Getting the Upper Hand

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October 2001

By Romina P. Astifidis, MS, PT, CHT

Romina P. Astifidis, MS, PT, CHT, fabricates a thumb spica splint.

The use of splints/orthoses in the treatment of upper extremity injuries is an integral and necessary part of rehabilitation. As the specialization of hand therapy has evolved, so have the fabrication and use of splints. The physician and upper extremity therapist may use a splint for a variety of reasons including immobilization/protection, mobilization, or as a means to increase function. During the rehabilitation process, the use of a splint may change. It may go from being a protective or supportive device to being one that enhances motion or function.¹

Splinting is a skill learned through a variety of venues. Some therapists learn the basics of splinting through graduate schooling. Other therapists learn from the multitude of books and articles written on the subject, or from a combination of mentoring, continuing education, and trial and error. However, every therapist must begin with a good knowledge of upper extremity anatomy and a thorough understanding of the purpose and the function of the splint.¹ This knowledge is critical because a splint, no matter its purpose, will inhibit free movement and use of the hand, and may potentially do harm if used inappropriately.²

Following receipt of a splint prescription, the therapist should perform a thorough evaluation of the patient to identify what issues need to be addressed with the splint. This evaluation will help the development of a splint design and may also help the therapist decide what material to use for the splint, as well as whether the splint will be static or dynamic. Pattern designs are modified or adjusted to suit the particular needs of the patient.¹ For example, the splint can be made volar, dorsal, or circumferential depending on factors including whether the palm needs to be free for function, a wound needs to be protected, or the fracture site requires total immobilization.

The therapist also needs to decide on the type of thermoplastic material to use. Thermoplastic material is available in different thickness, memory (ability to return to original shape and size), drape (ability to conform to the hand with gravity), and resistance to stretch. A thinner material may be more appropriate for a finger, or for a circumferential design. A thicker, less elastic thermoplast may be more appropriate for a patient with neurological tone or weakness. Patients must understand the purpose and correct usage of the splint as this knowledge improves patient compliance. Other critical issues for patient compliance include a comfortable fit, functional positioning, and ease of donning and doffing.¹ Initiating the use of a splint and the type of splint made often depend on the physician and the type of injury or surgical procedure performed.¹ However, the therapist may recommend a splint depending on clinical need. For example, a patient with a healed wrist fracture currently using a static splint whose range of motion is not improving with just exercises may benefit from a static progressive or dynamic splint to increase wrist flexion or extension.

One of the main purposes of splinting is to immobilize or protect. During the inflammatory and early fibroblastic stages of healing, splints can immobilize the injured area to allow healing, and be removed for basic hygiene and wound care, which can be a major advantage over a cast.³ Splints are also used to immobilize the limb in the treatment of infections and after trauma or surgery.⁴ The grossly swollen, stiff infected hand that needs to be rested and positioned in an antideformity position to inhibit nonfunctional positioning is a good example.

Astifidis disccusses the splint's role in the stages of healing with a patient.

For newly repaired tissues such as tendons, nerve, and ligaments, splints can be used to maintain the limb in an optimal position for protection.4 In this case, the splint will also allow the patient to perform exercises that would promote better healing of the repaired area and allow the uninvolved fingers to be mobile.³ Splints can also be used to protect paralyzed or noninnervated muscle to allow rest and avoid overstretch.4 This helps maintain a normal muscle length so that when the nerve reinnervates the muscle, it will be better able to function.⁴

Splints offer a lightweight and adjustable alternative to casting and have been effectively used in fracture bracing. The bracing of long bone fractures uses a cylindrical-shaped splint to restrain muscle expansion, therefore directing force at the fracture site. This force stabilizes and compresses the fracture but allows the joints around the fracture site to move, decreasing contractures and stiffness.⁵ For patients with painful arthritic changes, splints function to rest the inflamed joint, as well as provide visual reminders to the patient to avoid painful activities.⁶ For these same patients, the splint can provide force to stabilize loose or unstable joints, therefore allowing continued function, for example, the hand- or forearm-based thumb spica splint, which is often used in the treatment of carpometacarpal arthritis. According to a study by Swigart et al,⁶ a forearm-based thumb spica splint can be used as a conservative initial treatment by the physician and can provide enough reduction in symptoms to avoid or postpone surgical reconstruction.

Therapists often use dynamic or static progressive splinting to provide motion to a joint(s). If a patient is unable to achieve motion with exercises and functional use, a mobilizing splint that uses the patient's own muscle power or rubber band/spring/static tension can be indicated. An example of a splint that uses the patient's muscle power is a dynamic extension splint for metacarpophalangeal joint replacement. This splint allows the patient to actively flex fingers for fisting, but assists the fingers into extension to protect the newly repaired extensor mechanism.

Dynamic splints use some additional component (springs, wires, rubber bands) to mobilize contracted joints. This dynamic pull functions to provide a controlled gentle force to the soft tissue over long periods of time, which encourages tissue remodeling without tearing.3 The issues that make dynamic or static progressive splinting technically difficult include determining how much force to use, how to apply the force, how long to apply the force, and how to prevent added injury to the area.²

The keys to making an effective mobilizing splint include: keeping the mobilizing pressure consistent over the area being stretched to prevent ischemia and pain at the skin site, using minimal force needed to achieve motion, maintaining mobilization for enough time to promote lengthening of the tissue at a cellular level, and balancing splint time with normal functional use. A proximal interphalangeal joint (PIPJ) flexion splint provides a static pull using a loop and nylon monofilament to flex the PIPJ. The patient may wear this splint with minimal tension for 5-30 minutes several times a day, followed by active motion and functional use of the involved joint.

Recent advancements in splinting have been related to improved splint materials, improved understanding of hand mechanics as related to splints, and continued research and publication of new and improved splinting techniques. Companies that provide splinting materials to therapists have manufactured different kinds of thermoplastics as well as precut patterns to allow ease of fabrication. Dynamic components and strapping can be purchased in kits or preassembled to improve the efficiency and speed of the therapist. Therapists have also increased their use of neoprene either with or without thermoplastic inserts to form semirigid splints that are more comfortable and more functional. In response to the widespread use of splints, more research is being done on the most efficient way to splint. New designs allow for smaller, less cumbersome splints that provide the same results and improve compliance. Continuing education and Internet usage have allowed therapists to network and share efficient designs for splints.

Splinting is one of the most versatile tools that upper extremity therapists can use. Because of their multiple purposes and functions, splints will continue to be a critical part in the rehabilitation process for upper extremity injuries.

References
1. Tenney CG, Lisak JM. Atlas of Hand Splinting. Boston: Little, Brown and Company; 1986:ix-x.
2. Brand PW. The forces of dynamic splinting: ten questions before applying a dynamic splint to the hand. In: Hunter JM, ed. Rehabilitation of the Hand: Surgery and Therapy. 4th ed. St Louis: Mosby; 1995:1581-1588. 3. Fess E, McCollum M. The influence of splinting on healing tissues. J Hand Ther. 1998;11:157-161.
4. Bunnell S. Splinting the hand. Hand Clin. 1996;12:173-9.
5. Colditz JC. Functional fracture bracing. In: Hunter JM, ed. Rehabilitation of the Hand: Surgery and Therapy. 4th ed. St Louis: Mosby; 1995:395-408.
6. Swigart C, Eaton R, Glickel SZ, Johnson C. Splinting in the treatment of arthritis of the first carpometacarpal joint. J Hand Surg [Am]. 1999;24:86-91.

Romina P. Astifidis, MS, PT, CHT, is a senior physical therapist at Curtis National Hand Center, Lutherville, Md.

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October 2001