Velez College
F. Ramos St., Cebu City
Pediatric Splinting
Submitted by:
Abarra, Eileen Kristine S.
Alturas, Angela Cristy A.
Bacayo, Nicole Christianne Mae B.
Balbuena, Mazie Therese J.
Beloria, Euka Maria R.
Buñing, Rey Xristan B.
Buo, Queenie Ann O.
Cabahug, Erika Marie V.
Caballero, Khisha Joan A.
Cabañero, Debbie Rose D.
Chiongbian, April Grace
Clarin, Cadiene Concepcion C.
Daral, Allaine Marie C.
Dimitiman, Cristito Jr. D.
Estores, Frances Vince V.
Go, Krishia
Jung, Jung Won
Submitted to:
Mr. Von Bryan Darcera
September 24, 2012
PEDIATRIC SPLINTING
Similar to fabricated splints for adults, splints made especially for children may be used
to prevent deformity, to increase function or to do both. However, splinting children involves
more than just making a smaller splint pattern. The purpose of this topic is to guide the
beginning therapist in applying splinting knowledge to the special needs of children with
developmental disabilities or birth defects of both a neurological and orthopaedic nature, such
as cerebral palsy or arthrogryposis multiplex congineta. The resting hand, weight-bearing wrist,
MacKinnon, thumb and serpentine splints are basic designs that serve as a foundation for
pediatric splinting. Modifying these designs or creating entirely new ones should be considered
by the therapist to ensure that they meet the needs of a child. However, it may not be possible
that all splinting goals may be achieved with just one splint. Before splinting decisions are made,
the therapist must first establish overall treatment goals based on the frame of reference
appropriate to the child and the environment. The chosen splint then becomes a component of
the treatment program, which includes goals for improving function and the child’s ability to
participate in childhood occupations, including play, self-care, and such productive activities as
schoolwork. Splint designs are compatible with neurodevelopmental treatment (NDT),
rehabilitative or biomechanical FOR. Splinting decisions must be compatible with the lifestyle,
values, and culture of the child and the family, as well as child’s home, day care, community,
and school environments.
Splinting a child is different from splinting with adults in many respects, including:
1. Abnormal muscle tone has been present since birth or infancy and may differ
qualitatively from abnormal muscle tone acquired after disease or injury.
2. The child experiences the dynamic process of maturational and neurological
development, which has a continuous effect on the acquisition of functional hand skills.
3. Children experienced continued growth of the upper extremities. As children grow,
splints fit and create pressure. During growth spurt, the risk of deformity or skin
breakdown may increase as a result of bone growth that exceeds growth or lengthening
of muscles and soft tissues because of spasticity. Deformity may also occur secondary
to a splint that has been outgrown and no longer fits properly.
4. Many children must rely on adults, such as parents or teachers, to apply and remove
their splints. Therefore the level of understanding and cooperation of these adults is a
factor.
5. Children have a low tolerance for interference by adults and the imposition of a piece of
equipment (splint) which is unfamiliar to them. Their cognitive level may be insufficient
for them to understand abstract concepts such as “prevention” or to comprehend causeand-effect relationship (if you wear this splint, then your hand will work better). They may
resist holding still, become fearful and cry, or be able to cooperate only for brief periods
of time because of short attention span. Any or all of these factors may create great
challenges to the fabrication and application of the splint or splints for children.
6. The placement and molding of a splint on a child is more difficult than on an adult
because the child’s hand is much smaller in proportion to the therapist’s hand.
DIAGNOSTIC INDICATIONS
The focus of this chapter is on splinting the child with a developmental disability or
congenital anomaly. However, many of the principles and splints described also apply to adults
with developmental disabilities. Developmental disabilities include a wide variety of chronic
conditions that are evident at birth or during childhood and that interfere significantly with
development and functional abilities (Yamamoto, 1993). Many developmental disabilities, such
as cerebral palsy, are accompanied by central nervous system dysfunction and abnormal
muscle tone. Central nervous system dysfunction can be the result of many types of brain injury
such as an intracranial hemorrhage, hypoxia, infections, tumors, or trauma. Abnormal muscle
tone can include increased, decreased or fluctuating tone and presents a number of splinting
challenges. Lower motor neuron dysfunction may also occur at birth as a result of excessive
stretch to the brachial plexus during delivery. Depending on the nature and extent of the nerve
damage, this may result in developmental hand dysfunction.
Other diagnoses in children for which splinting may be indicated include congenital
defects or anomalies of the hand or upper extremity, which are generally due to malformations
of the musculoskeletal system. These may include finger flexion contractures, soft-tissue or
bony fusion (syndactyly), or dysplasia of the ulna or radius. Another congenital or birth defect
that requires orthotic intervention is arthrogryposis multiplex congenita. “Arthrogryposis
multiplex congenital is not a specific disorder but rather a symptom complex of congenital joint
contractures associated with both neurogenic and myopathic disorders… The main feature
shared by these disorders appears to be the presence of severe weakness early in fetal
development, which immobilizes joints, resulting in contractures.” (Banker, 1985, page 30).
Programs that involve early passive stretching and serial splinting of contracted joints are
recommended (Sala, Rosenthal, & Grant, 1996; Williams, 1986; Bayne, 1986). Splints, such as
a dynamic elbow flexion splint, have also been developed to compensate for lost muscle power
(Kamil & Correia, 1990).
Children with developmental disabilities or congenital anomalies often present with
indwelling thumbs (thumbs held adducted into the palm). This may be the result of abnormal
muscle tone, weakness, or abnormal anatomy of the hand. To effectively grasp and manipulate
objects, it is crucial that the thumb be positioned in opposition. Splinting, along with active
movement, is often required to effectively position the thumb in opposition for grasp and optimal
hand function.
Juvenile rheumatoid arthritis (JRA) is a systemic rheumatic disease that causes major
disabilities in children younger than 16 years old. Children with JRA may present with pain,
fatigue, and reduced range of motion (ROM). These symptoms often result in difficulty
performing school tasks and activities of daily living. In addition to medical management,”…
forms of treatment may include splinting, active and passive range of motion of the joints, and
monitoring each joint to maintain maximal function and prevent deformity” (Gordon,
Schanzenbacker, Case-Smith & Carrasco, 1996, p. 124).
In summary, a number of pediatric diagnoses may indicate a need for splinting.
However, the final splinting decision is made on the basis of the limitations in specific
movements, the type and severity of abnormal muscle tone, the extent of soft-tissue and bony
involvement, the child’s functional level, the child’s environment, and the frame of reference
guiding therapy, rather than on a specific diagnosis.
ASSESSMENT
Before fabricating a splint, the therapist must complete a comprehensive assessment. These
factors should be considered:
Engagement in Childhood Occupations
Clinical observation of the child engaging in childhood occupations is necessary to
determine the overall direction of the intervention program and whether and how a splint will
contribute to that intervention program. The child and family attach meaning to different
activities and occupations, and it is the accomplishment of these occupations that ultimately
determines the success of the intervention program. On the basis of the child’s occupations, the
therapist can determine the relative emphasis for individual components.
Muscle Tone
The quality and distribution of muscle tone should be assessed at rest and during
functional activity. The therapist should also determine whether the amount of tone varies
according to the child’s mood, physical health, amount of effort exerted, or state of alertness.
Range of Motion
The therapist should measure both active and passive ROM and compare
measurements with those taken previously to determine whether range is increasing,
decreasing, or remaining the same. The position of the joint and the level of comfort of the
patient must be taken into consideration as well.
Contractures
The therapist should discriminate between types of joint end feel. When tightness of a
joint is primarily the result of muscle and soft-tissue shortening, with full passive range still
possible with effort, this effect is known as soft end feel. When the joint cannot be moved to the
end of passive range, it is said to have a hard end feel. When the latter cannot be obtained, it is
known as a contracture. A limb with a contracture is also said to have a deformity.
Active orthotic management or splinting during childhood may prevent many
contractures and resulting deformities thus improving quality of life for children and their
respective families. Early orthotic intervention is also usually less costly.
Understanding the possible physiological mechanisms for the formation of a contracture
can assist the therapist in splint design and establishment of wearing schedules. Preventing
contractures, or minimizing their severity, is one of the most important functions of splinting for
children with developmental disabilities or congenital anomalies.
Integrity of Skin, Bones and Circulatory System
Osteoporosis in children occurs due to lack of weight bearing while bones are growing.
In splinting a child with osteoporosis, stress to the bones could cause a fracture thus extreme
care must be given. Children with tightly fisted hands may develop skin breakdown in the palms
or between the fingers so maintenance of skin hygiene becomes a priority. Other children may
experience pain in certain positions; have sensitive skin; or have poor circulation, which would
require careful monitoring of the child’s skin temperature and color during splint wear. Some
children may have feeding problems and may be underweight. They have more difficulty
tolerating pressure on bony areas due to little subcutaneous fat.
Functional Use of Upper Extremities
The therapist should evaluate components of reach, grasp, manipulation, release,
bilateral hand use, and tactile and proprioceptive reactivity and discrimination. It is important to
evaluate function in different positions as this gives crucial information about the proximal
stability needed for effective distal function of the hand. Sensory system modulation should be
observed because this affects the therapist’s approach to the child and influences splint
selection and fabrication. The therapist should also obtain information about the child’s cognitive
level as this affects hand use. An objective measure of hand function, such as a criterion
references assessment tool, must be used to periodically reevaluate and compare the child’s
performance over time along with a qualitative description of how the child moves and performs.
Environment and Family Considerations
The fabrication and monitoring of a child’s splint may occur in any of the environments in
which the child lives, rests, plays and is productive in. When selecting and designing a splint,
persons who are responsible for donning the splint must be considered. Simplicity of design is
most desirable especially if multiple care providers are involved. Compliance with using the
splint is likely to decline as the complexity with the donning and wearing schedule increases.
Splinting in the intensive care units of the hospital must be fabricated with minimal
handling of the child and while navigating carefully around tubes and monitors. The use of
splints must be incorporated, and not cause difficulty, in the daily medical care provided by
nursing staff. The therapist must also be familiar with the child’s medical condition and be able
to recognize signs of stress that can be harmful to the child.
In the school environment, splints must contribute to the child’s ability to benefit from a
specially designed program of instruction. It is important for a child to be able to reach, grasp,
carry, manipulate, and release learning materials and other objects in order to function in the
school settings. The therapist should include the purpose of a splint as a part of educationally
related occupational therapy described by the individualized education plan.
Information about the home environment should be obtained from interviews with
significant others and a home visit, if possible. Splints with wearing schedules that are
incompatible with family schedules or cannot be understood by family members will be
ineffective. The therapist must individualize the splint design and wearing schedule to fit the
family’s strengths and needs.
OVERVIEW OF THE SPLINTING PROCESS
Prepare the Child
Position the child so that the effects of abnormal tone and postural reflexes on the arm
and hand are at a minimum. It is important to provide external stability through equipment or
handling for children who have not acquired internal stability of proximal joints. For the infant or
young child, it may be possible for the parent to hold the child and provide external stability with
the therapist’s instructions.
It is also important to reduce the child’s fearfulness and maximize his or her cooperation.
The therapist should have toys, music, books, stickers or other materials to establish reciprocal
interaction with the child before starting the fabrication process.
With an infant, the therapist can talk in a soothing voice and touch the child in a playful
manner. With an older child, the therapist can show the child what to expect by first fabricating a
splint on a doll or stuffed animal or by making thermoplastic jewelry or other play objects. When
appropriate, the child should be given opportunity to touch and feel the material while it is warm
and soft and again after it become cool and hard. The child’s response to tactile stimuli should
be noted, and if signs of tactile defensiveness occur the therapist should follow sensory
integration guidelines for improving sensory system modulation.
Giving the children a role to play in fabrication process may increase their cooperation.
Although preparing the child may take a few extra minutes at the beginning of a splinting
session, it can save hours of frustration in having to reschedule or remake a splint because of
lack of cooperation.
Prepare the Environment
It is recommended that the therapist plan to have a second pair of adult hands to help
with the fabrication process. This additional person might be a parent, teacher, professional, or
another therapist. This is especially important if the child has increased tone, is not able to
follow verbal instructions, or likely to be uncooperative. The therapist must clearly explain the
helper’s role so that efforts assist the process and not hinder it. This usually involves
maintaining the child’s overall position, calming or entertaining the child, holding the arm just
proximal to the joint being splinted, or stabilizing the material once in place and when it is
cooling.
Selection of Splinting Materials
- Pediatric splint may be made of many different types of materials
- Thermoplastic materials- commonly used for the fabrication of static splints or those that
require restricting motion at certain joints
- Examples of thermoplastic material used:
 QuickCast- thermoplastic material thinner than 1/8 inch
 Adapt-It Thermoplastic Pellets
- Soft splints- are commonly made of materials such as neoprene, leather, or webbing. It
may not totally immobilize joint but it provide support and comfort
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Children with athetosis or involuntary flailing movements should be protected from
possible harm from the splint by selection of a soft material or by covering a
thermoplastic material with a mitt or sock
When splinting with neoprene, therapist should be alert to the possibility of skin irritation
or rash. Skin contact with neoprene poses two dermatological risks: allergic contact
dermatitis and miliara rubra. It is recommended that therapist should screen the patients
for history of dermatological reactions, instruct the patient to discontinue use and inform
the therapist if a rash, itching, or skin eruptions occur, and report cases of adverse skin
reaction to the manufacturer of the neoprene material. Therapist are also recommended
to limit their own exposure to neoprene and neoprene glue because of the exposure to
thiourea compounds that are thought to contribute allergic reactions
Thermoplastic material with high plastic content have more conformability whereas
materials with a high rubber content have less stretch
When making a splint that counteracts the forces of spasticity, it is important to select a
thermoplastic material that resists stretch because it is necessary for the therapists to
apply considerable pressure to obtain the desired position of the wrist, thumb, and
fingers. Usually the rubberlike thermoplastic material is necessary when one is splinting
against spasticity
When working with a child, choose a material with a high degree of memory
When splinting a neonate or young infant, the therapist should use material that is 1/16
inch or 3/32 inch thickness
Patterns
- Patterns are made for each splint on each child, depending on the therapeutic goal of
the splint and the child’s characteristics
- Many children with abnormal tone may be unable to lay their hands on the table surface
for tracing. In this case, the pattern must be held under the extremity in whatever
position is least stressful. The therapist may also consider using uninvolved contralateral
side to start a pattern, given there is some symmetrical of anatomy
Heating the Thermoplastic Material
- The therapist should heat the water to the temperature range recommended by the
manufacturer
- After cutting out the splint, it may be necessary to reheat the plastic to obtain the desired
degree of pliability before the molding process
- Before placing the plastic on a child’s extremity, the therapist should dry off the hot water
and make sure the plastic is not too hot
- The child’s arm and hand can be moistened with cold water just before molding, or the
therapist can wait longer for the plastic to cool
- Some therapist use stockinette to protect the extremity
Hastening the Splinting Process
1. Rubber based plastics, which are necessary to resist stretch, are somewhat slower to
harden
2. Once plastic is in place on the extremity, an ice pack can be rubbed on the splint to
hasten the setting process.
3. A rubber glove filled with ice chips can easily serve the purpose
4. After partially hardened, the splint can be carefully removed and put into a pan of ice
water or placed under a faucet of cold running water to finish hardening.
5. A spray coolant may be used, but only with great care to spray after the splint is off the
child and with the spray directed away from the child
6. The use of the coolant spray should be avoided with children who are unable to keep
their heads turned away from the direction of the spray and those who have frequent
respiratory problems
7. Theraband roll that has been cooled in a freezer can help form the splint, especially
forearm. This will accelerate the cooling process at the same time
8. If not available, an Ace wrap can be useful to hold the forearm trough in place while the
therapist works on the hand portion of the splint, although this maintains heat and may
increase setting time.
9. The therapist should not apply the wrap or Theraband too tightly and should flare the
edges of the forearm trough away from the skin after formation of the splint.
Padding
- Necessary over bony areas to prevent skin problems
- Does not compensate for pressure resulting from a poorly made splint
- Padding takes up place, a factor that the therapist must take into account before
formation of the splint
- Types: closed- and open-cell foam; and gel products
- Pressure relief padding with a gel center is useful in protecting bony areas for children
with little subcutaneous fat
- To ensure proper fit, the therapist should lay the padding on the child’s extremity before
molding the plastic or place it on the thermoplastic material before molding the splint
- When molding the padding, the stretch of the thermoplastic material and contourability
may be compromised. Therefore the therapist should add padding only when necessary
- Becomes soiled and needs to be replaced
- Alternative: cover the prominence with small amount of firm therapy putty before forming
the splint. The putty creates a built-in bubble and is removed from the splint after cooling
- Thin forms may also be useful to create friction and reduce migration or shifting of
splints, or for covering edges
- Microfoam tape is useful for this purpose, especially on small splints
Strapping
- Strength, durability, elasticity and texture when strap is against skin should be
considered
- Straps with sharp edges should be avoided with younger children and those with
sensitive skin
- The wider the strap, the more force is dispersed, as long as the entire strap with is in full
contact with the skin
- Must be cut narrower, especially around the wrist and fingers, to proportionate to the
size of the child’s hand
- Secured at each end with hook Velcro, which is attached to the splint. This allows them
to be easily replaced when they become solid, which is important if the child drools on
the splint or mouths it
- Loose straps easily becomes lost and many times are not placed on the splint at the
correct angle or location
- Alternative: adhere strap at one end with a rivet or strong contact adhesive
- When soiled, straps must be removed by the therapist and a new strap attached
- A great deal of creativity is need to keep the little “Houdinis” in their splints
- Kid proof methods: Shoelaces, buttons, or tape
- Lacing can be done by punching holes along the lateral edges of the splint and lacing
with wide decorative shoelaces
- Thx should place padding under the laces against the skin
- “Bow Biter,” a plastic device to hold the laces in place and available in the children’s
department store
- Sock puppet worn over the splint may be used as a camouflage
- Care must be taken not to provide any attachment that the child could bite off and
swallow
Providing Instructions for Splint Applications
One must understand the splint’s:
 Purpose
 Rationale for using splint
 Precautions
 Risks of incorrect usage
These must also be known to others responsible for the child, such as:
 Teachers
 Nursing staff
 Parents
 Child caregivers
Complex splinting = more detailed and explicit instructions needed.
Parents and major care takers should already be familiar with the purpose and rationale
because their input is necessary for the splint design. Written instructions and along with a
phone number to call is important to be provided by the therapist. Demonstrations of steps and
practice in applying the splint under supervision are also important.
A photograph of the child's forearm and hand showing the correct position is an effective
teaching tool thus considering first any confidentiality matters. Instructing caregivers to inspect
skin every time splint is removed to assess splint for tightness is also important.
Wearing Schedules
This may vary according to the purpose of the splint, tolerance, musculoskeletal status,
occupations and daily routines of the child. Splints may be worn for long or short intervals; day,
night, and functional activities. Gradually increasing the time of wearing the splints will increase
the child's tolerance for the splint.
Splint for functional use f the hand is worn during the times of functional activities. Splint
for tone reduction is worn after activities of the child. Splint for preventing contractures is worn
when the child is not engaged in any activity. Splint for treating existing contractures is worn for
long periods of time. Time wearing for the splint that is more important than wearing it
continuously or intermittently is in the span of 24hrs.
Clinical judgment, based on the education, learning through reading, continuing
education, experience, and feedback from child and parents are the basis of making a wearing
schedule of the splint. These schedules will only work if the splint is placed on the child during
the times recommended. Including these in the child's regular routine will increase compliance
because it becomes less of a chore to the child's SO's. Evaluations of the splint will take place
for the child's ROM status may change thus requiring necessary modifications of the splint.
Precautions
Skin inspections should be made frequently at the initial wearing phase. If a distinct red
area or a generalized redness does not disappear within 15-20mins after splint removal will
indicate excessive pressure and the need for revisions. Problems associated with joint
compression, pressure on the nerves, compromised circulations, and dermatological reactions
must be notes by the therapist.
Evaluation of the Splint
Reassessment of the splint must be done on a regular basis to ensure proper fit and
function. The care provider must be able to put the splint an hour before the reassessment so
that the therapist can observe how the splint is put on and whether the splint migrates out of
position after initial donning. A poor fitted splint can cause harm to the patient. This applies to all
pediatric splints.
RESTING HAND SPLINT
Purpose
 Prevent contracture or deformity
 Prevent an existing deformity from becoming worse
 gradually improve or reduce deformity
 Children with moderately to severe increased tone or those severely decreased tone that
have no active movement have the greatest risk of developing a contracture.
 Maintenance of skin hygiene is needed for those with increased muscle tone and tightly
fisted hand.
Features
Components:
 Forearm trough
 Pan of fingers
 Thumb trough
 C bar
- Considering the function of the thumb, therapist should attempt to rotate the 1st
metacarpal in palmar and radial abduction.
- For children with moderately to severely increased tone, the functional position may not
be possible. The purpose is to prevent or reduce joint deformity; splint should provide as
much elongation of the tight muscles as possible without causing excessive stress.
- The child should be able to tolerate wearing the splint for several hours at a time to
obtain maximum benefit.
- If the splint places the hand in maximum passive of motion, the forces compromise
circulation, skin breakdown, elicit pain, and reduce length of time the child can tolerate.
- The splint should place the wrist joint in submaximum range to allow extension of the
fingers.
- If flexor spasticity is severe, serial splinting is necessary.
- Therapist can determine the best splinting position by handling the child’s extremity and
feeling the amount of passive resistance.
Process to Fabricate a Resting Hand Splint
Thermoplastic material selection
- Low temperature thermoplastic that resist stretch.
- Higher rubber content will have desired working characteristics.
Pattern
- Include measurements and markings of landmarks.
- After pattern is drawn and cut out, therapist fits it to child for further modifications.
- While making the pattern and molding, position the child to minimize the effects of
abnormal tone and postural reflexes.
Padding
- Padding places some restrictions on forming the splint and keeping it clean, it should not
be used unless the child is risk of skin problems.
- Creating bubbled-out areas over bony areas may be sufficient to avoid skin problems.
Forming the splint
- Before placing, pre-stretch the edge of the splint that forms C bar.
- The therapist should then place the soft plastic on the child’s extremity to conform to the
web space of the thumb.
- Form the splint into palmar arches and around the wrist and thumb.
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To obtain the desired contour and fit, the therapist may need to be aggressive when
molding into the palm and around thenar eminence, especially working against
spasticity.
The therapist must form the splint so that the bulk of pressure positioning the thumb is
directed below the thumb metacarpal joint distributed along the thenar eminence to
avoid hyperextension and dislocation of thumb in MP joint.
Thumb trough should cradle the thumb and extend about ½ inch beyond the end of
thumb.
IP joint of thumb should be slightly flexed.
C bar should fit snugly into web space and contour against the radial side of index finger.
Forearm Trough
- Edges of the trough should not be too high. High edges cause bridging of the straps.
- Bridging of the straps makes it difficult to keep the forearm securely in place which may
cause forearm rotation on the trough or the shifting of the splint distally. The position of
the wrist, fingers and thumb will be compromised
Pan
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Require reheating because controlling all the joints at the same time is often difficult
Distal portion of the pan should extend about ½ inch beyond the finger tips
Proximal and distal transverse arches should be followed when forming the curve of the
pan
Straps
- Correct placement of straps is as important as correct formation
- Straps and splint must work together to create the necessary leverage and to distribute
pressure
- Optimum location and angle of each strap should be determined in relation to the forces
being applied by the abnormal muscle tone.
- Forearm trough
o Two straps for older child
o One wide strap may be sufficient for a smaller child or an infant
- If considerable wrist flexion is present
o Two straps is necessary to provide 3 points of pressure to secure the wrist
 Directly across the wrist
 Angled from the thumb web space across the dorsum of the hand and
secured proximal to the MCP joints on the ulnar side
- If considerable finger flexion is present
o Straps may be needed across each of the three phalanges
o Add a strap between the MP and IP joints of the thumb
- Make straps narrower if splint is for a young child
Adaptations
- Resting hand splint provides a basic form for positioning the child in good alignment
- Deviate from the basic form to truly meet the needs of the child
- Finger separators
o Abduct fingers and assist in tone reduction
o Bubbling the material between digits
o Attaching a roll of thermoplastic material between the digits
o Can also be made from Adapt-It Thermoplastic Pellets
 Soften pellets in hot water and knead them together to the shape and size
 100% memory and attached in the same way as any other thermoplastic
material
 Work well when individualized finger separators are needed
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dorsal based resting splint
o allow sensory input to the palm of the hand
infants with congenital finger contractures
o resting hand splints
o when all digits are not affected,, splint may be altered to free non-affected digits
resting hand splints may be made with alternative materials
o semirigid pliable material
 for neonates
 less likely to cause abrasions
o Kushionsplint
 Semirigid low-temperature material lined with terry cloth
 Heated using conventional oven
o Permagum
 Silicone rubber dental impression material, mold into shape for neonatal
splints
o Adhesive cloth tape
 Several layers may also be an effective semirigid support
o High-density foam
 Alternative to decreasing upper extremity hypertonicity in children with
extremely high tone
Precautions
- Consider biomechanical principles of force distribution
- Monitor for any undesired lateral forces on the fingers or wrists
- Be aware of any circulation compromise or pressure on the nerves
- Be astute in observations and elicit important information from the child, parent, or
caregiver
Applying precautions for child with increased tone:
- Shorten initial wearing time to 15-20 minute intervals on the first day
- Carefully inspect the skin
- Distinct read area or generalized redness on the skin that do3es not disappear within 1520 minutes after splint removal indicates excessive pressure
- If no pressure areas are present, increase the wearing time to 20 minute intervals
- Wearing time is increased by adding 15 to 30 minutes of wearing time until maximum
wearing period for the child is reached
For moderately to severely increased tone
- Maintaining integrity of the MP joint of the thumb
- Direct pressure below the MP joint of the thumb
- Distal force to the spastic thumb can result hypertension and dislocation of the MP joint
Wearing Schedule
- Determined on an individual basis
- The more serious the threat of deformity, the longer the splint is worn each 24 hours.
- Splint is removed for periods of passive ranging, active movement, ad opportunities for
sensory experiences
- Flow chart or algorithm for making clinical decisions
- Describe the biological basis for limitations in joint ROM and increasing ROM
- Basis for limitations in joint ROM and increasing ROM
- Primary basis for using splints to increase ROM is that by holding the joint at or near its
end-range over time, therapeutic tensile stress is applied to the restricted periaarticular
connective tissues and muscles.
- Induces remodelling of tissues to a new, longer length, which allows increased ROM
- Remodelling
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Biological phenomenon that occurs over long periods of time rather than a
mechanically induced change that occurs within minutes
Work on functional activities immediately after removal of the resting hand splint
Splint should be removed more frequently or for longer periods of time
Providing Instruction for Splint Application
- Caregivers should understand
o Purpose
o Precautions
o Risks of incorrect usage
o How to reach the therapist
Evaluation of the Splint
- Self-evaluation can be used to evaluate the finished splint
- Fit of the splint should be reviewed at regular intervals
- Splint’s effectiveness in accomplishing state goals and outcomes should be re-evaluated
on an on-going basis
WEIGHT BEARING SPLINT
- Positions the hand in the most effective position for weight bearing activities.
- Requires significant wrist extension for effective use.
- Use as a therapeutic tool, generally with children who have mild to moderate spasticity in
their upper extremities.
- Worn only during therapy sessions.
- According to Lindholm, (1986), the splint positions the wrist in extension to counteract
the usual position of wrist flexion resulting from spasticity.
- This position allows weight bearing through the heel of the hand
- The splint positions the hand to allow normal weight bearing through the lateral borders
of the hand and the fingertips.
- An effectively positioned hand allows the child to work on more proximal control.
- The splint serves as an assist for positioning the hand, while the child is performing
weight – bearing activities.
- During therapy, the splint allows the therapist to focus less on the hand and fingers and
more on facilitation or inhibition techniques of the upper extremity
Features
- The splint was originally designed as a hand – based splint.
- More stability is provided when the splint is fabricated with a forearm trough.
- It has a similar in design to the resting hand splint; however, there is more extension at
the wrist, and the thumb is in more radial abduction.
Pattern
- The pattern for the weight – bearing splint is similar to that for the resting hand pattern.
 However, extra space is provided when tracing around the fingers and thumb.
 The web space is not tapered.
- The pattern should look like a mitt for the hand.
- If a forearm trough is added to the splint design, it should extend two thirds the length
and half the circumference of the forearm
Forming the Weight – Bearing Splint
- Mold the splint on the volar surface of the hand.
- The PIP joint and DIP joint should be in slight flexion and the thumb in radial abduction.
- The wrist should be in 450 to 500 of extension.
-
Much attention should be given to the palmar arches by positioning the hand in a cupped
position.
A small ball that fits comfortably in the child’s hand can be used to reinforce the arches.
A wide strap over the IPs will aid in keeping the fingers on the mitt.
A diagonal strap over the wrist reinforces the wrist position.
Straps should be placed proximally and distally on the forearm trough.
Precautions
- Requires adequate wrist extension.
- ROM must be obtained before it is fabricated.
- When the wrist is in extension, the fingers often attempt to curl into flexion.
- Attention should be given to stabilizing the fingers in slight abduction.
Adaptations to the Weight – Bearing Splint
- Slits should be made in the hand portion the splint to maintain stability of the fingers.
- This is accomplished by threading the strapping material through the slit and looping it
over each joint.
- A dorsal hood may be fabricated by draping the thermoplastic material over the dorsum
of the hand to ensure stability at the hand.
- If additional concerns exist with respect to stabilizing the wrist and dorsum of the hand,
the wrist and the forearm may be covered with thermoplastic material.
- This will create a clam shell type of splint.
- Since considerable pressure may be present, the dorsal piece of the splint may require
padding.
WRIST SPLINTS
Providing proximal stability at the wrist, the splint allows for improved control of distal
finger movement for grasp and release. When a therapist uses a wrist splint for a child who has
tightness of the long finger flexors, the splint may have to position the wrist in slight flexion.
Because of the tenodesis effect, the wrist splint may not be appropriate if the finger flexors have
severe tightness causing a fisted hand posture.
- If the child has only mildly increased tone or is hypotonic, a soft wrist splint with a
reinforcement component over the wrist may be preferable.
If tightness is also present in the opponens muscle, a splint that includes a thumb
trough may be indicated.
The thermoplastic wrist splint can be either volarly or dorsally based. The volar design is
more effective if wrist flexion is difficult to control; however, it covers the palm of the hand, thus
reducing sensory input and creating more bulk in the hand. The dorsal design allows more
sensory input in the palm but may be more difficult to construct when the child has wrist and
finger flexor spasticity. If the palmar bar is too narrow, it can be dangerous and painful
Features
Process to Fabricate a Volar Wrist Splint
Materials
- A thermoplastic material that resists stretch is frequently desirable when the therapist
positions the wrist of a child with spasticity.
- When the purpose of a wrist splint is to serve as a base for attaching pointers or holders.
Pattern
- After tracing the child’s extremity, the therapist make the splint makes the splint pattern.
Forming a Wrist Splint
- The splint should follow the contour of the palmar aches as they are configured during
grasp. The splint should not interfere with MCP flexion or thumb opposition.
-
The therapist rolls the edges around the thenar eminence and MP bar.
Straps
- Usually two straps secure the forearm tough and one strap secures the hand. The hand
strap is angled from the ulnar side of the metacarpal bar to hypothernar bar.
Precautions
- The splint should distribute pressure to avoid skin irritation.
- The splint must stabilize the forearm so that the splint does not shift during use.
- The splint should not interfere with thumb opposition or MCP flexion of the fingers.
Wearing schedule
- The therapist should consider the child’s therapeutic goals, occupations, and the extent
of functional hand skills with and without the splint.
- The child wears the splint during activities that require grasp and release that can
accomplish more easily while wearing the splint.
Evaluation of the Splint
- The therapist can use self-evaluation form to determine whether the fabrication of the
splint is correct.
- The therapist should also perform frequent, on going re-evaluation of the splint’s
effectiveness and the child’s functional hand skills.
Adaptations to the splint
A unique adaption to the wrist splint is the attachment of pointers, crayon, holders, or
other assistive devices. When designing a pointer, the therapist should angle it so that the
pointer is within the child’s visual field. When possible, the therapist makes a finger trough to
position the index finger pointing, thus allowing sensory feedback to the tip of the index finger
after contact is made with the target.
Some children may benefit from the addition of a spiral strap to facilitate partial
supination while wearing the wrist splint. This can be accomplished by dorsum of the hand over
the wrist and forearm and attaching it to itself just proximal to the elbow.
MACKINNON SPLINT
- A semi dynamic wrist splint that facilitates wrist extension while inhibiting finger flexor
tone
- Provide touch pressure to the metacarpal heads to inhibit flexor tone while providing
stretch on the intrinsic to facilitate the muscles.
- Used with children who have mild to moderate hyper tonicity and aids in positioning the
hand for gross grasp and finger isolation activities.
- Original design with dowels and nails.
Features
- MacKinnon splint provides an inhibitory components to the fingers, provides support for
wrist extension, and also aids in thumb position
- It has metacarpal bar that exerts pressure across the metacarpal heads.
- Bar is attached with flexible tubing to a dorsal forearm trough.
- Attachment site may be also in wrist bar but more stability is gained in forearm trough
- Often visually appealing and less restrictive, thus giving the child more opportunistic for
sensory experiences.
- Splint Increases grasp and bilateral hand.
- Improved hand function in children with hemiplegia
Process to fabricate a modified MacKinnon Splint
- Constructed of a thermoplastic material with moderate stretch as used with the resting
hand or wrist splint.
- A piece of ¼-inch flexible aquarium tubing is needed for the semi dynamic wrist support.
- Closed-cell padding may be used to help prevent migration of the forearm piece and for
increased stability of the splint on the forearm
Pattern
- Metacarpal bar is formed from a rectangular piece of thermoplastic material.
- Rectangle is equal to the length of the distal palmar crease and wide enough to roll and
self-adhere.
- Forearm trough is a rectangular covering 2/3 of the length of the forearm and ½ of the
circumference.
- Length of the tubing is the distance from the attachment site on the dorsal side of the
forearm trough, across the volar aspect of the metacarpals and back to the dorsal
attachment site
Forming Splint
- Fabricate MC bar by rolling the tubing in the rectangular thermoplastic material.
- Diameter of the palmar bar depends on the size of the child; it ranges from ½ to ¾ inch.
- Hold the bar straight until it hardens, simulating wooden dowel. Position the wrist in
slight extension.
- Place MC bar across the MC heads, and pull the tubing to maintain the wrist slight
extension. Attach the tubing to the center for the distal portion of the forearm piece.
- Use a small square of thermoplastic material to attach the tubing to the forearm piece.
- Removing the nonstick coating with bonding solvent or marring the top surface with
scissors should be done before adhering the pieces.
- One or two straps across the forearm are needed to secure the forearm piece.
Wearing Schedule
- It should be worn when the child is awake, active, and engaged in functional task.
- Inhibitory effect should improve the child’s ability to grasp and release objects, to
perform activities requiring bilateral hand use, and to execute isolated finger movement.
- Wearing schedule is influenced by the child’s tolerance, the effects of the splint while on
and type of occupations the child engages in during the day
Precautions
- Skin should be inspected for signs of excess pressure.
- FA trough must be securely attached to FA or splint may migrate distally and rub against
the radial styloid or distal ulna.
- The length of the tubing should position the wrist in slight extention while also allowing
for small gradations of the wrist flexion and extension
- Tubing that is too tight will restrict wrist and finger movement, and tubing that too loose
will allow excessive wrist flexion and fail to hold MC bar in place across MC heads
Adaptation
- Thermoplastic thumb trough may be added to the palmar bar to provide support
- Objects such as pipe cleaners may be threaded through the tubing to provide more
support and decrease the semi dynamic qualities of the splint
THUMB SPLINTS
- Increased muscle tone frequently pulls the thumb into palmar abduction.
- The purpose of a thumb splint is to improve functional use of the hand by stabilizing the
thumb in a functional position of palmar abduction.
-
The therapist uses this splint for a child who has some active wrist and finger extension
but has difficulty actively moving the thumb out of the palm because of increased tone.
If tone is moderate to severe, the therapist makes the splint out of thermoplastic
material.
If tone is mild to moderate, the therapist makes the splint from more pliable material,
such as neoprene or webbing.
Thumb splints can be hand or forearm based.
THERMOPLASTIC THUMB SPLINT
Features
- Hand based thumb splint can be of palmar or dorsal design
- The dorsal design results in less bulk in the palm, but the splint may not apply adequate
pressure against thenar muscles.
- The palmar design includes metacarpal bar, a thumb trough with a C bar and a
hypothenar bar.
- Aside from the inhibitory and facilitory principles of pressure and position, the therapist
must remember that the first metacarpal cannot be stabilized unless thermoplastic or
another restricting material holds firmly to the adjacent metacarpal.
Process to Fabricate
- The selection of tools and materials are essentially the same for the resting hand splint.
- After cutting out the splint and reheating the material, the therapist places the material
on the child’s hand and carefully molds the C bar to nthe humb webspace.
- The hypothenar bar wraps around the ulnar border of the hand far enough to secure the
hand, and the metacarpal bar is rolled proximal to the distal creases to allow finger
flexion.
- The body of the splint should conform to the palmar arches as they occur during grasp
and should extend proximally far enough to adequately position the CMC joint of the
thumb but not so far that it interferes with wrist flexion.
- The therapist should assure that the splint does not position the wrist in radial or extreme
ulnar deviation.
- The therapist forms the thumb trough by positioning the thumb in palmar abduction and
the stretching the plastic to form the C bar.
- The therapist should distribute pressure along the thenar eminence, thus providing
optimal positioning of the thumb and avoiding hyperextension of the MP joint.
- The thumb trough should extend just past the IP joint of the thumb but should leave the
tip of the thumb free for sensory contact during grasp.
- The finished splint should allow the index and middle fingers to contact the tip of the
thumb.
- The therapist should place a strap across the dorsum of the hand.
- If necessary, the therapist should also place a strap across the thumb trough.
- Sometimes during fabrication, it is necessary to modify a small area.
- This can be especially challenging when one is working on a small, curved splint.
- If the therapist wants to use hot water but does not want to risk losing the overall shape,
a kitchen baster can be used to draw up hot water and place it repeatedly over the target
area.
- Ultratorch is a fine spot heater that allows pinpoint modifications even with 1/16 inch
material.
Precautions
- The pressure to position the thumb should be directed below the MP of the thumb to
prevent stress and possible dislocation of this joint.
- The splint should also fit snugly into the thumb web space.
- The therapist must watch for signs of skin irritation and pressure.
-
The therapist should monitor the child for circulation and nerve compression problems
caused by an ill-fitting splint.
Wearing Schedule
- The child should wear the thumb splint during functional activities that require grasp and
release.
- The thumb splint can also be worn during the day to prevent the opponens muscle from
remaining in a fully shortened position.
- If contractures are a concern, the child may also need to wear a resting hand splint to
provide further stretch of the thenar muscles.
- The therapist should give the child opportunities to use the thumb actively, especially
after the splint is removed to take advantage of the elongation of the thenar muscles.
- As the child, gains active control of the thumb abduction, the therapist should reduce
wearing time of the splint.
SOFT THUMB SPLINT
- Allows more movement of the intrinsic muscles of the hand and active movement of the
thumb
- Restricts palmar abduction but does not prevent it entirely
- Available commercially in different sizes from infancy to youth
- Fabrication materials may include webbing and neoprene
- Neoprene thumb splint have an advantage of providing neutral warmth, which may have
an inhibitory influence on hypertonicity
- In buying a neoprene thumb splint therapist should consider whether the splint has a
Velcro closure
- A thumb splint that slides over the fingers and thumb may be more difficult to apply
- The tone and positioning (TAP) splint is made of neoprene for thumb positioning and
forearm supination
- Provides constant low level stretch to the forearm pronators
Adaptations
Web Space Opener
Some children have difficulty maintaining an open thumb web space with a neoprene
splint due to moderate to severe hypertonicity. The therapist may make a web space opener out
of elastomer to be worn under the thermoplastic splint. Elastomer-silicone based product
designed to modify scars, is in liquid and putty form. Once the putty is combined with a catalyst
a web space opener can be formed.
Crayon/Marker Attachment
Positioned so tip will contact paper while forearm is in neutral or slight supination(not
pronated). A Velcro strap can secure the marker and Sticky Tac or rubber bands above and
below to keep the marker from sliding. A separate holder could also be made out of
thermoplastic material if necessary (Benik glove).
Fabrication Process for a Soft Thumb Splint with Thumb Loop
- The wrist band and thumb loop are made from a strapping material like webbing or
neoprene. The material should be pliable enough to conform to the web space of the
thumb
- The therapist can determine the specific dimensions by placing strap material on the
child’s arm and hand to measure lengths and widths and determine the desired angle of
pull
- Thumb Loop-Strap must be wide enough to support the thumb but not so wide that it
buckles or wrinkles in the thumb space
-
Wrist Band-Strap should be wide enough to secure the thumb loop,remain in place on
the wrist and distribute pressure. It should also be long enough to form an adequate
overlap to secure the Velcro.
Pattern
- Wrist band should overlap the volar side of wrist
- Length of the thumb loop should be the distance from the proximal edge of the wrist
band, around the thumb and back to the point of origin
Forming the Splint
- Neoprene
- Heat sensitive tape can be used to bond the pieces together
- Sewing may be difficult but can be done with the proper needle, thread and variable
tension sewing machines
Webbing
1. Sew hook and loop Velcro to each end of the wrist band that is to overlap on the volar
side of the forearm
2. Sew one end of the thumb loop to the dorsal portion of the wrist band, sew loop Velcro
to the free end of the thumb loop, then sew hook Velcro to the dorsal portion of the wirst
band(partially covering origin of thumb loop)
3. Thumb loop shoud be directed up across the web space, around the thenar eminence
and pulled diagonally to attach to the dorsal portion of the wrist band
The amount of tension on the thumb loop and attachment location of the free end on the wrist
band influences the amount of radial and palmar abduction of the thumb. If the wrist band does
not fit snugly, the splint shifts distally on the wrist, thus reducing the amount of tension on the
thumb loop. The wrist band must avoid circulatory restrictions
Precautions and Wearing Schedule
- Similar to thermoplastic splint, although the soft thumb splint presents less danger of
pressure related problems due to the softer material.
- Care should be taken so that the wrist band is not so tight that it interferes with
circulation.
- Persons applying splint should be sure the thumb loop fits snugly into the web space
with pressure against the thenar muscles.
- If thumb loop is applying pressure above the MP joint of thumb, there is a risk of
deviating, hyperextending or dislocating.
- Therapist must also monitor the amount of tension on the thumb loop to prevent excess
stress to the thumb MP joint.
- If the child is active and wears the splint often, it is likely to be soiled and worn.
- The splint requires washing and eventual replacement.
SERPENTINE SPLINT
- By Thompson Rangel
- A hand-based splint
- To position the thumb out of palmar adduction with a little bit inhibitory of finger flexion
- Children with hypertonicity, hypotonicity, muscle weakness, or decreased ROM
Features
1. Easy to make, no significant amount of skill to achieve its fabrication
2. Made of spiral wrap
3. Thermoplastic material opens up the web space and provides good support to the
thumb, while allowing for some mobility; allows the child to move the thumb within a
specified range
Process to Fabricate
Materials
1. A small rectangular piece of thermoplastic material used; with some stretch to ease
making the tube
2. No necessary pattern needed but accurate length of the splint is required
Forming the splint
1. Measure from hypothenar area just below the distal palmar crease across the dorsum of
the hand just below the metacarpal joint through the web space around the thenar
eminence to the dorsum of the hand
2. Cut a piece of thermoplastic material one half to three fourths the length of the measured
length just described and 1 inch in width (width varies among children)
3. Heat the material and roll the piece into a smooth tube
4. Wrap the tube around the hand while it’s still soft, starting at the hypothenar area, below
the distal palmar crease, and proceed to wrap as indicated with measuring for the tube
(mentioned above)
 Straps may be added for extra support
 Splint should be labeled to orient the caregiver on how to don the splint
Wearing schedule
- During functional activities for it was designed to facilitate function
- At intervals during the day and night to minimize thumb palmar adduction contractures
Precautions
- Not excessive pressure into the hypothenar area to prevent any skin irritation
Adaptations
- Wrist support is provided by the adaptation of continuation of the spiral tube over the
wrist and onto the forearm
- Flat piece of thermoplastic material also allow more molding thus additional stabilization
and support of the thumb
Summary
- Several types of hand splint in the management of children who have developmental
disabilities as a result of central nervous system damage, lower motor neuron injury, or
upper extremity congenital malformations
- Splint designs for a child differ from many of the adult designs cause the types of
environments in which they live, learn, work and play differ.