Exam 4: UE Orthoses (includes powerpoint) Flashcards Preview

Bringman class fall 2015 > Exam 4: UE Orthoses (includes powerpoint) > Flashcards

Flashcards in Exam 4: UE Orthoses (includes powerpoint) Deck (73):
1

What type of materials can we use to make UE Orthoses?

Same as LE Orthoses:

  1. Metal
  2. Plastic
    • thermoplastic
    • thermoset
  3. Leather (straps)
  4. Velcro (straps)
  5. Foam/padding

2

What are three main purposes of UE Orthoses?

  1. Immobilization (allows no movements)
  2. Mobilization (helps or assists motion)
  3. Restriction (allows some movements but not others)

**Mostly Serve same purpose as LE orthoses (except we do try to increase ROM sometimes in UE) Figure 14-2 on pg 394

3

What are four things for which immobilization might be a goal for an UE orthosis?

Immobilization (allows no movements)

  • surgery
  • fracture
  • gross instability
  • preventative (rollerblading hand braces)

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4

More about Mobilization purpose of UE Orthosis

Mobilization (helps or assists motion)

  • Trying to help move something
  • In LE we didn’t try to change ROM
  • In UE we will add parts of splints to slowly mobilize tissue
  • Also includes Tenodesis splints that help use use the mobility we have better

5

More about Restriction purpose of UE Orthosis

Restriction

  • Allows some movement but stops other motions
  • Allows us to do one thing, but not the other
  • Some can be bought OTC for massage therapists

6

Ten Cardinal Rules of Splints (will not be asked to list them on actual exam)

  1. Amount of Force: How much force do we need to apply?
  2. Involved Structures: What structure is involved?
  3. Involved Surfaces: Over what surface?
  4. Wear Time: How long are we actually going to wear the splint?
  5. Leverage: we know the longer the lever arm the more control
  6. Pressure: remember force/area
  7. Purpose: To what purpose are we making the splint?
  8. Goals: (to what goal?)
  9. Harm Prevention: Avoid harm
  10. Warning Signs: Always be cognizant of warning signs of a problem caused by said splint

7

Details on Amount of Force:

Force Amount: How much force do we need to apply?

  • muscles may not as big in the UE compared to LE, so we might use too much force if not paying attention
    • pain, redness, skin breakdown (worry about people who are insensate)

8

Details about Involved structures

Involved Structures: What structure is involved?

  • muscle-tendon unit, bone

9

Details about involved surfaces

Involved Surfaces: Over what surface?

  • volar, dorsal, ulnar, radial, do I need to past the wrist, do I need to go past the DIP, etc? LEs are typically easier than UE because they don't have as many directions of motion

10

Details on wear time

Wear Time: How long are we actually going to wear the splint?

  • Pt with carpal tunnel.
    • maybe just at work, night splint will definately help them.
  • how long do you want it to be stretched (when trying to mobilize)
  • is it safe, is it functional?
  • Wolffe's law tells us low extended pressure over long periods of time should create tissue deformation.

11

Details on Leverage

Leverage: we know the longer the lever arm the more control

12

Details on Pressure

Pressure: remember force/area

  • have we spread it out as much as we can
  • straps big if possible
  • consider boney prominences

13

Details on Purpose

Purpose: To what purpose are we making the splint?

  • some will not be comfortable to pts (shouldn’t be painful, but might not be comfortable)
  • Pt needs to understand the purpose

14

Details on Goals

Goals: (to what goal?)

  • What is the goal for this splint (write a goal for it). Goal may change as time goes on.

15

Details on Harm Prevention

Harm Prevention: Avoid harm

  • just because you can do that, make sure you don’t hurt them. Have we allowed the motions that we want so we are not creating other problems.

16

Details about Warning Signs

Warning Signs: Always be cognizant of warning signs of a problem caused by said splint

  • pain (the biggest)
  • Edema (straps too tight), or if they start having edema we need to worry about size of splint
    • check cap refill
  • Temperature intolerance
    • overheated
      • sweat
      • There are thermoplastics that are perforated for breathability

 

17

Describe the functional position of the hand

  • wrist in 20-30 degrees of extension
  • 35-45 degrees of MP flexion
  • PIP joints 45 degrees flexion
  • DIP in relaxed flexion
  • Thumb in palmar abduction

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18

describe the Anti-deformity position

  • Wrist 30-40 degrees extension
  • MP 60-90 degrees flexion
  • PIP and DIP in extension
  • Thumb in palmar Abduction

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19

what is unique about the anti-deformity position?

Anti-deformity position is used after surgery because it is a middle of the road position for both flexion and extension (favoring extension? since it is easier to get back to flexion then extension - like in the knee).

If we keep it in this position for weeks it causes the least problems.

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20

Imagine/Draw a Volar wrist cock-up splint?

 

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21

Imagine/draw a dorsal wrist cock-up splint?

(Same as volar but on dorsal side of hand)

.

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22

For a volar cock-up splint Imagine/Draw

  • hypothenar bar
  • metacarpal bar (what is another name?)
  • forearm trough

metacarpal bar in this case is also called a palmar bar

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23

For a dorsal cock-up splint Imagine/Draw

  • hypothenar bar
  • metacarpal bar
  • forearm trough

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24

How should the therapist position

the (palmar) metacarpal bar?

The therapist should position the metacarpal bar just proximal to the distal palmar crease and follow the natural angle of the distal transverse arch.

Note the rolled thermoplastic material around the thenar eminence (in the picture).

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25

What do you have to be careful with when molding the end of the metacarpal bar that comes around the dosal part of hand (for a volar cock-up splint, shown in picture), or that comes around the palmar side of the hand (for a dorsal cock-up splint)?

Cannot have too much of a C shape (NOT the same as a C-Bar!) or it will dig in.

**The picture is showing how the metatarsal bar comes around back on a volar cock-up, and how it supports the hypothenar imenence.

**The caption to the picture says: "The metacarpal bar and hypthenar bar help position and hold the wrist."

**Dr. bringman took the opportunity to tell us it would be called an ulnar gutter if the splint came up higher towards the dorsum of the hand than in this picture.

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26

Imagine/Draw a resting hand splint

Pciture Caption: "A resting hand splint with the hand in a functional (midpoint) position"

**Dr Brinmant mentioned that he doesn’t agree that this looks like enough wrist extention for functional position

***Dr. Bringman also called this a Resting Pan Splint (see the quizz he gave us)

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27

Name and Imagine/Draw four components of a resting hand(pan) splint:

The components of a resting hand splint are:

  • Forearm Trough
  • Pan
  • Thumb Trough
  • C-Bar

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28

Imagine/Draw a long thumb spika:

What is something it could be for in particular (mentioned in the caption of the picture)?

Picture Caption: "A long thumb spica splint for de Quervain's Tenosynovitis including the immobilzation of the thumb IP joint"

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29

What are two things we need to be especially cognizant of when creating a long thumb spika?

Two related things

  1. Circulation
    • check capillary refill
  2. Swelling
    • could inhibit circulation or cause pt to get stuck in the splint
      • make sure they can get their thumb out
    • Pt is likely in inflammation phase, so splint needs to be adaptable enough for them to be able to get out of it if they experience swelling
      • should try to wait until initial swelling has gone down before making the splint, but a flair-up could cause additional swelling (or the splint could become too big if the swelling goes down - but this shouldn't happen if we wait long enough to make the splint)

 

30

Draw/Imagine a hand based thumb spica

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31

Draw/Imagine a volar thumb spica splint

I'm guessing the long thumb spika splint was also a type of volar thumb spica splint.
 

This one doesn't have the word "long" in it's name. Maybe because the IP joint is not immobilized.

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32

Draw/Imagine a dorsal thumb spica splint

Almost the same as the volar thumb spica splint

(note the IP joint looks mobil - or maybe the splint is not quite low enough for it to be comfortable)

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33

Imagine/Draw a radial gutter thumb spica splint

This one allows IP flexion to help with oppposition

Thumb is in some palmar abduction to allow a little opposition

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34

What is another name for thumb spica?

Thumb Post

35

Imagine a hand-based thumb spica and name three major parts

  1. C-Bar (bar inside the C-space between the thumb and the fingers)
  2. Thumb Post
  3. Opponens bar (will stop oppositions)

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36

Imagine/Draw the hand position for splinting an ulnar nerve injury;

Why is this the position?

This splint keeps the hypothenar eminence in a good position

**Dr. Bringman said Ulnar nerve damages will cause hypothenar problems and the 4th and 5th digits will not stay extened (they will want to flop to flexed position).

However, this doesn't make good sense because ulnar nerve innervates the extrinsic Flexor carpi ulnaris and Flexor digitorum profundus; and most of the intrinsic hand muscles: the hypothenar emminence, medial two lumbricals, adductor pollicis, and interossei of the hand.

Therefore, I think opposition, possibly finger flexion, and stability/function especially of the 4th and 5th digits would be a problem (not extension particularly, since extrensic extensors would be intact).

Trouble with opposition seems to be the main motor symptom!

 

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37

When would we use a dorsal vs volar cock-up splint?

(2 big reasons and general rationale)

Also what are each of them better at?

They do almost the same thing as each other

  • Volar will limit more wrist flexion
  • Dorsal will limit more wrist extension

Usually we would use a volar splint, unless we need to accomodate something  or get access to palm of hand. Then use a dorsal splint

  • Wound on palm of hand
    • burn
    • post surgery
    • Do not want skin breakdown or adaptive shortening
  • Discomfort of resting forearms on splint during typing

38

Wha are some important details about the metacarpal (palmar) bar? (3)

Metacarpal bar.

  • Very important that it is not on a crease!!!
  • •Rolled edges (we do this with every edge)
  • •Include arch to accommodate distal arch

39

Should we roll the edges of the dorsal metacarpal bar?

Not neccesarily because MCP joints don't usually hyperextend that far (norm is 45 degrees?)

(unless you are hypermobile laura beth!!)

still smoothe the edges, maybe roll a little (or maybe a lot if your pt is LB, lol)

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40

What is a gutter?

A gutter is just a trough that runs up the side (it is ulnar or radial)

41

What type of pt would benefit from an ulnar gutter added to their volar cock-up splint?

Someone with RA (if we start controlling ulnar deviation at the wrist, it can go a long ways in slowing/preventing ulnar deviation of the fingers).

**Preferrably we would start splinting (at least at night) before the deformity gets really bad

42

Who might benefit from a resting hand/pan splint?

who might it be overkill for?

Benefit:

  • Pt with burn?
  • Stroke with Spasticity
    • •Reduce amount of spasticity pt is dealing with. May mostly wear at night (so not all the time)
  • May put someone who is completely flaccid in one (not as common) to protect them

 

43

What should we think of off the shelf versions of the resting hand/pan splint?

There are Off the shelf versions of these. They don’t have to fit perfectly as long as skin breakdown is not occurring.

44

What does the long thumb spica limit?

All thumb movements

(goes up to tip of thumb)

45

What is a major consideration for a hand based thumb spica?

How much motion will they allow at:

  • CMC
  • MCP

Is it an appropriate splint for both of these joints?

We must make sure we stop soon enough with covering hand with splint for the wrist to move freely (don't take plastic too proximal).

  • if we don't want wrist movement, we need to go to a WHO, not a HO

Probably will wiggle a little at CMC, but not at MCP

Depending on how much motion you want to limit at CMC or MCP it could be appropriate for both. However, it is more appropriate for MCP

46

How does the hand-based thumb spica compare to the volar (or dorsal) thumb spica WHO?

What would this be better for than the the hand based thumb spica HO?

Same thing  but won’t be able to move CMC

  • A little extra material across metacarpals

When would you use a hand-based vs the wrist involved one?

  • •UCL might be able to be immobilized with hand based
  • CMC may not be able to be immobilized with hand based, so error on the side of safety and go with wrist brace.

I'm guessing the volar vs dorsal thumb spica WHOs would be almost the same in function, but you would use dorsal if you needed access to palmar skin or if palmar splint was uncomfortable or prevented pt from doing some functional task that the dorsal splint allowed.

47

What could you use to control severe hand spacticity?

A resting pan splint that seperates the fingers is the best for severe spacticty

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48

When is the NIH Stroke certification due?

Stroke certification due December 9th at 6pm (can email a screenshot or certificate to Dr. bringman).

49

What could a Basic Volar Cock-Up be good for? (4-7)

  1. Carpal Tunnel
  2. Fracture that we need immobilized
    1. after cast is removed and pt is still painful
    2. Smith or
    3. colles
    4. scaphoid
  3. RA (if we don’t have a lot of ulnar deviation yet) - but make ulnar side higher

50

If a nerve injury is the reason we are splinting a pt, what should we keep in mind?

**Dr B mentioned that if the pt has function at a joint, we won't want to fully immobilze it (I am assuming from a nerve injury, as opposed to a fractrue or sprain/strain or itis/osis).

51

Dorsal Wrist Cock-Up: who would we want this for?

does same thingas Volar Wrist Cock-Up, so use for same pts but they have some other issue

  • recent palmar surgery
  • palmar injury
  • palmar burn

Things that are the same as Volar Cock-up:

  1. Carpal Tunnel
  2. Fracture that we need immobilized
    1. after cast is removed and pt is still painful
    2. Smith or
    3. colles
    4. scaphoid
  3. RA (if we don’t have a lot of ulnar deviation yet) - but make ulnar side higher

52

Cock-up where we also encapsulate the thumb (not above the MPC): who might benefit from this? (2-3)

Anyone who has a condition where we want to limit some CMC

  1. scaphoid fracture
  2. TFCC Triangular Fibro Cartilage Complex inury (even though it is mostly on the other side??)

53

What type of splint will be good for a Boxer's or Bennet's fracutre?

You don't use a splint on these fractures (except maybe after cast comes off)

Boxer’s or Bennet’s Fracture  will be casted not splinted

54

What might we use a Wrist cock-up with thumb spica for? (3)

Wrist cock-up with thumb spica

  • Te quarivanes Tenosynovitis
  • Arthroplasty for CMC
  • Median nerve injury?

**Not UCL because UCL splint could be just hand based

55

What might we use a Resting Splint (pan splint) for? (3)

Resting Splints (pan splint)

  1. RA  that doesn’t have a lot of deformity yet (at night, use more functional splint in daytime)
  2. Spasticity
  3. Flaccidity

56

What might we use a hand based thumb spica for? (2)

Hand Based thumb spica:

  1. UCL because it is not crossing the wrist
  2. Horrible thumb OA depending on what joint is giving them the problem. Still be functional, but limit the motion in the affected joint.

57

What about a Tenodesis Splint?

 

Tenodesis Splint

  1. Would be used for pt using tenodesis
  2. to use a tenodesis Splint, pt must have wrist extension

**A tenodesis splint is too complicated for us to know much about right now . . .

58

What did dr Bringman say about learning all of the problmes that each splint could be for?

Don’t kill ourselves on all of the problems that could be for a splint

Focus on things like If someone had a nerve injury, what position would we want to split them in, etc.

**He mentioned that if they have function at a joint, we won't want to fully immobilze it (I am assuming from a nerve injury, as opposed to a fractrue or sprain/strain or itis/osis).

 

59

What is an outrigger Splint?

(Imagine an example and the common components)

these can get crazy with different options

These can get big

There are:

  1. Finger loops that come up to the outrigger and
  2. wires attach to
  3. rubber bands.

 

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60

What is the special kit that clinicians use to create outrigger splints?

Caboodle kit contain tons of rubber bands

61

What is unique about the rubber bands used for outrigger splints?

There are tons of rubber bands that give known amounts of pressure

(sort of like how we use therabands with known resistance for each color)

62

What are two main purposes of Outrigger Splints?

(and what type of impairment would pt have to be most appropriate for each?)

Outriggers Purpose

  • Increase motion (pt lacking PROM)
  • Assist motion (pt weak in AROM)

63

True/False: an Outrigger Splint to increase motion will probably be worn all day because it is very helpful in assisting function

False

An Outrigger Splint for the purpose of increasing motion probably won’t be very functional, and the pt will probably not have it on all day.

64

Is there a certain direction of movement that Outrigger Splints most commonly assist with?

Yes: extension

65

What 2 things should we remember when we put an outrigger on?

  1. Finger loops cannot be too tight (don’t cut of circulation with finger loop)
  2. can’t create shear forces with the finger loop, both at the skin and at the joint
    • finger loop should pull at 90 degree angle or  joint will be compressed/sheared

66

what is something sort of like outriggers that can be used to get more flexion?


Can also make special gloves, and velcro parts down. (example, finger flexion glove)

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67

Is flexion or extension generally easier to regain in the hand?

Flexion is typically a lot easier to regain than extension (like at the knee).

68

What is a difference between working on regaining flexion vs extension in the hand?

We can work on mass flexion everywhere (at all joints at the same time)

unlike extension where we have to do one joint at a time

69

From book:  Superficial structures Vunerable to Pressure for UE splints: Boney Prominences (6)

  1. Olecranon process at the elbow
  2. Lateral and medial Epicondyles of the humerus
  3. Ulnar and radial styloid precesses at the wrist
  4. Base of the first metacarpal
  5. Dorsal thumb and digit mCP and IP joints
  6. Pisiform bone

70

From book: Superficial structures Vunerable to Pressure for UE splints: Superficial Nerves (5)

  1. Radial nerve at the radial groove of the humerus
  2. Ulnar nerve at the cubital tunnel
  3. Superficial branches of the ulnar and radial nerves at the dorsal forearm
  4. Median Nerve at the carpal tunnel
  5. Digital nerves on the volar aspect of the digits

71

From Book: Purposes of Immobilization Orthoses (11)

 

Orthoses designed to hold or immobilize a joint or limb segment can be used to do the following:

  1. Provide symptom relief
  2. Portect and position edematous structures
  3. Aid in maximizing functional use
  4. maintain tissue length
  5. protect healing structures and surgical procedures
  6. provide support and protection of soft tissue healing
  7. maintain and protect reduction of fracture
  8. Improve and preserve joint alignment
  9. Block and transfer muscle and tendon forces
  10. Influence a spastic muscle
  11. Prevent possible contracture development

72

From Book: Purposes of Mobilization Orthoses (7)

Orthoses designed to change or mobilize tissues or structures are used to do the following:

  1. Remodel long standing, dense, mature scar
  2. Elongate soft tissue contractures, adhesions, and musculo-tendinous tightness
  3. Increase passive joint ROM
  4. Ralign or maintain joint and ligament profile
  5. Substitute for weak or absent motion
  6. Maintain reduction of an intraarticular fracture with preservation of joint mobility
  7. Provide resistance for exercise

73

From Book: Purposes of Restriction Orthoses (5)

Orthoses designed to restrict or limit motion may be used to do the following

  1. Limit motion after nerve injury or repair
  2. Limit motion after tendon injury or repair
  3. Limit motion after boin or ligament injury or repair
  4. Provide and improve joint stability and alignment
  5. Assist in functional use of the hand