Hand Deformities & Elbow Orthosis PDF

Hand deformities &wrist orthosis Dr. Ramy Salama pt. MSc. PhD  Resting Hand Orthosis Positions The two most common positions used for wrist and hand orthoses are the resting (functional) hand position and the antideformity position. The resti...

Hand deformities &wrist orthosis Dr. Ramy Salama pt. MSc. PhD  Resting Hand Orthosis Positions The two most common positions used for wrist and hand orthoses are the resting (functional) hand position and the antideformity position. The resting hand position: In the absence of disease or injury, the hand and wrist assume a typical 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 The antideformity position (also known as (the intrinsic plus position, or the position of safe immobilization (POSI)) It is often used to place the hand in such a fashion as to maintain a tension of anatomic structures to avoid contracture 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  Some special cases and Position of immobilization Rheumatoid Arthritis (Acute exacerbation) Wrist: Neutral or 20 to 30 degrees of extension depending on person’s 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 is a progressive condition that causes the tissue in the palm of the hand to thicken and contract, leading to the inability to flatten the hand. It is more common in men of European descent and affects up to 20% of men over the age of 65. The most common treatment is surgery to remove the thickened tissue and release the contracted joints. Non-surgical treatments, such as needle fasciotomy and collagenase injection with manipulation, are becoming more popular due to their decreased complications and faster recovery times Wrist: Neutral or slight extension MCP, PIP, and DIPs: Full extension  Anti-spasticity orthosis or Tone- Reducing Orthosis places 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) and serves to reduce tone  Splints Acting on the Fingers (Hand-Based Orthosis) The goals of a hand-based orthosis will depend on the condition or diagnosis for which the orthosis is being prescribed 1- Metacarpal fractures: Metacarpal neck fractures are the most common type, and they often occur in the fourth and fifth metacarpal bones (boxer’s fractures). These fractures are usually treated conservatively with a hand-based ulnar gutter design immobilization orthosis. Wearing Schedule Metacarpal neck and shaft fractures heal rapidly. Immobilization for 3 to 4 weeks is recommended. Active PIP and DIP joint motion, both flexion and full IP joint extension, are encouraged within the orthosis. The IP joints can be placed in an extension orthosis at night if an extension lag develops (loss of active PIP and/or DIP joint extension). The position of protection for a metacarpal fracture is with the MCP joints positioned in 70 ⁰ of flexion. Inclusion of the wrist, PIP, or DIP joints depends on fracture stability, presence of edema or pain, and surgeon preference. If included, the PIP and DIP joints should be 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 these 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 that positions the 4th and 5th MCP joints in flexion helps to prevent development of fixed contractures. Wearing Schedule Ulnar nerve injuries: The length of orthosis use will depend on the location of the nerve injury/repair, age of the client, and involvement of other structures. Nerve injuries that occur more proximal in the upper extremity will take longer to recover as compared with more distal nerve injuries, hence length of time needed for restoration of muscle function varies considerably. The orthosis should be worn until the interossei and lumbrical muscles are strong enough to prevent MCP hyperextension during active digit extension (typically a minimum of grade 3 muscle strength).  Finger orthosis Swan neck deformity Swan neck deformity is a condition in which the PIP joint is hyperextended, and the DIP joint is flexed. It is commonly caused by rheumatoid arthritis (RA), but it can also be caused by other conditions, such as trauma or overuse. Swan neck deformity can severely affect a person's ability to use their hands. In cases where the swan neck deformity is flexible (meaning it can be passively corrected), a finger orthosis can be used to improve function. The orthosis is typically made from two connected oval-shaped rings that are joined at an angle to each other that corresponds to the joint axis of the PIP joint. This design prevents full PIP joint extension but allows the client to actively flex their PIP joint within the orthosis. The ovals should encompass as much of the length of the proximal and middle phalanges as possible for leverage and to optimize mechanical advantage of the orthosis. It is important to note that not all people with swan neck deformity need an orthosis. If the deformity is not permanent or disabling, there is no need to intervene, and orthotic intervention is not necessary. Trigger finger (Digital stenosing tenosynovitis) is a condition affecting the movement and gliding of the long digit flexor tendons Trigger finger is thought to be caused by inflammation of the flexor tendon sheath, irritation of the tissues, and subsequent narrowing of the space. It typically occurs in the fifth to sixth decades of life. Symptoms include pain, clicking, a catching sensation, and an inability to flex or extend the involved finger Digit-based orthoses that block full MCP motion (to limit the full excursion of the flexor tendon) are commonly prescribed until the inflammation has resolved. The orthosis covers the proximal phalanx and the MCP joint of the involved digit. for clients with trigger finger is to wear it as much as possible to reduce the incidence of triggering Sometimes the orthosis is offered after the client has received a corticosteroid injection also aimed at reducing inflammation. The client is allowed to remove the orthosis for periods of gentle ROM exercises and hygiene.  Elbow orthoses (Eos) The elbow has many articulations, the ulno-humeral joint, a hinge joint, and the radiohumeral and proximal radioulnar joint, (axial rotation joint). These articulations combine to permit two degrees of freedom of motion, flexion–extension and supination–pronation. Without sufficient elbow flexion, the ability to get one’s hand to the face and mouth is significantly compromised; lack of elbow extension makes reaching objects in the environment and performing some personal care activities difficult or impossible. Several authors report that good upper extremity function is possible with elbow motion of -30° extension to 130° flexion. The orthosis used for elbow joint should apply Prolonged gentle splinting improves elbow ROM through remodeling of contracted soft tissue structures. When splinting elbow injuries, it is important to avoid pressure over the ulnar nerve. This nerve may have been injured at the time of the original trauma Non-articular proximal forearm strap. Common Name: Tennis elbow strap; This orthotic device is a firm strap against which the extensors or flexors press when they are contracting; it is placed approximately two fingerbreadths distal to the lateral epicondyle. Indications: Inflammation of the common tendon origin of Wrist extensors (lateral epicondylitis (Tennis elbow)) and Wrist flexors (medial epicondylitis (Golfer’s elbow)). Functions: The orthosis reduces pain and inflammation of the wrist extensors or flexors at their origins by changing the lever arm against which they pull. In essence, it puts the origin of the extensor or flexor muscles at rest, which decreases microtrauma from overuse with lifting activities.  Elbow extension and flexion restriction splint, This soft splint also has high patient compliance when it is used to treat arthritic conditions of the elbow. Patients report that it provides support and warmth to the elbow and helps reduce pain and increases overall function of the arm. o It is used frequently following discontinuation of more rigid splinting to provide a lighter form of restriction. o It is used for minor soft tissue injuries, compression, sprains, and strains. Posterior Elbow Splint or sugar-tong orthosis Name: 90-degree flexion immobilization If the wrist is included, it will be named 90-degree elbow flexion immobilization Indications: Rheumatoid arthritis. Forearm fractures (proximal radius fracture). Post-operative elbow arthroplasty. Elbow surgeries: o Ulnar nerve transposition. o Tendon transfers. o Nerve repairs. Functions: Support and rest the elbow to relieve pain. Immobilize the elbow to promote tissue healing. It prevents flexion and extension at the wrist. Limits flexion and extension at the elbow. Prevents supination and pronation