Lecture 6: UE Orthoses Flashcards
OT scope of practice in regard to orthotics
assessment, design, fabrication, application, fitting, and training in orthotic devices
domains of hand therapy practice
- assess upper limb and relevant pt characteristics
- determine prognosis and individualized POC
- Implement POC and therapeutic interventions
- basic science and fundamental knowledge
articular vs non articular orthoses
articular crosses a joint
nonarticular does not cross or does not have a mechanical joint
purposes of UE orthoses
immobilize
mobilize/assist with movement
restrict motion
what characteristics need to be described when talking about an UE orthoses
fabrication (custom?)
articular or non?
location
direction of applied forces
purpose of orthoses
what do immobilizing UE orthoses do and examples of possible indications
stabilize joints/tissues by preventing excessive/abnormal movement
manage a deformity bu preventing contracture
protect structures from harmful/excessive load
i.e. stabilize unstable/painful joints, reduce inflammation, prevent deformities, facilitate healing, etc
what do mobilizing UE orthoses do and examples of possible indications
assist with movement
manage deformity by applying corrective force
i.e. assist with lost movement from nerve injury, elongate shortened tissue
what do restricting UE orthoses do and examples of possible indications
protect structures from harmful/excessive load
i.e. prevent joints from unsafe movements
what is a budding taping orthoses used for
stringer digital assists with movement of impaired digit
what are blocking splints used for
assists AROM by blocking movement of more mobile joints
Anti-deformity position of the UE
90 deg shoulder abduction with ER
elbow extension
neutral to slight supination of forearm
20-30 deg wrist ext
70-90 deg MCP flexion
IP extension
thumb and palmar abduction
*important considerations for burns
UE orthoses design principles
wear time depends on orthoses/purpose
longer splints = more comfy
wider straps = more even force distribution
contoured edges = for pt comfort
avoid pressure over bony prominences
in dynamic braces, angle of pull should be 90 deg
apply tension only sufficient to take the joint to comfortable end range
design categories of UE orthoses
static
dynamic
functional
types of static UE orthoses
static
- articular
- non-articular
- motion blocking (dorsal or volar)
serial static
static progressive
purpose of static splints
provide passive support
commonly prescribed for immobilization
provides protection for proper positioning
general position for static splints
for contracture prevention and healing
resting position = holds tissue in elongated position but not at end range
functional position of hand and wrist
20-30 deg wrist ext
40-45 MCP flexion
45 PIP flexion
relaxed flexion of DIPs
thumb abducted and in opposition to fingers
Healing time, non-union rate, and radial nerve palsy rate for pts with a closed humeral shaft fx using a static splint vs surgical treatment
non operative
- healing time = 16 weeks
- non union = 11%
- radial nn palsy = 1%
operative
- healing = 14-15 weeks
- non-union = 3-6%
- radial nn palsy = 3-4%
indication for elbow flexor spasticity static splint
due to UMN pathology
may be worn at night to maintain elbow extension ROM and prevent flexion contracture
purpose, position, and indication for airplane splint
purpose = immobilization
position in abduction
indications:
- axillary burns
- contracture prevention
- humeral neck fx
- brachial plexus injury
indications and position for abduction external rotation shoulder brace
indications
- s/p RTC repair
- after shoulder dislocation
- s/p shoulder arthrodesis
position = 30 deg ABD and 30 deg ER most comfy
shoulder sling purpose and indications
purpose = immobilization
indications
- post trauma
- post sx
- AC or GH dislocation
long term use can lead to elbow contracture
sling vs abduction brace for s/p RTC repair
no difference in effectiveness- function, pain, or healing
sling may be more cost effective
purpose and indications for elbow, forearm, wrist orthoses
stabilizes injuries of the forearm and wrist by preventing supination and pronation
typically positioned in neutral
indications:
- distal radius fx
- forearm fx
- triangular fibrocartilage injury
- terrible triad- elbow dislocation with associated radial head and coronoid fx
- contracture prevention
sugar tong splint purpose and indication
purpose = limits forearm supination/pronation, elbow extension, and wrist motion
indications
- carpal fxs
- distal radius fx
- distal ulna fx
indications for static wrist hand orthoses
burns
joint replacements
RA
peripheral nn injury
nn and tendon repair
carpal tunnel
wrist pain (prevent or manage)
contracture prevention
what does the carpal tunnel CPG say about bracing
neutral positioned orthoses worn at night
can suggest adjusting wear time to include day time, symptomatic, or full time use when night time only use is ineffective at controlling S&S
should recommend orthoses for those with CTS during pregnancy
purpose and position of dorsal blocking splint
purpose
- block wrist and finger extension
- protect repaired flexor tendons
typically positioned in 0 or 30 deg wrist flexion
at neutral position may result in less flexion deformities, complications, and earlier return to activities
purpose and indications for volar blocking splint
purpose = block wrist and finger flexion
indications:
-contracture prevention
- spasticity control
- distal radius fx
indications for ulnar gutter splint
soft tissue hand injuries to 4th/5th fingers
4th and 5th metacarpal fx (i.e. boxers)
4th and 5th phalange fx (extended)
positioning for RA
indications for radial gutter splint
soft tissue injury to 2nd and 3rd fingers
fx to 2nd and 3rd metacarpals
fx to 2nd and 3rd phalanges
positioning for RA
laceration over joints of 2nd and 3rd phalanges or metacarpals
symptoms of DeQuervain’s Tenosynovitis
pain or tenderness while moving thumb
pain when grasping an object or making a fist
radiating pain to forearm
swelling at base of thumb
kinds of splints used for DeQuervain’s
short hand based (wrist free) splint including the IP joint of the thumb
short hand based splint excluding the IP joint of the thumb
long lower arm based (wrist immobilized) splint including the IP joint of the thumb
long lower arm based splint excluding the IP joint of the thumb
symptoms of gamekeepers or skiers thumb
pain with pinch grasp
weakness with pinch grasp
difficulty gripping objects
swelling or bruising at base of thumb
can be a tear or sprain of the UCL
purpose/indications for thumb splint
immobilizes the thumb and possibly wrist
indications:
- scaphoid fx
- lunate fx
- thumb phalanx fx or dislocation
- gamekeeper’s or skier’s thumb
- DeQuervain’s tenosynovitis
- carpal tunnel syndrome (not standard)
- CMC osteoarthritis
indications for thumb opponens splint
CMC OA
spastic CP
congenital deformity of thumb
recommendation for CMC joint OA
strong rec for soft or rigid hand orthosis
recommendation for other hand joint OA (aside from CMC joint)
conditionally recommendation for orthosis such as finger splints, digital orthoses, soft or rigid
what does mallet finger look like
DIP flexion
what does Boutonniere deformity look like
PIP flexion and DIP extension
what does swan neck deformity look like
PIP extension with MCP and DIP flexion
common after trauma or in pts with RA
what is Elson’s test
diagnostic test used for early detection of injuries to the central slip of the extensor tendon
when it becomes noticeable = Boutonniere
what are relative motion orthoses
static orthoses - holds the affected finger in relative ext or relative flx compared to adjacent fingers
protects or unloads injured or repaired tendon
limits excursion of injured or repaired tendon
usually made of firm thermoplastic
typically worn for 4-7 weeks
usually 3 or 4 finger designs
what is a relative motion flexor orthosis
15-20 deg MCP flexion relative to adjacent fingers
provides laxity in lumbricals while increasing tension on extensor hood
indications for relative flexor orthosis indications
central slip laceration
Boutonniere deformity
digital nn repair
flexor tendon repair
interosseous repair
lateral band sprain/tear
post-PIP joint arthroplasty
unexplained pain in palm of hand
after metacarpal fx
improve alignment of fingers with RA
how much extension is recommended for a relative motion extensor orthosis for long extensor tendon repairs vs sagittal band injuries
long extensor tendon repairs = 10-15 degrees of relative metacarpal joint extension recommended
sagittal band injuries = 15-20 degrees of relative extension recommended
indications for relative extensor orthosis
extensor tendon repair zones IV-VIII
sagittal band disruption
intrinsic tendon transfer
limit motion of split skin graft on dorsum of hand
swan neck deformity
mallet or trigger finger
unexplained pain about the MCP joints or dorsum of the hand
metacarpal head fracture
improve alignment of fingers with RA
purpose of a serial static orthoses and how they work
mobilization
prolonged low load
cast or brace with ROM control
worn full time
indication for a serial static splint
elbow fracture or contracture
s/p biceps tendon repair
PIP flexion contracture
possible MOI for a PIP flexion contracture
dislocation/hyperextension or hyper flexion
torsional injury
soft tissue injury
comparison of serial static cast, dynamic orthosis, or static progressive splint for PIP flexion contracture
no difference in effectiveness
factors to consider:
- total end range time
- pt comfort
- compliance
what is a static progressive orthosis and how is it used
single splint that is adjustable
worn at least 30 min 3x/day
joint held at current end range
positioning readjusting each wear
possible indications for static progressive orthoses
PIP joint contractures
elbow flexion contractures
knee flexion contractures
purpose of dynamic splints and how they work
purpose = mobilization
use elastics, coils, or spring tensioning mechanisms to provide low long prolonged duration stretch in typically one direction
shouldn’t produce pain
not as effective as static tension
possible indications for dynamic splint
radial nn injury
s/p flexor tendon repair
how is a dynamic splint used for s/p flexor tendon repair
dorsal blocking- limited MCP ext
elastic bands substitute/protect healing flexor tendons
resists finger extension
purpose of specialized UE orthoses
act as a substitute for irreversible functional loss
purpose of a tenodesis splint
intended to enhance tenodesis grip
indications = C6-C7 quadriplegia
what does research say is the best intervention to reduce UE spasticity post stroke and level of evidence
static splinting (low)
dynamic splinting (low)
what does research say is the best intervention to increase hand function post stroke and level of evidence
use of static splinting (moderate)
use of dynamic splinting (moderate)
manual stretching (moderate)
what does research say is the best intervention to improve functional tasks post stroke and level of evidence
static splinting (moderate)
dynamic splinting (moderate)
manual stretching (moderate)
post op protocol for extensor tendon repair
immobilization
early passive (controlled) mobilization
early active mobilization
prior evidence recommends early active mobilization with orthosis (unspecified) or controlled immobilization over immobilization
what does research say about UE orthotic intervention for children with CP
lack of evidence to support UE orthoses in kids with CP
what does research say about non-pharmacological interventions for spasticity in adults
low quality evidence for non-pharm interventions targeting spasticity, including splinting
what does research say about using splints/orthoses for the treatment of RA
insufficient support for use of wrist splints/orthosis for pain management or to improve function in people with RA
