Introduction to Orthotics
Tammy J. LeSage MOT OTR/L,
CHT
Elisabeth McGee DPT, MOT, PT,
OTR/L, CHT, MTC
Guess Who???
Splint or Orthosis

What are your thoughts about the terms?

http://www.asht.org/practice/l-codes
Why Orthotics for OT?
 Uses
 How
of Orthoses for OT
can you use ?
Client-Centered Biooccupational Approach
Rehabilitation of the Hand and Upper Extremity, 2011
History of Orthotics
rehab – WWII (1939 – 1945)
 Sterling Burnell MD
 Splints/orthotic devices commercially
available – 1940’s
 Splints/ orthotic devices for function –
1950’s polio
 Low temperature thermoplastics
(temps 135 – 180 degrees) 1960’s
 Physical
Anatomical Structures of
Importance for Orthotics

Wrist
 Digits
 Thumb
 Muscles and
Tendons
 Nerve Supply

Blood Supply
 Arches of the Hand
 Creases of the Hand
 Prehension and
Grasp Patterns
Wrist – Joints and Ligaments
 Joints
 Radiocarpal
Joint
 Midcarpal Joint
 Distal Radioulnar Joint
 Ligaments
 Intrinsic
Ligaments
 Extrinsic Ligaments
The Hand Examination and Diagnosis, 3rd Ed., 1990
The Hand Examination and Diagnosis, 3rd Ed., 1990
Digits – MCP, PIP, DIP Joints
 Metacarpals
– two joints each
 Carpal
bone articulation
 Metacarpophalangeal joints – MCP/ MP
joints.
 Ligaments
 Collateral
Ligaments
 Volar Plate
MCP’s extension = shortening
of laxed collateral ligaments –
contraction and adherence of
volar plate
***Contracture of the MCP’s in
extension results in decreased
flexion of the MCP’s and
decreased function of the hand.
Proximal Phalanx & Distal
Phalanx
are hinge joints – flexion/
extension
 Ligaments
 Both
 Collateral
Ligaments
 Volar plate
The Hand Examination and Diagnosis, 3rd Ed., 1990
Position of the PIP/ DIP joints
to prevent contracture is
opposite of MCP joint.
The PIP joint is very susceptible to
adhesion and flexion contracture.
Safe Position Orthotic Device

MCP flexion with IP
(PIP/DIP) extension
 Why????
The Hand Examination and Diagnosis, 3rd Ed., 1990
To prevent deformity!!
Especially if edema is present.
** there are some injuries/
diagnoses that state differently
and are exceptions to this
Thumb –
Joints and Ligaments
 Joints
 Carpometacarpal
(CMC) Joint
 Metacarpophalangeal (MP) Joint
 Interphalangeal (IP) Joint
 Ligaments
 Collateral
ligaments
Muscles and Tendons of the
Hand
 Extrinsic
Muscles of the Hand
 Intrinsic Muscles of the Hand
Extrinsic Muscles of the Hand
 Two
groups: Extensor muscle group
Flexor muscle group
 Each has a retinacular system
 Extensor
retinacular system
 Flexor retinacular system
 Digital pulley system
Extrinsic Extensor Tendons
 APL,
EPB
 ECRL, ECRB
 EPL
 EDC, EIP
 EDM
 ECU
Extrinsic Flexor Tendons
index – small
 FDP index – small
 FPL
 FDS
What is Tenodesis?
How can this affect design of
orthotic device??
Decreased wrist motion, due
to joint or extrinsic tendons?
How can you evaluate? How
would you position in orthotic
device to increase motion???
Intrinsic Muscles of the Hand
 Organize
 Thenar

them in three compartments
eminence
OP, FPB, APB, AP
 Hypothenar

eminence
ADM, FDM, ODM, PB
 Central
Compartment
Lumbricals x 4
 Interossei – 4 dorsal, 3 palmar

What is an intrinsic plus
position?
Intrinsic minus hand?
How would you position in
orthotic device?
Intrinsic Vs Extrinsic Tightness
Digits
 Extrinsic
 What
is it? How would you position it?
 Extrinsic
 What
Extensor Tightness
is it? How would you position it?
 Intrinsic
 What
Flexor Tightness
Tightness
is it? How would you position?
Nerve Supply Considerations
with Orthotic Devices
 Areas
of pressure by orthosis upon
nerves
 Decrease sensation due to peripheral
nerve disruption.
 Decrease peripheral nerve motor
function leading to muscle imbalance
and dysfunctional posturing of the hand.
Common areas of pressure
 When
fabricating an orthosis, you want
to avoid applying pressure over sites
where the nerve is superficial and prone
to compression.
nerve – a) elbow b) guyon’s canal
 Radial nerve – a) elbow b) dorsal/ radial
anatomical snuffbox
 Digital nerves – lateral borders of fingers
and thumb
 Ulnar
Decrease Sensation
Peripheral Nerve Disruption
 Sensory
 Radial,
 Care
Nerve Distribution
Ulnar, Median Nerves
must be taken with orthotic device
 Monitor
skin, check for area of abrasion or
irritation.
The Hand Examination and Diagnosis, 3rd Ed., 1990
Decreased Peripheral Nerve
Motor Function

Leads to muscle imbalance and dysfunctional
posturing of the hand.

Radial Nerve – wrist drop, decreases MP
extension digits, thumb extension.


Ulnar Nerve – Flat hand, claw hand ring and small
fingers


How would you position?
How would you how would you position?
Median nerve – Decreased thumb function

How would you position?
The Hand Examination and Diagnosis, 3rd Ed., 1990
Radial Nerve Orthosis
Used with permission from Sammons Preston
The Hand Examination and Diagnosis, 3rd Ed., 1990
Ulnar Nerve Orthosis
Used with permission from Sammons Preston
The Hand Examination and Diagnosis, 3rd Ed., 1990
Median Nerve Orthosis
Used with permission from Sammons Preston
Blood Supply to the Hand
 Ulnar
Artery, Radial Artery
 Superficial Palmar Arch, Deep Palmar
Arch
 Common digital arteries, digital arteries
 Care must be taken when splinting not
to compress on arteries to compromise
circulation
The Hand Examination and Diagnosis, 3rd Ed., 1990
Arches of the Hand

The intrinsic musculature has an important
relationship with the arches. Collapse of the
arches can contribute to severe disability and
deformity
 Proximal Transverse Arch



Distal Transverse Arch



Distal row of carpal bones
Fixed arch without much motion
Distal palmar crease
Mobile arch
Longitudinal Arch


Longitudinal axis of each finger
Rigid and mobile portions
The Hand Examination and Diagnosis, 3rd Ed., 1990
Creases of the Hand

Distal Digital Crease
 Middle Digital Crease
 Proximal Digital Crease
 Distal Palmar Crease
 Proximal Plamar Crease
 Thenar Crease
 Distal Wrist Crease
 Proximal Wrist Crease
The Hand Examination and Diagnosis, 3rd Ed., 1990
Functional Prehension, Grasp
Patterns, and Manipulation
Skills
Functional Prehension
Patterns
 Prehensile
movements: incorporate
grasping of an object and can be
subdivided into having two purposes,
precision grasp and power grasp.
 Precision
grasp: uses opposition of the
thumb to the fingertips
 Power grasp: uses the whole hand with
thumb flexion or abduction according to the
control needed for the task
Functional Grip Patterns

A position of the hand that facilitates contact
of an object against the palm and palmar
surface of the partially flexed digits.





Cylindrical grip
Spherical grip
Hook grip
Intrinsic plus grasp
Disc grasp
Manipulation Skills

Finger-to-palm translation
 Palm-to-finger translation
 Shift
 Demonstrated when an object that is being held
on the radial aspect of the hand is moved linearly
on the finger surface in order to reposition it on the
finger pads (e.g. repositioning a pen after grasping
it)
 Rotation
 E.g. Rotating a pen to use the eraser
 In-hand manipulation with stabilization

E.g. Picking up coins while holding them in their palm