1. Splints acting on the wrist

2. Introduction
Keeping the alignment of the wrist is important as the wrist is key to the health and balance of the entire hand
The wrist is positioned in extension for grasp and prehension during functional activities
The wrist cock-up splint is the most common type of splint used in practice
A wrist ext. immobilization splint allows full ROM in the MCP’s and fingers so person can perform in fx activities
Wrist is neutral or mildly extended (0-30) depending on diagnosis and tx goals

3. Introduction Wrist immobilization splints can be:
volar
Dorsal
Ulnar
circumferential
The splint can be a base for mobilization and static progressive splints

4. Volar wrist immobilization splint

5. Volar wrist immobilization splint
Depends on a dorsal wrist strap to hold the wrist in extension
The volar design is recommended for rest or immobilization of the wrist when the person still has muscle control of the wrist
One study: best dexterity of custom made wrist splint
The disadvantage of this splint is that it interferes with the palmar tactile sensibility and the loss of the hand function to conform around objects
In the presence of edema, you must design the dorsal strap carefully as it interferes with the lymphatic and venous flow
You can fabricate a continuous Velcro strap from the radial to the ulnar borders of the splint

6. Dorsal wrist immobilization splint

7. Dorsal wrist immobilization splint
The larger the palmer bar, the better, it tends to distribute pressure well which is necessary for function and comfort
But compromise sensory input to the hand
Just like the volar, both be used as a base for dynamic splinting
However these designs tend to migrate and suboptimal splint performance

8. Ulnar Wrist Immobilization S
Easy to don and doff
Good if we needs more protection to the ulnar side of hand
Maybe used for CTS or for ulnar wrist pain
It can be base for mobilization splint

9. Circumferential wrist immobilization splint

10. Circumferential wrist immobilization splint
It is helpful in prevention of migration (especially in dynamic splints)
It provides good forearm support, controls edema, provide good pressure distribution, and avoid edge pressure
But it gives a feeling of being confined
Be aware of the pressure over the distal ulna and check that the fingers and thumb have full range of motion

11. Zipper splint option/ circumferential

12. Features of the wrist immobilization splint
You have to be aware of:
1. Forearm trough
2. Metacarpal bar
3. Hypothenar bar

13. Features of the wrist immobilization splint
The forearm trough should be two thirds of the length of the forearm
One half of the circumference of the forearm to distribute pressure evenly
Be aware that sometime you have to notch over the ulnar styloid to avoid pressure point

14. Features of the wrist immobilization splint
The hypothenar bar helps to place the hand in a neutral position preventing extreme ulnar deviation
Be ware that the hypothenar bar SHOULD NOT limit the MCP flexion of the ring and little finger
The metacarpal bar supports the transverse metacarpal arch
Palmar bar when its on the palmar side only
It is placed proximal to the distal crease and distal and ulnar to the to the thenar crease  to ensure full MCP flexion

15. Features of the wrist immobilization splint
The MP bar should allow complete flexion on the middle, index finger and thumb
When making a dorsal WIS, make the MP proximal to the MCP heads
Straps should be placed on the level of the MP bar, exactly at the level of wrist and at the end of the splint
The larger the strap the better the fit
If you fear of pressure or shear problems, apply padding

16. Diagnostic indications
WIS is prescribed for any condition which requires the wrist to be static
Goals for using the WIS are:
Decrease wrist pain or inflammation
Provide support
Enhancing digital function
Preventing wrist deformity
Minimize pressure on the median nerve
Minimize tension on the involved structures

17. Diagnostic indications
In some cases, a wrist immobilization serial static splint is used to increase PROM
Some indication are (not limited to):
Tendonitis
Distal radius/ulnar fracture
Wrist sprain
Radial nerve palsy
Carpal ganglion
Stable wrist fracture
Wrist arthroplasty
CRPS
Nerve compression (CTS)

18. Diagnostic indications
The specific wrist positioning depends on the diagnostic protocol, physician referral, and the persons treatment goals
You must avoid extreme flexion/extension
They limit function and might lead to CTS
Exception when the goal is to increase PROM
You should perform a hand evaluation, a wearing schedule, instructions and precautions, and exercise protocol

19. Wrist splinting for CTS
Place the wrist as possible to 0 degrees to help avoid pressure on median nerve
Majority may benefit, but some may benefit from 15 degrees of flexion/ extension (Kue et al. 2001)
You should be careful not to prescribe prefabricated splints to CTS (as they put the hand in functional position degrees of extension)
Generally custom made splints are prescribed for patients with CTS as they provide better support, positioning, and allocation of pressure
You should consider the amount of flexion allowed (more flexion can cause more CT pressure (Apfel et. Al 2002))
So the instruction to wear for the patient: “Do NOT flex your fingers beyond 75%”
Consider the occupational demands
Finger flex. Increase carpal pressure
IF symptoms of CTS not improving: Consider splint that block MCP flex to decrease finger flexion

20. Wrist splinting for CTS
All studies indicate the early intervention (conservative methods i.e. splinting, exercise, modification of activities, staying warm) are indicated for CTS
When this does not work, surgery is advised.
The goal of the WIS after surgery is:
Minimize pressure on the median nerve
Prevent bowstringing of the flexor tendons
Provide support during stressful activities
Maintain gains from exercise
Rest the extremity during the healing phase

21. Wrist splinting for CTS
The evidence show that the best time is for 1 week after surgery to prevent nerve entrapment and tendon bowstringing
Postoperatively, WIS is recommended only to prevent extreme nighttime wrist postures
Studies have shown that surgery is better than splinting only, so it is recommended to use the splint if the patient does not desire surgery, or while waiting for it.
Some people do not immobilize after surgery bcz of stiffness. So they start with 1 week then hours only

22. Wrist splinting for radial nerve injuries
RNI occur mainly from fractures of the humeral shaft, fractures and dislocation of the elbow, or compressions on nerves
Classic picture of a radial nerve injury is a wrist drop position where the wrist and MCP’s can’t extend actively
The amount of extension required from the splint is totally up to the therapist and client (according to how much function the patient requires from his hand)
Commonly 30 degrees of extension is considered a position of function as it facilitates grasp and prehension

23. Wrist splinting for tendinitis and tenosynovitis
They are painful conditions that benefit from conservative management
They occur from cumulative and repetitive motions in work, home and leisure activities
This results in an overuse cycle
Friction microscopic tears  pain  limitation in motion  resting in the involved area  avoidance of use  development of weakness
Splinting helps in minimizing friction at the insertion of the muscle

24. Wrist splinting for tendinitis and tenosynovitis
Splints provided during flare-ups are worn continuously followed by gradual weaning
When splinting is for flexor crapiradialis (FCR) tenosynovitis it is recommended that the splint is in neutral position to rest the tendons
Wrist extensor tendinitis can be splinted in 20 to 30 degrees of wrist extension as this provides balance between flexors and extensors

25. Wrist splinting for Rheumatoid arthritis
In functional position
Its challenging because joint tend to move and laxiaty occurs volarly and ulnarly
Material used here should have high drapability to help prevent pressure areas

26. Wrist splints for fractures
Goal is to regain functional wrist extension
Splinting should occur in slight extension to achieve this
It provides protection and low load stress
Serial static splinting may be needed for PROM
The patient should wean away from the splint ASAP to regain function

27. Wrist splints for sprains
WIS help people with grade 1 and II sprains
Grade 1: 3 weeks, grade II: 6 weeks
This splint helps the hand during the acute healing phase and removes stress form the healing ligament

28. Wrist splinting for CRPS
Extreme pain, diffuse edema, stiffness trophic skin changes and discoloration
WIS is used to relief pain, muscle spasm relief, regaining a functional wrist position
Serial static splint maybe needed

29. Fabrication