Splinting the hand needs

Splinting The Hand Needs Definition,Classification and Nomenclature

Š Nandgaonkar Hemant P.

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Splints Definition Purposes Classification Nomenclature Design Options Principles

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Definition

Made from a variety of materials, splints are external devices that are applied to treat upper-extremity problems resulting from injury, disease, birth defects, or the aging process. Š Nandgaonkar Hemant P.

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Splints serve one or more of four basic functions They may be used to 1.Support 2.Immobilize, or 3.Restrict a body part to allow healing after inflammation or injury to tendon, vascular, nerve, joint or soft tissue structures.

4.Correcting or preventing deformity is another function performed by splints. Š Nandgaonkar Hemant P.

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Hand Problems

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Hand Problems

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Classification Dynamic splint Static Splint Serial Static Splint Static Progressive Splint Š Nandgaonkar Hemant P.

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Dynamic Splints

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Dynamic Splints

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Dynamic Splint A dynamic splint includes a resilient component (elastic, rubber band, or spring), which the patient moves. Dynamic splints are designed to increase passive motion, to augment active motion by assisting a joint trough its range, or to substitute for lost motion. Dynamic splints generally include a static base on which to attach the movable, resilient components.

E.g. radial cock up splint Š Nandgaonkar Hemant P.

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Static Splint A static splint has no resilient components & immobilizes a joint or part. Static splints are fabricated to rest or protect, to reduce pain, or to prevent muscle shortening or contracture. An example of static splint is a resting pan splint that maintains the hand in functional or resting position. Š Nandgaonkar Hemant P.

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Static Splint

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Serial Static Splint A serial static splint achieves a slow, progressive increase in range of motion by repeated remolding; each remolding positions the joint at its end of motion. The serial static splint has no movable, resilient components such as rubber bands or springs; it uses static forces along with remolding and repositioning to achieve its goal. A cylindrical cast designed to reduce a PIP joint flexion contracture through frequent removal and recasting is classic example of serial static splint. Š Nandgaonkar Hemant P.

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Static Progressive Splint Static progressive splints include a static

mechanism that adjusts the amount or angle of traction acting upon a part. Frequently this mechanism is a turnbuckle, cloth strap, nylon line or a buckle. The static progressive splint is distinguished from the dynamic splint by its lack of a movable, resilient force. It is distinguished from a serial static splint in that its adjustment mechanism is built in, so it does not need to be remolded.

E.g. Robert Jones splint Š Nandgaonkar Hemant P.

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What is the purpose of the splint?

Restrictive Splints Immobilizing Splints Mobilizing Splints

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Purposes of the Splints

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Purposes of the Splints

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Purposes of the splints

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Which of the design options is indicated?

Three-point or loop design

Single-surface or Circumferential Design

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Indications for design choices?

Indications for single surface splinting

Indications for Single-surface or Circumferential Design

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The Splint classification system (SCS) The SCS defines splints according to series of 4 descriptors 1.Anatomic focus 2.Kinematic Direction 3.Primary Purpose 4.Inclusion of Secondary joints Š Nandgaonkar Hemant P.

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Anatomic focus Defines the primary joint(s) or segment(s) affected by the splint(e.g.MP,IP,wrist, thumb,finger)

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Kinematic Direction Designates which way the primary joint(s)/segment(s) is moved(flexion,extension,rotation)

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Primary purpose of a splint Is described as one of three options 1.Mobilization-enhance or encourage motion 2.Immobilization-stop motion 3.Restriction-allow motion only in a partial,predetermined range. Š Nandgaonkar Hemant P.

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Secondary Joints Inclusion of Secondary joints-number of joints in a longitudinal pattern that are included in the splint but are not considered primary focus joint(s).

IF no secondary joint is included in a splint,it is designated as type 0;one secondary joint is type 1……….

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Let’s Name it!

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Let’s Name it!

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Let’s Name it !!

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The SCS The combination of the four descriptors accurately defines a splint without becoming lost in multitude of specific design options e.g.�cock-up splint Wrist extension immobilization splint,type 0 Š Nandgaonkar Hemant P.

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The SCS Enhances communication between medical personnel by defining the important aspects of splints while leaving decisions about design options to those who actually fabricate splints.This allows therapists greater flexibility & use of their knowledge bases. Š Nandgaonkar Hemant P.

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Mechanical Principles Reduce pressure by increasing the area of force application.

Control parallel force system by increasing the mechanical advantage.

Use optimum rotational force when mobilizing a joint by dynamic traction.

Consider the torque effect on a joint.

Consider the relative degree of passive mobility of successive joints within the longitudinal segmental kinetic chain. Š Nandgaonkar Hemant P.

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Mechanical Principles Consider the effects of reciprocal parallel forces when designing splints and placing straps.

Increase material strength by providing contour.

Eliminate friction.

Avoid high shear stress. Š Nandgaonkar Hemant P.

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Principles of using dynamic assist for mobilization Identify optimum force parameters.

Identify optimum torque parameters.

Correlate physical properties of the dynamic assist with patient requirements.

Correlate physical properties of the dynamic assist with the design of the splint.

Consider the principles of mechanics and fit.

Control and maintain force magnitude. Š Nandgaonkar Hemant P.

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Design Principles(General) Consider individual patient factors.

Consider the length of time the splint is to be used.

Strive for simplicity and pleasing appearance.

Allow for optimum function of the extremity.

Allow for optimum sensation.

Allow for efficient construction and fit.

Provide for ease of application & removal.

Consider the splint/exercise regimen. Š Nandgaonkar Hemant P.

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Specific principles of design Identify key joints.

Review the purpose: to immobilize, to increase passive motion, to substitute for active motion.

Determine if the wrist should be incorporated.

Consider kinetic effects.

Identify the areas of diminished sensibility.

Decide whether to use static or dynamic forces. Š Nandgaonkar Hemant P.

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Specific principles of design Determine the surface for splint application.

Use mechanical principles advantageously.

Adapt for anatomic variables.

Choose the most appropriate material.

Adapt to the general properties of the material. Š Nandgaonkar Hemant P.

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Construction Principles Starve for good cosmetic effect.

Use equipment appropriate for the material.

Use type of heat & temperature appropriate to the material.

Use safety precautions.

Round corners Smooth edges.

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Construction Principles Analyze the mechanical principles.

Stabilize joined surfaces.

Finish rivets.

Provide ventilation as necessary.

Secure padding.

Secure straps.

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Fit Principles Mechanical considerations Use principles of mechanics.

Reduce pressure.

Use optimum rotational force.

Eliminate friction.

Use optimum leverage.

Anatomic considerations Š Nandgaonkar Hemant P.

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Fit Principles Accommodate bony prominences.

Incorporate dual obliquity concepts.

Consider ligamentous stress.

Maintain arches.

Align splint axis with anatomic axis.

Use skin crease as boundaries.

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Kinesiologic Considerations Allow for Kinematic changes.

Employ kinetic concepts.

Technical considerations Develop patient rapport.

Work efficiently.

Change method according to properties of materials used. Š Nandgaonkar Hemant P.

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SPLINT CHECKOUT Review the splint using these questions as guidelines Does the splint achieve the purpose?

Does the splint maintain the proper position of the joints?

Check angles with a goniometer if necessary Does the splint fit the contours of the hand, the arches, and bony prominences?

Does the splint restrict or immobilize any joint unnecessarily? Š Nandgaonkar Hemant P.

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SPLINT CHECKOUT Is the splint long enough to support the splinted part?

Are all edges smooth and all possible pressure points relieved?

Does the splint allow the functional use of the hand if allowed?

Can the patient apply and remove the splint?

Does the patient understand wear and care instructions?

Is the splint cosmetically acceptable to the patient?

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Steps of splint construction 1. Design splint 2. Select material 3. Make pattern 4. Cut splinting material 5. Heat splinting material 6. Form splint 7. Finish edges, straps, padding and attachments 9. Evaluate the splint for fit and comfort Š Nandgaonkar Hemant P.

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Strategies to increase splint wear compliance Offer splint options to the patient if possible Teach the patient about the benefits of splint wear Provide for easy application and removal of the splint Make the splint comfortable Use a lightweight material if possible Immobilize only the joints being treated Make the splint cosmetically pleasing to the patient If feasible, collaborate with the patient on a wearing schedule

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Selecting the splint design How many joints must be immobilized or mobilized What is the best application?

Should the splint be volar or dorsal, ulnar, radial or circumferential, static or dynamic?

Should the splint be based on the forearm, hand, finger, or thumb to provide the necessary support for the splinted part?

Is there a cost-effective commercial splint that achieves the goals?

Will the patient be able to apply and wear the splint as recommended?

Which material is best to achieve the purpose of the splint?

Does the material affect the design of the splint? Š Nandgaonkar Hemant P.

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Influence of splinting on Scar Remodeling.

When mobility is lost to immobilization from casting, injury, or a neurological condition, collagen fibers develop increased intermolecular bonds, which result in dense tissue with relatively little mobility. This response causes tissues to adapt and shorten, resulting in contracture. Such a limitation in mobility may be treated with splinting. Š Nandgaonkar Hemant P.

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Is it by stretching existing tissue?

There is some controversy regarding how splinting creates changes in soft tissues.

The mechanism of stretching was initially thought to be creep, the elongation of tissues under a prolonged stress over time.

However if tissues are stretched excessively, they rupture or produce an inflammatory response.

Research suggests that ideal tissue remodeling occurs with gentle elongation of tissues. Tissues lengthen and grow if gentle stress is applied.

This process is not stretching but rather growth of new tissues to accommodate the stress placed on them Dynamic splinting, serial static splinting, and casting are based on this mechanism.

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Tissue Healing Splinting applies gentle stress to healing tissues to influence change.

Inflammatory phase to immobilize and protect the healing tissues.

Fibroplastic phase to mobilize healing tissues while protecting them.

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Tissue Healing As the strength of the healing tissues increases and the scar tissue matures in the maturation phase, low load force may be applied with splinting.

As maturation progresses, the tissues can tolerate an increased amount of stress.

A splinting program must recognize these changes in healing tissues with appropriate changes in the splint as needed.

Exercise programs and functional activity must begin simultaneously with splinting to maximize the benefit.

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PROLIFERATIVE

ACUTE

CHRONIC

Static splinting

Serial Static Splinting Static Progressive splinting

Dynamic Splinting

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Total End Range Time (TERT) Theory suggest that the amount of increase in passive ROM of the stiff joint is directly proportional to the amount of time the joint is held at the end of its range TERT theory states that if a joint held at the end of its range, the dense connective tissue around the joint grows. This lengthening of tissues increases ROM. The longer the joint is positioned at its end range, the greater the gain in mobility.

Serial static splinting or casting is used in the application of TERT theory in splinting. Š Nandgaonkar Hemant P.

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stress relaxation OR static progressive stretch therapy This approach elongates tissues through progressive incremental stretch. The static progressive stretch approach applies 30-minute sessions of splint wear with stretch increased every 5 minutes to the patient's tolerance to increase ROM Static progressive splints apply this theory by applying a low-load force that can be adjusted incrementally.

These splints use method such as MERiT (Maximum End Range Time) components for gradual advancement of static stress on the splinted part. Š Nandgaonkar Hemant P.

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