of orthosis
• Restore mobility-drop out cast,flexion
glove, dynamic ext splint
• Substitute for weak or absent muscles-
MAS, eltoid aide, flexion assist spring,
tenodesis splint, WDWHO, ratchet brace
• Prevent contractures or Modify tone- air
splint, ball splint, neoprene thumb loop,
wt. bearing splint
Safety precautions for
orthosis
 Impaired skin integrity
 Pain
 Swelling
 Stiffness
 Sensory disturbances
 Increased stress on unsplinted joints
 Functional limitations
 Purpose of splints
 Static
 Rest
 Prevention of further deformity
 Prevention of soft tissue contracture
 Substitution for lost motor function

 Dynamic
 Substitution for lost motor function
 Correction of a deformity
 Control of motion
 Aid in alignment and wound healing
Types of Splints
 Static splint
 Drop-out
 Articulated splints
 Self adjusting or elastic components
 Static progressive-
 Hinges, velcro, turnbuckles
 Serial static or casting
Anatomical considerations
 Landmarks
 Distal IP creases
 DPC
 Proximal palmar crease
 Thenar crease
 Wrist crease
 Styloids, MP joints, IP joints, CMC, IP of Th
Anatomy (continued)
 Arches of the hand
 Longitudinal
 Distal transverse
 Proximal transverse
 Fingers flex toward scaphoid
 Functional position of hand
 Position of safe immobilization- intrinsic
plus position
Influence of splinting on
tissue
 Inflammatory phase- use splint to
immobilize and protect
 Fibroplastic phase: use splints to
mobilize healing tissues while protecting
 Maturation phase: low load force may
be applied gradually increasing the
stress tolerated
Tissue Remodeling
 Ideal tissue remodeling occurs with
gentle elongation of tissues (dynamic
and serial splinting/casting)
 Total end range time suggests that
the amount of increase in PROM of a
stiff jt is proportional to the time joint
is held at end range (serial static
splinting/casting)
 Stress relaxation or static
progressive stretch therapy
Mechanical principles applied
to splint design
 Increase the area of force application to
disperse pressure
 Increase the mechanical advantage to
reduce pressure and increase comfort
 Ensure three points of pressure
 Add strength through contouring
 Perpendicular traction for dynamic
splinting
 Acceptable pressure for dynamic splinting
 High vs. low profile outriggers
Other considerations for
splinting
 Compliance
 Offer options
 Educate about benefits
 Provide easy application and removal
 Lightweight material
 Immobilize only joints being treated
 Cosmetically pleasing
 Collaborate w/pt on wearing schedule
 Education
Construction of Hand Splints
 Purposes:
 Protection
 Positioning for function
 Immobilization for healing
 Restriction of undesired motion
 Correction or prevention of deformity
 Substitution of absent or weak muscles
Construction of a hand splint
 Design splint
 Select material
 Make pattern
 Cut splinting material
 Heat splinting material
 Form splint
 Finish edges
 Apply straps, padding and
attachments
 Evaluate the splint for fit and comfort
Materials and their properties
 Low temperature thermoplastic
 High temperature thermoplastics
 Metal braces and parts
 Soft splints
 Properties of materials
 Memory
 Drapability
 Elasticity
 Bonding
 Self-finishing edges
 Time to heat
Performance characteristics
of materials for splinting
 Conformability
 Flexibility
 Durability
 Rigidity
 Perforations
 Finish, colors, and thickness
Pattern Making
 Tracing the hand
 Marking landmarks
 Cutting pattern
 Fitting pattern on client
 Forearm splint should go 2/3rds up forearm
and trough should be ½ around the forearm.
Should not restrict DPC if splint goes into
hand, doesn’t restrict fingers
 Adjusting pattern
 Refitting
 Tracing pattern onto material
 Cutting and molding a splint
 Cutting material
 Soften material
 Mold material on client
 Padding if needed prior to molding or
after
 Adjusting
 Reheating vs. spot heating
 Strapping
 No tourniquet effect
 Wider distributes pressure better
Dynamic Splinting
 Learning Objectives: After this
session, the learner will:
 Explain the purposes of dynamic hand
splinting
 Be able to identify the line of pull for
muscles and joints in the UE
 List common pressure areas with dynamic
splints
 Fabricate a dynamic flexion or extension
splint
Purposes of Dynamic
Splinting:
 Definition- The application of a
moving part of a force which remains
approximately constant as the part
moves.
 Purpose: To give MOBILITY to a
joint, muscle, tendon, etc... (as
opposed to static splinting, which is
designed to give STABILITY).
 Joint MOBILITY can:
 Decrease adhesions
 maintain joint function
 promote tendon gliding
Uses of Dynamic Splints:
 Skeletal Substitution
 aides in alignment
 supports bones and joints
 Muscle Balance
 paralyzed muscles
 divided tendons or muscles (as in tendon transfers)
 Joint Motion
 preserve or increase joint motion
 Rest:
 promote wound healing
 treat infection
 relieve pain
Parts of Dynamic Splints
 Static Base
 Serves as the foundation for the splint, it:
 provides alignment
 provides the foundation for the outrigger
 provides the foundation for a hinge
 aides in relaxation of a spastic muscle
 allows tissues to adapt to new position
 protects a newly repaired structure
 provides proximal support
 aides in positioning and edema control
 Dynamic Component
 Can be slings, ratchet, springs, elastic bands, hinge
 These features give the splint its MOBILITY
 Benefits of Dynamic
Splinting:
 Constant or longer duration of steady tension is more
successful than vigorous passive exercise for 20 minutes
(especially where contractures are present)
 Early motion=more effective healing
 increased circulation
 decreased edema due to increased pumping of stagnant
fluids
 increased gliding of tendons
 increased flushing of synovial fluids
 decreased adhesions
 Can be used to introduce exercise more gradually and
insure that the patient is doing exercise in good alignment
Using Exercise with
Dynamic Splinting:
 Aides in :
 Joint excursion
 tone of skin
 increased circulation
 Increased patient confidence by seeing to what degree the
hand can be moved safely
 Because part is supported proximally, patient can do
exercise more independently and more safely
 Therapist should instruct patient not to go the the point of
pain
 Where there is decreased sensation, one must be
extremely careful to avoid pressure or push too rapidly
 Heat prior to exercise may promote increased movement
Medical/Biomechanical
Principles:
 Moving muscles must be given an opposing,
balance force in order to maintain joint mobility
and tendon gliding
 Movement prevents joint/muscle atrophy and
limits deformity
 Joints should never be immobilized needlessly
 Where the injury is on the flexor surface, wrist
and fingers should be placed in flexion.
 Where the injury in on the extensor surface,
wrist and fingers should be placed in neutral or
resting position.
 Edema should be decreased ASAP
 Strapping or construction of a splint should not
constrict venous return
 Edema
 Has a high protein content which congeals around the
hand structures, joint capsules, collateral ligaments, and
other fibrous structures
 When these structures are surrounded by edematous
fluid, the tissues swell, thicken, and shorten and become
and unyielding fibrous tissue
 The best program for edema is motion and elevation
 Swollen fingers tend to go into hyperextension and the
thumb into adduction
 Edema
 Has a high protein content which congeals around the
hand structures, joint capsules, collateral ligaments, and
other fibrous structures
 When these structures are surrounded by edematous
fluid, the tissues swell, thicken, and shorten and become
and unyielding fibrous tissue
 The best program for edema is motion and elevation
 Swollen fingers tend to go into hyperextension and the
thumb into adduction
 Edema is more common in the dorsum of the hand where
the skin allows more fluid to accumulate
 In the palmar surface of the hand, edema causes the
arches to become flattened and hence clients have
difficulty making a fist
 Splint strapping, when applied too tight, can worsen
edema due to decreased blood flow
 Edema can also be aided by removal of a splint every two
hours and allowing range to the unaffected joints
Patient Education:
 Patients should be educated in:
 purpose of the splint
 accurate positioning of the splint
 what motion or range is being sought
 simple anatomy and mechanism of injury /
surgical repair
 specific wearing instructions that include:
 wearing times
 placement of splint and strapping
 common pressure areas
 exercises allowed while in (or out of ) splint (if allowed)
 Hand Architecture
 Directional Pull of the fingers:
 All the fingers , excepting the middle finger (which
may flex straight down) cross the palm obliquely
from 10-30 degrees
 Anatomical center of the Hand:
 is located at the level of the head of the third
metacarpal
 To find this point, converge all five fingers at one
point with the fingers forming a cone
Bones
 Radius
 Ulna
 Carpals
 DistalRow
 Proximal Row

 Thumb
 Metacarpals
 Interphalangeal joints
The Mechanics of Splinting
 Principles
 Addition of forces
 two or more forces acting upon an object
may be added and be replaced by a single
force which is their sum
 Transmissibility of a force
 A force acting on a rigid body may be
considered to have a point of application
anywhere along its line of action
The Mechanics of Splinting
 Principles
 Equilibrium
 If the forces and the torque applied to a
body add up to zero the body will remain at
rest
 Action and Reaction
 The interaction between two bodies in
contact may be represented by two forces
equal in magnitude and opposite in
direction having the same line of action
Friction
 the horizontal component of the force applied
along the cuff of a dynamic splint when it pulls
along the surface of the skin is called friction
 Friction is an unreliable force and splints
should not be designed to depend upon friction
for maintenance of a position. As patients move,
slippage of cuffs and splints is bound to occur
 Therapists should attempt to reduce friction
effects as much as possible
 One should assume that skin is essentially
frictionless and it should not be depended on
during splint design
Tension and
Compression-
 Rubber bands, velcro strapping can have
traction effects, the weight of the tension
needs to match the weight of the extremity
being placed in tension. For example, If a
rubber band is too tight or too loose, it will
not match the weight of the extremity and
hence not have the desired effect
 Compression forces are those that
squeezed together - A splint with a hinge on
it might have this effect if it acts to hold two
parts together, but still allows motion
 Balancing forces
 Equilibrium of a splint- all forces should
balance out within a dynamic splint if the splint
is not to cause problems (such as friction,
shearing, pressure areas)
 Equilibrium of axial forces- Horizontal forces
in a splint must = zero. If a hand presses
against a splint and thus cancels out the
horizontal force of a rubber band, the horizontal
forces can be at equilibrium
 Wedging- changes the forces from small to
large by changing the distribution of the force
over a larger space. This increases the chance
of pressure areas if the wedge is not widely
distributed over the skin.
Common pressure points
 MP joints
 IP joints
 Ulnar styloid
 Center of the palm
 Any surface on which a finger cuff or
traction bar exerts a force
 Web space
 Dorsal-lateral aspect of the thumb
Documentation about
splinting
 Document why client needs splint
 Position that client was splinted in
 Instructions you gave client
 Follow up needed
Splinting Lab