Introduction to Orthotics

Tammy J. LeSage MOT OTR/L, CHT

Elisabeth McGee DPT, MOT, PT, OTR/L, CHT, MTC

Guess Who???

Splint or Orthosis What are your thoughts about the terms?

http://www.asht.org/practice/l-codes

Why Orthotics for OT?Uses of Orthoses for OT

How can you use ?

Client-Centered Bio-occupational Approach

Rehabilitation of the Hand and Upper Extremity, 2011

History of OrthoticsPhysical rehab – WWII (1939 – 1945)Sterling Burnell MDSplints/orthotic devices commercially

available – 1940’sSplints/ orthotic devices for function –

1950’s polioLow temperature thermoplastics

(temps 135 – 180 degrees) 1960’s

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

Wrist – Joints and LigamentsJoints

Radiocarpal Joint Midcarpal Joint Distal Radioulnar Joint

Ligaments Intrinsic Ligaments Extrinsic Ligaments

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

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

Digits – MCP, PIP, DIP JointsMetacarpals – two joints each

Carpal bone articulation Metacarpophalangeal joints – MCP/ MP

joints.Ligaments

Collateral Ligaments Volar Plate

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.

Proximal Phalanx & Distal PhalanxBoth are hinge joints – flexion/

extensionLigaments

Collateral Ligaments Volar plate

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

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.

Safe Position Orthotic Device

MCP flexion with IP (PIP/DIP) extension

Why????

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

To prevent deformity!! Especially if edema is present.

** there are some injuries/ diagnoses that state differently and are exceptions to this

Thumb – Joints and LigamentsJoints

Carpometacarpal (CMC) Joint Metacarpophalangeal (MP) Joint Interphalangeal (IP) Joint

Ligaments Collateral ligaments

Muscles and Tendons of the Hand

Extrinsic Muscles of the Hand Intrinsic Muscles of the Hand

Extrinsic Muscles of the HandTwo groups: Extensor muscle group

Flexor muscle group

Each has a retinacular system

Extensor retinacular system Flexor retinacular system Digital pulley system

Extrinsic Extensor TendonsAPL, EPBECRL, ECRBEPLEDC, EIPEDMECU

Extrinsic Flexor Tendons

FDS index – smallFDP index – smallFPL

What is Tenodesis?

How can this affect design of orthotic device??

Decreased wrist motion, due to joint or extrinsic tendons?

How can you evaluate? How would you position in orthotic device to increase motion???

Intrinsic Muscles of the HandOrganize 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

What is an intrinsic plus position?

Intrinsic minus hand?

How would you position in orthotic device?

Intrinsic Vs Extrinsic Tightness DigitsExtrinsic Flexor Tightness

What is it? How would you position it?Extrinsic Extensor Tightness

What is it? How would you position it? Intrinsic Tightness

What is it? How would you position?

Nerve Supply Considerationswith 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.

Common areas of pressureWhen 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

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.

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

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 How would you position?

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

Radial Nerve Orthosis

Used with permission from Sammons Preston

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

Ulnar Nerve Orthosis

Used with permission from Sammons Preston

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

Median Nerve Orthosis

Used with permission from Sammons Preston

Blood Supply to the HandUlnar Artery, Radial ArterySuperficial Palmar Arch, Deep Palmar

ArchCommon digital arteries, digital arteriesCare must be taken when splinting not

to compress on arteries to compromise circulation

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

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

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

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

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

Functional Prehension, Grasp Patterns, and Manipulation Skills

Functional Prehension PatternsPrehensile 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

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

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