Upper Limb Orthosis PDF

Upper limb Orthosis Part 1 ANATOMY-RELATED PRINCIPLES: ▪ The upper extremity is a complex anatomical structure, consisting of the shoulder, ▪ arm, forearm, wrist, and hand. The bones, muscles, nerves, and other soft tissue ▪ structures of the upper extremity work together to allow for a wide range o...

Upper limb Orthosis Part 1 ANATOMY-RELATED PRINCIPLES: ▪ The upper extremity is a complex anatomical structure, consisting of the shoulder, ▪ arm, forearm, wrist, and hand. The bones, muscles, nerves, and other soft tissue ▪ structures of the upper extremity work together to allow for a wide range of movement. ▪ Any disruption to this delicate relationship can result in dysfunction, such as pain, weakness, or loss of range of motion (ROM). Arches of the hand: ▪ The three arches of the hand work together to allow for a wide ROM in the hand ▪ Also providing a stable base for grasping & manipulating objects ▪ The proximal transverse arch is formed by the distal row of the carpal bones and the taut volar carpal ligament. ▪ The mobile distal transverse arch is located at the level of the metacarpal heads and is adaptive due to the mobile ulnar fourth and fifth carpometacarpal (CMC) joints ▪ The longitudinal arch spans the length from the metacarpal to the distal phalanx and is maintained by the intrinsic muscles of the hand. ▪ Disruption of the longitudinal arch can occur in patients who have sustained an ulnar nerve injury, resulting in a claw-like deformity. Palmar Creases (“skin joints”): ▪ The volar surface of the hand has a regular arrangement of creases. ▪ These creases are formed by fibrous connections that attach the thick palmar skin to the underlying structures. ▪ The creases are often used as an anatomical guide when creating orthosis patterns. For example, the distal palmar crease and proximal palmar crease must be fully cleared ▪ when fabricating a wrist immobilization orthosis to allow for unrestricted ROM at the metacarpophalangeal (MCP) joints. ▪ However, care must be taken not to clear too much, as this can adversely alter the mechanical advantage of the orthosis. Wound Healing Principles &Tissue Response to Stress ▪ Orthoses are often used to help heal injuries. ▪ The correct choice of orthosis depends on the stage of healing of tissue. Wound Healing Principles &Tissue Response to Stress Inflammatory Phase (Immediate Response): ▪ Key Features: Increased blood flow to injured area; signs of inflammation include redness, heat, swelling, and pain. ▪ Care: Rest is prioritized. Immobilization orthoses (supportive devices) are used to protect the area after injury or surgery. Fibroplasia/Proliferation Phase (4–6 weeks): ▪ Key Features: New granulation tissue forms, with collagen and blood vessel networks developing. Wound begins to close. ▪ Care: Mobilization orthoses (devices that allow gentle movement) can provide controlled stretch, promoting tissue growth and lengthening to improve passive range of motion (PROM). Scar Maturation/Remodeling Phase (6 weeks to 12–24 months): ▪ Key Features: Scar tissue reorganization and strengthening. ▪ Care: Orthoses help mobilize joints to encourage proper scar tissue alignment and flexibility. Wound Healing Principles &Tissue Response to Stress Inflammatory Phase (Immediate Response): ▪ Key Features: Increased blood flow to injured area; signs of inflammation include redness, heat, swelling, and pain. ▪ Care: Rest is prioritized. Immobilization orthoses (supportive devices) are used to protect the area after injury or surgery. Fibroplasia/Proliferation Phase (4–6 weeks): ▪ Key Features: New granulation tissue forms with collagen and blood vessel networks developing. Wound begins to close. ▪ Care: Mobilization orthoses that provide low, prolonged force are ideal, as excessive force can cause inflammation. ▪ Techniques: Serial static and static progressive orthoses are effective approaches for gently mobilizing tissue (used day and night if needed) to promote tissue growth and lengthening for improved passive range of motion (PROM). Scar Maturation/Remodeling Phase (6 weeks to 12–24 months): ▪ Key Features: Scar tissue reorganization and strengthening. ▪ Care: Orthoses are used to mobilize joints, promoting proper alignment and flexibility of scar tissue. Categorization of UL orthoses ▪ Purpose of application ▪ mechanical properties ▪ Configuration ▪ Anatomic site ▪ descriptive phrase ▪ Material ▪ power source While some classification systems were more precise than others, none effectively provided clear definition and separation of individual splints and splint components American Society of Hand Therapists’ Splint Classification System (ASHTSCS) ▪ ASHT-SCS is a comprehensive system that used to describe a wide variety of splints. ▪ It is a valuable tool for hand therapists, physicians, and other healthcare professionals who need to communicate about splints. ▪ According to the ASHT there are six orthotic classification divisions Location according to the classification Articular orthoses ▪ Are a type of orthosis that uses three-point pressure systems to affect a joint or joints. ▪ They can be used to immobilize, mobilize, restrict, Or transmit torque. Most orthoses are articular, but the term "articular" is often not Specified in technical name of orthosis Identification of articular or non-articular ▪ Non-articular orthoses are a type of orthosis that uses a two-point ▪ pressure force to stabilize or immobilize a body segment. ▪ Term "non-articular“ should always be included in name of the orthosis. ▪ Examples include that affect the long bones of body (e.g., humerus). Location according to the classification Articular orthoses ▪ Orthoses are classified further according to the location of primary anatomic parts included in the orthosis. ▪ For Articular orthoses, they are named after the joint or joints that they affect, such as "elbow orthosis" or "thumb metacarpal (MCP) While Non-articular orthoses, they are named after the long bone that they affect, such as "ulna orthosis" or "humerus orthosis Direction according to the classification ▪ The direction of an orthosis is only relevant for articular orthoses, as non-articular orthoses work in the same way regardless of direction ▪ The direction of an orthosis is its primary kinematic function, and it is classified according to terms such as flexion, extension, and opposition. ▪ For example, orthosis designed to flex proximal interphalangeal (PIP) joints of the index, middle, ring, & small fingers would be named an index–small-finger PIP flexion orthosis Purpose according to the classification: ▪ The purpose of an orthosis is how it works. ▪ There are four purposes of orthoses: 1. Immobilization orthoses 2. Mobilization orthoses 3.Restriction orthosis 4. Torque transmission orthoses 1. Immobilization orthoses: ▪ Also known as static orthoses, have no moveable parts and are used to immobilize primary and secondary joints. ▪ They are used to protect a joint from further injury, to allow healing and to reduce pain and provide support. 2. Mobilization orthoses: ▪ These orthoses are designed to move or mobilize primary and secondary joints. ▪ They are used to increase range of motion, reduce pain, and improve function Problem Potential solution of using orthosis: Color changes ▪ (skin turns red, purple, or pale/white since wearing the orthosis) or temperature changes ▪ These may indicate compression or constriction of the blood vessels due to tight strapping or a tight-fitting orthosis. ▪ Loosen the straps, flare away the orthosis edges, and recheck the fit. Skin integrity: breakdown of skin or highly fragile Skin ▪ Use perforated and/or lightweight materials and issue a stockinette sleeve for wearing under the thermoplastic orthosis. ▪ Consider a dorsal approach if the volar skin is highly sensitive or vice versa. ▪ Make sure the straps hold the limb securely in place and that the limb does not rotate inside the orthosis Edema If edema in the limb is significant, use an elastic wrap initially ▪ To hold the orthosis in place on the extremity. ▪ The wrap should be applied in a distal to proximal direction to help the flow of Fluids into the venous system for drainage. ▪ Additionally, the orthosis may need to be remolded to accommodate for the Reduction in edema. Improper positioning of Joints: ▪ Check to see that the orthosis maintains the correct positioning of all joints. ▪ Pay attention to radial or ulnar deviation at the wrist, too much wrist flexion, & thumb positioning. ▪ Unless otherwise specified, client should be able to oppose the thumb to the index finger easily. Red markings on the skin along the border of the orthosis and/or on bony Prominences ▪ Take care to flare away edges and pad where needed so that the orthosis does not cause red marks on the skin. ▪ Carefully heat and flare out areas that directly cover bony prominences. ▪ Do not place pads on the underside of the orthosis without first flaring out the area because the padding will create unwanted compressive and shear forces. The following are precautions that warrant further consideration: ▪ Compromised cognitive state regarding wear and care of the orthosis. ▪ Allergic reaction to the material used (the client may develop a rash following provision of the orthosis). ▪ Diminished or absent sensation in the extremity. ▪ Unclear diagnosis or unclear prescription request. ▪ Compromised circulation in the area where the orthosis is applied (history of peripheral vascular disease, recent arterial repair, or noted color changes in the skin). Effective Orthotic Design: Keep it simple ▪ Make sure the orthosis is simple in design to do the required job. Avoid unnecessary components and stick to basic design principles. Easy on, easy off ▪ The orthosis should be easy to put on and take off. The straps should not interfere with function. No unnecessary joints included ▪ Do not include uninvolved joints in a simple orthosis unless this is necessary to increase the leverage or mechanical advantage. Aesthetics Do your best to make the orthosis look professional: ▪ Cut with smooth scissor strokes to avoid uneven edges. ▪ Do not leave markings on the orthosis. ▪ Make all edges smooth and round all corners. Durable: ▪ Choose a material that will last for the expected duration of orthosis wear. Wrist orthoses (forearm-based orthoses): Circumferential Non-articular Ulna-Stabilizing Orthosis Characteristics of the orthosis ▪ Common Name: Ulnar fracture/functional brace Indications: ▪ Midshaft ulnar fractures Functions: 1- Stabilize an ulnar fracture to promote healing, without immobilizing any joints. 2- Protect fragile bones from fracture. Wrist “Immobilization” Orthosis ▪ The orthosis is designed to immobilize the wrist joint. ▪ The MP joints are always free. ▪ It covers 2/3 of the forearm length Wrist “Immobilization” Orthosis Common Names ▪ Volar/palmar wrist splint, Volar wrist cock-up splint, Wrist immobilization splint, ▪ Carpal tunnel splint, Drop wrist splint, Wrist extension immobilization splint, Ulnar gutter splint, Radial gutter splint. There are three types of wrist immobilization orthoses: volar, dorsal, and circumferential. The forearm trough is the part of the orthosis that supports the forearm. It should be two-thirds the length of the forearm and one-half the circumference of the forearm. The hypothenar bar helps to prevent ulnar deviation of the wrist. It should be positioned proximal to the distal palmar crease & distal & ulnar to the thenar crease. The metacarpal bar supports the transverse metacarpal arch.. On a dorsal orthosis, it should be positioned slightly proximal to the MCP heads on the dorsal surface of the hand when it winds around to the palmar surface. Straps are applied to the orthosis at the level of the metacarpal bar, exactly at the wrist level, and at the proximal end of the orthosis Suitable conditions Specific characteristics Arthritis in the carpal joints Straight wrist, length equal to one-third of the Forearm Non-operated carpal tunnel syndrome Straight wrist, length equal to one-third of the forearm Lateral epicondylitis 0°–20° wrist extension, slight radial inclination, length equal to one-third of the forearm Wrist instabilities Straight wrist, length equal to one-third of the forearm, allow for pronation-supination and inclination positions depending on the type of instability Distal radius fracture with or without an ulnar styloid fracture Straight wrist, length equal to two-thirds of the forearm Distal ulna fracture Straight wrist, length equal to two-thirds of the Forearm Fractures of the carpal bones ▪ Straight wrist, length equal to two-thirds of the forearm Flexor carpi radialis and/or ulnaris tendon sutures with or without nerve or artery Sutures ▪ Straight or slightly flexed wrist (if there is nerve or artery damage), length equal to two-thirds of the forearm