SPLINTING Elizabeth L.

Spencer Steffa, OTR/L, CHT

INTRODUCTION Splinting Force Newton: To every action, there is an equal and opposite reaction. Know and control force. Pressure is equal to the force divided by the area and is referred to as pounds per square inch. Splint Design A pattern may be made by drawing an outline of the area to be splinted. When drawing a pattern of the hand or forearm, the hand is placed palm down on the pattern paper. If the injury prevents the palm down position, a drawing of the other hand may be used and reversed. Locate and indicate anatomy landmarks on the pattern. The splint is 2/3 the length and 2/3 the circumference for a three point pressure splint. Patterns may be drawn on the splint material with ball point pen and ink removed with rubbing alcohol. Flow pens will wash off when the splint material is heated in water. A China marking pen may be used but will not wash off with alcohol. Splint Materials Reveals, Aquaplast and similar splint materials will shrink approximately 3 % as it cools. Reveals, Aquaplast and similar splint materials may be cracked to break the bond when cold. Wiping both sides of the splint material with a moist sponge and acrylic floor wax gives additional control for a difficult splint. Ultra-coated material may be ordered from WFR Corp.

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Cutting Splint Material Cold material may be scored with a utility knife and cracked into smaller pieces. Holes are punched on cold material prior to heating. Material is easier to cut when semi soft. Do not heat the material until completely limp when cutting. Heat only until edges are clear and material remains opaque. After the splint is formed, trim the material while it is semi soft. Use a heat gun to soften an edge and rub out any scissors cut irregularities. Never grind, file or sand edges. Heating Splint Material Material may be heated in water at 165 or with an industrial heat gun. Material will not readily bond to itself when wet or double coated. Dry heated material bonds well, especially if the protective coating has been removed. High temperature plastic mesh pan guard or paper towel may be used to keep material from sticking to the bottom of the pan and may be used to lift the softened material from the water to avoid stretching. Never place plastic mesh in the pan without water while the heat is on. Splint material is heated until completely limp before molding. Material is draped and gently stroked to form to the desired shape. Do not pinch or grasp the material firmly which may create pressure points. Padding may be placed over a bony prominence before molding the material or the material stretched to dome over the area. Lotion may be used on the patient to decrease the heat intolerance on infants, young children and the elderly. Lotion also prevents material from bonding prematurely, but also must be removed from the splint before attaching adhesive backed strap material. Splint material is placed on a towel to remove excess hot water before placing material in contact with the patients skin to avoid possible burns.

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Molding the Splint Position the patient with the upper extremity to be splinted on a table, if possible. A neutral position in function is desired but not always possible. The patient may be positioned with the elbow stabilized in flexion, supported on the table, wrist in neutral, fingers relaxed and thumb in palmar opposition. A towel or pad under the elbow decreases pressure to the ulnar nerve. Material is molded to support the arches of the hand. A flat hand is a potential stiff hand and weak hand. Form the areas to be stretched first (holes, curves or folds) before the material begins to cool. Splint Straps Velcro loop or hook may be attached directly to the splint material. The Velcro will not pull off when folded back on itself forming a tab. A 2 inch wide strap distributes the pressure more effectively than a 1 inch strap. When a strap is used over the dorsum of the hand, the patient is advised to avoid pressure over the venous return to prevent distal edema to the hand and digits. A small crescent cut may be used to decrease pressure around the thumb web space or wrist area at the radial nerve. Splint Wear and Care The splint will not change shape unless exposed to heat greater than 125. It may be worn in the sun or in a sauna but not left in a car, on a windowsill or in a clothes dryer. The thermal plastic may be cleaned with mild soap and warm water or deodorized with rubbing alcohol. Strap adhesive will not tolerate cleaning and metal rivets may rust when exposed to moisture. The splint and straps must be thoroughly dry before wearing. Cotton stockinet or a terry knit tube sock may be worn with the splint to absorb moisture.

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Precautions and Contraindications The custom splint is fabricated by a qualified healthcare professional per physician prescription. Circumferential splinting should not be used when edema is present. Splint or straps should not restrict circulation. The splint should not produce pain or skin discoloration. The patient or care giver must be instructed in the splint wearing schedule, precautions and splint care. Written instructions are recommended.

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Hand Based Thumb Spica Splint Fabrication: The preferred position is with the thumb in palmar abduction and the The hand based thumb splint is frequently used to provide CMC

adductor muscle length maintained. support for the patient with arthritis. Osteoarthritis may enlarge the IP joint which may make splint removal difficult. It is important not to create additional joint trauma with the splint. A. The splint provides thumb CMC support without limiting wrist or thumb IP

motion. The splint may be fabricated over the dorsum of the hand or the palmper patient and therapist preference. o around the thumb. o As the thermoplastic cools, place a large paper clip between the thumb and the thermoplasticmaintaining a consistent cylinder between the MP and IP joints, and preventing an hour glass shape as the paper clip is moved around the thumb. B. Another method of splinting the thumb CMC is with a symmetrical pattern Gently drape the softened thermoplastic material over the hand and wrap the tabs around the thumb. Use care not to stretch the material tightly

with an ulnar hand opening. The center of the wings is placed in the webspace and the two straight edges are kissed together. Excess material is trimmed away with scissors. As the thermoplastic cools, place the large paper clip between the thumb and the thermoplastic, maintaining a consistent cylinder between MP and IP joints. C. The circumferential splint may fasten on the volar or dorsal area per

therapist and patient preference. It is a little more difficult to don and doff, but provides good support when performing more resistive use. Drape the softened thermoplastic over the hand and wrap the material around the thumb with care not to stretch or crimp the material. Again, the large paper clip is used to maintain the cylinder.

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Hand Based Thumb Splint:

Additional support for thumb CMC is provided without limiting wrist motion. The splint is easy to don and doff through the ulnar opening.

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Hand Based Thumb Splint:

The ulnar opening makes this splint easy to don and doff through the side opening. It limits most CMC motion but allows the hand to mold to objects when grasping.

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Hand Based Thumb Splint:

The circumferential hand based thumb splint may overlap and fa sten with Velcro in the palm or on the dorsum of the hand per p atient and therapist preference.

2003-2005 E. Spencer Steffa, OTR/L, CHT

It provides the most CMC stability for a hand based thumb splint.

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Wrist Extension Splint Fabrication: A wrist extension splint is usually fabricated with the wrist in 20 - 30 extension. It allows full thumb and finger motion but should prevent wrist motion. The splint does not limit pronation and supination. The wrist extension splint may be fabricated with the forearm in a neutral positionmidway between pronation and supination. Straps should not compromise circulation. The splint should be easy to don and doff without pressure to the radial and ulnar styloids. A. The volar wrist extension splint may be referred to as an ulnar gutter splint.

It is easy to don and doff. Because it does not have any circumferential thermoplastic areas, this splint may be the preferred choice for a patient with edema. B. The thumb hole wrist extension splint provides more support to the radial

carpals. The thumb hole is tolled away from the thumbproviding full thumb circumferential motion and opposition. A limited thumb hole wrist extension splint is not recommended when thumb edema is present. The patient position with the thumb opposed to the middle finger is used to maintain the palmar arches. Straps are placed across the dorsum of the hand, wrist and proximal forearm. C. The dorsal wrist extension splint places the fingers through the palmar

opening and is circumferential. It is not recommended for the patient with hand edema. This splint has the advantage of requiring only a proximal forearm strap for some patients, which allows the hand to be placed in water without wetting the splint straps. The splint is fabricated by inserting the fingers through the distal openingslide back to the palmar crease. The wider part of the distal opening is for the radial side of the hand. Gently drape the remaining material over the dorsum of the hand, wrist and forearm. Oppose patients thumb to middle finger to define the palmar arches and smooth the material on the radial and ulnar edges into folds.

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Volar Wrist Extension Splint

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Thumb hole Wrist Extension Splint

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Dorsal Wrist Extension Splint

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Volar Pan / Resting Splint Fabrication length. The thumb is placed in palmar abduction and the radial splint edge is formed into The splint limits digit and wrist motionbut does not limit pronation and Straps are placed across the digits, dorsum of the hand, wrist and proximal The splint should be easy to don and doff without pressure to the radial or ulnar The splint is placed on the volar hand and forearm area. The thumb C bar area a C bar. supination. forearm. The strap over the dorsum of the hand should not restrict circulation. styloids. is stretched while the material is very pliable. Care is used to maintain the wrist and digits in proper position while the material cools. Continue to form the splintcurving radial and ulnar edges to increase the splints strength and customize the fit. Safe Splint Wrist Extension 30 MP Flexion 90 Finger IPs 0 Extensor Tendon Repair (zones V, VI, VII & VIII) Wrist Extension 30 MP full Extension Finger IPs 0 MP Implant Arthroplasty Wrist Extension 0-15 MP full Extension Finger dividers neutral to radial deviation The volar pan or resting splint may also be referred to as a safe splint. the wrist is positioned in 20 extension, the finger MPs in flexion and the PIPs

and DIPs extended. The position maintains MP collateral ligament and intrinsic muscle

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Volar Resting Pan Splint

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Volar Forearm Based Thumb Spica Splint:

The wrist extension splint with thumb spica provides additional support to the thumb CMC, scaphoid and lunate. Due to the circumferential fit of the thumb piece, it is not recommended for use when edema is present. Thumb IP motion is not restricted. forearm. The splint material is placed on the volar surface of the hand to the The thumb is placed in opposition to the middle finger and the wrist in 20 The material is molded to the hand and forearm. A large paper clip is used in the thumb piece to maintain the cylinder. Straps are placed over the dorsum of the hand, wrist and proximal

palmar crease, and to the thumb IP joint. to 30 extension.

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Volar Forearm based Thumb Spica Splint

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SPLINT SELECTION READY REFERENCE

WRIST Ulnar Cock-Up: Preferred wrist extension splint following dressing or cast removal when increased edema present following injury, fracture or surgery. Thumbhole Cock-Up: Preferred when more support is required for the radial wrist area or TFCC, provides more protection but may not be used when excess edema present due to thumb hole. Dorsal Cock-Up: Preferred for light support such as carpal tunnel syndrome and may be used during the day for the individual who must be able to wash their hands frequently. Forearm Based Thumb Spica: Used for wrist support when the Scaphoid is involved such as a fracture or scapho-lunate ligament injury or following thumb CMC surgery. Wrist Extension Dynamic or Static Progressive Splint: May be used following radial nerve injury, to regain lost functional wrist extension following wrist fracture, trauma or joint reconstruction. THUMB Hand Based Static Thumb Spica Splint: used following MP ligament injury (game keepers thumb skiing injury) or, CMC degenerative joint disease. Forearm Based Static Thumb Spica Splint: used following MP ligament surgical repair, thumb CMC arthroplasty or de Quervains first dorsal compartment inflammation. JOINT RECONSTRUCTION OR ARTHROPLASTY MP Arthroplasty requires s forearm based MP Dynamic Extension Splint for up to 6 weeks. A Volar Pan Resting splint is used nighttime for up to 6 months. Thumb CMC Arthroplasty requires a Forearm Based Thumb Spica Splint.

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Splints: Clinical Examples

Hand Based Thumb Spica Splint Rheumatoid Arthritis CMC arthritis, OA older patient MP arthritis Radial or Ulnar collateral ligament strain/sprain

Volar Wrist Extension (cock-up) Splint

Rheumatoid Arthritis Carpal Tunnel Syndrome Radial Tunnel Syndrome s/p Total Wrist Arthroplasty s/p Ulnar Styloid Fracture s/p Radial Nerve Repair

Dorsal Wrist Extension Splint

Rheumatoid Arthritis Carpal Tunnel Syndrome Radial Tunnel Syndrome

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Thumbhole Wrist Extension Splint

Rheumatoid Arthritis Carpal Tunnel Syndrome Total Wrist Fusion Partial Wrist Fusion TFCC Injury

Forearm Based Thumb Spica Splint

Rheumatoid Arthritis De Quervains Intersection Syndrome s/p Arthroplasty Thumb CMC soft tissue reconstruction s/p EPB and APL repair Bennetts Fracture Scaphoid Fracture

Volar Pan Resting Splint

Rheumatoid Arthritis s/p MP Joint Arthroplasty night splint s/p Dupuytrens Contracture fasciectomy Extensor Tendon Repositioning, subluxation at MP joint level s/p Flexor Tenosynovectomy s/p Extensor Tenolysis Zones I-V

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