ORTHOSIS OF HAND

SUBMITTED TO : Dr. SHABNAM JOSHI

SUBMITTED BY : MANOJ PUROHIT
170171720001
 ORTHOSIS
• Derived from the Greek word ORTHO meaning
straight, upright or correct.

• A force system designed to control, correct or

compensate bone deformity, deforming forces or
forces absent from the body.
• Orthoses are devices applied externally to
restore or improve functional and structural
characteristics of the musculoskeletal and nervous
systems.
 General Classification

Orthosis Type
• Static
• Dynamic
• Hybrid

Regional Classification
• Volar or Dorsal
• Joints crossed
 Finger / thumb splint
 Wrist Splint
 Wrist Hand Orthosis
Functional
• Corrective

• Supportive
• Protective
• Orthosis which strengthen certain group of muscle
E.g. Tenodesis Splint
• Relief of pain
• Prevent weight bearing
• Facilitate Motion
 BIOMECHANICAL PRINCIPLES
1) Three Point Pressure

2) Mechanical Advantage

3) Torque

4) Degree and Duration of Stress

5) Repetitive stress

6) Control Normal force across the joint

7) Control Axial Force across the joint

8) Control line of action of Ground reaction force

1) THREE POINT PRESSURE: (JORDAN’S Principle)

• A three-point pressure system consists of three

individual linear forces in which middle force is directed
in opposite direction to the other two forces.

• It is multiple direction force where one force

immobilize one joint and mobilize the other joint.

Example: cock-up splint

2) MECHANICAL ADVANTAGE:

• Splint incorporate lever system, which incorporate

forces, resistance, axes of motion and movement arm.

• Example:
Volar based wrist cock-up splint for mechanical
advantage forearm length is made longer so that splint
has better pressure distribution support and
comfortability.
3) DIRECTION OF STRESS:

• There are three direction of force to act:

 Tension
 Compression
 Shear
4) TORQUE:

• It is biomechanical principle defined as rotational effect

of mechanism.

• Torque is the production of the applied force multiplied

by perpendicular distance from the axis of rotation to the
line of application.

• Most important for dynamic splint.

4) DEGREE AND DURATION OF STRESS :

• Generally low stress can be tolerated for longer period

of time, whereas high stress over long period of time
cause damage.

• Therapist must remember the least stress is tolerated

by the skin.

•Skin become ischemic if load increases.

• Distribution of stress is most important for long term

wearing of orthosis.
5) REPETITIVE STRESS:

•If repetitive stress is applied in moderate amount may

lead to breakdown and damage to skin.

• So to avoid that traction must be release to avoid

unnecessary tension and well distributed pressure.

6) CONTROL NORMAL FORCE ACROSS THE JOINT:

Now two free, body load carrying bones when subjected

to ground reaction force are free to rotate that are
maintained in extension this is normal joint is
maintained by capsule and ligaments.

But in abnormal joint we require orthosis to correct it.

7) CONTROL AXIAL FORCES ACROSS A JOINT:

• In normal healthy individual load is carried through

bony structures and layers of articular cartilage which
have immense strength to bear this weight.

• Now due to some degenerative change the integrity of

this structure is lost which will cause excessive
compression on joint.

• So, orthosis is used to offload the joint. This process of

offloading
depends on two thing:
 How the orthosis is fitted
 Orthosis and body segment interface
1) The orthosis here is incorporated as rigid orthosis
framework and strapping it at the end of two limb
segment which would divide the force into half.
2) The second criteria is the transfer of load across skin
and orthosis solely depend on friction of orthosis and
underlying skin.
8) CONTROLS ACTION OF GROUND REACTION FORCE:

• This principle is only applicable to lower limb orthosis.

In normal joint line of gravity passes from front of Hip,
back of knee, front of ankle.

• Now due to some asymmetric movement for this

pattern, GRF is altered so we need a orthosis for its
correct alignments.

• In this case orthosis management would be moving the

line of gravity to center that is close to joint line.

•Which can be achieved by modifying the limb movement

during gait.
 COCK-UP SPLINT
It is static in nature.

• Common Name:
1) Volar/Palmar Wrist splint
2) Volar Wrist Cock up splint
3) Wrist Immobilization Splint
4) Drop Wrist Splint
5) Carpal Tunnel Splint
6) Wrist Extension Immobilization Splint
• Objectives:
1) To reduce Pain and Inflammation
2) To protect against joint damage
3) To promote hand function
4) To prevent or correct contractures
5) To provide base for Outriggers
• Indications:

1) Tendinitis/Tenosynovitis of wrist tendons

2) Joint Inflammation such as Rheumatoid Arthritis

3) Skin Graft

4) Unstable Wrist Joint

5) Wrist Sprain

6) Weak/Paralyzed Wrist Extensor

7) Congenital Hand Deformity

8) Volar style for flexion outriggers

9) Dorsal style for extension Outriggers
GAUNLET IMMOBILIZATION SPLINT

Common Name: Circumferential working Splint

• Objectives:
1) Greater wrist stability

• Indications:
1) An evaluation tool before wrist arthrodesis

2) To immobilize and stabilize a fracture of radius or

base of Metacarpal
DYNAMIC WRIST EXTENSION SPLINT
• Objectives:
1) To Passively extend the wrist while allowing active
wrist flexion

2) To prevent contracture of unopposed innervated wrist

flexors

• Indications:
1) Weak or Paralyzed wrist Extensors (e.g.. Radial Nerve
Palsy)
STATIC WRIST WRITING/PAINTING ORTHOSIS
Common Name: Wrist Splinting

• Objectives:
1) To enable writing, drawing or painting by positioning
wrist in functional extension and providing attachment
of pen, pencil , eraser etc.

• Indications:
1) Spinal Cord Injuries at level C5 or above where wrist
extensors Paralyzed
RADIAL THUMB GUTTER SPLINT

• Objectives:
1) To immobilize wrist, thumb CMC, MCP Joints, which
are crossed by inflamed tendons

2) To rest and reduce inflammation

• Indications:
1) De Quervain’s tenosynovitis: Inflammation of tendon
of abductor polices longus and extensor polices brevis in
their synovial sheath.
DYNAMIC MCP FLEXION SPLINT

• Objectives:
1) To gently stress the MCP collateral ligaments to
promote desired growth and increase flexion range

• Indications:
1) Extension contracture of MCPs caused by
shortened collateral ligaments
RESTING HAND ORTHOSIS

It is Static or Serial Static type of splint.

• Objectives:
1) To immobilize the wrist, MCPs, and IPs of Finger and
thumb
2) To reduce or prevent contractures
3) Reduce pain and inflammation

• Indications:
1) Scleroderma
2) Dupuytren’s release
3) Boxer’s fracture (Base of 5 MCP fracture)
4) Burns
5) Inflammatory joint disease
7) Crush injury
ANTISPASTICITY SPLINT
Common Name: dorsal volar hand splint

• Objectives:
1) To immobilize wrist, MCP, IP
2) To prevent and reduce contracture
3) To reduce tone of hypertonic muscles

• Indications:
1) Hand Trauma or surgery
TENODESIS SPLINT
• Objectives:
1) To train a tenodesis grasp
2) To promote tripod pinch

• Indications:
1) Quadriplegia at level of C6 with at least grade 3
strength of the wrist extensors

• This splint is a functional aid for such patient which

uses extensor carpi radialis muscle giving potential grasp
by reciprocal wrist extension and finger flexion.
KLEINERT SPLINT

It allows protective flexion of MCP and IP and Blocks

Extension of MCP.

• Objectives:
1) To position wrist in static flexion and passively flex
the MCP and IP while permitting limited active
extension of wrist and MCP and full extension of IP.

• Indications:
1) Flexor Tendon Laceration in zone 2.
EXTENSOR TENDON REPAIR SPLINT

• Objectives:
1) To position wrist in static extension and passively
extend the MCP and IP while permitting limited active
flexion of MCP.

• Indications:
1) Extensor tendon Laceration.
METACARPAL FRACTURE BRACE

Common Name: Metacarpal(fracture) Brace

• Objective: To stabilize MC fracture to promote healing.

• Indication: Midshaft fracture of third, fourth or fifth

metacarpal.
STATIC ULNAR DEVIATION SPLINT

Common Name: MCP protection splint, static ulnar

drift/deviation splint, metacarpal ulnar deviation
orthosis, trigger finger splint, blocking splint

1)Joint Inflammation: To promote restabilization of

tendon to restraints at MCPs, To prevent or correct ulnar
drift of MCP

2) Trigger Finger: To block MCP Flexion and limit

excursion of long finger flexor. By subsiding irritation at
A1 pulley and inflammation subside.
3) Surgical release of Dupuytren’s Contracture
To maintain surgical gained extension.

4) Intrinsic muscle tightness and extension contracture:

To block MP joint so FDP and FDS can actively stretch IP
joint and intrinsic muscle.

5) MC head fracture for stabilization.

DYANAMIC MCP EXTENSIION SPLINT

• Objectives: To passively extend MCP to 0* extension

and allow active flexion movement and IP movement.

• Indication: Radial nerve injury when reinnervation

reach to wrist

•Repair of extensor tendon rupture, extensor

contracture
STATIC ANTICLAW DEFORMITY SPLINT

Common: Static Anticlaw deformity splint, static ulnar

nerve splint

• Objective: To stabilize the fourth and fifth MCPs in

flexion.
To correct fourth and fifth MCPs hyperextension

To prevent shortening of MCP Collateral Ligament

To promote active IP Extension

• Indication: Ulnar Nerve Lesion

DYNAMIC MEDIAN-ULNAR NERVE SPLINT

Common Name: Dynamic anticlaw deformity splint,

dynamic median/ulnar nerve splint, spring wire knuckle
bender.

• Objectives: To passively flex the MCP of fourth and fifth

finger and to allow active extension.

To correct Hyperextension

To prevent shortening of MCP

To promote active IP Extension

• Indication: Combined median and ulnar nerve lesion at

level of wrist.
FLEXION BLOCKING SPLINT

Common Name: Blocking Splint

• Objective: To Block MCP and PIP so that the flexor

digitorium profundus can actively stretch DIP to
increase the flexion range of motion

• Indication: Extension contracture of DIP Joint

FINAL FLEXION SPLINT

Common Name: Final Flexion Splint

• Objectives: To progressively flexion MCPs IPs in

composite flexion applying gentle
prolonged stretch to contracted tissue.

• Indication: Contracture of extrinsic Extension Tendon,

IP Extension Contracture.
SHORT DORSAL OUTRIGGERS

• Objective: To apply gentle prolonged stretch to the

contracted PIP capsule and ligaments to promote growth
of the shortened tissues and restore extension ROM.

• Indication: Flexion Contracture Of PIP joint

TRAPPER

Common Name: Buddy splint, trapper

• Objectives: To strap affected finger to an unaffected
finger at proximal middle phalanges

To stabilize finger

To provide passive movement of affected joint by moving

unaffected finger

• Indication: PIP Collateral ligament injury

flexor tendon reconstruction and PIP flexion
PIP EXTENSION SPLINT

It is a extension blocking static splint.

Common Name: Swan Neck Deformity splint, PIP

hyperextension splint, Fiqure of eight splint

• Objective: Index finger PIP extension restriction

• Indication: Swan Neck Deformity, (caused by: RA,

Trauma, intrinsic muscle tightness, Dorsal migration of
extension mechanism,)
Trigger finger
CAPENER SPLINT

• Objective: Index finger pip extension mobilization

• Indication: PIP flexion contracture, PIP dislocation,

Volar plate injury, flexor tendon repair partial or
complete tear of collateral ligament,

• Boutonniere Deformity
SHORT OPPONENCE ORTHOSIS

• Objective: To relieve CMC pain

To immobilize CMC and MCP

To position the thumb in functional opposition

To correct first web space

• Indication: Inflammation of CMC or injury

CMC Arthroplasty, Median nerve injury, Quadriplegia
GENERAL PRINCIPLES
• Use of forces:
• Orthosis utilises forces to limit or assist movements

 Rigid material spanning a joint prevents motion,

e.g posterior tube splint

 A spring in a joint is stressed by one motion and

then recoils to assist, the opposite desired motion.
E.g. leaf spring orthosis
• Limitation of movement: Limiting motion may reduce
pain.

• Correcting a mobile deformity: a flexible deformity may

be corrected by an orthosis. Corrective forces must be
balanced according to principle of Jordan.
• Fixed deformity: if the fixed deformity is
accommodated by an orthosis, it will prevent the
progression of deformity.

•Adjustability: orthotic adjustability is indicated for

children to accommodate their growth and for patients
with progressive or resolving disorders.

• Maintenance and cleaning: the orthosis should be

simple to maintain and clean.

• Application: the design should be simple for easy

donning and doffing.

• Sensation: An orthotic device does not provide

sensation, in fact it often covers skin areas and decreases
sensory feedback.
• Comfort: The Orthosis should be comfortable. Pressure
should be distributed over the largest area possible.

• Utility: the Orthosis must be useful and serve a real

purpose.

• A well functioning opposite extremity is a major

deterrent to the use of an upper extremity orthosis as
most activities can be performed with the good hand.

• Gravity: Gravity plays an important role in upper limb

orthosis, especially in those joints where the heaviest
movement masses are present.

• Cosmesis: Cosmesis is important especially in hand

orthosis. A functional but unsightly orthosis is often
rejected if the patient values appearance over function.
CONTRAINDICATIONS

• Skin infections.

• When the muscle power is very much affected by the

weight of the orthosis.

• In case of severe deformity which cannot be

accommodated in the orthosis.

• If it limits the movement at other normal joints.

• Where the orthosis interferes grossly with clothing or

limits other functions.

• Lack of motivation or other psychological problems

• Very young or old patients.
PHYSICAL THERAPY INTERVANTION

• Assessment
• Pre-orthotic assessment and prescription evaluate:
• Joint mobility
• Sensation
• Strength and motor function
• Functional level
• Psychological status
• Orthotic prescription
• Consider the patients abilities and needs
• Level of impairments, functional limitations, disability
• Status: consider if the patient’s condition is permanent
or changing
• Consider level of function, current lifestyle.

• Consider if the patient is going to be a community

ambulator versus a household ambulator.

• Consider recreational and work related needs.

• Consider overall weight of orthotic devices, energy

capabilities of the patient. Some individuals abandon
their orthoses quickly in favor of wheelchairs because of
the high energy demands of ambulating with orthosis.

• Consider manual dexterity, mental capacity of the

individual. The donning and use of devices may be too
difficult or complicated for some individuals.
• Consider the pressure tolerance of the skin and tissues.

• Consider use of a temporary orthosis to assess

likelihood of functional independence, reduce costs.

Orthotic Assessment check out

• Ensure proper fit and function; construction of the

orthosis.
1. Static assessment

2. Dynamic assessment
• Fit and function during activities of daily living,
functional mobility skills.
• Fit and function during gait.
ORTHOTIC TRAINING

• Instruct the patient in procedures for orthotic

maintenance: routing skin inspection and care.

• Ensure orthotic acceptance

• Patients should clearly understand the functions,

limitations of an orthosis.

• Can use support groups to assist

• Teach proper application (donning-doffing) of the
orthosis, teach proper use of the orthosis.

• Balance, gait and functional activities training.

• Reassess function and construction of the orthosis at
periodic intervals; assess habitual use of the orthosis.
 RECENT ADVANCES
1.) Pilot Study Combining Electrical Stimulation and a Dynamic
Hand Orthosis for Functional Recovery in Chronic Stroke.
Barbara M. Doucet and Joni A. Mettler

OBJECTIVE. We investigated the effect of a combined

neuromuscular electrical stimulation (ES) and dynamic hand
orthosis (DHO) regimen with a group of people with chronic stroke
to improve performance on specific daily tasks.

METHOD. Four people with chronic stroke participated in an ES–

DHO regimen using the affected upper extremity 5×/wk for 6 wk.
Outcome measures included grip strength, range of motion (ROM),
and analysis of muscle activation–deactivation during release of
grasp through electromyography. Ability to perform specific daily
living tasks was assessed using the Assessment of Motor and Process
Skills (AMPS).
RESULTS. Results suggested that improvements in strength, ROM, and
grasp deactivation are possible with the combined ES–DHO regimen. All
participants’ AMPS motor scores improved.

CONCLUSIONS. An ES–DHO regimen may improve motor skills needed for

functional task performance in people with chronic stroke. Results should
be interpreted cautiously because of the pilot nature of the study and the
small sample size.
2.) Design of an electrohydraulic hand orthosis for people with
Duchenne muscular dystrophy using commercially available
components
Ronald A. Bos1, Kostas Nizamis2, Dick H. Plettenburg1, Member,
IEEE, and Just L. Herder3, Member, IEEE

Introduction: People with Duchenne muscular dystrophy are

currently in need of assistive robotics to improve their hand
function and have a better quality of life. However, none of
the available active hand orthoses is able to address to their
specific needs.

Methods: In this study, the use of hydraulic technology is proposed

in the design of an active hand orthosis.

Commercially available components were used to identify where

customization is necessary for a new electrohydraulic hand orthosis.
The presented prototype was able to move four finger modules with
a single actuator. The finger modules were separable and had a total mass of
only 150 g, whereas the valve manifold added another 250 g.

Results revealed that the prototype was able to function well with full
flexion/extension cycles up to 2 Hz, but with hysteretic losses between 37–
81% of the total input energy. Specialized valves and slave cylinders are
required to increase efficiency at higher speeds and to obtain more robust
sealing performance.
REFERENCES

• Textbook of Rehabilitation: S Sunder

• Physical Rehabilitation: Susan B. O’Sullivan

• Orthotics in Rehabilitation: Pat Mckee and Leanne

Morgan

• Splinting: Brenda M Coppard and Helene Lohman

• Orthotics and Prosthetics Rehabilitation: Michelle M

Lusardi and Milgros George
• DELISA’S physical medicine & rehabilitation
PRINCIPLES AND PRACTICE 5th EDITION
THANK YOU