Short Opponens Hand Splint

Capsulotomy/Capsulectomy

Capsulectomy involves the surgical division (capsulotomy) or excision (capsulectomy) of a portion of the collateral ligaments of a digital joint with normal articular surfaces but limited passive motion due to contracted periarticular ligamentous structures. Although a substantial improvement of motion may be reliably anticipated at the MP level, the results of a capsulectomy procedure at the PIP joint are less predictable.14,44,85,100,109 Mobilization efforts are usually initiated within 1 to 7 days postoperatively. These efforts routinely involve assertive and focused splinting and exercise programs, which are vigilantly monitored.

Preoperative splinting and exercises are designed to attain as much passive joint motion as possible, enhancing the postoperative arc of motion and assuring adhesion-free tendon excursion essential to the active maintenance of passively improved postoperative motion. Splints are adapted to meet individual patient variations. The decision as to the type of splint to be applied depends on the presence or absence of wrist-produced tenodesis effect. If the limitation is purely articular, a hand-based splint will suffice (Fig. 15-12, A,B). Splints with secondary level wrist immobilization are required to control the effects of wrist position on distal joints in the presence of extrinsic tendon adhesions or poor postural habits that unfavorably affect digital joint mechanics (Fig. 15-12, C).

Splinting of a joint that has undergone a capsulec-tomy procedure maintains the motion gained from the combined preoperative and operative efforts. Because of potential recurrence of extension contractures, the MP joints are usually splinted to encourage joint flexion. In contrast, extension is often more difficult to regain than is flexion in the capsulectomized PIP joint. For this reason extension splinting, which is interspersed with frequent exercise periods, and limited flexion splinting may need to be prolonged to prevent recurrence of deformity. It is important that postcapsulectomy splinting and exercise programs are frequently reevaluated by members of the rehabilitation team during the first 2 or 3 postoperative months, and appropriate changes be instigated to ensure optimum results. One should emphasize to the

Fig. 15-12 A, Small finger MP flexion immobilization splint, type 2 (3) B, Finger PIP extension mobilization splint, type 1 (2) C, Index-small finger IP flexion mobilization splint, type 2 (13) A, Immobilization of the small finger MP joint allows collateral ligament healing. B, Serial cylinder casts, which are changed every 2 or 3 days, may be used to enhance passive PIP joint motion before a capsulotomy/capsulectomy procedure is undertaken. Cylinder casts are also effective in maintaining postoperative motion once the initial edema subsides and the incision is healed. C, Splint designs that incorporate the wrist eliminate compensatory tenode-sis effect as traction is applied to more distal joints.

Fig. 15-12 A, Small finger MP flexion immobilization splint, type 2 (3) B, Finger PIP extension mobilization splint, type 1 (2) C, Index-small finger IP flexion mobilization splint, type 2 (13) A, Immobilization of the small finger MP joint allows collateral ligament healing. B, Serial cylinder casts, which are changed every 2 or 3 days, may be used to enhance passive PIP joint motion before a capsulotomy/capsulectomy procedure is undertaken. Cylinder casts are also effective in maintaining postoperative motion once the initial edema subsides and the incision is healed. C, Splint designs that incorporate the wrist eliminate compensatory tenode-sis effect as traction is applied to more distal joints.

patient undergoing these difficult joint mobilization procedures that the tendency for recurrent stiffening of the involved joints is great and that splinting may be necessary for many months.21

Neurovascular Peripheral Nerve Injuries

The potential for the restoration of optimum hand function after peripheral nerve injuries of the upper extremity depends on the preservation of good passive joint motion. It is also necessary to protect periarticu-lar structures and denervated musculature by avoiding improper positioning of the partially paralyzed extremity.39,42 In the presence of existing deformity, splints may be designed to restore passive mobility to upper extremity joints. Adapted to the individual requirements of the patient, these splints range from uncomplicated rubber bands to complex multifunction splints. Once free gliding of articular surfaces has been established, maintenance and positioning splints may be used until reinnervation occurs or until tendon transfer procedures are carried out to restore balance to the hand. These positioning splints should be used in conjunction with a high-quality exercise program. Splints serve to prevent deformity that results from the unopposed antagonists of the paralyzed muscles as well as to position the hand for use while awaiting nerve regeneration. These splints often assume predictable design configurations based on the nerve(s) involved69 and they must be light, without excessive components, and easily applied or they will not be worn.

In the supple hand, the need for protective splinting varies according to the type of lesion and the inherent laxity of the ligamentous structure of the individual hand.5 For example, not all patients who have sustained ulnar nerve injuries proceed to develop the classic claw hand posture of hyperextension of the fourth and fifth MP joints and concomitant IP flexion. Some have unusually firm palmar plate restraint at the MP joints and are not predisposed to hyperextension deformities, despite the lack of intrinsic opposition to the long extensor muscles. It is important, however, that these patients be monitored throughout rehabilitation to ensure that late-blooming deformity does not occur. In contrast, all patients with total loss of radial nerve innervations to the wrist and digital extensors develop wrist drop, requiring external support to properly position the hand, both to avoid deformity and to allow function.

Median Nerve. The median nerve provides the critical sensory perception to the palmar surface of the hand with the exception of the small finger and ulnar half of the ring finger. This nerve is also respon-

Fig. 15-13 Thumb CMC palmar abduction mobilization splint, type 1 (2)

This splint prevents first web space contracture in a median nerve injury. (Courtesy Sharon Flinn, MEd, OTR/L, Cleveland, Ohio.)

Fig. 15-13 Thumb CMC palmar abduction mobilization splint, type 1 (2)

This splint prevents first web space contracture in a median nerve injury. (Courtesy Sharon Flinn, MEd, OTR/L, Cleveland, Ohio.)

sible for innervations of the pronator teres and prona-tor quadratis, the flexor carpi radialis, the flexor digi-torum superficialis, flexor digitorum profundus of the index and long fingers, and the flexor pollicis longus of the thumb. At a more distal level, the median nerve innervates the intrinsic thenar muscles, whose function is abduction and opposition. High median nerve lesions, therefore, are more disabling than is interruption at the wrist level, with the former affecting extrinsic as well as intrinsic digital function. However, a main functional disability with a median nerve lesion is loss of sensibility.

Splinting median nerve injuries depends on the level of lesion and the etiology.83,110 Emphasis is placed on maintenance of passive mobility of the involved joints and enhancement of function. High, proximal interruption may require splints that assist finger flexion as well as opposition of the thumb.30 Emphasis may be reduced to the prevention of thumb web contractures after more distal loss (Fig. 15-13). Splinting is frequently used in treating nerve entrapment problems such as carpal tunnel syndrome.* An understanding of each patient's functional capacity and substitution patterns is important before a splint design is initiated. For example, many patients whose long thumb flexor or short abductor and opponens action has been lost achieve adequate thumb use through substitution of the abductor pollicis longus, flexor pol-licis brevis (deep head), and adductor pollicis.

Radial Nerve. A high-level radial nerve injury results in loss of active wrist, thumb, and finger extension and a weakening of supination and thumb radial abduction. Because the wrist provides the key to hand function at the digital level, the loss of the ability to properly position the hand in extension markedly weakens grasp and diminishes coordination. The coexisting deficit of metacarpophalangeal extension presents a less significant problem because the intrinsic muscles provide active extension of the interpha-langeal joints.

The most important objective in splinting a high radial nerve injury is to support the wrist in extension, enhancing hand function and preventing overstretching of the extensor muscle groups. For most patients the use of a wrist extension splint is sufficient to allow satisfactory hand use (Fig. 15-14, A). Extension outrigger attachments are sometimes considered excessive and should be used in situations in which full digital extension is required for successful accomplishment of given tasks.23,39,48,69,102 Since these are substitution rather than correction splints, low-profile outrigger configurations are preferable. Several different splint designs improve hand function for radial nerve patients (Fig. 15-14, B-M).

Fig. 15-14 A, Wrist extension mobilization splint, type 0 (1) BD, Wrist flexion: index-small finger MP extension / index-small finger MP flexion: wrist extension torque transmission / thumb CMC radial abduction and MP extension mobilization splint, type 0 (7) E, Wrist flexion: index-small finger MP extension / index-small finger MP flexion: wrist extension torque transmission splint, type 0 (5) F, Wrist flexion: index-small finger MP extension / index-small finger MP flexion: wrist extension torque transmission splint, type 0 (5) G-I, Wrist flexion: index-small finger MP extension / index-small finger MP flexion: wrist extension torque transmission splint, type 0 (5) J, Index-small finger MP extension, thumb CMC radial abduction and MP extension mobilization splint, type 1(7) K-M, Index-small finger MP extension, thumb CMC radial abduction and MP extension mobilization splint, type 1 (7)

A, Stabilization of the wrist allows functional use of the hand in radial nerve palsy. B-D, This splint mobilizes the wrist and digits in extension, encouraging hand use. E-I, Other splints for radial nerve palsy make use of torque transmitted to the wrist or MP joints to produce synergistic tenodesis extension or flexion. Splints J-M, demonstrate a fourth design option that mobilizes the primary finger MP and thumb CMC and MP joints while the wrist is immobilized secondarily. [Courtesy (B-D) Jean-Christophe Arias, Saint-Etienne, France; (E) from Colditz JC: Splinting for radial nerve palsy, J Hand Ther 1(1):18-23, 1987; (F) Paul Van Lede, OT, MS, Orfit Industries, Wijnegem, Belgium; (G-I) Lori Klerekoper DeMott, OTR, CHT, Columbus, OH; (J) Christine Heaney, BSc, OT, Ottawa, Ontario; (K-M) Dominique Thomas, RPT, MCMK, Saint Martin Duriage, France.]

For legend see opposite page.

For legend see opposite page.

Ulnar Nerve. The ulnar nerve, with its important intrinsic innervation, is largely responsible for delicate coordinated movements of the hand. In addition, it also influences flexion of the ring and small fingers and ulnar deviation and flexion of the wrist.49,79 Disruption of the ulnar nerve may result in the development of a claw deformity with metacarpophalangeal joint hyperextension and interphalangeal joint flexion of the fourth and fifth digits. Loss of small finger abduction and opposition and adduction of the thumb with the resultant weakness of pinch also accompanies ulnar paralysis.

The goals of splinting a hand that has sustained an ulnar nerve lesion are directed toward the attainment and maintenance of full passive motion and the improvement of hand function.72 Existing joint limitations, often at the PIP joint of the ring or small finger, must be corrected before maintenance or substitution-splinting programs may be initiated. Splints designed to correct deformity should be specifically created to meet individual needs and should be changed to maintain optimum mechanical purchase as joint motion improves. When full passive motion has been established, or if the hand is supple at the time of initial examination, preventive splinting may commence.

Positioning the fourth and fifth MP joints in slight flexion allows the amplitude of the extrinsic digital extensor muscles to act effectively on the IP joints. Numerous splint designs accomplish this objective. One of the most acceptable is a three-point piano wire splint described by Wynn Parry.75,76 Adaptation of this splint to the use of low-temperature materials for the dorsal and palmar metacarpal bars and dorsal pha-langeal bar makes construction and fitting easier (Fig. 15-15, A). Splinting, using a selection of suitable designs until nerve regeneration is complete or until tendon transfer procedures are done, is a critical element in successful management of nerve injuries. (Fig. 15-15, B-G).

Combined Nerve Injuries. Damage to multiple nerves of the upper extremity is not uncommon, and the resulting potential for the development of deformity is, of course, magnified. Splinting programs should continue to incorporate the concepts previously mentioned for each individual injury, with even more care taken to monitor progress and make necessary adaptations as changes occur. Designs for the combined median and ulnar nerve injury resemble single-nerve ulnar or median nerve splints but multinerve splints encompass all digits (Fig. 15-16).

Splinting patients with peripheral nerve injuries must be augmented with individually designed exercise programs that promote the maintenance of active and passive motion and enhance hand dexterity.

Although the goals of exercise and splinting programs are almost identical, each brings a unique contribution to minimizing the resultant disability, and in conjunction with one another they provide an integrated and practical approach to rehabilitation. Each splint and exercise routine should also be interspersed with periodic objective reevaluation sessions, which allow program modification and continued patient progress.

See Chapter 17, Splinting for Work, Sports and the Performing Arts, for further information on peripheral nerve compression.

Spinal Cord Nerve Injury: Tetraplegia

Splinting of the quadriplegic upper extremity depends on the level of the spinal cord lesion.26,41,60,65 Extremities that lack innervation above the seventh cervical nerve (C7) level often require the development of a passive or active tenodesis function for grasp, whereas those at C7 have active gross grasp and release through innervated extrinsic flexors and extensors. The intrinsic muscles of the hand are usually innervated at the first thoracic nerve level, allowing normal hand function.

Fifth Cervical Nerve. Patients with lesions at this level usually have active elbow flexion and deltoid shoulder movements, allowing gross positioning of the forearm and hand. Paralyzed wrist and hand musculature necessitates external wrist support in the form of a wrist immobilization splint to provide distal stability of the extremity. Accommodation of the splint to serve as the basis of attachment for adapted equipment is important to establishing independence in activities of daily living. Thumb CMC position and passive motion may be maintained through alternately positioning the thumb in palmar and radial abduction. Wrist and thumb splints are usually combined into one (Fig. 15-17).

If the patient is a candidate for an externally powered splint, development of a passive tenodesis hand may be considered (see next section). Most externally powered splints create a gross grasp or pinch by providing a power source to drive a conventional wrist-operated tenodesis splint. Power sources vary, as do triggering mechanisms (Fig. 15-18, A).

Sixth Cervical Nerve. In spinal cord lesions at this level, shoulder and elbow motions are stronger, resulting in more coordinated extremity positioning, but active elbow extension is absent. The important wrist extensors are spared, permitting a tenodesis hand in which grasp is achieved through an active wrist extension-passive finger flexion pattern. Tenodesis hands can be maximally developed through carefully supervised exercise and splinting programs (Fig. 1518, B-D).13 Exercises are oriented toward allowing

Fig. 15-15 A, Ring-small finger MP extension restriction / IP extension torque transmission splint, type 0 (6) C,D, Ring-small finger MP extension restriction / ring-small finger IP extension torque transmission splint, type 0 (6) E, Ring-small finger MP extension restriction / ring-small finger IP extension torque transmission splint, type 0 (6) F, G, Ring-small finger MP extension restriction / ring-small finger IP extension torque transmission splint, type 0 (6)

A, Piano wire coil is utilized in fabrication of the classic Wynn-Parry splint. B, Injury to the ulnar nerve typically results in a "claw deformity" with hyperextension of the ring and small finger MP joints and compensatory flexion of the IP joints. C-G, Using three-point fixation, these splints restrict joint extension of the fourth and fifth digits, allowing the transmitted torque of the extrinsic extensors to extend the IP joints. [Courtesy (B-D) Peggy McLaughlin, OTR, CHT, San Bernadino, Calif.; (E) Sharon Flinn, OTR/L, Cleveland, Ohio; (F,G) Sandra Artzberger, MS, OTR, Milwaukee, Wis., and Bonnie Fehring, LPT, Fond du Lac, Wis.]

Fig. 15-17 A, Wrist extension mobilization splint, type 0 (1); with grasp assist B, Wrist extension mobilization splint, type 0 (1); with grasp assist C, Wrist extension, thumb CMC palmar abduction mobilization splint, type 0 (2)

A, To help patient independence, splints may be designed to hold ADL, homemaking, or work-related equipment. B,C, Several splint designs may be used to stabilize the wrist and accomplish independent function. D, This wrist and thumb CMC/MP positioning splint also stabilizes the wrist and maintains the first web space of a C5 spinal cord lesion patient. [Courtesy (B) Allyssa Wagner, MS, OTR, Indianapolis, Ind.]

Fig. 15-16 A, Index-small finger MP extension restriction / IP extension torque transmission splint, type 0 (12) B, Index-small finger MP extension restriction / IP extension torque transmission splint, type 0 (12) C, Index-small finger MP extension restriction / index-small IP extension torque transmission / thumb CMC palmar abduction and MP extension mobilization splint, type 0 (14)

These splints prevent hyperextension of the second through fifth MP joints while allowing partial to full digital flexion. They may be used for treating combined ulnar and median nerve lesions. Extrinsic extensor torque transmission to the IPs for extension is accomplished by preventing hyperextension of the MPs. [Courtesy (A) Ruth Coopee, OTR, CHT, Athol, Mass.; (C) Gretchen Maurer, OTR, CHT, Norfolk, Va.]

Fig. 15-17 A, Wrist extension mobilization splint, type 0 (1); with grasp assist B, Wrist extension mobilization splint, type 0 (1); with grasp assist C, Wrist extension, thumb CMC palmar abduction mobilization splint, type 0 (2)

A, To help patient independence, splints may be designed to hold ADL, homemaking, or work-related equipment. B,C, Several splint designs may be used to stabilize the wrist and accomplish independent function. D, This wrist and thumb CMC/MP positioning splint also stabilizes the wrist and maintains the first web space of a C5 spinal cord lesion patient. [Courtesy (B) Allyssa Wagner, MS, OTR, Indianapolis, Ind.]

controlled extrinsic flexor tightness to occur while maintaining passive range of motion of the wrist and digits. Finger extension exercises are performed with the wrist in flexion, and finger flexion exercises are carried out with the wrist in extension. Splints designed to augment these patterns are used to reinforce the tenodesis motion in functional activities. As habit patterns become established, gradual weaning from the splint is encouraged, allowing increasingly independent tenodesis hand use.

Moberg70 describes a surgical procedure for using the wrist extensors to enhance flexor hinge key grip of the thumb. Splinting for this procedure involves maintaining passive motion of the thumb car-pometacarpal and metacarpophalangeal joints preop-eratively and protecting splinting of the transfer during the early postoperative mobilization phase. A thumb abduction splint may occasionally be required to maintain carpometacarpal joint motion as postoperative time increases.

Seventh Cervical Nerve. Patients with lesions at the C6 level usually have gross active finger flexion and extension but lack the intrinsic musculature that allows fine hand coordination and dexterity. Splinting and exercise programs are directed toward maintenance of passive joint range of motion with emphasis on thumb CMC joint mobility and prevention of extension deformities at the MP joints. Splinting to position the thumb in opposition enhances prehension of small objects.

As a result of severe muscle imbalance and limited active motion, many tetraplegic hands have a tendency to become slightly edematous and to assume a resting posture of MP joint extension, PIP joint flexion, and thumb adduction. These factors may lead insidiously to stiffness and eventually to severe joint contractures, which are correctable only through surgical

Fig. 15-18 A, Index-long finger extension and flexion, thumb CMC palmar abduction and MP-IP extension mobilization splint, type 1 (7); left. \\ Wrist extension mobilization splint, type 0 (1); with prop; right B,C, Wrist extension: index-long finger flexion / wrist flexion: index-long finger extension torque transmission / thumb CMC palmar abduction and thumb MP-IP extension immobilization splint, type 2 (10) D, Wrist extension: index-long finger flexion / wrist flexion: index-long finger extension torque transmission / thumb CMC palmar abduction and MP-IP extension immobilization splint, type 2 (10)

A, A battery-powered external orthosis allows this C5 quadriplegic patient to grasp and release objects. The orthosis is triggered when the patient touches his watchband to the copper plate mounted on his lapboard. (United States patent No. 3967321: Ryan, Fess, Babcock et al.). B-D, These tenodesis splints produce passive approximation of the index and long fingers to the thumb through active wrist extension. [Courtesy (B,C) Cheryl Kunkle, OTR, CHT, Allentown, Pa.]

intervention. In anticipation of these problems, preventive measures should be initiated within the first week after injury, since joint stiffness and contractures severely limit rehabilitative potential. As with direct injury to the hand, it is important to position the resting tetraplegic hand in a posture of antidefor-mity to prevent shortening of digital ligaments. So-called functional position splints do not provide sufficient MP joint flexion and PIP joint extension to prevent collateral ligament shortening. With the wrist in neutral position, the MP joints should be splinted in 70-90° of flexion, the IP joints in 0-10° of flexion, and the thumb CMC joint in palmar or radial abduction (safe position). Although a vigil for early deforming forces must always be maintained, the need for safe position splinting during periods of rest diminishes as the patient increases the use of his hands in functional compensatory patterns and the potential for edema subsides.

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