upper extremity orthoses fabrication--summit ag · mallet finger protocol (typical) • 6‐8 weeks...
TRANSCRIPT
Upper Extremity Orthoses FabricationA Hands On Experience
Greg Goertzen OTR CHTUniversity of Kansas – 1990 CHT‐1996Saint Luke’s Sports Medicine and Rehabilitation
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Icebreaker • How many of you consider yourself “experienced” splint makers?
• How many have ever made a splint?• Where do you were work?
• Outpatient• SNF/LTC• Other
• PT’s/PTA• OT/COTA• CHT• ATC
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Course Objectives:• Develop knowledge base of basic anatomy/biomechanicsnecessary for optimal design, fit and fabrication of orthoses
• Review general facts about orthosis fabrication processes• Understand grasp patterns relative to orthosis design• Understand the importance of key landmarks of thehand/wrist and forearm
• Fit and fabricate 5 Finger/Wrist based orthosis for practiceand critique (we will try our best!) *goal – 90% time spentin lab
• Point of emphasis—how does the orthosis affect function?
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Schedule of Events(subject to change)
I. Discussion of orthosis fabrications:A. Safety, processes, mechanics, etc.
II. Pathologies/Orthosis specific to: Finger injuries/CTD’sA. Finger Based orthosis fabrication lab
1. Mallet finger2. Trigger finger option 1 and 23. Ulnar nerve palsy
III. Pathologies/Orthosis specific to: Wrist fractures/UCL injuries/CTS
A. Wrist Based orthosis fabrication lab1. Thumb spica and/or2. Dorsal gauntlet (aka wrist cock up)
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Before we make we must talk.
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Orthosis FabricationScience?Or…..Art?
Or both?YES!!
“Functional craft”
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Orthosis Selection and Design:
• Diagnoses and/or protocol?• Goals of Orthosis – positioning? stabilize? • How will it impact function? Environment,
precautions, sports• Can the patient utilize effectively? Don/Doff?
Follow instructions?• Potential medical issues (insensate skin,
DBM)• What does the evidence say?
• Payment systems and reimbursement?
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Primary Purposes of Static Orthosis Fabrication
1. To immobilize a body part2. Assist in deformity prevention3. Prevention of soft tissue contractures
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Example: ImmobilizationConditions may include:• Peripheral nerve entrapments eg. CTS/Cubital tunnel• Fractures eg. Distal radius, radial head, Boxers fracture
• RA/OA for positioning or to prevent further deformity• Soft tissue injuries eg. Tendon lacerations/burns/tenosynovitis
• Pain
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Splint design‐How will it affect grasp/pinch?...and ultimately function.• Some will significantly: affect ‐ For example: RHO/Lumbrical +
• Some will enhance: Radial nerve orthosis
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Grasp/pinch continued….
Some should not:
• Volar wrist cock‐up
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Grasp & Pinch Patterns
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Functional Example:
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Arches of hand:
• Longitudinal• Transverse• Oblique
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Arches of the hand‐critical to orthosis fabricationProtip:Fabricate orthosis so that the volar arches of the hand are preserved!
Here they are:
Distal transverseLongitudinalObliqueProximal transverse
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Relative precautions• DBM‐‐‐especially insensate skin or circulatory issues• Fragile skin eg. Age related; prolonged steroid use• Over open wounds—coverings needed—check with provider
• Education level—keep directions simple—ask patient and or caregivers to demonstrate donning/doffing—provide pictures use video capture on patient or caregivers phone
• Environment—healthcare or food service workers—infection control
• Fluctuating edema—see next slide16
Edema
Consider diagnoses: eg. Acute vs. chronic condition
May need to make orthosis larger to accommodate in acute conditions and/or issues surrounding fluctuating edema; eg. lymphatics
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Pressure points
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Pressure points avoidanceAfter fabrication‐consider client wearing orthosis 15 min
If they do have redness—modify contour and/or smooth edge PRN
Pad or recontour (with heat gun or dipping edge)
Lipstick trick—see following picture!
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Lipstick “trick”
Used to assist in identifying pressure points.
Will demonstrate in lab!!
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Palmar creases to keep in mind
1. Thenar2. Distal palmar
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Keeping orthosis proximal to DPC/thenar crease!
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What happens if:
• Orthosis is too SHORT or too LONG on finger or forearm?
• POINT of EMPHASIS!! This will be critiqued.
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This is what happens:
• Orthoses are first-class levers (From Fess, 2005)
Too short to support hand willcause increased pressure.
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Orthosis fabrication safety• Hot water is hot! 130 F melting point• Avoid keeping heat gun near water sources• Double check skin sensitivities or allergies; review EMR/ask patient – latex
• Layer patients arm with stockinette• Use PPE if working around open wounds• Instruct on precautions and wearing and schedule!!! Verbalize instructions (also have chart copy) through with patient/caregiver.
• Have patient/caregiver don/doff orthosis• Check for pressure points/red marks and adjust PRN
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Minimal equipment needs for orthosis fabricationstockinettesplint material of choicesharp scissors2” strappingvelcro hookheating panmarking pen
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Critical points in fabrication• FA trough: should be 2/3 length of forearm. • Width of any trough should be 1/2 circumference,
finger and or forearm based!!• Roll or round edges on orthosis for finished product.• Continuous uniform pressure over a bony prominence
is preferable to unequal pressure on the prominence. Eg. Ulnar styloid/ 2nd metacarpal head/radial styloid (Fess, 2005)
• Can utilize putty to “bubble” out and or identify landmarks with lipstick
• I will be critiquing this!
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Orthosis Care• Melting temperature of most materials 130 F• Use clean soapy water—make sure to dry before donning
• Can also use rubbing alcohol, bleach solutions and H2O2
• Change straps PRN or send some home • Educate – NO home recontouring or modifications• No use of microwave or crock pots to heat material
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Material characteristics‐points for consideration• Perforated v. solid—temperature/climate• Rigidity needed? 1/32” to 1/8” ‐ consider body part, length
• Drapability/conformability – expertise of therapist• Working time – expertise of therapist• Client demographic—pediatric v. elderly Cast better?
• Skin fragility v. edging• Edging ‐ self closing vs. other• Self adhering?
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Wearing schedule• Name of patient/date• Type of splint fabricated• Wearing schedule on/off time• Precautions‐swelling, redness, numbness• Name of therapist/clinic phone #• Chart or EMR copy
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Orthosis fabrication tips• Use sharp scissors• Cut with LARGE strokes to avoid lots of rough edges• To save fingers‐score large pieces of material with Exacto knife or similar
• Warm material just enough to cut so its not draping too much
• When fitting orthosis use LARGE and “meaty” parts of hands to contour vs. fingertips
• Water temp 150‐160/melting point at 130+ (ish)• Let gravity help you! Positioning patient for draping—eg.Supine
• spatula vs. tongs 31
Finger/Hand based applications
• Trigger finger• Mallet finger• dislocations• fractures
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Mallet finger splint fabricationPoint of emphasis! 5‐10 degree DIP HYPERextension
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Mallet finger fabrication continued
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Mallet finger protocol (typical)• 6‐8 weeks of CONTINUOUS wear—if allowed to drop off calendar starts from day 1!!
• Check for skin breakdown and maceration often• Can utilize Oval 8 or ring splint for washing and hygiene—teach patient how to change over.
• At 6‐8 weeks check for drop—if falls out refer back to provider
• If actively able to hold – splint another 1 month at night—
• Less is more‐‐‐use patience!! • Do not overpower (eg. Lots of power gripping exercises)
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Mallet finger alternativeCan also use for Zone 3 injuries (boutonnierre)
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Orthosis fabrication process1. Pick lab partner2. Trace pattern of partners hand on paper towels (use patterns for reference)3. Ask me to approve pattern!4. Once approved‐ cut pattern and trace onto splint material using grease pens5. Soften material in heat pan—just soften enough to cut.6. Cut material using large strokes on outside of line.7. Watch demonstration.8. Soften material fit and fabricate!• Ask partner if material is too hot!• Come get me for critique. • Have fun!
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Are you ready???
Lets make!!!
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Trigger finger (stenosing tenosynovitis)
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Trigger finger fabrication continued
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Trigger finger option 1 fabrication
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Trigger finger fabrication option 2
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Splint strips for ring splint fabrication
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Cubital tunnel syndrome+ clinical findings (Wartenbergs/Froments/elbow flexion sign)
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Cubital tunnel syndrome—ulnar nerve palsy• Pathology: Entrapment @ cubital tunnel or low laceration of ulnar nerve
• Long finger flexors become unopposed due to lumbrical inactivity causing:
• Intrinsic ‐
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Ulnar nerve palsy orthosis fabrication
Round those edges!
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Ulnar nerve palsy splint goal = 70‐90
degrees MP flexion
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Zone 4 and 5 Extensor tendon laceration• Typically sharp laceration caused by: knife, tooth
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Relative motion splint As proposed by Merritt (2014) for Zone 4/5 EDC lacerations
VS.
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Relative motion orthosis
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Relative motion orthosis protocol (typical)• Holds affected digit in relative extension• Immediate postop wear – upto 4‐6 weeks‐then wean out
• Patient allowed to flex and extend fingers in orthosis freely
• Utilized with wrist orthosis pitched up 30 degrees (check with surgeon)
• Relative precaution = Check for web space skin issues PRN
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Relative motion orthosis fabrication
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FAB orthosis fabrication‐applicable diagnosesDorsal wrist cock up• CTS• Distal radius fracture• S‐L dissociation• UCL of thumb• Consider diagnosis and wrist position.
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Wrist Immobilization Orthoses• Usually maintain the wrist in either a neutral or extended position depending upon the diagnostic protocol for a particular condition.
Example: Neutral for CTS and in mild to moderate EXTENSION for wrist fractures
Can also utilize in SERIAL fashion to increase ROM
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The case for splinting CTS 0 degree positioning advocated Nuckolls 2011
Evans 2011‐‐ suggested 2 degree flexion/3 degree UD
This‐combined with dedicated and appropriate HEP eg neurodynamics/ manual therapy/ PAM’s
No consistency in literature for wear time
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Picture of dorsal cock up
Consider an alternative if:
+ Berger sign – provocation of CTS symptoms > 30 seconds and/or Or consider if patient still has + symptoms at night with WRIST splint only Increase in CT pressure with full fist—lumbrical incursion; Baker etal 2012
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Dorsal gauntlet pattern
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Stockinette!
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Dorsal gauntlet fabrication
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Thumb spica diagnoses applications (typical)• Scaphoid fracture• Dequervains tenosynovitis• CMC OA (short opponens)• UCL injury of thumb metacarpal aka skiers/gamekeepers thumb
• Thumb pain
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Dequervains tenosynovitis1st dorsal compartment
structures involved?‐‐‐EPB/APL
Finkelsteins test
This Photo by Unknown Author is licensed under CC BY‐SA 62
Scaphoid fractureAnatomical snuffbox:
Borders: EPB/APL and EPL
Inside sits the scaphoid!
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UCL location (thumb)
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CMC Osteoarthritis• Highly hereditary• Affect women more than men• Can affect one thumb or both and dominant/nondominant
• “Wear and tear arthritis” • CMC saddle shape trapezium and 1st metacarpal—allows for extreme mobility
• + shoulder sign – 1st metacarpal subluxation due to volar beak ligament attenuation
• Loss of motion/1st web space as disease progresses/pain
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Low grade (I and 2) UCL sprain
• Often can be treated effectively with orthosis for 6 weeks
• Higher grades (> grade 3) often need surgery—although grade 3 controversial
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Thumb spica fabrication—forearm based*Can be cut to make short opponens for CMC OA
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Thumb spica fabrication—Important!• Thumb needs to be @ 45 degree PALMAR abduction for optimal function.
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Thumb spica orthosis pattern
Extend Tab A to at least PIP of index finger!
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Thumb spica fabrication
Wrap Tab A first through web space then Tab B
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Thank [email protected]
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