Vanessa: Today's presentation is on upper extremity custom orthoses or orthotics, depending on how we are referring to them, and we will go over that in a minute. We all learned how to make a certain orthoses while we were in school, but perhaps you are in a situation where you need a little bit of a refresher or you are switching specialty areas. Whatever your reason for being here, I hope this information is helpful to you.
American Society of Hand Therapists (ASHT) Definitions
First I would like to talk about the definition of splint versus orthosis. I think colloquially we often use the term splint, when we are really referring to an orthosis. There was a guideline published by ASHT recently that specifically divided splint versus orthosis. Orthosis is the singular term for orthoses, whereas orthotics is the science of fabricating an orthosis. ASHT refers to an orthoses as a rigid or a semi-rigid device that supports weak or a deformed part of the body or restricts motion.
There are three different categories of orthoses. Pre-fabricated is one that you purchase "off the shelf". An example that we might use in our clinic would be a wrist cock-up, perhaps with Velcro strapping and the metal stay that you might commonly use for carpal tunnel syndrome. This is something that you do not really make a change to. It is an orthosis that comes out of a box that you give to the patient. Custom fitted would be if there is a piece that needs fitted to the patient's hand. An example would be a neoprene thumb spica orthosis that has a thermoplast stay inside that has to be heated up and then molded to their hand. The entire thing is not custom, but it is custom fit to them. And then thirdly, custom fabricated is what we will be going over today. This is where you have the thermoplastic material, you make the pattern, and form it to the patient's hand.
A splint, per ASHT, refers to casting or strapping when you are reducing a fracture or a disc location. This is totally different. A splint comes first after the fracture is set, and then the orthosis comes later down the line after the healing process is more underway and it would be safe to put them in a orthosis versus a splint. According to ASHT and also CMS, you cannot actually bill for a splint if you are a therapist. Again, the term splinting should not be used by therapists who are fabricating or issuing orthoses. The term is used by physician offices for applying a cast. Figure 1 shows me wearing a splint that was applied by the orthopedic office after an enchondroma repair.
Figure 1. Example of a splint.
Orthosis Location
When you get a referral, you need to know the location to place the orthosis.
- Digit based
- Hand based
- Forearm based
- Long arm
- Radial
- Ulnar
- Volar
- Dorsal
This is something that is particularly important when you get the referral. You want all the information that you can have about the orthosis and what the doctor is looking for. In my clinic, we have changed our referral system to computer-based. The referring physicians have to designate the location in this system when they set the referral; it is not open text. We need them to spell out whether it is volar or dorsal and radial or ulnar? Do they want the long arm orthosis to include the wrist? For example, if you are trying to immobilize the wrist, it needs to be 2/3 the length of the forearm, and we would refer to that as forearm based. A hand based example would be a thumb spica. Digit based would be just be placed on the finger. You can even designate further than that. For example, they may say they want the MCP joints included, the PIP joints free, or in the case of a mallet finger only the distal end of the digit immobilized. You want to make sure you have all of that information before you fabricate an orthosis. Sometimes they actually need something that is that specific and we will touch on that again when we go through the videos.
We are going to go over two splints today. The first one is a wrist cock-up and the second is a resting hand orthosis.
Wrist Cock-Up Orthosis
Wrist cock-up is synonymous with wrist extension orthosis. It is typically set at 10 to 30 degrees of extension. However, you should note that each clinic or facility might have slightly different indications for that. For example, our clinic works together with our musculoskeletal clinic, where they do EMG studies, and have decided as a team to position a wrist cock-up orthosis for carpal tunnel syndrome in zero degrees at extension. This is only for this disorder. Now that is a project that we went about doing on our own, and that might be something that your facility might want to do as well. That is a great example of therapists and the doctors working together to come up with a solution for a common condition.
This orthosis can also be used for strains, sprains, arthritis, tendonitis, or fractures. Now we are going to go the the video example of how to make a wrist cock-up orthosis.
Video #1
Figure 2. Video of wrist cock-up fabrication.
Figure 3 shows an outline of the steps and I will also talk you through them as the video is playing.
Figure 3. Outline of the steps to make the wrist cock-up splint.
First we start with the template which usually is just a paper towel. You want to make sure that the patient's arm is on the table without any ulnar deviation as this is a really common thing that I see. You want to draw the pattern about half an inch all the way around the client's hand and make a little "bunny ear" on the top there. That extension or bunny ear is going to wrap around their hand and you want to make sure that it is going to clear the head of the first metacarpal. The part that goes in will be rolled to account for the thenar eminence. You want to make sure that when you actually put this pattern on your material that your edges are rounded. You always want to put the template back on the patient to check it prior to cutting out the material. This is really your chance to see it in a 3D way and make sure you do not need to make any changes to your template. When I go to put it back on the patient, I always make sure I have a pen handy because that is where you are going to make your little notations, a half an inch extra here or whatever change it might be.
