Dynamic Splinting Research Articles

Long-Standing Extended Dynamic Splintage and Release of an Abnormal Restraining Structure in Camptodactyly

62 patients with camptodactyly of the little finger have been reviewed, and only five cases failed to respond to conservative treatment. These cases are reported. One patient could straighten the deformed PIP joint with snapping, and the other two were resistant to conservative treatment and were found to have a restraining structure requiring release. These findings are in keeping with an imbalance between flexion and extension forces due to long-standing malposition of the extensor lateral bands. Operative treatment should be reversed for cases of failed conservative treatment, which should be started as early as possible.

Severe contractures of the proximal interphalangeal joint in Dupuytren's disease: Results of a prospective trial of operative correction and dynamic extension splinting

In a prospective study, 23 proximal interphalangeal joints that were severely contracted (> or = 45 degrees) as a result of Dupuytren's disease underwent operative correction and 6 months of dynamic extension splinting. Proximal interphalangeal joint extension was measured preoperatively and postoperatively at 3-month intervals for 1 year and at 6-month intervals thereafter. Mean follow-up was 2 years (minimum, 1 year). Overall, at 2 years, 44% improvement in proximal interphalangeal joint extension was noted. Mean improvement of 59% in proximal interphalangeal joint extension was noted in patients who complied with the postoperative dynamic extension splinting program. Patients who were noncomplaint demonstrated a 25% improvement in proximal interphalangeal joint extension. The difference in values between patients who were compliant and those who were not was statistically significant. Other factors--severity of contracture, digit involved, and the necessity for capsular release--were not significantly related to outcome. This study suggests that soft tissue responds to continuous dynamic extension stresses and can be remodeled over time.

REHABILITATION TECHNIQUES FOR LIGAMENT INJURIES OF THE WRIST

The contributions of the hand therapist to the treatment of ligament injuries in the hand requires a combination of skills. A thorough knowledge of the pathomechanics of these injuries is a necessary prerequisite in the initial evaluation and treatment planning stage. Focus should never be entirely on the injury; it is also important to understand the emotional effect that the injury has had on the patient's work and leisure activities. Therapy programs usually require edema control and reduction and a variety of static and dynamic splints. The ultimate goal is returning the patient to fully functional activities.

Electrophysiologic basis of dynamic extensor splinting

The use of dynamic extension splinting in the rehabilitation of extensor tendon injuries is gaining interest because of its apparent ability to improve clinical results. With such splinting, the extensor musculature is theoretically quiescent during both active flexion and rubber band-mediated extension; the gliding produced thereby decreases adhesion formation. Our initial intent was to perform electromyographic studies on volunteers in dynamic extension splinting to test this electrophysiologic principle. It was found, however, that only 16% of normal volunteers have quiescent extensor digitorum communis muscle activity within the dynamic extension splint typically used in this type of rehabilitation. A second splint was developed with a dorsal hood to keep the metacarpophalangeal joints in approximately 15 degrees of flexion. In this splint, 18 of 19 volunteers (95%) showed no extensor activity. The explanation for this phenomenon is not yet clear, but it shows that splint design plays a more significant role than previously expected. The expected electrophysiologic principle of dynamic extension splinting for extensor tendon injuries has been validated, but only in a splint design that is not commonly used.

Management of burn contractures of the first web space of the hand

First web space contractures of the hand affect predominantly the movements at the trapeziometacarpal joint, rendering the thumb ineffective for opposition and thereby destroying the essential elements of grasp and pinch. Adequate release of contractured first web space followed by a local skin flap cover and dynamic abduction splintage for the subsequent 6 weeks gives excellent results. Documenting the first web angle at every follow-up visit can detect early recurrences and the dynamic splintage can be reinstituted to achieve the normal first web space. Secondary surgery in the form of flexor pollicis longus tendon lengthening or opponens-plasty helps to prevent recurrences.

Upper Extremity and Hand Orthotics

The general principles of upper extremity orthoses are discussed in this article, and the materials used to fabricate the orthoses are described. Static and dynamic splints and their indications are reviewed.

Hand splinting in quadriplegia: current practice.

A mailed survey was conducted to collect information about the application of hand splints to patients with spinal cord injuries resulting in quadriplegia at levels C-5, C-6, C-7, and C-8. Survey respondents were occupational therapists in spinal cord injury centers nationwide. Frequency and descriptive statistics were collected concerning both static and dynamic splints, the clinical reasoning behind splint selection, and methods used for the evaluation of hand function. The results of the survey indicate that hand splinting is an accepted intervention for the target population. A variety of static splint designs were used, depending on level of injury, muscle strength, and the patient's acceptance. The dynamic splint designs were used most frequently with patients whose lesions were at C-6 and C-7. The reasons for not splinting were primarily related to the patient's compliance and acceptance. Observation of patients' performance of functional tasks was the preferred method of evaluation of hand function, as there are no appropriate standardized tests available for this population.

Validation of Spring Forces Applied in Dynamic Outrigger Splinting

Theoretically, when an outrigger or a pulley is used on a dynamic splint, the amount of spring force lost to friction could be substantial enough to invalidate the use of a premeasured spring system. This study had three purposes: 1) to establish length-tension relationships for 1-inch custom-made and 2-inch commercial springs, 2) to determine how much force was lost when an outrigger or a pulley was added to a simulated dynamic splint, and 3) to develop a “clinically friendly” method for measuring the actual amount of force applied with a dynamic outrigger splint. The force measurement system consisted of two Haldex force gauges that were tested for calibration and reliability. Lengthtension curves for 1-inch custom-made and 2-inch commercial 200-g springs placed on 100-500 g of tension at 50-g intervals were obtained by applying vertical tension to the springs with precision weights and horizontal tension to the springs with the force gauge. Next, the lengths of the 1-inch and the 2-inch springs and the amount of force applied were measured when a brass brazing rod outrigger and a Phoenix pulley were added to simulate a variety of dynamic splinting conditions. The results of this study demonstrated that: 1) custom-made 1-inch springs and commercial 2-inch 200-g springs maintain reliable length-tension relationships in the test range of 100–500 g and 2) friction between the dynamic components of a splint and a brass brazing rod outrigger or a Phoenix pulley does affect spring length-tension relationships. These results suggest that friction in this simulated dynamic splint experiment does affect the spring length-tension relationships and the amount of resultant force applied. Because each spring had to be lengthened to accommodate for friction in order to generate the desired force, the validity of the forces applied by a premeasured spring system is questionable. An alternate method of validating the actual forces applied by a spring on dynamic outrigger splints is discussed.

Management of Proximal Interphalangeal Joint Fractures Using a New Dynamic Traction Splint and Early Active Movement

This paper introduces a newly designed dynamic traction splint for the management of digital intea-articular fractures. These fractures, particularly when involving comminution of the joint surface, often result in limitation of hand function due to joint stiffness, tendon adhesion, and chronic pain. Fourteen patients with intea-articular fractures were studied. Thirteen cases involved the proximal interphalangeal joint of the finger and one case involved the interphalangeal joint of the thumb. The splint, a compact, lateral-hinge type, was designed to apply dynamic traction to the fracture. Follow-up at 7 months (range 2 to 19 months) demonstrated functional, pain-free movement. The mean total arc of active motion was 80° in the proximal interphalangeal joints of the fingers and 60° in the interphalangeal joint of the thumb. Radiologic examination demonstrated remodeling of the articular surfaces with maintenance of joint space. The results, when compared with those of other treatment methods, support the use of this splint and treatment program for the management of difficult intea-articular fractures.

Extensor Tendon Injuries

A thorough knowledge of anatomy, injury patterns, repair techniques, and evolving rehabilitation methods is necessary to best treat extensor tendon injuries. These injuries are conceptualized as occurring in one of eight zones, which are numbered distally to proximally in the hand and forearm. Even though surgical technique and rehabilitation are specific in each zone, injuries over and proximal to the proximal interphalangeal joint tend to yield less satisfactory results. Dynamic postoperative extension splinting is one factor that is improving long-term results.

Results of acute zone III extensor tendon injuries treated with dynamic extension splinting

Motivated by the favorable results of dynamic splinting in the treatment of more proximal extensor tendon injuries, we explored the use of dynamic splinting in the treatment of zone III extensor tendon lacerations. Twenty-two tendon repairs in 19 patients were available for review. On the basis of degree of extension lag and pulp-to-palm distance, 14 repairs were rated as excellent, 6 as good, and 2 as fair. Using total active motion at 10 weeks, the proximal interphalangeal and distal interphalangeal joints averaged 170 degrees. There was one mild boutonniere deformity. The results of this prospective study show that carefully monitored dynamic splinting is safe in the treatment of zone III lacerations. When results were compared with the results of our method of static splinting used prior to this prospective study, patients returned to full activities with good-to-excellent results 8 weeks earlier instead of at 16 to 18 weeks.

Adduction contracture thumb

Adduction contracture of the thumb predominantly affects the movements at the trapeziometacarpal joint, rendering the thumb ineffective in opposition and thereby destroying the essential element of grasp and pinch. It is the dominant hand of a family bread earner which is most commonly involved and proper primary management can avoid contracture development. Adequate release of the contracted first web space from hinge to hinge followed by a local skin flap cover and dynamic abduction splintage for the subsequent six weeks can give excellent results. Documenting the first web angle at every follow-up can detect early recurrences and dynamic splintage can be reinstituted to revert it back to normal dimensions. Secondary surgery in the form of flexor pollicis longus tendon lengthening or opponens-plasty helps to prevent recurrence of the contracture.

Reconstruction of finger and elbow function after complete avulsion of the brachial plexus

Simultaneous reconstruction of elbow and finger function with free muscle and nerve transfers after complete avulsion of the brachial plexus (nerve roots C5 to T1) and its long-term results are presented. The basic procedure combined free or vascular pedicle latissimus dorsi muscle transfer with reinnervation by the spinal accessory nerve to obtain elbow and finger flexion, intercostal nerve transfer of the radial nerve to activate elbow and wrist extensors, and suture of the supraclavicular nerve or intercostal sensory rami to the median nerve to restore hand sensibility. Six patients had some or all of these procedures. Postoperative follow-up ranged from 2 to 5 years. Elbow function was restored completely, and some finger flexion was achieved in all cases, although a dynamic splint was necessary to straighten the digits. Patients have continued to improve in grasp power and finger control. This procedure appears to be promising for the restoration of basic hand function in severely handicapped patients.

Complications experienced in the rehabilitation of zone I flexor tendon injuries with dynamic traction splinting

A retrospective review of all flexor tendon repairs done between January 1985 to June 1987 determined the complication rate with our method of rehabilitation. One hundred sixty-three flexor tendon lacerations in 83 patients were reviewed. Follow-up ranged from 6 to 42 months. All patients participated in the same 12-week rehabilitation protocol. All patients had passive motion exercises of the interphalangeal joints in the first 2 weeks. We believe that passive stretching of zone I injuries during the first 2 weeks contributed to the zone I complication rate. Of the 20 patients with zone I tendon-to-tendon repairs, 7 patients had significant complications. The 35% complication rate found with zone I injuries has prompted us to modify our postoperative rehabilitation protocol in zone I injuries.

A Dynamic Mouth Splint for the Patient with Facial Burns

A Dynamic Mouth Splint for the Patient with Facial Burns

Further Experience in Rehabilitation of Zone II Flexor Tendon Repair with Dynamic Traction Splinting

A review of all flexor tendon repairs in the "no man's land" performed from January of 1985 to June of 1987 was done to evaluate the efficacy of our method of rehabilitation. There were 60 fingers (57 patients) with complete laceration of the flexor digitorum profundus and flexor digitorum superficialis tendons in zone II. Fingers with phalangeal fractures, joint injuries, or significant skin loss were excluded. Follow-up ranged from 12 to 48 months. Rehabilitation consisted of a 12-week protocol using the U.S. military combined regimen of controlled motion. Features from the technique of controlled active extension against rubber band passive flexion as well as those of controlled passive extension and passive flexion were incorporated. The palmar pulley modification of Kleinert's dynamic traction splint was utilized. Strickland's total active motion formula was employed to determine results. The results were classified into the four categories of excellent, good, fair, and poor. Fifty-two fingers (86 percent) were rated excellent, 4 fingers (7 percent) were rated good, 1 finger (2 percent) was rated fair, and 3 fingers (5 percent) were rated poor.

Postburn contracture of the neck - our experience with a new dynamic extension splint

Twenty-eight examples of postburn contracture of the neck managed during the last 5 years gave us a better understanding of the problems of anaesthesia, contracture release, skin grafting, splintage and maintenance of the fully released state. The severe contracture should be incised before incubation under a local anaesthetic agent. The release should include the adjoining contractures of mandibular and pectoral regions lest the skin graft is pulled by the existing contracture. Haemostasis should be meticulously secured to avoid graft loss. Splintage should be a static splint for 4–6 weeks followed by a dynamic splint until the applied graft becomes soft, supple and wrinkle free. Ideally, however, contractures should be prevented by nursing the patient with a neck extension in the acute phase and wearing a cervical collar during the subacute phase of wound healing.

Correction of ulnar drift during silastic metacarpo-phalangeal joint arthroplasty

In previous published accounts of silastic replacement arthroplasty of the M.P. joint of the finger in rheumatoid disease, dynamic splintage has been used for up to six months after operation to ensure correction of ulnar drift. We have investigated two methods of surgical correction in a prospective trial in consecutive patients. No dynamic splintage was used. Both resulted in correction of ulnar drift from an average of 34° (maximum 92°) to 8° (maximum 32°) in 86 fingers. The two methods both corrected ulnar drift well, but crossed intrinsic transfer gave a better range of active movement and is recommended as an alternative to dynamic splintage.

Serial Casting as a Technique to Correct Burn Scar Contractures A Case Report

Serial casting is a fast, relatively simple, and inexpensive way to effectively correct burn scar contractures. Plaster casts provide circumferential pressure and a prolonged stretch to contracted tissue and cannot be removed by the patient. When casts are applied well and padded appropriately, there is little risk of pressure areas, since the casts are conforming and do not slip distally. Serial casting may be a successful alternative when low-force dynamic splinting cannot be sized small enough for a child, or when patient compliance is unreliable. A case study of a 2-year-old male patient with severe plantar-flexion contractures of the ankles is presented.

An Evaluation Device for Quantifying Joint Stiffness in the Burned Hand

An electronic device capable of measuring finger joint stiffness has been developed and used to evaluate the effects of dynamic flexion splinting on the recovery of joint motion in patients with burned hands. The device locates an angle of primary (greatest) resistance and the reactive torque at that angle for a selected joint. Using the device, four subjects with stiff hands were measured before and after dynamic splinting treatments. During the 3-day treatment period, there were statistically significant differences in the angle of primary resistance (p less than 0.0001) and reactive torque (p less than 0.001). This initial trial suggests that: (1) finger stiffness can be quantified in terms of reactive torque as well as joint excursion, (2) dynamic rubber-band flexion splinting does alter joint condition and allow increased motion, (3) the amount of initial joint stiffness may be an indicator of treatment outcome, and (4) increasing treatment time may not enhance outcome.