Transcript Splinting and orthotics

Orthosis and Splinting
Radomski ch 16 and 17
OT 624
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
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Orthosis
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Any medical 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
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Device for immobilization, restraint, or
support of any part of the body.
 Usually thought of as more temporary than
and orthosis
 ASHT splint classification
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Static splint
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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:
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Type
 Design
 Purpose
 Fit
 Comfort
 Cosmetic
appearance
 Weight
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Cost to purchase vs.
fabricate
 Ease of care
 Durability
 Ease of donning and
doffing
 Effect on unsplinted
joints
 Effect on function
Patient related factors
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Clinical status
 Functional status
 Attitude
 Lifestyle
 Preference
 Occupational roles
 Living envio
 Working envio
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Social support
 Issues related to
safety and
precautions
 Ability to understand
and follow through
 Insurance and
financial issues
Purpose of orthosis
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Support a painful joint- slings, troughs, laptray and splints
Immobilize for healing –dorsal block, buddy strap, figure 8,
sh immobilizer
Protect tissues, gun slinger, airplane spl,
Provide stability and Restrict unwanted motion- resting
pan splint, dorsal block
Restore mobility-drop out cast,flexion glove, dynamic ext
splint
Substitute for weak or absent muscles- MAS, Deltoid 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
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Static
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Rest
Prevention of further deformity
Prevention of soft tissue contracture
Substitution for lost motor function
Dynamic
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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,
 Serial
velcro, turnbuckles
static or casting
Purpose of splints
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Static
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Rest
Prevention of further deformity
Prevention of soft tissue contracture
Substitution for lost motor function
Dynamic
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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,
 Serial
velcro, turnbuckles
static or casting
Other considerations for
splinting
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Compliance
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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
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
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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
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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
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Compliance
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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
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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
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Low temperature thermoplastic
 High temperature thermoplastics
 Metal braces and parts
 Soft splints
 Properties of materials
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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
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Tracing the hand
 Marking landmarks
 Cutting pattern
 Fitting pattern on client
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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, but
doesn’t restrict fingers
Adjusting pattern
 Refitting
 Tracing pattern onto material
Cutting and molding a splint
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Cutting material
 Soften material
 Mold material on client
 Padding if needed prior to molding or after
 Adjusting
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Reheating vs. spot heating
Strapping
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No tourniquet effect
Wider distributes pressure better
Dynamic Splinting
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Learning Objectives: After this session, the
learner will:
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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:
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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).
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Joint MOBILITY can:
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Decrease adhesions
maintain joint function
promote tendon gliding
Uses of Dynamic Splints:
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Skeletal Substitution
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Muscle Balance
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paralyzed muscles
divided tendons or muscles (as in tendon transfers)
Joint Motion
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aides in alignment
supports bones and joints
preserve or increase joint motion
Rest:
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promote wound healing
treat infection
relieve pain
Parts of Dynamic Splints
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Static Base
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Serves as the foundation for the splint, it:
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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
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Can be slings, ratchet, springs, elastic bands,
hinge
These features give the splint its MOBILITY
Benefits of Dynamic Splinting:
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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 in conjunction
with Dynamic Splinting:
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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:
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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.
Position of function should be maintained prior to
application of any dynamic splint
Edema should be decreased ASAP
Strapping or construction of a splint should not constrict
venous return
Edema
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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:
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Patients should be educated in:
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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:
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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
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To find this point, converge all five fingers at one
point with the fingers forming a cone
Metacarpophalangeal joints
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Metacarpophalangeal joints are the most
common site of joint limitations in the hand.
Contributing factors might include:
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adhesions of the extensor tendons over the
dorsum of the hand or of the extensor hood
mechanism
thickening of the dorsal capsule of the MP joint
contracture of the collateral ligaments
insufficient skin coverage over the dorsum of the
hand
a bony block within the joint
Bones
 Radius
 Ulna
 Carpals
Distal Row
 Proximal Row
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 Thumb
 Metacarpals
 Interphalangeal
joints
The Mechanics of Splinting
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Principles
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Addition of forces
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Transmissibility of a force
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A force acting on a rigid body may be considered to have
a point of application anywhere along its line of action
Equilibrium
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two or more forces acting upon an object may be added
and be replaced by a single force which is their sum
If the forces and the torque applied to a body add up to
zero the body will remain at rest
Action and Reaction
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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
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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
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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
Common pressure points
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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