Braddom - Upper Limb Orthotic Devices Flashcards
Orthos means
Correct or make straight
Any externally applied device used to modify structural and fx characteristics of the neuromuscular skeletal system
Orthosis
Orthosis alternatively known as
Orthotic device
Upper limb orthotic applications
Objectives
Protection
Correction
Assistance with function
Will act as a keystone for hand position
Wrist
The wrist will act as the keystone for hand p ing and outlines the basis for all splinting, except
Isolated digital splinting
Weight of the hand pulls the wrist into
Flexion
Flexion of wrist will inc tension in the
Extrinsic extensor tendons - pulling metacarpophalangeal joints into hyperextension
Goal of hand splinting
To prevent claw hand
How does wrist splinting prevent claw hand
Prevent wrist flexion
Inc tension extrinsic extensor tendons, pulling MCP (pulled into hyperextension)
Extrinsic flexor -tension -> PIP and DIP flexion
Metacarpal arch of hand flattens
Thumb- adduction
Key for finger function
MCP joint
When MCP joint are hyperextended
IP joints flex
Tension of flexors
Hand splinting should
Position
Wrist - slight extension - maintain flexor tendon length and improve hand function
MCP -maximum stretch - IP flexed
Oppose development of a claw hand deformity
Slight wrist extension
MCP max stretch
Safe, intrinsic plus
Hand splinting
Slight wrist extension
MCP max stretch
Fosters the weaker intrinsic motions of the MCP flexion and IP extension that are difficult to obtain
Slight wrist extension
MCP max stretch
2 basic hand grips
Power and precision
The wrist is held in dorsiflexion with the fingers wrapped around an object held in the palm
Power grip
Holding a screw driver in a cylindrical grip
Power grip
Is useful for holding a ball
Spherical grip
Useful for carrying heavy objects
Hook pattern
The thumb is held against the tip of the index and middle finger
Precision grip
Functional hand splinting is aimed at improving this functional activity of
Pinch
Three of types of pinch
Oppositional pinch
Precision pinch
Lateral key pinch
Three jaw chuck
Oppositional pinch
Best to splint towards this type of pinch
Oppositional pinch
Allows best compromised between fine precision pinch and strong lateral pinch
Splint towards oppositional pinch
What practical orthosis can substitute or improve thumb adduction
None
Splinting thumb
Enhance prehension, do not forced to extend and radial abduction
When increasing joint range of motion with splinting, the angle of pull needs to be
Perpendicular to bony axis that is being mobilized
Improvement of range of motion is directly proportional to the length of time a joint is
Held at its end range
The improvement in range of motion is directly p portional to the length of time a joint is held at its end range.
What principle is this?
TERT principle
TERT is used with this type of splinting
Static progressive splinting
Provides support to a body part without crossing any joints
Nonarticular
Used for circumferential support to the arm during fracture healing
Humeral fracture splint
Non articular
Used to immobilize a proximal radius fracture
Sugar tong splint
Non articular
To extert pressure over a healing scar to prevent hypertrophic scarring
Gel shell splint
Provides static support to hold a joint or joints stationary
Static splint
Splint for acut carpal tunnel syndrome
Volar wrist splint
Static
Splint to reduce tone in spastic muscles
Volar wrist splint
Is also a static but is periodically changed to alter the joint angle at which splint is positioned
Serial static
Serial static are applied with the tissue at its
Tissue of Max length
Permits motion in one directon but blocks motion in another
Static motion blocking
Designed to allow flexion but block hyperextension of the PIP joint (rheumatoid arthritis)
Swan neck splint
One of the most commonly used splint for regaining joint motion
Static progressive
Orthosis is not remolded to increase joint motion
Static progressive
They use nonelastic components such as stayic lines, hinges, screws, turnbuckles to place force on a joint to induce progressive chnge
Static progressive
Decreases the static line length as it turned, thereby inc the range of joint motion
MERit static progressive component
Provides the elastic force to help regain joint motion
Dynamic splint
Uses a spring coil or wire tension assist to inc extension in a PIP joint with a mild contracture
Finger extension splint
Dynamic
Allows certain motions but blocks others
It uses a passie eslastic line of pull in the desired direction but permits active motion in oppsitve motion
Dynamic motion blocking
Splint for flexor tendon repairs
Passively pulls the finger into flexion with an elastic thread or rubber band
Kleinert postoperative splint
Dynamic motion blocking
It allows active digital extension, while parts of the splint block full extension of the MCP joint and the wrist
Kleinert postoperative splint
Dynamic motion blocking
Offers traction to joint while allowing controlled motion
Dynamic traction
Hand-based PIP extension split with an outrigger which gives constant longitudinal traction while joint is gently flexed and extended
For intraarticular fracture
Type of splint
Dynamic traction
Facilitates fx in a hand that has lost motion because of nervous system injury
Tenodesis
Electrically powered devices that mchanically move joints through a desired range of motion
Continuous passive motion orthoses
Keeps the joint suple and maintains articular, ligamentous and tenginous structure mobility during healing phases after injury or surgery
Continuous passive motion
Promote functional use of the upper limb with impairment resulting from weakness, paralysis, or loss of a body part
Adaptive or functional usage devices
Promote fx use the upper limb with impairment resukting from weakness, paralysis or loss of a body part
Adaptive or functional usage devices
Inflammation at a muscle or tendon origin or insertion
Enthesopathy
Tendonitis, tenosynovitis, enthesopathy result from
Result from excessive repetitive movement or external stressors
Tendonitis, tenosynovitis, enthesopathy Usually involve (upper limb tendons)
Wrist extensors
Abductor pollicis longus
Extensor pollicis brevis (thumb)
Wrist extensors
Abductor pollicis longus
Extensor pollicis brevis (thumb)
Tenosynovitis
De Quervain’s stenosing tenosynovitis
Goal of splinting in tendonitis
Immobilize the affected structures in order to facilitate healing and dec inflammation
More common enthesopathy of the upper limb
Lateral epicondylitis
Lateral epicondylitis tx with
Tennis elbow orthosis
Forearm band that changes the lever arm against which the wrist extensors pull
Tennis elbow orthosis
Essence of tennis elbow orthosis
Puts the origin of the extensor muscles at rest and dec microtrauma from overuse
Tennis elbow orthosis is placed
2 fingerbreadths distal to lateral epicondyle and is a firm strap against which the extensors press against when contracting
Medial epicondylitis brace
Golfer’s elbow
Causes snapping sensation in the volar surface of the digits on release of grasp
Trigger finger
Trigger finger is usually a result of trauma to the
flexor tendon sheath of the fingers or thumb (thickened tendinous sheaths and restriction of motion)
Digit can become locked in flexion
Advanced trigger finger
Goal in triggerfinger
Halt the repetitive motion temporarily to allow healing
Hwo to achieve goal in trigger immobilization
Immobilization
Splint of trigger finger covers
Proximal phalanx and the MCP joint of digit
Splin for trigger finger
Mechanism
Dec tendinous excursion through the first annular pulley at the base of the MCP joint, allows inflamed structures to rest
Momentary subluxations with spontaneous resudction that result in torn ligamentous structures
Sprains
Sx sprain
Experience pain, swelling and dec function
Sprains tx
Immobilizartion in a position of fx
Common sprains include
Dislocation of the IP and MCP joints caused by hyperextension injuries (sports)
First and second degree ligamentous tear goal is to
Protect and rest the area by applying functional splinting
Goal of third degree ligamentous tear is
Fully mobilize and approximate the ligaments
Common splint for digital splints are
Finger extension splints that hold PIP joint extension
Allow flexion DIP
-keeps oblique retinacular ligament and terminal extensor tendon lengthened
Finger extension splint for digital sprains prevent
Boutonniere deformities
Ulnar collateral ligamentous injuries at the MCP joint of thumb are tx with
Hand-based thumb spica spint producing immobilization during healing phase
Wrist sprains management
Wrist splints in slight extension
Some motion but avoid creating significant stress.
Limit available range to 40 degrees of total motion
Splints with no splint (metal bar insert)
Are helpful for mild sprains at the elbow because they limit the extremes of range but allow limited fx
Lbow neoprene
Circumferential
Permits motion of elbow, forearm and hand
Arm fractur
Humeral fracture brace
Humeral fracture of brace prevents
Edema
Resultant joint stiffness
Used primarily for phalangeal and metacarpal fractures
Splint extend from the proximal forearm to beyong the dip joint
Gutter splint
Has been credited woth enhancing cartilage nutrition and preventing intraarticular adhesions
Joint movement
Most common dse affecting the joins in the upper limb
Osteoarthritis
Joint dse in this area have most significant impact on fx
Hand
Wrist
Chronic inflammatory dse that affects snyovial joints
RA
RA most commonly affects
Wrist, MCP joint, PIP joint
RA deformities include
Subluxation, ulnar deviation at the wrist
Swan neck deformity
Boutonniere deformity of fingers
Deformed position of the finger in which joint closest to tge fingertip is permanently bent toward palm while nearest joint to the palm is bent away from it (DIP flexion with PIP hyperextension)
Swan neck deformity
PIP flexion with DIP hyperextension
Boutonniere deformity
Most common form of arthritis
Osteoarthritis
Osteoarthritis is primarily a disease of
Cartilage, not synovium
Osteoarthritis most commonly involves the
CMC joint of thumb
CMC joint osteoA
Management
Thumb spica hand based or forearm based
Limit motion at base of thumb, splint dec pain, esp pinching
What deformity is incurred in distal median nerve injury
Simian hand
Fx most affected by simian hand
Thumb palmar abduction and opposition
Thumb palmar abduction and opposition
Nerve
Distal median nerv injury
Distal median nerve injury
Simian hand
Management
Spring coil design
MCP joint slight extension
Position thumb in palmar abduction
Most common presentation with radial nerve injury distal to humeral spiral groove
Wrist drop
Finger drop
Goal radial nerve injury
Wrist drop
Finger drop
Enhance wrist and finger extension
Position of radial nerve palsy splint
Fore-arm based with an outrigger, holds the wrist fingers and thumb in extension and allows flexion digit
Benediction hand
Proximal ulnar nerve injury
Features hyperextension of the 4th and 5th MCP joint
And flexion of PIP
Loss of balance between extrinsic and intrinsic hand muscles
Benediction hand
Proximal ulnar nerve injury
Goal proximal ulnar nerve inury/ benediction
Prevent fixed deformity of 4th and 5th MCP and improve fx
holds the MCP joints of the fourth and fifth fingers in slight flexion by a spring coil or figure-of-eight splint design
Ulnar nerve palsy splint
Position goal ulnar nerve palsy splint
The spring coil design assists MCP flexion and permits extension of the MCP joints but blocks hyperextension
This is compromised in low median and ulnar nerve injuries
Thumb position - weakened opposition and palmar abduction
Incomplete nerve injury by compression median nerve
Carpal tunnel syndrome
Purpose of splint
Carpal tunnel syndrome
Immobilize the wrist to minimize swelling from overuse of the tendons
Carpal tunnel
Wrist extension degres
0-5
Wrong common name of carpal tunnel syndrome splint
Wirst cock-up splint
Prefabricated wrist splints for carpal tunnel syndrome degree of extension
45, exceeds dec pressure in carpal tunnel
Carpal tunnel splint should be worn until
4-6 weeks
Compression of the ulnar nerve in elbow
Cubital tunnel syndrome
Cubital tunnel syn tx with
Long arm splints that hold elbow in 45 degrees flexion
Forearm neutral
Wrist in 0-5 degrees extension
Thumb fingers free
Brain injury
Orthotic devices design for
Prevent doformities and to help adjust muscle tone
In upper limb paralysis a resting hand splint is commonly used to position the wrist in slight extension, the MCP joints in slight flexion, and the IP joints in extension.
wrist in slight extension, the MCP joints in slight flexion, and the IP joints in extension.
thumb is supported in a position between palmar and radial abduction.
vents ligamentous stresses on the thumb, especially in the insensate hand.
Full support of the first CMC joint
Now used to dec tone in patients with focal spasticity
Botulinum toxin
Followed by serial and dynamic splinting - normal posture and position
Places the fingers and hand in a reflex-inhibiting position and serves to reduce tone
Ball antispasticity splint
dynamic orthosis with functional electrical stimulation that is most appropriate for patients who have some shoulder and elbow movement but no hand function (i.e., lack of active finger extension).
positions the wrist and fingers into extension in preparation for functional activities
SaeboFlex
mobile arm support
enhance function for patients with proximal upper limb weakness, especially when the weakness is profound and the outlook for recovery is guarded.
particularly helpful when performing such activities of daily living as eating and grooming. When attached to a wheelchair with a swivel joint, this is often also called a balanced forearm orthosis.
mobile arm support
slings restrict active motion of the shoulder by
keeping the humerus in adduction and internal rotation and placing the elbow in flexion
designed to unload the weight of the arm on the s der, but do not approximate the humeral head back into the glenoid fossa
Shoulder sling (brain injury)
Slings or half arm trays have not been found to correct the shoulder subluxation completely.
T
is often preferred because it will not restrict use of the limb, and the humerus is more naturally approximated into the glenoid fossa.
arm trough or half lap board
spinal cord injury at the C1-C3 level
Goal
prevent contractures and to hold the wrist and digits in a position of function with a resting hand splint
C4-level injury the goal
use the available shoulder strength, p viding a mobile arm support to enhance function as previously described.
C5-level injury the goal
statically position the wrist in extension with a ratchet-type hinged orthotic device to hold devices and use the shoulder musculature for function.
C6 tetraplegic goal
enhance finger flexion using a tenodesis flexion effect from wrist extension.
Rehabilitation Institute of Chicago tenodesis splint
Thumb position - Palmar abduction
PIP joints of index and long fingers in slight flexion
Produces three point pinch
Rehab tenodesis splint
Flexor tendon repair
Postsurgical and postinjury orthoses
Kleinert and Duran
features dynamic traction into flexion, but allows active digit extension within the constraints of the splint.
Kleinert splint
statically p tions the wrist and MCP joints in flexion and the IP joints in extension
Duran splint
Kleiner + Duran +
a tenodesis-type action splint for a specific, active assisted range-of-motion exercises, can be used only if a specific surgical suture technique has been used.
Indiana Protocol splint
Mallet finger injury
Stax splint
static splint holding the DIP joint in full extension.
Stax splint
Proximal injury
Extensor tendon
wrist statically in extension with dynamic extension of MCP (allows active flexion 30 degrees) and IP joints
Burn patients typically prefer
adducted and flexed p tion of the upper limbs to maintain comfort (loss of fx range motion)
Burn dorsak surface of hand
wrist is kept in 15 to 20 degrees of extension, the MCP joints in 60 to 70 degrees of flexion, the PIP and DIP joints in full extension, and the thumb between radial abduction and palmar abduction
If tendons are exposed burn)
burns of the dorsal surface of the hand
wrist is kept in 15 to 20 degrees of extension, the MCP joints in 30-40 degrees of flexion, the PIP and DIP joints in full extension, and the thumb between radial abduction and palmar abduction
MCP 30-40 flexion (slack tendons until wound closure)
Palmar hand burns require
maximum stretching to p vent the contracting forces of the healing burn.
15 to 20 degrees of wrist extension, extension of the MCP and IP joints, digital abduction, and thumb abduction and extension.
Open palm
Pancake position
Axillary burns
Goal
Prevent shoulder adduction deformity
Axillary burns
Held in
shoulder should be held in abduction with an airplane splint.
tendency toward hypertrophic scarring after a burn is addressed with
compression garments, e tomer molds, facial splints, gel shell splints, and silicone gel sheeting
Patients with arthritis who have been taking c steroids for long periods often have fragile skin, so their splints should be
Padded throughout
Tells an overly aggressive stretch is being applied to the shortened neurovascular bundles
Blueness or redness of the digits
Neurovascular bundles sometimes shorten because of joint contracture
Management
splint tension must be decreased and the contracture stretch should be less aggressive. 20
