1. Introduction to Orthotics
Tammy J. LeSage MOT OTR/L, CHT
Elisabeth McGee DPT, MOT, PT, OTR/L, CHT, MTC

2. Guess Who???

3. Splint or Orthosis What are your thoughts about the terms?

4. Why Orthotics for OT?
Uses of Orthoses for OT
How can you use ?

5. Client-Centered Bio-occupational Approach
Rehabilitation of the Hand and Upper Extremity, 2011

6. History of Orthotics Physical rehab – WWII (1939 – 1945)
Sterling Burnell MD
Splints/orthotic devices commercially available – 1940’s
Splints/ orthotic devices for function – 1950’s polio
Low temperature thermoplastics (temps 135 – 180 degrees) 1960’s

7. Anatomical Structures of Importance for Orthotics
Wrist
Digits
Thumb
Muscles and Tendons
Nerve Supply
Blood Supply
Arches of the Hand
Creases of the Hand
Prehension and Grasp Patterns

8. Wrist – Joints and Ligaments
Radiocarpal Joint
Midcarpal Joint
Distal Radioulnar Joint
Ligaments
Intrinsic Ligaments
Extrinsic Ligaments

9. The Hand Examination and Diagnosis, 3rd Ed., 1990

10. The Hand Examination and Diagnosis, 3rd Ed., 1990

11. Digits – MCP, PIP, DIP Joints
Metacarpals – two joints each
Carpal bone articulation
Metacarpophalangeal joints – MCP/ MP joints.
Ligaments
Collateral Ligaments
Volar Plate

12. MCP’s extension = shortening of laxed collateral ligaments – contraction and adherence of volar plate
***Contracture of the MCP’s in extension results in decreased flexion of the MCP’s and decreased function of the hand.

13. Proximal Phalanx & Distal Phalanx
Both are hinge joints – flexion/ extension
Ligaments
Collateral Ligaments
Volar plate

14. The Hand Examination and Diagnosis, 3rd Ed., 1990

15. The PIP joint is very susceptible to adhesion and flexion contracture.
Position of the PIP/ DIP joints to prevent contracture is opposite of MCP joint.
The PIP joint is very susceptible to adhesion and flexion contracture.

16. Safe Position Orthotic Device
MCP flexion with IP (PIP/DIP) extension
Why????
The Hand Examination and Diagnosis, 3rd Ed., 1990

17. To prevent deformity!! Especially if edema is present.
** there are some injuries/ diagnoses that state differently and are exceptions to this

18. Thumb – Joints and Ligaments
Carpometacarpal (CMC) Joint
Metacarpophalangeal (MP) Joint
Interphalangeal (IP) Joint
Ligaments
Collateral ligaments

19. Muscles and Tendons of the Hand
Extrinsic Muscles of the Hand
Intrinsic Muscles of the Hand

20. Extrinsic Muscles of the Hand
Two groups: Extensor muscle group Flexor muscle group
Each has a retinacular system
Extensor retinacular system
Flexor retinacular system
Digital pulley system

21. Extrinsic Extensor Tendons
APL, EPB
ECRL, ECRB
EPL
EDC, EIP
EDM
ECU

22. Extrinsic Flexor Tendons
FDS index – small
FDP index – small
FPL

23. How can this affect design of orthotic device??
What is Tenodesis?
How can this affect design of orthotic device??

24. Decreased wrist motion, due to joint or extrinsic tendons?
How can you evaluate? How would you position in orthotic device to increase motion???

25. Intrinsic Muscles of the Hand
Organize them in three compartments
Thenar eminence
OP, FPB, APB, AP
Hypothenar eminence
ADM, FDM, ODM, PB
Central Compartment
Lumbricals x 4
Interossei – 4 dorsal, 3 palmar

26. What is an intrinsic plus position?
Intrinsic minus hand?
How would you position in orthotic device?

27. Intrinsic Vs Extrinsic Tightness Digits
Extrinsic Flexor Tightness
What is it? How would you position it?
Extrinsic Extensor Tightness
Intrinsic Tightness
What is it? How would you position?

28. Nerve Supply Considerations with Orthotic Devices
Areas of pressure by orthosis upon nerves
Decrease sensation due to peripheral nerve disruption.
Decrease peripheral nerve motor function leading to muscle imbalance and dysfunctional posturing of the hand.

29. Common areas of pressure
When fabricating an orthosis, you want to avoid applying pressure over sites where the nerve is superficial and prone to compression.
Ulnar nerve – a) elbow b) guyon’s canal
Radial nerve – a) elbow b) dorsal/ radial anatomical snuffbox
Digital nerves – lateral borders of fingers and thumb

30. Decrease Sensation Peripheral Nerve Disruption
Sensory Nerve Distribution
Radial, Ulnar, Median Nerves
Care must be taken with orthotic device
Monitor skin, check for area of abrasion or irritation.

31. The Hand Examination and Diagnosis, 3rd Ed., 1990

32. Decreased Peripheral Nerve Motor Function
Leads to muscle imbalance and dysfunctional posturing of the hand.
Radial Nerve – wrist drop, decreases MP extension digits, thumb extension.
How would you position?
Ulnar Nerve – Flat hand, claw hand ring and small fingers
How would you how would you position?
Median nerve – Decreased thumb function

33. The Hand Examination and Diagnosis, 3rd Ed., 1990

34. Radial Nerve Orthosis
Used with permission from Sammons Preston

35. The Hand Examination and Diagnosis, 3rd Ed., 1990

36. Ulnar Nerve Orthosis
Used with permission from Sammons Preston

37. The Hand Examination and Diagnosis, 3rd Ed., 1990

38. Median Nerve Orthosis
Used with permission from Sammons Preston

39. Blood Supply to the Hand
Ulnar Artery, Radial Artery
Superficial Palmar Arch, Deep Palmar Arch
Common digital arteries, digital arteries
Care must be taken when splinting not to compress on arteries to compromise circulation

40. The Hand Examination and Diagnosis, 3rd Ed., 1990

41. Arches of the Hand
The intrinsic musculature has an important relationship with the arches. Collapse of the arches can contribute to severe disability and deformity
Proximal Transverse Arch
Distal row of carpal bones
Fixed arch without much motion
Distal Transverse Arch
Distal palmar crease
Mobile arch
Longitudinal Arch
Longitudinal axis of each finger
Rigid and mobile portions

42. The Hand Examination and Diagnosis, 3rd Ed., 1990

43. Creases of the Hand Distal Digital Crease Middle Digital Crease
Proximal Digital Crease
Distal Palmar Crease
Proximal Plamar Crease
Thenar Crease
Distal Wrist Crease
Proximal Wrist Crease

44. The Hand Examination and Diagnosis, 3rd Ed., 1990

45. Functional Prehension, Grasp Patterns, and Manipulation Skills

46. Functional Prehension Patterns
Prehensile movements: incorporate grasping of an object and can be subdivided into having two purposes, precision grasp and power grasp.
Precision grasp: uses opposition of the thumb to the fingertips
Power grasp: uses the whole hand with thumb flexion or abduction according to the control needed for the task

47. Functional Grip Patterns
A position of the hand that facilitates contact of an object against the palm and palmar surface of the partially flexed digits.
Cylindrical grip
Spherical grip
Hook grip
Intrinsic plus grasp
Disc grasp

48. Manipulation Skills Finger-to-palm translation
Palm-to-finger translation
Shift
Demonstrated when an object that is being held on the radial aspect of the hand is moved linearly on the finger surface in order to reposition it on the finger pads (e.g. repositioning a pen after grasping it)
Rotation
E.g. Rotating a pen to use the eraser
In-hand manipulation with stabilization
E.g. Picking up coins while holding them in their palm