Splinting: An Important Component of Upper Extremity Rehabilitation

Darrin E. Ausman, MBA, OTR, CHT, CEAS II, Accelerated Rehabilitation Centers

Splinting is a common technique use by therapists who treat patients with hand problems. Recent developments of low-temperature thermoplastic material have simplified the construction of these splints which can be used as an adjunct to therapy to achieve many goals. Splints may be altered during the rehabilitation process to address changes in edema, range of motion, joint mobility and strength. As an integral component of the treatment plan, the fabrication and fitting of a splint is an important skill required by the therapist for the patient to regain functional use of an extremity.

History
Prior to the availability of low temperature thermoplastic material in the 1970’s, therapists relied on materials such as plaster of Paris, metal, and leather to achieve goals involving splinting. Custom fitting to the patient was cumbersome, time consuming and required several visits due to the number of modifications and adjustments. Since the introduction of thermoplastic materials, splints are fabricated directly on the patient quickly and effectively.

Splinting for Protection and Early Mobilization
After an injury to the hand, maintaining proper joint motion and gliding of tissue layers is required to maintain the complex mechanics. The therapist’s job is to thoroughly understand the anatomy, the injury, and the surgical repair in order to create a balance of protecting healing structures while safely maintaining movement and function.

Research on splinting for severe trauma has led to many new protocols in immediate post-operative rehab. One example is the standard treatment of stable fractures which often consists of a custom-molded removable splint. This allows early motion while providing protection to the healing fracture and is a well utilized strategy with pediatric fractures when casting material is too bulky. Pediatric splinting is often referred to as fracture bracing and allows for use of all uninvolved structures while protecting the fracture site. Another example would include the management of a repaired flexor or extensor tendon. These injuries may now be treated with hand therapy immediately following surgery with protected active motion which is accomplished utilizing a custom fitted splint.

The purposes of the splint become intertwined with the goals of therapy, and at each therapy visit the splint and its use is reevaluated. As tendon healing proceeds or bony union is achieved, the patient is weaned from the splint. During this period, the splint may undergo numerous adjustments, freeing up joints to allow additional motion, repositioning joints for better tendon glide, or refitting the splint to accommodate edema reduction, pin removal or change of contour of a wound area.

Splints are also used to immobilize inflamed ligaments, tendons, or nerves. Splinting allows the inflamed tissues to rest while maintaining function of the extremity. This rest, coupled with oral or local anti-inflammatory medications allows non-surgical intervention to be highly successful.

In conclusion, splinting of an extremity has evolved into an effective adjunct of therapy when treating a variety of injuries and illness from the very simple to the very complex. It allows patients to be more functional during rehabilitation and allows for excellent recovery.


Reference
1. Hunter JM, Mackin EJ, Callahan AD, et al. Rehabilitation of the Hand and Upper Extremity, 5th ed.

Darrin E. Ausman, MBA, OTR, CHT, CEAS II, is a 1989 graduate of the Occupational Therapy Program at Washington University School of Medicine in St. Louis, MO., with an emphasis in Hand Therapy, Functional Capacity Evaluations, and Injury Prevention Programs. He is a Certified Hand Therapist (CHT) as well as a Certified Ergonomics Assessment Specialist II (CEAS II) by the Back School of Atlanta. Mr. Ausman is trained in the IMPACC program for Ergonomic Assessment, Injury Prevention and Alternative Duty Programs for early Return-To-Work. He is also certified by Advanced Ergonomics, Inc. for performing Pre-Employment/Post-Offer Assessments. Mr. Ausman currently manages the Hand Therapy program in Des Moines for Accelerated Rehabilitation Centers.

Early Mobilization Following a Distal Radius Fracture

Deena Covey, OTR, Occupational/Hand Therapist
Accelerated Rehabilitation Centers/Gary Gray Physical Therapy - Adrian, MI

One of the most common fractures of the human skeletal system occurs at the distal radius.  This fracture usually occurs after a fall on an outstretched hand.  Peak incidence is 60 – 69 years of age, with women significantly out-numbering men. 

Any fracture is a frightening experience.  Often accompanying this fear comes guarding - a desire to protect the arm.  Patients hold the arm against their chest with the elbow flexed and the shoulder internally rotated.  They also may keep the extremity as still as possible; this posturing leads to further disability. 

Therapy for these injuries may prevent frozen shoulder, Metacarpophalangeal Joint (MCP joint),  Interphalangeal Joint (IP joint) tightness and Reflex Sympathetic Dystrophy if patients are treated as soon as their fracture is stable in the immobilizing device.  During the initial visit we:

• Review patient’s history and complaints regarding:
    - pain
    - numbness
    - tingling and sleep patterns

• Check the immobilizing device for unnecessary restrictions. The Distal Palmar Crease requires movement to prevent MCP joint tightness. The Carpometacarpal joint requires movement to prevent web space contractures. 

• Identify pressure sores secondary   to a rough cast.    Excessive tightness of the cast may require a follow-up with the physician for further adjustments. 

•  Observe for trophic changes such as:
    - temperature
    - sweating
    - vasoconstriction/dilation
    - nail changes
• Take circumferential measurements.  Additional measurements include:
    - digital
    - thumb
    - elbow
    - shoulder range-of-motion 

Therapy for these injuries focuses on education, splinting and home exercises: 

•  The patient is educated in caring for their immobilizing device and is made aware of edema and vascular changes that may occur during immobilization. 

• A home exercise program is established consisting of   digital and thumb active/passive range-of-motion (A/PROM), tendon glides, intrinsic and extrinsic stretching, edema control techniques, elbow and shoulder A/PROM and forearm exercises. 

• Dynamic splinting may be added to a cast in cases where IP joint or MP joint tightness is significant. Assistive devices are provided for a short period of time as needed. 

In summary, therapy for distal radius fractures is required to restore function and facilitate healing.  With early intervention, proper treatment, education and reassurance these patients make a speedier recovery.


Reference
1.  Cannon NM, Beal BG, Walters KJ, et al. (eds): Diagnosis and Treatment Manual for Physicians and Therapist, 4th ed. Indianapolis, Ind.: The Hand Center of Indiana PC, 2001.     

Deena Covey, OTR has extensive experience in hand rehabilitation.  A 1997 graduate of Baker College, she has 11 years experience as the lead Hand Therapist at Accelerated Rehabilitation Centers/ Gary Gray Physical Therapy, Adrian, MI.  Ms. Covey’s expertise and treatment of the upper extremities has allowed her to form excellent working relationships with the regions top hand surgeons.
 

This online CEU course is worth .2 CEU's (CCM and CRC). 

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