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HAND EVALUATION

Evaluation that is recommended by the physician,


sometimes an orthopedic referral

Basis for developmental of treatment plan


o Any identified problems will
determine design of the splint
Helps to determine the splinting approach
o Conservative or aggressive
treatment
o Immobilize or increase ROM
Assists in predicting the rehab potential
o Prognosis, expected improvement
o Based on assessment or literature

Instrument Criteria

Use of standardized or non-standardized tools

History should be investigated


o What is the medical hx on what was done after
injury
o Relevant medical hx
Functional status
o If pt opens the door
o If pt brings their stuff

Source or Parameters of the Problem

Detailed history
o Interview of pt, relevant persons,
medical chart
Obs of posturing and use of the hand
Skin and soft tissue condition
Skeletal and joint stability
Composite motion
Strength and musculo tendinous continuity
Pain
Neurovascular Status
Subjective

Interview and Review of Records (referral


usually comes from a physiatrist)

Demographics
Diagnosis
o Design of splint
o Length of treatment
Mechanism and onset of history
Other pertinent medical hx
o Diabetes
o Hypertension
Received treatment of medications
Precautions
Results of pertinent ancillary procedures

Xrays, EMG (conducting muscular


impulses)

Subjective info

Occ profile
Difficulties in role participation
Handedness
Generalized sensation
Pain

Objective Information

ROM
Muscle strength
Sensory eval
Grip pinch
Hand coordination/dexterity
Edema
Hand deformity
Functional capacity

Factors influencing test results

Position of extremity
Effect of fatigue
Physiologic adaptation
Length of test
Motivation

Recording and Timing

Evaluation is done to have a baseline

After like 3 days or so, re-eval must be done (in ortho)

Status of patient upon referral

Reevaluation especially for orthopedic patients

Freq of reevaluation depends on:

Diagnosis
o Ex. ALS pt in relapse
Physiologic timing
o Stage of inflammation
Pts response to the app of the splint

Clinical Examination of The Hand


1. Referral Information

3 days prior to injury/consult

Should include:

o
o
o

Diagnosis
Date and reason of injury
Other pertinent medical hx

Purpose and timing of splint


application
o Specific instructions and precautions
When dealing with postoperative pts, it is
essential to know
o

o
o
o

2.

3.

Which structures were involved


Which structures were repaired
Specific method of repair

Height

Pertinent medical hx with dates


o Because timing is important
Posture
Normal hand at rest
o Wrist 10-15 deg flexion
o Thumb in slight extension/abduction
o MCP/IPs flexed approximately 15-20 deg
Skin And Subcutaneous Tissue

Take into consideration:

Pliabilit
y

Skin color
o Black: ischemia
o White: maceration
o Red: rubor
o Blue: cyanosis
o Yellow: jaundice
Sensation
Temperature
o Heat: inflammation
o Cold:
Texture and moisture
o Gangrene is the death of tissue in
part of the body
o No sweat: layers of the skin*
** Nail beds are always free when
bandaged

4.

Normal

1
2
3

Pink
Red
Purple (circulation is a problem

Supple

2
3
4

Yielding
Firm
Adherent

0
1
2
3
4

Normal
1-2mm
3-4mm
5-6mm
>6mm (Worst)

Massage to increase pliability of skin if it is firm


> pliable = better
Rubber skin = indicates more ROM limitation
Bone

The site and type of fracture


The method used to obtain and maintain
good alignment (stability of reduction)
When fracture occurs:
o Closed reduction is done first

Splinting should be knowledgeably integrated with the


pace of physiologic healing and should not unduly
stress the mending fracture site.
Incorrect splinting or timing may result in pain or
deformity
What surgical intervention was done?

5.

Joint
Immobilization = protection
Immobilization or blocking splints are used to protect
healing until tensile strength is sufficient to tolerate
motion and resistance

Mobilization splints correct passive joint deformity


(gentle, prolonged forces)

Hand based splint that do not incorporate the wrist

Tenodesis action must be identified

Timing dictates the type of splint that will be used

Analyze whether the tendon runs over multiple joints


o This information is essential to production of
proper splints

Splints should not place normal structures, healing


structures or tissue of questionable viability in jeopardy
Extremities that are too inflamed are not given splints
o Immobilize the joint through other means
Vascularit
y

Normal

Identify

*indicators of neurovascular status, tissue viability and


inflammatory status
*Ex: absence of wrinkles at or near the joints may indicate loss of
motion or inflammation (acute arthritis)

6.

Muscles and tendon

Diminished movement may be present


o Loss of muscle tendon continuity
o Impaired contractile capacity or limitation in
tendon glide (burns,fascia)

What is the exercise and ROM for? Possibly for


tension gliding of the tendon.
2.

7.

Nerve

Motor and sensory aspects of nerve function must


be evaluated to prevent pressure/friction leading to
tissue breakdown

Test by dermatomes for sensory

Test by myotomes for motor

Check whether there is deficiency

Avoid splints on areas with sensory nerve affectation


because joint pressure cannot be detected by client

Usage of DASH assessment

8.

Vascular status
Monitor skin temperature, color and composite
mass and size of extremity
Check for edema
o Fluctuationg edema splint should be longer
(T sling)

9.

Function

How is the injury affecting their hand function?


Assessed by observation,interview,task performance,
standardized test
o Observe guarded position, abnormal hand
movement,muscle,paint in functional
tasks,willingness to touch and move
Assessment tool: DASH
o 30 predetermined questions where client will
rate their difficulty with: no difficulty, mild
difficulty, moderate difficulty, severe difficulty,
extreme difficulty.
Take into consideration pt views on disability and how
she performs daily ax

Upper Extremity Assessment Instruments


1. Condition assessment instruments

Involves neurovascular system as it pertains to


tissue viability, nutrition, inflammation, patency of
vessels, arterial, venous and lymphatic flow

Volume
o Thru volumeters
o Circumferential measurements may also be
taken at predetermined levels using tape
measure or calipers

Vessel capacity
o Use of Doppler scanner (map arterial flow
thorugh audible and ultrasonic response to
arterial pulsing)

Sees whether there is deep vein thrombus in


the LE or UE
Motion assessment instruments

ROM and MMT

Involves muscle/tendon continuity,contractile and


gliding capacity, neuromuscular communication
and voluntary control
Sensibility assessment instruments

Relies on neural continuity, impulse transition

Detection
o The most fundamental level on the sensibility
continuum is the ability to perceive a single pt
stimulus from normal background stimuli
(Semmes-Weinstein)

Discrimination capacity to perceive stimulus A


from stimulus B
o 2-pt discrimination commonly used method
for assessments of sensibility

Predictor of sensory healing/fxn of the


sensory system due to nerve
regeneration
o Requires finer reception acuity and more
judgement on the part of the patient than does
first level detection
o Significant due to use for hand manipulation
o

3.

4.

Function Assessment Instruments


Grip
o Hydraulic dynamometer
o Strongest grip measurements wrist in 0-15 deg
extension
o 3 trials
Pinch strength
o Pinchometer that assesses lateral/key, 3 jaw
chuck, tip to tip
Coordination and dexterity
o Jebsen, Purdue Pegboard

Other Considerations

Ability to carry out and understand instructions

Age,motivation,response to injury and


application/wearing of splint

Compliance to splint wearing schedule

Splint care
Non-acute inflammation extremity can be moved to reduce the
inflammation

SPLINTING THE GERIATRIC HAND


Client Factors: To Consider
1. Neuromusculoskeletal & Movement-related changes

2.

Diminished flexibility
Due to changes of collagen, decreased activity leading
to stiffness, effects of disease (ie arthritis) and possible
dietary deficiencies
Implication: static splints may lead to faster joint
stiffness
Static splints for stiffening of joints; do not put
splints on for too long
o Bigger bones = thicker splints
Diminished muscle strength
Decrease in number & size of muscle fibers
Decrease in number of motor units
Affect coordination and speed of muscle contraction
Implication: splint design should be lightweight;
weakness may interfere with the ability to don and doff
splint

3.

4.

5.

6.

7.

8.
9.

Problems with compliance design splint


that is easy to don & doff; easy to follow;
friendly looking device

Context and Disability Status changes associated with aging

Thinner splints

Diminished bone strength & density


o Osteoporosis & osteopenia increase risk for
fracture
o Implication on splinting: look into impact of
splits on persons mobility; safety first
Diminished dexterity & coordination
o Due to weakness & pain
o Implication: strapping consider prehension
patterns

Wide strap Velcro, etc.

Leather straps

Consider needs of client and match


Sensory functions & pain
Due to microscopic losses in integrity & numbers of
peripheral receptors & nerve fibers
Sensitivity thresholds are raised, diminishing the
perception of temperature, pain and pressure
Pressure areas are avoided; add pads (gel, foam) if
needed; more surface area available, better functional
sensation
Visual acuity

Presbyopia or far-sightedness is the result of the


devt of rigidity within the eye lens

Implication: will have difficulty seeing small


components of splint; need for contrast for
strapping
o Contrasted colors
Hearing acuity
o Written instructions or verbal
CNS problems

Affect mobility, dexterity, strength and skin integrity

Ability to remember, learn , problem solve, reason ,


plan, abstract , use judgement and complete ADL
Implication : splint that is easy to don and doff; for
Alzhiemers: compliance---may resist new routine of
wearing splint

Pathologies
o arthritis, dupuytrens cc; overuse conditions
such as CTS, Trigger finger
Physical and social contexts
o greater risks for falls due to balance,
coordination, visual and environmental
changes
o greater risk for fractures due to osteoporosis
o * consider the implication of splint---does it
contribute to fall?
o Elders could become confused with changes in
their immediate environment, especially at
night
o Splint use can compound the issue if the hand
is not free to reach out in protection (ie unable
to manuveur bedsheets and could become
tangled; can also be frustrating)
o Availability of caregiver (living alone or with
family)
Consider social context
o Embarrassment ( as a sign of weakness)
may affect compliance with wearing
o Cosmesis (including size and profile) is
also important

Edema

Trauma

congestive heart
failure

dependent positioning

IV infiltration

prolonged
immobilization
Ecchymosis (bruise)

Trauma

anticoagulants

fractures

Applications to Splinting

Reduce edema
before applying splint

Design splint larger to


accommodate slight
edema

Soft, stretchy straps


(removable)

Padding
Monitor splint
frequently for
pressure areas
Soft straps
Avoid transverse

Fragile skin

Dehydration

DIabetes

Renal disease

Psoriasis

radiation therapy

long term steroid use

advanced age

Joint Contracture

Fractures or other
orthopedic conditions

poor positioning

prolonged immobility

Diminished cognition

Dementia,
alzhiemers disease

CVA

Multi-infarct dementia
over medication

depression

Sensory loss

Diabetes, CVA

Peripheral vascular
disease

Motivation

Depression

dorsal straps
Padding
Monitor for pressure
areas
Soft straps

Synamic or static
progressive splints
Splint to regain
functional position

D-ring straps if the


patient spontaneously
removes the splint
Provide thorough
patient and caregiver
instructions on the
splints wear and care
Structured routine for
splint wear and care
Teach patient or
caregiver to
frequently monitor
splint for pressure
areas
Design that avoids
coverage of affected
area (dorsal vs volar)
Educate about
responsibility for
following the splint
schedule
Identify goals and
relate the splint use to
goal achievement
Refer the patient for
appropriate
psychological support

Bases

involve as little joints as possible to avoid joint stiffness


Weight and structure

should be lightweight when elderly has weakness

should be low profile (cosmesis)

perforated if it will not compromise stability allow


better air ventilation, lighter weight, minimize potential
for skin maceration
Comfort and fit
bony prominences need padding since less skin
coverage in elderly
pad uniformly as selected padding can just increase the
pressure in arm or hand surface in that small area
choose proper padding material
Strapping & closures

consider motor skills of px in removing or attaching


straps

consider attaching permanently one side of strap for


ease

label straps properly

keep straps as wide as possible to ensure good


pressure distribution
Donning and doffing ease

be simple for both dexterity and cognitive reasons

Design choices

free palmar area if sensation is decreased


minimize size of the splint will preserve sensation and
prevent unnecessary stiffness
visually inspect for pressure areas

Checklist for Splinting the Geriatric Hand

*Avoid skin problems when wearing splints because skin


breakdown will lead to infection, longer healing.

Specific considerations for splinting the geriatric hand

Review the chart and interview the client for history,


physical and social contexts and secondary disease and
disability that could affect splint selection
Evaluate by assessing skin integrity, joint flexibility,
sensation, muscle strength and dexterity of bilateral
hands
Screen client factors and body function (cognition);
evaluate the clients understanding instructions and
rationale for splint use
Inspect the limb for potential pressure areas
Use lightweight material, padding and stockinette and
appropriate straps. Only those joints requiring
immobilization are included in the splint (unobstructive)
Provide clearly written instruction or splint wear and
care, including drawing or photos if indicated
Instruct caregivers in splint wear and care if indicated

Allow time to review instructions and for the client to


practice donning and doffing the splint
Instruct client in precautions of splint wear, including
skin inspection
Check the splint 30 minutes after the first application for
signs of pressure
Follow-up with the client in 1 or 2 days if not being
followed in therapy
Document

Precautions/Contraindications
Sensation

skin should be inspected at regular intervals to


ensure that breakdown of skin is not occurring
Fragile skin

proper splint padding and fit are essential for


protection
Contracted joints:

pressure should be minimal/prolonged stretch


o used in dynamic or static progressive
splints in an effort to reduce contractures
o The rate of turnover for collagen in the
elderly population is decreased, forceful
stretching could cause damage to
ligaments, tendons, skin
Dexterity and coordination

Diminished functional mental capacity can create


difficulty in donning and doffing the splint and lead
to frustration and anxiety
Blood circulation

Straps and splint components should not cause


pinpointed pressure because of an increased
tendency to impair capillary flow.

Monitor the splinted extremity for signs of impeded


circulation such as swelling, bluish tint to skin or
whiteness of skin
Visual, auditory and cognitive changes

Bold, visible instructions that should be given in written


and verbal form to the elder.

Repeating instructions and donning and doffing trials


will also facilitate independence
Advanced Alzhiemers disease or other forms of dementia

Elders who are not aware of why they are wearing a


removable splint/unable to verbalize discomfort may not
be splinting candidates.

Options exist for cones to be held in contracted hands


or to use bulky dressings applied with ace wraps or
gause following surgical procedures
Violent tendencies

Should not be given a thermoplastic splint that could


potentially be used as a weapon against themselves or
others.

Soft prefabricated or custom-designed splints can be


used if appropriate
Osteoporosis

Weak bone structures could break if forces with a


dynamic or static progressive splint are too great.
Case: Sadie is a frail 82 year old r handed woman, with oa and
diabetes mellitus. She is alert and oriented x 3. Sadie ambulates
independently with a walker, but she has difficulty grasping the
walker with her left hand. She is experiencing increasing pain in
her left wrist and MCP joints bec. Of arthritis. She states her
hands are clumsy when she performs self-care activities. Since
the recent death of her sister who assisted Sadie with ADLS and
with whom she shared a first-floor apartment. Sadie realized she
can no longer function independently. She has been admitted for
outpatient rehabilitation therapy for splinting, ADL training, and
functional activities to increase upper body strength. Now sadie
has a home health aide 4 hours a day,3 x a week. The aide
assists with bathing, shopping and housekeeping. Family
members live nearby.
1.Which splints do you recommend for night use?
A. Resting hand
B. Arthritis mitt*
C. Wrist immobilization splints
2. what is your splinting rationale?
A.
B.

To rest all hand and wrist joints


To immobilize the wrist and MCP and allow
movements of the PIPs*
C. To immobilize the wrist and allow movement of
MCP, PIPs
3. which kind of strap should you use?
A. Velcro loop strapping
B. Soft foam like strapping
C. D-ring strapping*
4. what is the purpose of the strapping?
A.
B.

To accommodate edema
To provide leverage to control tightness and
allow easier application*
5.what do you recommend to help sadie grasp her walker?
A. Building up the handle of the walker by using
adhesive foam
B. Using walker splint*
C. Using neoprene thumb support
6. How might the diagnosis of DM affect splinting of this frail
older woman?
A.

She may have impaired sensation*

B.
C.

She may have compromised peripheral


circulation*
DM does not affect the splinting program