Pediatric SplintingPediatric Splinting

ObjectivesObjectives

At the end of the lecture the student will:At the end of the lecture the student will:» Understand the history of splintingUnderstand the history of splinting

» Understand classification and nonmenclature of Understand classification and nonmenclature of splints and splint components.splints and splint components.

» Understand the mechanical, design, construction, fit Understand the mechanical, design, construction, fit principles of splinting.principles of splinting.

» Understand the goals of splinting a pediatric patient. Understand the goals of splinting a pediatric patient.

» Understand specific splints used with patients Understand specific splints used with patients diagnosed with JRA.diagnosed with JRA.

Definition and Purpose of Definition and Purpose of SplintingSplinting

Splint, brace or orthosis-terms are many Splint, brace or orthosis-terms are many times used interchangeably.times used interchangeably.

– Rationale for splinting application:Rationale for splinting application:1)1) Increase functionIncrease function

2)2) Prevent deformityPrevent deformity

3)3) Correct deformityCorrect deformity

4)4) Protect healing structuresProtect healing structures

5)5) Restrict motionRestrict motion

6)6) Allow tissue growth or remodelingAllow tissue growth or remodeling

Functional Splint

Prevent Deformity; Functional

Correct deformity; Protect healing structures; Functional

Protect Healing Structures; Prevent deformity

Restrict Motion; increase function; protect; prevent deformity

General HistoryGeneral History

In early years, splints were used to immobilize In early years, splints were used to immobilize fractures.fractures.– Splints were made from bamboo sticks,leaves, rods, Splints were made from bamboo sticks,leaves, rods,

and bark padded with linen.and bark padded with linen.

– In medieval times (1000 AD) plaster-like substances In medieval times (1000 AD) plaster-like substances were made from flour dust and egg whites, and were made from flour dust and egg whites, and vegetable concoctions were made of gummastic, clay, vegetable concoctions were made of gummastic, clay, pulped fig, and poppy leaves.pulped fig, and poppy leaves.

– The Aztecs (1400 AD) made use of wooden splints and The Aztecs (1400 AD) made use of wooden splints and large leaves held in place by leather strapslarge leaves held in place by leather straps

Continue with HistoryContinue with History

By 1517-joint contractures were treated with turn-By 1517-joint contractures were treated with turn-buckle and screw-driven metal splintsbuckle and screw-driven metal splints

By 1592-armor-based splints were designed.By 1592-armor-based splints were designed. 17501750’’s-1850s-1850’’s-surgeons worked closely together s-surgeons worked closely together

with appliance makers, or mechanics to design and with appliance makers, or mechanics to design and build custom braces and splints.build custom braces and splints.

Early 1900Early 1900’’s plaster of paris was widely used.s plaster of paris was widely used.

2020thth Century Century

1924-the 1924-the ““functionalfunctional”” splint or position for splint or position for hand infections was advocated.hand infections was advocated.

The use of Plastic Materials for The use of Plastic Materials for SplintingSplinting

Late 1930Late 1930’’s-early 1940s-early 1940’’s-high temperature s-high temperature thermosetting materialthermosetting material

Late 1960Late 1960’’s-early 1970s-early 1970’’s-low temperature s-low temperature thermoplastic materialthermoplastic material

Mid-late 1970Mid-late 1970’’s-Polyform and Aquaplasts-Polyform and Aquaplast Early 1990Early 1990’’s splinting material proliferation s splinting material proliferation

took offtook off

History-ConclusionHistory-Conclusion

Between 1967 and 1971-publications, seminars, Between 1967 and 1971-publications, seminars, and grants significantly affected splinting practice and grants significantly affected splinting practice in terms of therapist being involved in an evolving in terms of therapist being involved in an evolving field of expertise.field of expertise.

By the 1970By the 1970’’s therapists enthusiastically embraced s therapists enthusiastically embraced splinting. Splinting vs. orthoticssplinting. Splinting vs. orthotics

Therapists started building tighter and tighter Therapists started building tighter and tighter alliances with physicians, ASHT was formed, alliances with physicians, ASHT was formed, hand certification took holdhand certification took hold

Splinting was the impetus for opening many doors Splinting was the impetus for opening many doors for therapists today.for therapists today.

Anatomy and KinesiologyAnatomy and Kinesiology

As therapistAs therapist’’ splinting the upper and lower splinting the upper and lower extremity, it is imperative to have a extremity, it is imperative to have a working knowledge of anatomy and working knowledge of anatomy and kinesiology.kinesiology.

Anatomy of the forearm, wrist and hand is Anatomy of the forearm, wrist and hand is essentialessential

Why is it important to understand Why is it important to understand Anatomy?Anatomy?

The application of an external device on a The application of an external device on a body part may change the dynamics of the body part may change the dynamics of the working or non-working system. As working or non-working system. As therapists, we need to know what those therapists, we need to know what those changes can and will be.changes can and will be.

Anatomy we need to knowAnatomy we need to know

Skeletal structuresSkeletal structures JointsJoints Musculotendinous unitsMusculotendinous units Blood supplyBlood supply Nerve supplyNerve supply Surface anatomySurface anatomy Tissue RemodelingTissue Remodeling

Quick ReviewQuick Review

Extensor Tendons of the hand

Flexor muscles and tendons

Arteries of the hand Veins of the hand

Nerves of the hand

Peripheral Nerve Distribution and Dermatomes

Surface Anatomy

Splint Classification and Splint Classification and NomenclatureNomenclature

S p lin t C la ss ifica tio n S ys tem

type

Im m ob i liza tion

type

m ob i liza tion

type

re str ict ion

type

T o rq ue tra nsm ission

D ire ction

L oca tion

A r ticu la r

L oca tion

N on -a r ticu la r

S p lin ts/o r th os is

Upper Extremity AssessmentUpper Extremity Assessment

PosturePosture Skin and Skin and

Subcutaneous tissueSubcutaneous tissue BoneBone JointJoint Muscle and TendonMuscle and Tendon NerveNerve Vascular statusVascular status FunctionFunction

EdemaEdema ROMROM Muscle strengthMuscle strength SensationSensation PainPain Grip and pinch strengthGrip and pinch strength Coordination and Coordination and

dexteritydexterity ADLADL’’ss Patient satisfactionPatient satisfaction

Splint Evaluation CriteriaSplint Evaluation Criteria

NeedNeed Design/PatternDesign/Pattern MechanicsMechanics ConstructionConstruction FitFit Client EducationClient Education

General Design PrinciplesGeneral Design Principles

Patient factorsPatient factors Length of time splint will Length of time splint will

be usedbe used Strive for simplicity and Strive for simplicity and

pleasing appearancepleasing appearance Allow optimal function of Allow optimal function of

extremityextremity Allow optimal sensationAllow optimal sensation Allow for efficient Allow for efficient

construction and fitconstruction and fit Provide for ease of Provide for ease of

application and removalapplication and removal

Consider Consider splint/exercise splint/exercise regimenregimen

Patient-associated risk Patient-associated risk factorsfactors

Specific Design PrinciplesSpecific Design Principles

Age, intellect, Age, intellect, location,economic status, location,economic status, general health, lifestylegeneral health, lifestyle

Identify primary joint segmentsIdentify primary joint segments Determine kinematic directionDetermine kinematic direction Purpose, immobilization, Purpose, immobilization,

mobilization, restriction, torque mobilization, restriction, torque transmissiontransmission

Identify secondary jointsIdentify secondary joints Determine if wrist, forearm, Determine if wrist, forearm,

and/or elbow should be and/or elbow should be includedincluded

Adapt for anatomic variablesAdapt for anatomic variables Integrate medical and surgical Integrate medical and surgical

intervention variablesintervention variables Use mechanical principles-Use mechanical principles-

length/width/sizelength/width/size Consider kinetic effects-altered Consider kinetic effects-altered

forcesforces Decide whether or not to employ Decide whether or not to employ

inelastic or elastic forcesinelastic or elastic forces Determine surface for splint Determine surface for splint

applicationapplication Identify insensate areasIdentify insensate areas Choose appropriate materialChoose appropriate material

Fit PrinciplesFit Principles

Mechanical considerationsMechanical considerations Anatomic considerationsAnatomic considerations

– Adapt to skin/soft tissue Adapt to skin/soft tissue alterationsalterations

– Use skin crease as Use skin crease as boundariesboundaries

– Mechanical principles to Mechanical principles to protect skin/soft tissueprotect skin/soft tissue

» Reduce pressureReduce pressure» Eliminate shear and Eliminate shear and

frictionfriction» Protect bone prominencesProtect bone prominences» Use optimum leverageUse optimum leverage

Maintain archesMaintain arches Consider ligamentous Consider ligamentous

stressstress Use optimal rotational Use optimal rotational

forceforce Align splint forces to joint Align splint forces to joint

rotational axis and bone rotational axis and bone longitudinal axislongitudinal axis

Consider vascular and Consider vascular and neural statusneural status

Consider kinematicsConsider kinematics

Technical considerations to fit Technical considerations to fit principlesprinciples

Develop patient rapportDevelop patient rapport Work efficientlyWork efficiently If your pattern fits, your splint will fitIf your pattern fits, your splint will fit Change method according to properties of Change method according to properties of

materials usedmaterials used Adapt prefabricated splints when Adapt prefabricated splints when

appropriateappropriate Assessed finished splintAssessed finished splint

Construction PrinciplesConstruction Principles

Strive for good cosmetic effectStrive for good cosmetic effect Match material to construction Match material to construction

circumstancescircumstances Use equipment appropriate to Use equipment appropriate to

materialmaterial Use type of heat and Use type of heat and

temperature appropriate to temperature appropriate to materialmaterial

– Wet/dryWet/dry Use safety and ergonomic Use safety and ergonomic

precautions and work efficiencyprecautions and work efficiency

Consider information data Consider information data on material safety data on material safety data sheetssheets

Round corners and smooth Round corners and smooth edgesedges

Analyze and integrate Analyze and integrate effective mechanical effective mechanical principlesprinciples

Stabilize joined surfacesStabilize joined surfaces Provide ventilation as Provide ventilation as

necessarynecessary Secure padding and strapsSecure padding and straps

Mechanical PrinciplesMechanical Principles

Understand basic force Understand basic force systemssystems– Increase area of force Increase area of force

applicationapplication– Increase mechanical Increase mechanical

advantageadvantage– Use optimal rotational Use optimal rotational

forceforce– Consider torque effectConsider torque effect– Control reaction effect Control reaction effect

of secondary jointsof secondary joints

– Consider reciprocal parallel Consider reciprocal parallel forcesforces

– Use appropriate outrigger Use appropriate outrigger systemssystems

– Increase material strength Increase material strength by contouringby contouring

– Eliminate frictionEliminate friction

– Avoid high shear stressAvoid high shear stress

Goals for Pediatric SplintingGoals for Pediatric Splinting

Maximize hand functionMaximize hand function Provide protection and support Provide protection and support

to weak muscles and jointsto weak muscles and joints Provide proximal support and Provide proximal support and

stability for improved distal stability for improved distal functionfunction

Normalize toneNormalize tone Provide positioning of a joint, Provide positioning of a joint,

which allows overall limb use which allows overall limb use and improved body movement and improved body movement and functionand function

Compensate for muscle Compensate for muscle imbalanceimbalance

Substitute for muscles that are Substitute for muscles that are not functionalnot functional

Increase joint ROMIncrease joint ROM Improve joint alignmentImprove joint alignment Decrease edemaDecrease edema Prevent/ or correct deformityPrevent/ or correct deformity Make skin care/hygiene easierMake skin care/hygiene easier Assist in task performanceAssist in task performance

Pediatric conditions that might Pediatric conditions that might require splintingrequire splinting

CPCP HemiplegiaHemiplegia QuadriplegiaQuadriplegia Duchene MDDuchene MD Rett SyndromeRett Syndrome PolioPolio Thumb hypoplasiaThumb hypoplasia JRAJRA Thumb duplicationThumb duplication MyelodysplasiaMyelodysplasia

Radial or Ulnar deficiencyRadial or Ulnar deficiency Ostiogenesis imperfectaOstiogenesis imperfecta Charcot-marie-tooth Charcot-marie-tooth

diseasedisease ArthogryposisiArthogryposisi Brachial plexus palsyBrachial plexus palsy Radial ulnar synostosisRadial ulnar synostosis BrachydactylyBrachydactyly CamptodactylyCamptodactyly ClinodactylyClinodactyly

Neonatal Splinting and Positioning

Neonatal Splinting and positioning

Ideas to consider and aid in splint Ideas to consider and aid in splint construction for childrenconstruction for children

Muscle toneMuscle tone Presence of primitive reflexesPresence of primitive reflexes Splint sizeSplint size Short attention spanShort attention span Lack of ability or desire to cooperateLack of ability or desire to cooperate May want to make splint with two May want to make splint with two

therapiststherapists Functional hand positionFunctional hand position

Splint consideration for AdultsSplint consideration for Adults

What is the purpose of the splint?What is the purpose of the splint? Protect healing structures: follow specific Protect healing structures: follow specific

protocolprotocol Increase function: wearing time according Increase function: wearing time according

to patient needsto patient needs Correct deformity: wearing time according Correct deformity: wearing time according

to deficitto deficit

Materials to useMaterials to use

Rubber-based thermoplastic-very easy to work with-good Rubber-based thermoplastic-very easy to work with-good with spasticity-good for larger splints- not very durablewith spasticity-good for larger splints- not very durable

Plastic-based thermoplastic-good conformability-difficult Plastic-based thermoplastic-good conformability-difficult with spasticity or difficult behaviors-not great for beginner with spasticity or difficult behaviors-not great for beginner therapiststherapists

Elastic-based thermoplastic-good for serial splinting-very Elastic-based thermoplastic-good for serial splinting-very durabledurable

Rubber-plastic-based thermoplastic-not good fro increased Rubber-plastic-based thermoplastic-not good fro increased tonetone

NeopreneNeoprene ElastomerElastomer

Ideas to assist with wearing Ideas to assist with wearing compliance for childrencompliance for children

Make wearing schedule compatible Make wearing schedule compatible to childto child’’s typical routine and if s typical routine and if appropriate protocolappropriate protocol

Provide information to care giver Provide information to care giver about the application of the splint about the application of the splint and wearing time and useand wearing time and use

Let child pick color of material Let child pick color of material and/or straps if possibleand/or straps if possible

Decorate splintDecorate splint Call the splint a Call the splint a ““funfun”” name i.e.; a name i.e.; a

neoprene splint can be called a neoprene splint can be called a ““scuba divers glovescuba divers glove””

Donning on and off (depends on Donning on and off (depends on

the purposethe purpose of splint)of splint)

Issue bilateral hand-based neoprene Issue bilateral hand-based neoprene splints splints

Splint a teddy bear or doll so child Splint a teddy bear or doll so child can don and doff on their toy when can don and doff on their toy when they have to wear theirsthey have to wear theirs

Have child decorate splint with Have child decorate splint with stickers or markersstickers or markers

Provide written and verbal Provide written and verbal instructions to care giverinstructions to care giver

Label splint R or LLabel splint R or L

Precautions to remember for Precautions to remember for childrenchildren

Make sure object adhered to splint are not too small Make sure object adhered to splint are not too small for child to swallowfor child to swallow

Make sure splinting material is not too hot for Make sure splinting material is not too hot for patientpatient’’s skins skin

Patient who might be tactile defensivePatient who might be tactile defensive Avoid glues or adhesives that may be toxicAvoid glues or adhesives that may be toxic Allergies to latex-high risk groups: myelodysplasia Allergies to latex-high risk groups: myelodysplasia

or spina bifida; CP; bladder extrophy (reaction will or spina bifida; CP; bladder extrophy (reaction will be rash, hives, edema, watery eyes, and respiratory be rash, hives, edema, watery eyes, and respiratory symtoms)symtoms)

Should not use outriggersShould not use outriggers

Common problems associated with Common problems associated with splinting the pediatric patientsplinting the pediatric patient

Elbow flexionElbow flexion Limited supinationLimited supination Wrist flexionWrist flexion Ulnar or radial deviationUlnar or radial deviation Thumb in palm positioningThumb in palm positioning Hand fistingHand fisting Difficulty weight bearingDifficulty weight bearing Inability to graspInability to grasp Difficulty with finger isolation tasksDifficulty with finger isolation tasks

General types of pedi splintsGeneral types of pedi splints

Elbow extension for elbow contracturesElbow extension for elbow contractures Supination positioning splint/strappingSupination positioning splint/strapping Wrist extensionWrist extension Ulnar gutterUlnar gutter Thumb spicaThumb spica Thumb opponensThumb opponens Anti-spasticityAnti-spasticity Weight bearing splintsWeight bearing splints Functional handFunctional hand

Functional Functional ““safesafe”” resting hand resting hand Splint or Intrinsic Plus PositionSplint or Intrinsic Plus Position– Functional or Functional or ““safesafe”” position to protect: position to protect:

» Traumatic hand (burn; crush; infection):Traumatic hand (burn; crush; infection): Wrist: 30-35 wrist extensionWrist: 30-35 wrist extension MCP: 60-90 flexionMCP: 60-90 flexion IPIP’’s: 0 extensions: 0 extension Thumb: between palmar abduction and oppositionThumb: between palmar abduction and opposition

Functional Resting Hand Functional Resting Hand Splint(for neurological deficits)Splint(for neurological deficits)

Wrist: 30 extensionWrist: 30 extension MCP: 45 flexionMCP: 45 flexion PIP: 30 flexionPIP: 30 flexion DIP: 10 flexionDIP: 10 flexion Thumb: abduct and opposed Thumb: abduct and opposed

Arthritis Resting Hand SplintArthritis Resting Hand Splint

Wrist: 0-30 extensionWrist: 0-30 extension MCP: 30 flexionMCP: 30 flexion IPIP’’s slight flexions slight flexion Thumb: abduction and oppositionThumb: abduction and opposition

Splinting the patient with JRASplinting the patient with JRA

ImmobilizeImmobilize StabilizeStabilize ProtectProtect Decrease painDecrease pain Increase functionIncrease function Use in conjunction with medical and surgical Use in conjunction with medical and surgical

treatmenttreatment Usually implemented during an exacerbationUsually implemented during an exacerbation

Specific splints for JRASpecific splints for JRA

Arthritis restingArthritis resting Wrist extensionWrist extension Thumb Thumb AnkleAnkle FingerFinger DynamicDynamic Adaptive devicesAdaptive devices

Common problems associated Common problems associated with JRAwith JRA

Elbow contracturesElbow contractures Wrist deformity (radial deviation)Wrist deformity (radial deviation) MCP deformity (ulnar deviation)MCP deformity (ulnar deviation) Finger deformity (swan neck and Finger deformity (swan neck and

boutonniere)boutonniere) Thumb deformity (swan neck)Thumb deformity (swan neck) Ankle instabilityAnkle instability

Pattern MakingPattern Making

Wrist cock-up splingWrist cock-up spling Thumb opponensThumb opponens Finger Finger Decide on creative ways to decorate splintDecide on creative ways to decorate splint Creative ways to keep splint onCreative ways to keep splint on

ReferencesReferences

Coppard, B. M., Lohman, H. (2008). Coppard, B. M., Lohman, H. (2008). Introduction to splinting: A Introduction to splinting: A

clinical-reasoning & problem solving approach, clinical-reasoning & problem solving approach, (2(2ndnd ed). ed).

St. Louis, MI: Mosby.St. Louis, MI: Mosby.

Fess, E. E., Gettle, K. S., Philips, C. A., Janson, J. R. (2004). Fess, E. E., Gettle, K. S., Philips, C. A., Janson, J. R. (2004). Hand and Hand and upper extremity splinting: Principles & methods, upper extremity splinting: Principles & methods, (3(3rdrd ed). St. Louis, ed). St. Louis, MI: Mosby.MI: Mosby.

Jacobs, ML., Austin, N. (2003). Jacobs, ML., Austin, N. (2003). Splinting the hand and upper extremity: Splinting the hand and upper extremity: Principles and process. Principles and process. Philadelphia, PA: Lipponcott Williams & Philadelphia, PA: Lipponcott Williams & Wilkins.Wilkins.