Upper Extremity Orthoses PDF

Principles of Wearing Orthoses  In common practice, the patient initially wears the orthosis for a relatively short period (5 to 30 minutes), then removes the orthosis and inspects the skin for persistent red marks.  Red marks should disappear within 20 minutes. If they do not, the...

Principles of Wearing Orthoses  In common practice, the patient initially wears the orthosis for a relatively short period (5 to 30 minutes), then removes the orthosis and inspects the skin for persistent red marks.  Red marks should disappear within 20 minutes. If they do not, the orthosis should be adjusted to alleviate the excessive pressure on the skin.  If the red marks disappear within the 20-minute period, wearing time can be gradually increased (e. by 15 minutes) until the patient can tolerate wearing the device for several hours. Shoulder and Arm Orthosis Wilmer Carrying Orthosis  Wilmer carrying orthosis is intended for people suffering from a partial dislocation due to a brachial plexus lesion or hemiplegia or complete dislocated shoulder.  With the WCO, the upper arm pushes itself upwards, reducing tension on the joint capsule and tendons, the pain is relieved, bringing the shoulder head back into its joint position again. Page 2 of 41 Function:  No neck loading.  Regaining some of the arm functions.  Effective neutralization of shoulder subluxation.  Reduced pain and discomfort in arm and shoulder.  Reduced chance on edema formation in hand, fingers and forearm. Shoulder Sling  Used to restrict shoulder motion in cases of shoulder subluxation by providing humeral cuff and chest straps to keep the humeral head in the glenoid cavity. Cuffed Hemi Slings Hemi Harris Sling  2 cuffs for elbow and wrist, arm in adduction, internal rotation, elbow flexion. Figure of 8 strapping, chest, and cuff strap to approximates glenohumeral alignment help prevent subluxation Hemi Harris Sling Static Shoulder Elbow Orthoses  The coupling between the forearm trough and the iliac cap can be customized to permit a variety of motions for the glenohumeral joint. Common examples include: gunslinger, forearm trough, or shoulder abduction orthosis. Used in brachial plexus injury. Page 3 of 41  Gunslinger Orthosis forearm trough shoulder abduction orthosis Shoulder Elbow Wrist Orthosis  These orthoses also known as a shoulder stabilizer or airplane orthosis. Indication: 1) Axillary burns. 2) Post rotator cuff repairs. 3) Anteroposterior capsular repairs. Shoulder External Rotation Splint  After anterior shoulder dislocation.  The tense subscapularis kept the capsule in contact with the underlying bone structures in external rotation, whereas in internal rotation the subscapularis became redundant and the labrum and the capsule folded into the joint. Page 4 of 41   There was no contact force generated on the glenoid edge when the arm was internally rotated, while maximum contact force was generated when the arm placed in 45 degrees of external rotation, indicating that the torn-off labrum was reopposed best when the arm was externally rotated. So, some researchers prefer to immobilize the shoulder in external rotation instead of internal rotation position after shoulder injury. Elbow Orthosis Static Posterior Elbow Splint Objectives: 1) To block elbow extension. 2) To immobilize, support and rest elbow to relieve pain. Indications: 1) Rheumatoid arthritis. 2) Elbow surgeries (like ulnar nerve transposition, tendon transplant, nerve repairs). Page 5 of 41 Static Anterior Elbow Splint Objectives: 1) To prevent or correct elbow flexion contractures. 2) To block elbow flexion. Indications: 1) Burns. 2) Capsular tightness. 3) Ulnar nerve entrapment. 4) Elbow surgeries like (triceps rupture, tumor resection). Counter Force Brace or Tennis Elbow Brace  Also called arm band or epicondylar splint, its concept is to limit full muscular expansion and reduces muscle contraction force.  Provides a compressive force and creates a secondary origin of the extensor tendons. Thus, unloading the true origin at the lateral epicondyle to permit healing. Dynamic Elbow Splint  It can assist both flexion and extension of the elbow. Indications: 1) Joint stiffness. 2) Soft tissue contracture. 3) Limited range of motion. 4) Used to improve ROM gradually while allowing soft tissue healing. Page 6 of 41 Clinical Uses for Dynamic Elbow Orthosis:  Rehabilitation after ulnar collateral ligament reconstruction.  After 2 weeks postoperatively, the elbow is placed in a hinged brace set at 30 to 100 degrees.  At three weeks the ROM of the brace increased to 110 degrees.  ROM is then advanced weekly by 5 degrees of extension and 10 degrees of flexion to week 6, when the patient should have full motion and no longer need the brace. Hand Position Used in the Upper Limb Orthoses 1) Resting Position.  Is when the wrist is in 10-20 degrees of extension, the thumb is in partial opposition and forward, and the distal and proximal interphalangeal and metacarpophalangeal joints are slightly flexed. Page 7 of 41 Neuromuscular Conditions: Nerve Injuries  When a peripheral nerve is injured, the level and completeness of the injury determines the extent of the deficit incurred.  For example, in a distal median nerve injury, a simian (ape) hand deformity may occur, and the functions most affected are thumb palmar abduction and opposition. The goal of an orthotic device is to help restore this function.  The splint usually has a spring coil design that holds the MCP joints in slight flexion but permits MCP extension.  This splint also has a portion to position the thumb in palmar abduction.  Radial nerve injuries distal to the humeral spiral groove commonly present with wrist drop and finger drop. The goal in these cases is to enhance wrist and finger extension. Page 28 of 41  A radial nerve palsy orthosis is based on the forearm, with an outrigger holding the wrist, fingers, and thumb in extension and allowing flexion of the digits.  With a proximal ulnar nerve injury, the patient has a “benediction hand,” characterized by hyperextension of the fourth and fifth MCP joints and flexion of the PIP joints because of the loss of balance between the extrinsic and intrinsic hand muscles.  Here the goal is to prevent fixed deformity of the fourth and fifth MCP joints and improve function. An ulnar nerve palsy orthosis holds the MCP joints of the fourth and fifth fingers in slight flexion by a spring coil or figure-of-eight splint design.  The spring coil design assists MCP flexion and permits extension of the MCP joints but blocks hyperextension. Page 29 of 41  This can also be accomplished with a static splint that uses a “lumbrical bar” to prevent hyperextension of the MCP joints of the fourth and fifth digits.  Thumb position is most often compromised in low median and ulnar nerve injuries, which leave the patient with no or a weakened ability to place the thumb in opposition and palmar abduction.  Incomplete nerve injuries can be caused by compression without producing complete paralysis (for example, in median nerve injury from carpal tunnel syndrome).  The purpose of the splint is to immobilize the wrist to minimize swelling from overuse of the tendons.  Complete resolution of carpal tunnel syndrome can occur if wrist orthoses are applied early, when symptoms first appear.  The splint is molded to the patient from a thermoplastic that offers excellent conformity to hold the wrist in 0-5 degrees of extension.  The splint’s commonly used name, wrist cock-up splint, is misleading and should be avoided because it implies that the wrist should be placed in extension. Page 30 of 41   The patient should be instructed to reduce activities that stress the wrist and to wear the splint all night.  A word of caution is in order regarding prefabricated wrist splints for carpal tunnel syndrome. Many of these splints have an angled metal bar to hold the wrist in 45 degrees of extension. This angle far exceeds the recommended 0-5 degrees of extension needed to decrease pressure in the carpal tunnel. Patients need to be instructed to remove the metal spline, flatten it, and then replace it in the fabric sleeve.  Usually, this splint should be worn for 4-6 weeks, with gradual weaning from the splint and return to activity with workstation modifications.  Cubital tunnel syndrome (compression of the ulnar nerve at the elbow) can be treated with long arm splints that hold the elbow in 45 degrees of flexion, the forearm in neutral position, and the wrist in 0-5 degrees of extension, leaving the thumb and fingers free. Brain Injury and Stroke  Depending on the area of brain injury and ensuing deficits, particularly if there is a change in muscle tone, orthotic devices should be designed to prevent deformities and help adjust muscle tone. Page 31 of 41  Resting and positioning orthotic devices are also necessary to help prevent complications, such as:  Distal edema.  Joint subluxation.  Contracture formation.  In upper limb paralysis, a resting hand splint is commonly used to position the wrist in slight extension, the MCP joints in slight flexion, and the IP joints in extension. Stroke Hand Brace  The thumb is supported in a position between palmar and radial abduction. Full support of the first CMC joint prevents ligamentous stresses on the thumb, especially in the insensate hand. This thumb position uses a reflex-inhibiting posture to decrease tone in the hand.  The antispasticity ball splint places the fingers and hand in a reflex-inhibiting position and serves to reduce tone. Page 32 of 41  A mobile arm support is particularly helpful when activities of daily living, such as eating and grooming, are performed.  When attached to a wheelchair with a swivel joint, the mobile arm support is often called a balanced forearm orthosis.  Many types of slings are available for patients with decreased tone in the upper limb. Decreased tone can result in shoulder subluxation, and a sling can decrease this deformity.  These slings restrict active motion of the shoulder by keeping the humerus in adduction and internal rotation and placing the elbow in flexion.  They are designed to unload the weight of the arm on the shoulder, but they do not approximate the humeral head back into the glenoid fossa. Slings or half-arm trays do not completely correct shoulder subluxation. Page 33 of 41   The arm trough or half-lap board is often preferred because it does not restrict use of the limb and places the humerus in a position that is more naturally approximated into the glenoid fossa. Spinal Cord Injury  In patients with spinal cord injury, orthotic devices are needed to enhance function, help with positioning, or both.  The type of device depends on the level of injury and the extent of neurologic compromise.  With spinal cord injury at the C1-C3 level, the goals are to prevent contractures and hold the wrist and digits in a position of function with a resting hand splint.  In a C4-level injury, the goal is to use the available shoulder strength by providing mobile arm support to enhance function, as previously described.  In a C5-level injury, the goal is to statically position the wrist in extension with a ratchet-type hinged orthotic device to hold devices and use the shoulder musculature for function.  An orthotic device for a C6 tetraplegia patient can enhance finger flexion with a tenodesis flexion effect from wrist extension. Page 34 of 41  For example, a Rehabilitation Institute of Chicago tenodesis splint, molded from thermoplastic materials, has several positioning components.  A thumb post component positions the thumb in palmar abduction. A dorsal finger piece component, which is attached with a static line to a volar forearm component, holds the PIP joints of the index and long fingers in slight flexion.  When the patient extends the wrist, the static line pulls the fingers toward the thumb post. This produces a three-point pinch, allowing the patient to grasp an object.  When the patient relaxes the wrist, the fingers extend passively, releasing the object.  The degree of pinch varies depending on the strength of the wrist extensors and the degree of finger flexion, extension, and opposition.  This custom-made thermoplastic tenodesis device is mainly used in training and practice. If a patient finds the device useful, a light metal custom-made tenodesis orthosis achieves better functional restoration.  An adaptive or functional use orthosis promotes functional use of an upper limb that is impaired because of weakness, paralysis, or loss of a body part. Page 35 of 41   An example is the universal cuff, which encompasses the hand and holds various small items, such as a fork, pen, or toothbrush, to enhance independence. Orthoses for Other Injuries Postsurgical And Postinjury Orthoses  Many types of splints have been developed to help regain motion in stiff joints. Examples of such splints include dynamic elbow flexion and extension splints after upper arm or elbow fracture, dynamic wrist flexion and extension splints after a Colles fracture, and dynamic finger flexion and extension splints for stiffness after crush injuries to the hand.  Similar splints can be fabricated with a static progressive approach. Joints that have a soft end feel do well with dynamic splints. Those with a rigid end feel typically respond better to a static progressive approach that will maintain a constant joint position while the tissue gently accommodates to the tension, without the influence of gravity or motion. Page 36 of 41  Examples of static progressive splints are the Joint Jack or cinch straps and splints for PIP and DIP joint contractures with the MERiT components. Cinch Straps Joint Jack Finger Splint MERiT Static Progressive Component  Selection of forearm-based or hand-based splints is determined by the need for stabilization. In general, the goal is to immobilize as few joints as feasible.  Forearm pronation– supination splints with both dynamic and static features are very helpful in regaining motion after fractures of the radius and ulna. Page 37 of 41  Several splint designs are currently used after repair of tendon injuries. The type of surgical procedure or injury level often dictates the type of splint used so that the splints cannot be used interchangeably.  After flexor tendon repair, Kleinert and Duran splints are commonly used. Kleinert Splint Duran Splint  The Kleinert splint features dynamic traction into flexion but allows active digit extension within the constraints of the splint. The Duran splint statically positions the wrist and MCP joints in flexion and IP joints in extension.  The Indiana Protocol splint can also be used. This splint adds a tenodesis-type action splint to the Kleinert componentry for specific, active-assisted ROM exercises. It can be used only if a specific surgical suture technique has been used.  A mallet finger injury requires only a Stax splint, which is a static splint holding the DIP joint in full extension. A more proximal injury, however, needs a splint that holds the wrist statically in extension, with dynamic extension of the MCP and IP joints. Page 38 of 41