1. Thumb immobilization splints Somaya Malkawi, PhD

2. Introduction The most common thumb splint is the thumb palmar abduction immobilization splint (Thumb Spica, short/long opponens splint or thumb gauntlet splint) The most common thumb splint is the thumb palmar abduction immobilization splint (Thumb Spica, short/long opponens splint or thumb gauntlet splint) The purpose is to immobilize, protect, rest and position one, two or all of the thumb CMC, MCP and IP joints while allowing other digits to be free The purpose is to immobilize, protect, rest and position one, two or all of the thumb CMC, MCP and IP joints while allowing other digits to be free

3. Introduction TIS are divided into: TIS are divided into: 1.Forearm based splints 2.Hand based splints Forearms based- and hand splints are used to help manage different conditions that affect the thumb Forearms based- and hand splints are used to help manage different conditions that affect the thumb F-TIS: Stabilizing the wrist is beneficial for a painful wrist as the splint provides support F-TIS: Stabilizing the wrist is beneficial for a painful wrist as the splint provides support

6. Introduction FTIS  people who have de Quervain’s tenosynovitis will benefit from it which provides rest, support, protection of the tendons across the radial side of the wrist into the thumb joint FTIS  people who have de Quervain’s tenosynovitis will benefit from it which provides rest, support, protection of the tendons across the radial side of the wrist into the thumb joint FTIS  after joint arthrodesis or dislocation, post surgery RA FTIS  after joint arthrodesis or dislocation, post surgery RA HTIS  Muscle imbalance after median nerve injury to maintain the web space HTIS  Muscle imbalance after median nerve injury to maintain the web space HTIS is also used to position the thumb before surgery HTIS is also used to position the thumb before surgery

7. Functional and anatomic considerations for thumb splinting The thumb is essential for hand functioning (grip, pinch and fine manipulation) The thumb is essential for hand functioning (grip, pinch and fine manipulation) High mobility due to being a saddle joint High mobility due to being a saddle joint Sensory input of the tip of thumb is essential Sensory input of the tip of thumb is essential You have to understand that the most crucial aspect of the TIS is the CMC joint (because it allows opposition and abduction) You have to understand that the most crucial aspect of the TIS is the CMC joint (because it allows opposition and abduction)

8. Features of the TIS TIS prevents motion for one, two or all thumb joints TIS prevents motion for one, two or all thumb joints Numerous designs: Numerous designs: It can be volar, dorsal or radial.. See fig 8- 1, 8-2, 8-3 It can be volar, dorsal or radial.. See fig 8- 1, 8-2, 8-3

9. Features of the TIS Usually the C bar and thumb are in some degree of palmar abduction Usually the C bar and thumb are in some degree of palmar abduction The Thumb post could The Thumb post could immobilize the MP joint alone or with the IP joint The position of the thumb The position of the thumb varies according to the diagnosis, (palmar/ radial Abduction) Opponens bar C bar Thumb post

10. Features of the TIS The TIS may do one of the following: The TIS may do one of the following: 1. Stabilize only the CMC joint 2. Include the CMC and MP joint 3. Encompass the CMC MCP and IP joints The Judgment goes back to you! You should fabricate a splint which gives the MOST support with the LEAST movement restriction The Judgment goes back to you! You should fabricate a splint which gives the MOST support with the LEAST movement restriction IP included: thumb replantation, tendon transfer, tendon repair IP included: thumb replantation, tendon transfer, tendon repair

11. Diagnostic indications TIS are prescribed for (but not limited to): scaphoid fractures of the proximal phalanx of the 1 st MC, tendon transfers, radial or ulnar collateral ligament strains, repair of the MCP joint collateral ligaments, RA, OA, de Quervian’s tenosynovitis, median nerve injuries, MCP joint dislocations, capsular tightness of the MCP and IP joints after trauma, posttraumatic adduction contracture, extrinsic flexor or extensor muscle contracture, FPL repair, uncomplicated EPL repairs, hypertonicity, and congenital adduction deformity of the thumb TIS are prescribed for (but not limited to): scaphoid fractures of the proximal phalanx of the 1 st MC, tendon transfers, radial or ulnar collateral ligament strains, repair of the MCP joint collateral ligaments, RA, OA, de Quervian’s tenosynovitis, median nerve injuries, MCP joint dislocations, capsular tightness of the MCP and IP joints after trauma, posttraumatic adduction contracture, extrinsic flexor or extensor muscle contracture, FPL repair, uncomplicated EPL repairs, hypertonicity, and congenital adduction deformity of the thumb

13. Splinting for De Quervain’s Tenosynovitis It results from repetitive thumb motion and wrist ulnar deviation It results from repetitive thumb motion and wrist ulnar deviation Affects the AbPL and EPB muscles in the first dorsal compartment Affects the AbPL and EPB muscles in the first dorsal compartment

14. Splinting for De Quervain’s Tenosynovitis How did this condition develop? Repeatedly performing wrist deviation and thumb motions such as grasping, pinching, squeezing, or wringing (construction: painting, scraping, hammering) may lead to the inflammation of tenosynovitis. This inflammation can lead to swelling, which hampers the smooth gliding action of the tendons within the tunnel. Arthritic diseases also cause tenosynovitis in the thumb Forearm based TIS

15. Splinting for De Quervain’s Tenosynovitis During the acute phase  immobilization of the thumb and the wrist for symptom control  wrist extension thumb CMC palmar abduction and MP flexion IS During the acute phase  immobilization of the thumb and the wrist for symptom control  wrist extension thumb CMC palmar abduction and MP flexion IS Wrist in 15 extension Wrist in 15 extension Neutral wrist deviation Neutral wrist deviation 40-45 degrees of palmar abduction of the CMC thumb joint 40-45 degrees of palmar abduction of the CMC thumb joint 5- 10 degrees of flexion in the MP joint 5- 10 degrees of flexion in the MP joint IP free, unless patient overuses thumb or fights the splint IP free, unless patient overuses thumb or fights the splint Continuous wearing with removal for hygiene and exercise within a pain free range Continuous wearing with removal for hygiene and exercise within a pain free range A prefabricated splint is indicated when pain subsides for sport and work activities A prefabricated splint is indicated when pain subsides for sport and work activities Post surgical management, same splint worn for 7-10 days Post surgical management, same splint worn for 7-10 days

16. Splinting for RA and OA RA often affects the thumb joints (CMC and MCP) RA often affects the thumb joints (CMC and MCP) splint reduces pain, slows deformity and stabilizes the joints splint reduces pain, slows deformity and stabilizes the joints RA involves three stages: RA involves three stages: 1. The inflammatory stage: splinting is used for resting the joint and reduce inflammation 2. Disease progression, help the stability of painful moving joints during activities 3. Grossly deformed splints, aid in putting the hand in a more functional position

17. Splinting for RA and OA The best splint during the periods on inflammation is: Forearm based TIS The best splint during the periods on inflammation is: Forearm based TIS immobilizing the thumb in a forearm based splint, with wrist in 20-30 degrees of extension, CMC in 45 degrees of palmar abduction or midway, MCP in 5 flexion immobilizing the thumb in a forearm based splint, with wrist in 20-30 degrees of extension, CMC in 45 degrees of palmar abduction or midway, MCP in 5 flexion “wrist extension thumb CMC palmar abduction and MP flexion immobilization splint!”

18. Splinting for RA and OA You should always fabricate a splint in a position of comfort You should always fabricate a splint in a position of comfort Use 1.8 mm or less material Use 1.8 mm or less material Watch out for bony prominences such as ulnar head radial styloid, scaphoid and pisiform bones Watch out for bony prominences such as ulnar head radial styloid, scaphoid and pisiform bones

19. Splinting for RA and OA CMC OA is a common thumb condition CMC OA is a common thumb condition Causes subluxation of the joint radially and dorsally  loss of extension compensated by adduction Causes subluxation of the joint radially and dorsally  loss of extension compensated by adduction In this case, splinting is used to manage pain, provides stability and preservation of the web space In this case, splinting is used to manage pain, provides stability and preservation of the web space Hand based TIS Hand based TIS

20. Splinting for ulnar collateral ligament injury A common injury that occurs at the thumb A common injury that occurs at the thumb Gamekeepers or skier’s thumb Gamekeepers or skier’s thumb The UCL helps stabilize the thumb by resisting radial stresses across the MCP joint The UCL helps stabilize the thumb by resisting radial stresses across the MCP joint The UCL is injured when the thumb is forcefully abducted or The UCL is injured when the thumb is forcefully abducted or hyperextended hyperextended

21. Splinting for ulnar collateral ligament injury Injuries are classified to I, II, III Injuries are classified to I, II, III For level I: hand based TIS with the CMC in 30-40 degrees of palmar abduction with MCP in neutral or slight flexion (3-4 weeks) For level I: hand based TIS with the CMC in 30-40 degrees of palmar abduction with MCP in neutral or slight flexion (3-4 weeks) For level II: same as above but worn for 4-5 weeks For level II: same as above but worn for 4-5 weeks For level III: requires surgery For level III: requires surgery

22. Splinting for scaphoid fractures Second most common fracture Second most common fracture Comes from falling on an outstretched hyperextended/ dorsiflexed hand more 90 degrees Comes from falling on an outstretched hyperextended/ dorsiflexed hand more 90 degrees If a result of a sports injury  volar FB-TIS If a result of a sports injury  volar FB-TIS

23. Splinting for scaphoid fractures VF-TIS VF-TIS Thumb in palmar abd Thumb in palmar abd MCP in 0 -10 flex MCP in 0 -10 flex Wrist in slight flex and radial dev or neutral depending on the physician preference Wrist in slight flex and radial dev or neutral depending on the physician preference

24. Splinting for Hypertonocity Thumb loop Thumb loop Figure of 8 thumb wrap Figure of 8 thumb wrap