Splints acting on the wrist

Introduction • Keeping the alignment of the wrist is important

as the wrist is key to the health and balance of the entire hand

• The wrist is positioned in extension for grasp and prehension during functional activities

• The wrist cock-up splint is the most common type of splint used in practice

• A wrist ext. immobilization splint allows full ROM in the MCP’s and fingers so person can perform in fx activities

• Wrist is neutral or mildly extended (0-30) depending on diagnosis and tx goals

Introduction• Wrist immobilization splints can be:

– volar– Dorsal– Ulnar– circumferential

• The splint can be a base for mobilization and static progressive splints

Volar wrist immobilization splint

Volar wrist immobilization splint • Depends on a dorsal wrist strap to hold the wrist

in extension• The volar design is recommended for rest or

immobilization of the wrist when the person still has muscle control of the wrist

• One study: best dexterity of custom made wrist splint

• The disadvantage of this splint is that it interferes with the palmar tactile sensibility and the loss of the hand function to conform around objects

• In the presence of edema, you must design the dorsal strap carefully as it interferes with the lymphatic and venous flow

• You can fabricate a continuous Velcro strap from the radial to the ulnar borders of the splint

Dorsal wrist immobilization splint

Dorsal wrist immobilization splint

• The larger the palmer bar, the better, it tends to distribute pressure well which is necessary for function and comfort

• But compromise sensory input to the hand• Just like the volar, both be used as a base

for dynamic splinting • However these designs tend to migrate

and suboptimal splint performance

Ulnar Wrist Immobilization S• Easy to don and doff• Good if we needs more protection to the

ulnar side of hand • Maybe used for CTS or for ulnar wrist pain• It can be base for mobilization splint

Circumferential wrist immobilization splint

Circumferential wrist immobilization splint

• It is helpful in prevention of migration (especially in dynamic splints)

• It provides good forearm support, controls edema, provide good pressure distribution, and avoid edge pressure

• But it gives a feeling of being confined • Be aware of the pressure over the distal

ulna and check that the fingers and thumb have full range of motion

Zipper splint option/ circumferential

Features of the wrist immobilization splint

• You have to be aware of:1. Forearm trough 2. Metacarpal bar3. Hypothenar bar

Features of the wrist immobilization splint

• The forearm trough should be two thirds of the length of the forearm

• One half of the circumference of the forearm to distribute pressure evenly

• Be aware that sometime you have to notch over the ulnar styloid to avoid pressure point

Features of the wrist immobilization splint

• The hypothenar bar helps to place the hand in a neutral position preventing extreme ulnar deviation

• Be ware that the hypothenar bar SHOULD NOT limit the MCP flexion of the ring and little finger

• The metacarpal bar supports the transverse metacarpal arch

• Palmar bar when its on the palmar side only • It is placed proximal to the distal crease and

distal and ulnar to the to the thenar crease to ensure full MCP flexion

Features of the wrist immobilization splint

• The MP bar should allow complete flexion on the middle, index finger and thumb

• When making a dorsal WIS, make the MP proximal to the MCP heads

• Straps should be placed on the level of the MP bar, exactly at the level of wrist and at the end of the splint

• The larger the strap the better the fit• If you fear of pressure or shear problems,

apply padding

Diagnostic indications • WIS is prescribed for any condition which

requires the wrist to be static • Goals for using the WIS are:1.Decrease wrist pain or inflammation 2.Provide support3.Enhancing digital function 4.Preventing wrist deformity 5.Minimize pressure on the median nerve 6.Minimize tension on the involved structures

Diagnostic indications • In some cases, a wrist immobilization serial static splint is used

to increase PROM • Some indication are (not limited to):• Tendonitis• Distal radius/ulnar fracture• Wrist sprain • Radial nerve palsy • Carpal ganglion • Stable wrist fracture • Wrist arthroplasty• CRPS• Nerve compression (CTS)

Diagnostic indications • The specific wrist positioning depends on the

diagnostic protocol, physician referral, and the persons treatment goals

• You must avoid extreme flexion/extension• They limit function and might lead to CTS• Exception when the goal is to increase PROM • You should perform a hand evaluation, a

wearing schedule, instructions and precautions, and exercise protocol

Wrist splinting for CTS • Place the wrist as possible to 0 degrees to help

avoid pressure on median nerve • Majority may benefit, but some may benefit from 15

degrees of flexion/ extension (Kue et al. 2001) • You should be careful not to prescribe prefabricated

splints to CTS (as they put the hand in functional position 20-30 degrees of extension)

• Generally custom made splints are prescribed for patients with CTS as they provide better support, positioning, and allocation of pressure

• You should consider the amount of flexion allowed (more flexion can cause more CT pressure (Apfel et. Al 2002))

• So the instruction to wear for the patient: “Do NOT flex your fingers beyond 75%”

• Consider the occupational demands• Finger flex. Increase carpal pressure • IF symptoms of CTS not improving: Consider splint

that block MCP flex to decrease finger flexion

Wrist splinting for CTS • All studies indicate the early intervention

(conservative methods i.e. splinting, exercise, modification of activities, staying warm) are indicated for CTS

• When this does not work, surgery is advised.

• The goal of the WIS after surgery is:1.Minimize pressure on the median nerve 2.Prevent bowstringing of the flexor tendons 3.Provide support during stressful activities 4.Maintain gains from exercise 5.Rest the extremity during the healing phase

Wrist splinting for CTS • The evidence show that the best time is for

1 week after surgery to prevent nerve entrapment and tendon bowstringing

• Postoperatively, WIS is recommended only to prevent extreme nighttime wrist postures

• Studies have shown that surgery is better than splinting only, so it is recommended to use the splint if the patient does not desire surgery, or while waiting for it.

• Some people do not immobilize after surgery bcz of stiffness. So they start with 1 week then hours only

Wrist splinting for radial nerve injuries

• RNI occur mainly from fractures of the humeral shaft, fractures and dislocation of the elbow, or compressions on nerves

• Classic picture of a radial nerve injury is a wrist drop position where the wrist and MCP’s can’t extend actively

• The amount of extension required from the splint is totally up to the therapist and client (according to how much function the patient requires from his hand)

• Commonly 30 degrees of extension is considered a position of function as it facilitates grasp and prehension

Wrist splinting for tendinitis and tenosynovitis

• They are painful conditions that benefit from conservative management

• They occur from cumulative and repetitive motions in work, home and leisure activities

• This results in an overuse cycle Friction microscopic tears pain

limitation in motion resting in the involved area avoidance of use development of weakness

• Splinting helps in minimizing friction at the insertion of the muscle

Wrist splinting for tendinitis and tenosynovitis

• Splints provided during flare-ups are worn continuously followed by gradual weaning

• When splinting is for flexor crapiradialis (FCR) tenosynovitis it is recommended that the splint is in neutral position to rest the tendons

• Wrist extensor tendinitis can be splinted in 20 to 30 degrees of wrist extension as this provides balance between flexors and extensors

Wrist splinting for Rheumatoid arthritis

• In functional position • Its challenging because joint tend to move

and laxiaty occurs volarly and ulnarly• Material used here should have high

drapability to help prevent pressure areas

Wrist splints for fractures • Goal is to regain functional wrist extension • Splinting should occur in slight extension

to achieve this • It provides protection and low load stress • Serial static splinting may be needed for

PROM • The patient should wean away from the

splint ASAP to regain function

Wrist splints for sprains • WIS help people with grade 1 and II

sprains • Grade 1: 3 weeks, grade II: 6 weeks • This splint helps the hand during the acute

healing phase and removes stress form the healing ligament

Wrist splinting for CRPS • Extreme pain, diffuse edema, stiffness

trophic skin changes and discoloration • WIS is used to relief pain, muscle spasm

relief, regaining a functional wrist position • Serial static splint maybe needed

Fabrication