Splinting Material, Processes, Tools and Techniques Chapter 3

Is Splinting the answer? Use the Clinical Reasoning approach… Activity analysis approach… Anatomy and biomechanics…

Purposes of splinting Improve position Prevent deformity/contracture Correct deformity/ contracture Provide rest to a joint b relieving stress Maintain skeletal alignment Improve function Position extremity for improved function

Continued… Assist weak movement Substitute for absent movement transfer movement from one joint to another Assist muscle re-education and exercise improve independence in activities of daily living

Splinting materials Low- temperature thermoplatic (LTT) material Soften in water heated btw 135 F and 180F (57º - 82º C) Therapist can put safely on patient’s skin while plastic is still moldable HTT material warmed to >250 F, cannot touch skin

LTT often used to adapt devices for improving function Example?

http://en.wikipedia.org/wiki/Polycaprolactone Polycaprolactone (PCL) is a biodegradable polyester with a low melting point of around 60°C and a glass transition temperature of about −60 °C. The most common use of polycaprolactone is in the manufacture of speciality polyurethanes. Polycaprolactones impart good water, oil, solvent and chlorine resistance to the polyurethane produced. This polymer is often used as an additive for resins to improve their processing characteristics and their end use properties (e.g., impact resistance). Being compatible with a range of other materials, PCL can be mixed with starch to lower its cost and increase biodegradability or it can be added as a polymeric plasticizer to PVC. Polycaprolactone is also used for splinting, modeling, and as a feedstock for prototyping systems such as a RepRap, where it is used for Fused Filament Fabrication (similar to theStratasys' Fused Deposition Modeling or FDM technique).

PCL also has many applications in the hobbyist market (sold under various tradenames, such as "InstaMorph", "Friendly Plastic", "ShapeLock", "PolyMorph", "Plastimake", "Plaast" etc). It has physical properties of a very tough, nylon-like plastic that melts to a putty-like consistency at only 60 °C. PCL's specific heat and conductivity are low enough that it is not hard to handle at this temperature. This makes it ideal for small-scale modeling, part fabrication, repair of plastic objects, and rapid prototyping where heat resistance is not needed. Though molten PCL readily sticks to many other plastics, if the surface is cooled, the stickiness can be minimized while still leaving the mass pliable.

Material selection Patient population Diagnoses Therapist preference Availability

Material selection Decisions on the best material are based on: Cost Properties of thermoplastic material Familiarity with splinting materials Therapeutic goals

Handling characteristics Performance characteristics Material properties When heated and softened Performance characteristics Material properties after the material hardens and cooled

Handling Characteristics of Splinting Materials Low Temperature Thermoplastics Warm water for consistent and overall coverage Heat gun for spot heating or dry heat Advantage: Can work with material directly on skin Disadvantage: May melt in hot car or if left near hot surface

Memory Ability of the material to return to former size, shape and thickness when re-heated (ranges from 100% to little or no memory) 100% memory (turn clear): return to the same thickness &size Advantage: easier to "start over" novice therapists, serial splinting (spastic) Disadvantages: Constant molding required during the cooling process.  May "shrink" during cooling (Spot heating) Constantly moulded throughout the cooling process

Drapability Ability of material mold intimately over contours of extremity without manual assistance Degree of ease with which the material conforms to the underlying shape Advantages: conforms well Disadvantages: Prone to fingerprints of therapist, Poor memory, Stretches and "grows", Requires cooperative patient,                           Requires a light touch

Elasticity Material’s resistance to stretch and tendency to return to it’s original shape after stretch Advantages: Can tolerate a heavy touch Good with uncooperative patient, high tone, when including multiple areas Disadvantages: Difficult to mould to contours

Self Bonding (uncoated) Ability to adhere (stick) to itself when heated Coated material required bonding agent Advantages: Can secure extra piece to the splint, such as when attaching a piece of hardware in dynamic splint Disadvantages: Difficult to take apart if the material folds What is scoring?

Self-finishing edges Edge is smooth and clean when cut Decreases need to roll edges Advantages: less jagged edges, less risk for pressure sores

Heating time Working time shrinkage

Performance Properties of Splints Conformability Fits intimately into contoured areas More comfortable they distribute pressure best No migration of splint on extremity High drapable

Performance Properties of Splints Flexibility Able to withstand stresses repeatedly Bends easily Example? Circumferential splints

Performance Properties of Splints Durability Length of time a material will last before becoming brittle with age

Rigidity Strong Does not bend easily Medium to large splints To support the weight a larger joints In small splint it is important if the splint Is to stabilize a joint Most LTT material cannot tolerate the repeated forces involved in WB such as in foot orthoses

Perforation Moisture permeability Air exchange Mini Maxi Micro perforated Reduce the weight of splint Should not be stretched. Increase the holes Decrease strength and pressure distribution Cutting a perforated splint

Finish Texture of the surface, smooth or grainy texture Colour Commonly white but tan A variety of other colours are available in some products Bright colors with children Colored with unilateral neglect

Thickness Common thickness is 1/8 inch This will soften and hardens faster than thicker material Thinner are used for children or for small splints and arthritis patients

Sticky-backed Velcro Bonds best when heated (dry heat) Rounded corners prevent "catching Padding Bonds best when heated (dry heat) Changes fit of splint (smaller, tighter) Moisture and odor absorption requires replacement

Splint fabrication Process Creating a Pattern Choosing appropriate material Choosing the type of traction Choosing splint design for a given purpose Fabrication

Step 1: Creating a Pattern Necessary for success Pattern should be made Standard patterns Tracing the outline of the hand (or body part) Position error (flat and neutral) Contra-lateral hand Landmarks of hands Draw splint pattern over the outline of the hand Cut out the pattern

Step 2: Fitting the Pattern to the client Fit the pattern on the extremity Adjust the size and shape by adding or subtracting from the pattern, using scissors and paper tame, so that the pattern conforms to the area to be covered by the splint Palpate through pattern material to find bony landmarks, borders, creases and skin folds, to provide cues to outline area If a pattern is cut much larger than necessary the splint will be difficult to mold. The pattern is easier to mold if cut true to size    

Step 2: Fitting the Pattern to the client Moistening the pattern paper Make a new pattern - major changes Form 3-1 hints for drawing and fitting a splint pattern

Step 3: Tracing, Heating and cutting After making and fitting the pattern to the client, therapist place on material sheet Trace it with a pencil, grease pencil Ink may smear into the plastic Ink maybe removed with clorine Cut with knife, or scissors (pattern maybe cut later .. Cut sheet into two halves

Step 3: Tracing, Heating and cutting Electric fry pan (Sause pan) Temperature dial (160 F) Water high (two thirds full) or (2 inches deep) Take out of water Put on mesh / flat cloth Cut pattern with long blade strokes Do not use the tip of the scissor

Step 3: Tracing, Heating and cutting After cutting the pattern from the sheet Position client Reheat the pattern

Step 4: Position client Seat client comfortably for elbow and hand Gravity assisted.. Dorsum of hand on towel roll, Forearm in supination OR: Hand in vertical position Stiff hand?? Pain medications (30-60 min)

Step 5: Molding the splint to client Retrieve material from water Wipe off any excess water Check how hot is the material Fragile skin? Material sticking to hair? Cold spray? Dip in cold water

Step 6: Making adjustments Cut with scissor Dip in hot water Heat gun (off, cool, hot) Warm unevenly Don’t use for major changes Hot-cold line Attachments

Step 7: Strapping Velcro hook and loop With /without adhesive back Variety of width and clors Rounded corners of velcro? Adhesive on scissors Padded straps Give extra to client Avoid losing straps fig 3-6

Step 8: Padding To avoid pressure areas Heat gun and push away from bony prominence. (The ulnar head) Allow for padding space in the splint Gel disks Put putty over prominence before applying material Replacement (open cell padding)

Step 9: Edge finishing If no self-finishing edges: Edges should be: Smooth Rolled Flared out If material cut hot.. Finishing of edges not needed Use heat gun or heated water in fry pan Smooth finger prints with water

Step 9: Edge finishing Finish Splint Edges Try these techniques to find which works best for you. Heat edges and trim with scissors Heat edges and rub with a wet finger Edges may be smoothed with an electric grinder or sander Dip in hot water until edges clear. Flare edges outward. Hardened edges may be trimmed with a deburring tool.

Splinting precautions Alter splint if red areas on skin persist 20 minutes after removal of splint Increasing surface area of splint decreases potential for pressure sores Arm toughs should be 2/3 length of forearm Troughs should be ½ the circumference of body part

Avoid pressure over bony prominences A pressure point should be bubbled out or enlarged rather than cut or padded Smooth, rolled or rounded edges decrease pressure sores Address moisture due to perspiration, wound drainage to avoid skin breakdown or infection

Give careful consideration for the following: The needs and expectations of the patient Position Areas to be supported Distribution of support (total contact Vs. small areas of contact) Areas to be exposed

Continued… Exposure of sufficient tactile surface for sensory input. Points and directions of forces. Movements which may be restricted by the splint Ease of application and removal of splint.