Hand Deformities & Wrist Orthosis Quiz

Hand Deformities & Wrist Orthosis

• Orthoses are used for wrist and hand deformities.
• Two common positions are resting (functional) and antideformity.

Resting Hand Position

• In the absence of disease or injury, the typical hand and wrist position is the resting position.
• Wrist: 10 to 20 degrees of extension
• MCP joints: 50 to 55 degrees of flexion
• PIP and DIP joints: 10 to 20 degrees of flexion
• Thumb: full palmar abduction

Antideformity Position (Intrinsic Plus Position/Position of Safe Immobilization (POSI))

• Used to maintain tension in anatomical structures to prevent contractures and promote function.
• Wrist: 20 to 30 degrees of extension
• MCP joints: 70 to 90 degrees of flexion
• PIP and DIP joints: full extension, or 0 degrees
• Thumb: full palmar abduction

Special Cases and Immobilization

• Rheumatoid Arthritis (Acute exacerbation):
  • Wrist: Neutral or 20 to 30 degrees of extension (depending on tolerance).
  • 15 to 20 degrees of MCP flexion.
  • 5 to 10 degrees of ulnar deviation.
  • Thumb: Position of comfort in between radial and palmar abduction.

Hand Burns

• Dorsal or volar hand burns:
  • Wrist: Volar or circumferential burn (30 to 40 degrees of extension), dorsal burn (0 degrees = neutral).
  • MCPs: Flexion of 70 to 90 degrees.
  • PIP and DIP: Full extension.
  • Thumb: Palmar abduction and extension.

Dupuytren Contractures

• Progressive condition causing palm tissue to thicken and contract, leading to inability to flatten the hand.
• More common in men of European descent, affecting up to 20% of men over 65.
• Treatment is typically surgery to remove the thickened tissue and release the contracted joints.
• Non-surgical treatments, like needle fasciotomy and collagenase injection, also exist with improved results regarding speed of recovery and reduced complications.
• Treatment involves:
  • Wrist: Neutral or slight extension.
  • MCP, PIP, and DIPs: Full extension.

Anti-spasticity or Tone-Reducing Orthosis

• Positions the fingers and hand in a reflex-inhibiting position (wrist joint in neutral, all 4 medial fingers in complete extension and the thumb in abduction), to reduce tone.

Splints Acting on the Fingers (Hand-Based Orthosis)

• Goals depend on the specific condition or diagnosis.
• Specifically, metacarpal fractures, with metacarpal neck fractures being most common, occurring often at the fourth and fifth metacarpals (boxer's fractures).
• Treatment is frequently conservative, using a hand-based ulnar gutter design immobilization orthosis.
• Metacarpal neck and shaft fractures heal rapidly. Immobilization for 3-4 weeks is usually recommended.

Wearing Schedule - Metacarpal Fractures

• Active PIP and DIP joint motion (both flexion and full IP joint extension) are encouraged during the immobilization. The IP joints may need to be placed in an extension orthosis at night if an extension lag develops in the PIP and/or DIP joint.
• The position of protection for metacarpal fractures involves positioning the MCP in 70 degrees of flexion.
• Inclusion or exclusion of the wrist, PIP and DIP joints depends on fracture stability, edema, pain, and the surgeon's preference. If included, the PIP and DIP joints are positioned in full extension to prevent stiffness. Fractures involving the second or third metacarpals are immobilized in the same position, but with a hand-based radial gutter design.

Ulnar Nerve Injuries

• Paralysis or weakness of muscles can cause "claw hand" (hyperextension of the 4th and 5th MCP joints and flexion of the PIP and DIP joints).
• A hand-based orthosis positioning the 4th and 5th MCP joints in flexion helps prevent contractures.
• The duration of orthosis use depends on nerve injury location, client age, and other structures involved.
• Orthosis use is continued until interossei and lumbrical muscles are strong enough to prevent MCP hyperextension during digit extension (typically a minimum of grade 3 muscle strength).

Swan Neck Deformity

• PIP joint hyperextension and DIP joint flexion.
• Commonly caused by rheumatoid arthritis (RA), trauma, or overuse, and may severely impact hand function.
• Flexible swan-neck deformities can be treated by finger orthoses.

Finger Orthosis

• Made from connected oval-shaped rings that are angled to correspond to the PIP joint axis.
• Prevents full PIP extension but allows for active PIP flexion.
• The design of the orthosis will support as much of the proximal and middle phalanges as possible to optimize leverage and mechanical advantage.
• Not all cases of swan neck deformity require an orthosis; temporary, non-disabling cases do not require orthosis treatment.

Trigger Finger (Digital Stenosing Tenosynovitis)

• Affects the movement and gliding of flexor tendons.
• Caused by inflammation of the flexor tendon sheath, irritation, and space narrowing.
• Typically occurs in 5th or 6th decades of life.
• Symptoms include pain, clicking, a catching sensation, and an inability to flex or extend the involved finger.

Digit-Based Orthoses

• Block full MCP motion to limit flexor tendon excursion.
• Cover the proximal phalanx and MCP joint of involved digit.
• Should be worn as much as possible after diagnosis, to diminish the incidence of triggering.
• Sometimes, corticosteroid injections are used with orthoses to reduce inflammation.

Elbow Orthoses (EOS)

• Articulations include the ulno-humeral joint (hinge), and radiohumeral and proximnal radioulnar joint (axial rotation).
• Allows two degrees of freedom: flexion-extension and supination-pronation.
• Sufficient elbow flexion is important for hand mobility and personal care activities. E.g. reaching to face, mouth, etc.
• Elbow motion of -30° extension to 130° flexion is typically required for good upper extremity function.

Elbow Extension and Flexion Restriction Splint

• Soft splint with high patient compliance for arthritic conditions for support, warmth, pain reduction and increased function of the arm.
• Frequently used after rigid splinting.
• Often used in soft tissue injuries, compression, sprains, and strains.

Posterior Elbow Splint (90-Degree Flexion Immobilization)

• Immobilizes elbow at specific angle, often 90 degrees.
• Wrist and elbow conditions like rheumatoid arthritis, forearm fractures, post-operative elbow arthroplasty, elbow surgeries (ulnar nerve transposition, tendon transfers, nerve repairs) can be indications.

Posterior Elbow Splint Functions

• Supports and rests elbow to relieve pain.
• Immobilizes elbow to promote tissue healing and prevents flexion and extension at the wrist.
• Limits flexion and extension at the elbow; also prevents supination and pronation.

Non-articular Proximal Forearm Strap

• Firm strap, used to prevent the proximal contracting of extensor or flexor muscles to relieve pain and inflammation in related conditions.
• Indicating common tendinitis, including lateral epicondylits (tennis elbow) and medial epicondylits (golfer's elbow).