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Splinting

Darsuna Mardhiah

Dr. Tertianto Prabowo, Sp.Kfr


Definition of a Splint

A device for immobilization, restraint, or support of any part


of the body
Definition of Orthosis

a force system designed to control, correct, or compensate


for a bone deformity, deforming forces, or forces absent
from the body
splint orthosis
splint refers to a temporary a permanent device to
device that is part of a replace or substitute for loss
treatment program of muscle function.
not only immobilize but also mobilize, position, and protect
a joint or specific body part
Purposes of Splinting, Orthotics

 Splinting and Orthotics are used for the following purposes:


Protection- prevention of injury, or used with decreased
sensation
Immobilization- used during the recovery stage of an injury
Support- used to prevent injury or joint deformities
Purposes of Splinting, Orthotics

 Splinting and Orthotics are used for the following


purposes:
Positioning- used to prevent edema, promote
functional position, or prevent deformities.
Can also be used to help weak muscles.
Correction- used to correct a deformity or
stretch out a contracture (c-splint)
Purposes of Splinting, Orthotics

 Splinting and Orthotics are used for the following purposes:


Function- may facilitate function (ulnar drift splint) or substitute for
lost function (wrist drop splint)
Modify tone- spasticity splints actually fatigue muscles out until
they relax
Splint Classification

According to the ASHT [1992]:


there are six splint classification divisions:
(1) identification of articular or nonarticular
(2) location,
(3) direction,
(4) purpose,
(5) type,
(6) total number of joints
1.Articular/Nonarticular

a) Articular splints :
 use three-point pressure systems “to affect a joint or joints by immobilizing,
mobilizing, restricting, or transmitting torque”
 Most splints are articular, and the term articular is often not specified in the
technical name of the splint.
b) Nonarticular splints:
 use a two-point pressure force to stabilize or immobilize a body segment
the term nonarticular should always be included in the name of the splint.
Examples of nonarticular splints include those that affect the long bones of
the body (e.g., humerus).
2. Location

 Splints, whether articular or nonarticular, are classified further


according to the location of primary anatomic parts
 included in the splint.
 For example, articular splints will include a joint name in the splint
[e.g., elbow, thumb metacarpal (MP), index finger proximal
interphalangeal (PIP)]. Nonarticular splints are associated with one
of the long bones (e.g., ulna, humerus, radius).
3.Direction

 Direction classifications are applicable to articular splints only


 Because all nonarticular splints work in the same manner, the
direction does not need to be specified.
 Direction is the primary kinematic function of splints.
 Such terms as flexion, extension, and opposition are used to classify
splints according to direction.
 For example, a splint designed to flex the PIP joints of index, middle,
ring, and small fingers would be named an index–small-finger PIP
flexion splint.
4.Purpose

 The purpose of the splint indicates how the splint works.


 The number in parentheses indicates the total number of joints incorporated into
the splint
 There are four purposes of splints:
 (1) mobilization designed to move or mobilize primary and secondary joints
ex: Wrist/finger-MP extension mobilization splint
 (2) immobilization designed to immobilize primary and secondary joints.
Ex: Elbow immobilization splint
 (3) restriction limit a specific aspect of joint range of motion for the primary
joints” Elbow immobilization splint
4.Purpose

 4) torque transmissionexercise splints


purposes:
(1) create motion of primary joints situated beyond the boundaries of the splint itself o
(2) (2) harness secondary ‘driver’joint(s) to create motion of primary joints that may be
situated longitudinally or transversely to the ‘driver’ jointexercise splints
Ex: Finger PIP extension torque transmission splint, type 1
5. Type

 specifies the secondary joints included in the splint.


 Secondary joints are often incorporated into the splint design to affect joints that are
proximal, distal, or adjacent to the primary joint.
 There are 10 joints that comprise the upper extremity:
shoulder, elbow, forearm, wrist, finger MP, finger PIP, finger distal interphalangeal (DIP), thumb
carpometacarpal (CMC), thumb metacarpophalangeal (MP), and thumb interphalangeal
(IP) levels.
5. Type

 Only joint levels are counted, not the number of individual joints
 For example, if the wrist joint and multiple finger PIP joints are included as
secondary joints in a splint the type is defined as 2 (PIP joints account for one
level and the wrist joint accounts for another level, thus totaling two secondary
joint levels). The technical name for a splint that flexes the MP joints of the index,
middle, ring, and small fingers and incorporates the wrist and PIP joints is an
index–small-finger MP flexion mobilization splint, type 2.
 If no secondary joints are included in the splint design, the joint level is type 0.
6.Total Number of Joints

 the total number of individual joints incorporated into the splint design.
 The number of total joints incorporated in the splint follows the type indication.
 For example, if an elbow splint includes the wrist and MPs as secondary joints the splint
would be called an elbow flexion immobilization splint, type 2 (3). The number in
parentheses indicates the total number of joints incorporated into the splint.
Splint Designs

 Splint Designs In the past, splints were categorized as static or dynamic. This
classification system has its problems and controversies. However, in some clinics ASHT
splint terminology is not often used.
 the ASHT classification system as well as other commonly used nomenclature.
 Static splints have no movable parts
 static splints place tissues in a stress-free position to enhance healing and to minimize
friction
 Dynamic splints have one or more movable parts and are synonymous with splints that
employ elastics, springs, and wire, as well as with multipart splints.
Splinting design classifications include:
(1) static

 A static splint can maintain a position to hold anatomical structures at the end of
available range of motion, thus exerting a mobilizing effect on a joint
 For example, a therapist fabricates a splint to position the wrist in maximum
tolerated extension to increase extension of a stiff wrist. Because the splint
positions the shortened wrist flexors at maximum length and holds them there, the
tissue remodels in a lengthened form
2) serial static

 Serial static splinting requires the remolding of a static splint


 The serial static splint holds the joint or series of joints at the limit of tolerable
range, thus promoting tissue remodeling.
 As the tissue remodels, the joint gains range and the clinician remolds the splint
to once again place the joint at end range comfortably. pointed out that
circumferential splints that are nonremovable require no cooperation from those
who wear them, except to leave them on.
(3) dropout

 A dropout splint allows motion in one direction


while blocking motion in another
 This type of splint may help a person regain lost
range of motion while preventing poor posture. For
example, a splint may be designed to enhance
wrist extension while blocking wrist
 Elastic tension dynamic (mobilization) splints (Figure
1-6) have self-adjusting or elastic components,
which may include
(4) dynamic

 Elastic tension dynamic (mobilization) have self-


adjusting or elastic components,
 include wire, rubber bands, or springs
 A splint that applies an elastic tension force to
straighten an index finger PIP flexion contracture
exemplifies an elastic tension/traction dynamic
(mobilization) splint
(5) Static
-progressive

 types of dynamic (mobilization) splints


 the use of inelastic components such as hook-and-loop
tapes, outrigger line, progressive hinges, turnbuckles,
and screws.
 the use of inelastic components to allow the client to
adjust the line of tension so as to prevent overstressing
of tissue more thoroughly addresses mobilization and
torque transmission (dynamic) splints. .
Type of splints

 Splints:
Resting Pan
Cock-up
Thumb Spica
Ulnar drift splint
C-Bar splint
Gutter splints
Boutonniere and Swan-Neck splints
Resting splint
Flaccidity
Cock-Up Splints
C bar splint
Median Nerve Injury

Used to maintain web space


No joint stabilization
Thumb Spica Splint
ulnar gutter splint
median nerve compression
(CTS)
Ulnar drift splint
Silver rings
Swan Neck Deformity
Boutonniere
Fabrication principles

 Requirements of a Well Designed Splint


Maintains arches, should contour to the skin
Maintains axis of motion
Permits balanced function of unaffected muscles (i.e.. does not
immobilize whole extremity just to splint the finger)
Allows maximal mobility while providing optimal stability
Fabrication Principles

 Requirements of a Well Designed Splint


Frees palmar surface of the hand and digits for the greatest
amount of sensory perception
Places minimal stretch on joints or muscles in a more prolonged
period, rather than going for a quick correction
Increases surface area to distribute pressure by using padding
Follows contours of the normal hand and forearm
General Precautions for Splints

 Splints should be designed for individuals and systematically re-


evaluated for fit
 Splints should be worn intermittently
 Splints should be worn for as long of a duration as they are functional
 Avoid tight circling around the extremities with the strapping, there
should be no blanched areas where circulation is decreased
General Precautions for Splints

 Avoid making the forearm too long or too short as this provides inadequate
leverage (generally go 2/3rds of the forearm)
 The palmar piece should fit the metacarpal transverse arch to avoid
blocking MP motion
 Avoid positions of hyperextension. The IP joints of digits should be flexed
about 15-25 degrees.
General Precautions for Splints

 Forearm shaft of the splint should be designed as a trough. The


sides should come up midway on the sides of the forearm
 An exercise program should be used in conjunction with splinting
wherever possible
Patient Compliance

 To ensure pt. compliance and efficient use of splints the splints


should be:
simple in design
as comfortable as possible
lightweight
easy to put on and take off
as cosmetically pleasing as possible
free of pressure areas
readily adjustable
Materials Overview

 Materials need to be evaluated for the following properties:


stretchability
drapability
rebound
elastic memory
Materials Overview

 High Temperature Materials:


Nyloplex
Royalte
Kydex
 Moderate Temperature Materials:
High Impact vinyl
Materials Overview

 Low Temperature Materials (continued)


Polyform
Kay-Splint
SOS-Plastazote
 No-Heat or Layered Materials
Plaster of Paris
Fiberglass casting
Splinting Supplies

 Equipment
Heat pan/ hydrocallator
Heat gun
Sewing machine
 Tools
Scissors for material such as velcro
Sharp scissors for cutting splinting materials
Curved scissors for cutting splinting materials
Leather punch
Splinting Supplies

 Tools (continued)
Wire snips
Utility Knife
Needle nosed pliers
Tongs
Wire bender
Splinting Supplies

 Materials other than splinting material


Paper towels or tissue for making patterns
Towels for drying splinting materials before application
Stockinette- to apply beneath the splint
Velcro, Velfoam, strapping materials etc....
Lining materials, moleskin
Splinting Supplies

 Materials other than splinting material


fishing line and leather for outrigger splints
adhesive and solvent to clean material in prep for glueing
safety pins and rubber bands for dynamic splints
cold spray
Patient education regarding splints

 education should consist of the following:


the purpose of the splint
the correct method of application
the need for regular review and ongoing evaluation of the client
and their splint
the importance of checking the skin for pressure areas
Patient Education

 Patient Education Should consist of the following:


the importance of understanding that the splint should not cause
pain
that splints should be worn according to the prescribed schedule
that clients must still perform their therapy programs
Anatomy of the forearm and hand

 Bones:
27 Bones- carpals, metacarpals and phalanges
8 carpals arranged in two rows:
radial to ulnar in proximal row= scaphoid, lunate,
triquetrum and pisiform
radial to ulnar in distal row= trapezium, trapezoid,
capitate, and hamate
Wrist Flexion/Ext and RDUD occur at the
radiocarpal and midcarpal joint
Anatomy of the forearm and
hand
 Arches:
Transverse Arch-
comprised of the heads of the metacarpals
it is always oblique
Longitudinal Arch-
follows the long lines of the metacarpal and carpal bones alone a slightly
oblique line along the third finger
Proximal Transverse Arch-
comprised of the carpal bones and the annular ligament
Anatomy of the forearm and hand

 Palmar skin is tight, irregular and has several creases that create
contour
Wrist crease
Thenar crease
Distal Palmar Crease
Palmar digital Crease
PIP crease
DIP crease
Anatomy of the forearm and hand

 Joints of the Wrist and Hand


Radiocarpal
Carpometacarpal
Metacarpophalangeal
Proximal Interphalangeal
Distal Interphalangeal
Anatomy of the forearm and hand

 Position of Rest in the wrist and hand:


midway between pronation and supination
wrist is 12 to 20 degrees of extension
phalanges are slightly flexed
thumb is in partial opposition and forward
Anatomy of the forearm and hand

 Position of function:
wrist in 20-35 degrees of extension
normal transverse arch
thumb in abduction and opposition and lined up with pads of
other fingers
PIP jts are flexed 45 to 60 degrees
Wrist must be stable to be able to use hands
Four Phases of Prehension

 Reach
client must have functional range in all proximal joints of forearm
client must be able to stabilize proximal arm and trunk during
reach
client must have adequate strength to maintain position and
accomplish as motion
Four Phases of Prehension

 Prehension Patterns (Grasp, Pinch, Hook)


Pinch:
Tip Pinch
Palmar, 3-Jaw, Tripod Pinch
Lateral Pinch
Four Phases of Prehension
 Grasp
Cylindrical
palm serves as an opposition platform for flexed
fingers
used to hold hand rails, tools and sports equipment
the grip of the 4th and 5th fingers stabilizes the grasp
need some degree of thumb abduction to get the
object into the palm
typically, wrist is in extension
Four Phases of Prehension
 Ball
palm acts as a platform with all five fingers around a
spherical object
wrist is stabilized in dorsiflexion (extension)
 Hook
accomplished by flexion of the fingers without the use
of the thumb
metacarpals and wrist joints are in neutral
Used to carry objects by a handle
Four Phases of Prehension

 Carry
Gravity- acts upon us as we carry objects
Balance- proprioception is necessary to carry objects
Inertia- is the resistance of objects to movement
Stability- of proximal joints is necessary when carrying objects
Leverage- changes during progression of an activity
Release
usually achieved by extension of digits
Indications for Splinting

 Acute arthritis, including acute gout


 Severe contusions and abrasions
 Skin lacerations that cross joints
 Tendon lacerations
 Tenosynovitis
 Puncture wounds/bites to the hands, feet, and joints
 Fractures and sprains
 Reduced joint dislocations
Splinting Equipment
 Stockinette
 Splinting material
 Plaster of Paris (at NMH)
Strips or rolls (2-, 3-, 4- or 6-inch widths)
 Prefabricated Splint Rolls
Plaster
Fiberglass with polypropylene padding (at CMH)
 Padding (Webril)
 Ace Wrap
 Bucket/receptacle of warm water
 Trauma sheers
Plaster Preparation

 Length: Measure out the dry splint at the extremity to be splinted


 remember the plaster shrinks slightly when wet, if too long, the ends can
be folded back
 Use plaster width that is slightly greater than the diameter of the limb
 Can be measured on the contralateral extremity to avoid excessive
manipulation of the injured extremity
 Thickness:
 UE: 8-10 layers
 LE 10-12 layers
General Splinting Procedure

1) Stockinette is applied
2) Webril is applied
3) The wet plaster is
positioned
4) Elastic bandage is
applied
5) The plaster is molded
General Splinting
 Measure and prepare the plaster
Procedure
 Apply the stockinette so that it extends 2 or 3 inches beyond the plaster
 Apply 2 or 3 layers of Webril over the area to be splinted
 Be generous
 Avoid wrinkles
 Place extra padding around bony prominences
 Place Webril between digits that are going to be splinted to avoid maceration
 Wet the plaster and place it over the area to be splinted
 Submerge the premeasured plaster in unused warm water
 Remove the splint from the water and squeeze out the excess water and remove wrinkles
 Fold the ends of stockinette over the the plaster to smooth the edges of the splint
General Splinting Procedure (cont’d)
 Place a layer of Webril over the plaster
 Apply the ace wrap around the splint to secure it in place
 Unwrap the bandage without placing too much tension around the
extremity
 While still wet, mold the plaster to conform to the shape of the extremity
 Use the palms of your hand rather than the fingers
 Place the patient’s extremity in the position desired
 Keep the patient still until the splint has dried and hardened (the plaster will
become warm as it’s drying)
 Fast-drying: 5-8 minutes
 Extra-fast drying: 2-4 minutes
 After the splint has dried, check the splinted extremity for function,
arterial pulse, capillary refill, temperature of skin, and sensation
Specific Splints

Upper Extremity Lower Extremity


 Long arm posterior splint  Posterior knee splint
 Double sugar tong splint  Jones compression dressing
 Volar splint  Posterior ankle splint
 Sugar tong splint  U-splint/stirrup splint
 Thumb spica splint
 Ulnar gutter splint
 Radial gutter splint
 Finger splints
Long Arm Posterior Splint
 Indications
 Injuries of the elbow and proximal forearm
 Construction
 Starts on the posterior aspect of the proximal arm
 Down the ulnar aspect of arm
 Ends at the MCP joints
 Application/Positioning
 Cut hole in stockinette for thumb
 Elbow at 90 degrees
 Forearm neutral position with thumb up
 Neutral or slightly extended wrist (10 -20 degrees)
Double Sugar Tong
 Indications
 Complex and unstable forearm and elbow
fractures
 Construction
 Forearm splint –from MC heads on the dorsal
hand, around elbow to volar MCP joints
 Arm splint – from anterior proximal humerus,
around elbow, to posterior arm to prox
humerus
 Application/Positioning
 Cut hole in stockinette for thumb
 Elbow at 90 degrees
 Forearm neutral with thumb up
 Slightly extended wrist (10 -20 degrees)
Volar Splint

 Indications
 Soft tissue injuries of the hand and wrist
 Carpal bone fractures, 2nd – 5th MC head fractures
 Construction
 Starts in the palm at the MC heads, down the volar
aspect of forearm to distal forearm
 Application/Positioning
 Cut hole in stockinette for thumb
 Forearm in neutral position with thumb up
 Wrist slightly extended (10-20 degrees)
Sugar Tong Splint
 Indications
 Distal radius and ulna fractures
 Construction
 From MC heads on the dorsal hand, around
elbow to volar MCP joints
 Application/Positioning
 Cut hole in stockinette for thumb
 Elbow at 90 degrees
 Forearm neutral with thumb up
 Slightly extended wrist (10 -20 degrees)
Thumb Spica Splint
 Indications
 Injuries to scaphoid, lunate, thumb and
1st metacarpal
 Gamekeeper’s thumb
 De Quervain tenosynovitis
 Construction
 From just distal to the interphalangeal
joint of thumb to mid-forearm
 Application/Positioning
 Cut hole in stockinette for thumb
 Forearm in neutral position with thumb in
wineglass position
Ulnar Gutter Splint
 Indications
 Construction
 Fractures and soft tissue injuries
of 5th digit  Starts at mid-forearm, runs
along ulnar aspect of forearm
 Fractures of the neck, shaft,
to just beyond the DIP joint
and base of 4th and 5th
metacarpals.  Include the 4th and 5th digits
 Application/Positioning
 Forearm in neutral
 Slight wrist extension (10-20
degrees)
 PIP and DIP joints 10-15 degrees
of flexion
 50 degrees of flexion of MCP
joints
 If Boxer’s fracture -> MCP joint
flexed to 90 degrees
Radial Gutter Splint
 Application/Positioning
 Cut hole in stockinette and
plaster for the thumb
 Indications
 Hand in position of function
 Fractures and soft tissue injuries
of index and 3rd digits  Forearm in neutral position
 Fractures of the neck, shaft  Wrist slightly extended
and base of the 2nd and 3rd
 MCP 50 degrees of flexion
metacarpals
 PIP and DIP joints 5 to 10
 Construction degrees of flexion
 Starts at mid-forearm, down the
radial aspect of forearm to just
distal to the DIP joint of 2nd and
3rd digits
Finger Splints

 Aluminum finger splints


 Buddy tape  Phalanx fractures
 Indications: minor finger sprains  After tendon repairs
Finger Splints for Mallet Finger

 Indication
 Mallet Finger
 Construction
 Splint only the DIP joint
 Application/Positioning
 Splint DIP joint in hyperextension
 Cannot be removed for 6-8 weeks
Posterior Knee Splint

 Indications
 Patients with legs too large for knee immobilizer
 Angulated fractures
 Injuries that require urgent operative fixation
 Construction
 Starts just below buttocks crease on dorsal aspect of
leg to 5 to 8 cm above the malleoli
 Application/Positioning
 Slightly flexed knee (especially in kids so they don’t
bear weight)
Jones Compression Dressing

 Indications
 Short-term immobilization of soft tissue injuries of knee
 Not for injuries that require strict immobilization
 Construction
 Webril and Ace wrap from the groin to a few inches above the malleoli
 2 to 3 layers of webril
 Application
 Slight flexion of the knee
Posterior Ankle Splint (Post Mold)
 Indications
 Severe ankle sprains
 Fractures of distal fibula and tibia
 Reduced ankle dislocations
 Can add stirrup splint for unstable ankle
fractures
 Construction
 From plantar surface of the metatarsal heads
to the level of the fibular head posteriorly
 Application/Positioning
 Most easily applied in the prone position
 Ankle to 90 degrees
U-Splint/Stirrup Splint
 Indications
 Severe ankle sprains
 Fractures of distal fibula and tibia
 Reduced ankle dislocations
 Can be added to post mold for unstable ankle
fracture
 Construction
 Passes under the plantar surface of foot and
extends up medial and lateral sides of leg to just
below level of fibular head
 Application/Positioning
 Most easily applied in the prone position
 Ankle to 90 degrees
 If placed with post mold, place post mold first