1. Splinting, Orthoses, and Casting for Occupational Therapy Students:
OT 460B

2. Learning Objectives At the end of this session, the learner will:
1. Review Anatomy of the Hand and Forearm
2. Identify and Explain the four phases of prehension
3. List and explain the purposes of splinting, casting and orthotic devices.
4. Describe types of splints, casts, and/or orthoses and their implications for use
5. Fabricate two splints cast with minimal supervision (after a demonstration)

3. Frames-of-References for Splinting
Biomechanical
Uses principles of kinetics and forces acting on the body
Sensory motor
Used to inhibit or facilitate normal motor responses
Rehabilitation
Facilitates maximal function

4. Definitions
Orthosis
Any medical device applied to or around a body segment to address physical impairment or disability
Brace and support are terms used for an orthosis
A force system designed to control, correct, or compensate for a bone deformity, deforming forces, or forces absent from the body
Refers to a permanent device to replace or substitute for loss of muscle function

5. Definition of Splint
Device for immobilization, restraint, or support of any part of the body
Usually thought of as more temporary than an orthosis
American Society of Hand Therapists (ASHT) Splint classification:
Static splint
Static progressive splints
Dynamic splints

6. 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

7. 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

8. 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

9. Anatomy of the forearm and hand
Joints of the Wrist and Hand
Radiocarpal
Carpometacarpal
Metacarpophalangeal
Proximal Interphalangeal
Distal Interphalangeal

10. 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

11. Anatomy of the forearm and hand
Position of function:
wrist in 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

12. 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

13. Four Phases of Prehension
Prehension Patterns (Grasp, Pinch, Hook)
Pinch:
Tip Pinch
Palmar, 3-Jaw, Tripod Pinch
Lateral Pinch

14. 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

15. 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

16. 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

17. Purposes of Splinting, Orthotics, and Casting:
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

18. Purposes of Splinting, Orthotics, and Casting:
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)

19. Purposes of Splinting, Orthotics, and Casting
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

20. Purposes of Splinting, Orthotics, and Casting
Casting is used for the following purposes:
Immobilization- done during the healing phase of a bone, joint, ligament, or tendonous structure
Protection, positioning and support during the healing phase
Correction -deformities can be gradually corrected through serial casting

21. Splint Evaluation Criteria:
Need
Design
Mechanics
Construction
Fit

22. Orthotic Selection Consider the following:
What is the clinical or functional problem?
What are the indications for and goals of splint use?
How ill orthosis affect the problem and the client’s function?
What are the benefits of the splint/orthosis?
What are the limitations of the splint/orthosis?
Should the splint be custom made or pre-fabricated?

23. Classification of Splints:
Forearm based, hand based; or finger based
Volar or Dorsal placement
Rigid (i.e... thermoplastic, plaster) or Soft (neoprene, velfoam, leather)

24. Types of static splints, orthoses and casts
Resting Pan
Cock-up
Thumb Spica
Ulnar drift splint
C-Bar splint
Gutter splints
Boutonniere and Swan-Neck splints

25. Types of static splints, orthoses and casts
Slings
AFO
BFO/ Mobile Arm Support, Deltoid Aide, Swedish Aide,
Lapboard, positioning wedge etc.....

26. Types of static splints, orthoses and casts
Immobilization casts
Serial Casts
Drop-out casts

27. 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

28. 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

29. 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

30. 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 degrees.

31. 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

32. 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

33. Materials Overview
Materials need to be evaluated for the following properties:
stretchability
drapability
rebound
elastic memory

34. Materials Overview High Temperature Materials:
Nyloplex
Royalte
Kydex
Moderate Temperature Materials:
High Impact vinyl

35. Materials Overview Low Temperature Materials: Orthoplast Synergy
Ezeform
San-Splint
Aquaplast

36. Materials Overview Low Temperature Materials (continued)
Polyform
Kay-Splint
SOS-Plastazote
No-Heat or Layered Materials
Plaster of Paris
Fiberglass casting

37. Splinting Supplies Equipment Tools 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

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

39. 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

40. 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

41. Patient education regarding splints, orthosis, and casts
Pt. 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

42. 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

43. Now You Do It! Divide up into pairs:
One person makes a thumb spica splint (a.k.a. Thumb palmar abduction immobilization splint or short or long opponens splint or thumb gauntlet splint)
One person makes a flexor tendon dynamic splint