UPPER LIMB ORTHOTICS

UPPER LIMB ORTHOTICS

Upper extremity orthoses are devices applied externally to restore or improve functional and structural characteristics of the musculoskeletal and nervous systems.

In general, musculoskeletal problems include those resulting from trauma, sports, and work-related injuries.

Upper extremity orthoses also are used frequently on patients who have had neurologic problems, such as stroke, traumatic brain injury

(TBI), multiple sclerosis (MS), cerebral palsy (CP), spinal cord injury (SCI), and peripheral nerve injury. They often are used in arthritic conditions as well.

The material used in orthotic devices includes low-temperature thermoplastics that can be custom-made for fit and other appropriations.

Other materials include casting, metal, strapping, and Velcro.

Custom-made upper extremity orthoses may be fabricated by physical, occupational, and hand therapists, as well as by orthotists.

GENERAL CLASSIFICATION

• Static orthoses - As the word static implies, these devices do not allow motion. They serve as a rigid support in fractures, inflammatory conditions of tendons and soft tissue, and nerve injuries.

• Dynamic / functional orthoses - In contrast to static orthoses, these devices do permit motion on which its own effectiveness depends. These types of upper extremity orthoses are used primarily to assist movement of weak muscles. Some dynamic splints have a dual or bilateral mechanism for providing tension, safely accommodating moments of spasm and so possibly limiting or avoiding soft-tissue injuries.

FUNCTIONS OF UPPER EXTREMITY ORTHOSES

• Increase range of motion (ROM)

• Immobilize an extremity to help promote tissue healing

• Apply traction either to correct or prevent contractures

• Assist in providing enhanced function

• Serve as an attachment for assistive devices

• Help correct deformities

• Block unwanted movement of a joint

One study indicated that patients who have suffered a stroke can be aided by a gravity-compensating arm orthosis that helps to loosen the grip of the affected hand.

The report looked at 10 individuals with chronic hemiparesis and found that after the patients had gripped a cylinder for 5 seconds with their affected hand, it took almost 3 times longer for them to terminate the grip than it did when they held the cylinder with their unaffected hand.

However, the use of a gravity-compensating arm orthosis to decrease the necessary activation of the proximal arm muscles reduced the length of time required to terminate the affected hand's grip.

The investigators suggested that treatments to shorten the amount of time needed to terminate the activity of finger flexor muscles may help patients who have had a stroke gain greater functional independence.

UPPER ARM ORTHOSES

CLAVICULAR AND SHOULDER ORTHOSES

v  Figure-8 harness / clavicular brace - Used to restrict motion in clavicular fractures to allow for tissue healing and bone remodeling

v  Shoulder sling - Used to restrict shoulder motion in subluxated shoulders by providing humeral cuff and chest straps to keep the humeral head in the glenoid cavity

v  Overhead sling suspension - Used for patients with proximal arm weakness or paralysis to allow hand or arm use when the muscles are at least antigravity in strength

v  Hemi-arm sling - Used for immobilization of the hemiplegic shoulder, which helps to decrease pain and subluxation

v  Balanced forearm orthosis

o    Used primarily in patients with high-level tetraplegia or severe proximal arm weakness or paralysis

o    Supports the weight of the forearm and arm against gravity

o    May be attached to a wheelchair or table

o    Patients may be able to perform tabletop activities.

o    Prerequisites for use of the device include a power source, such as neck or trunk muscles (to shift the trunk center of gravity) or adequate scapular movement.

ARM ORTHOSES

• Arm sling

  • Used in scapular or humeral fractures, acromioclavicular joint injury, rotator cuff injury, bicipital tendinitis, and hemiparesis with subluxation

  • Includes the figure-8 sling, cuff sling, and glenohumeral support

FUNCTIONAL ARM ORTHOSES

• Used primarily in patients with proximal arm weakness involving the shoulder and arm

  • Comprised of a shoulder saddle suspending a proximal forearm cuff by straps or a Bowden cable

  • Used in patients with arm weakness, such as that resulting from spinal cord injury (SCI) or peripheral nerve lesions

ELBOW ORTHOSES

• Posterior elbow splints - Used particularly for elbow immobilization in patients who have had recent elbow surgery and/or inflammation

• Serial cast - Used for prevention or correction of contractures by promoting soft-tissue stretch and passive ROM

• Air splint

  • Used to maintain or increase elbow extension

  • Form of circumferential inflatable sleeve, also used for contractures and elbow immobilization

• Dynamic elbow flexion orthosis - Used to maintain the elbow in 90° of flexion in cases of elbow contractures, burns, and fractures

FOREARM-WRIST ORTHOSES

Forearm/wrist orthoses are volar or dorsal and either gutter-based or circumferential.

Ideally, the wrist should be positioned in 15-30° of dorsiflexion (wrist extension), except in carpal tunnel syndrome, when the wrist should be maintained at neutral to minimize median nerve compression.

• The volar type should allow for metacarpophalangeal (MP) flexion by ending before the distal palmar crease.

• Examples of forearm-wrist orthoses include the following:

  • Wrist cock-up splint

  • Wrist extension splint

  • Ulnar gutter splint (See image below and Image 3.)

• • These types of orthoses are used for immobilization in patients with lateral or medial epicondylitis, wrist sprain, wrist or forearm fractures, postoperative wrist fusions, and arthritic conditions. 

FOREARM-WRIST-THUMB ORTHOSES

LONG OPPONENS THUMB SPICA SPLINT

v  The splint covers two thirds of the distal radial forearm up to the interphalangeal (IP) joint of the thumb. (See image below and Image 6.)

v  The wrist should be placed in 15-30° of dorsiflexion while maintaining motion of digits 2-5.

v  The thumb should be maintained in an abducted position to achieve a 3-point jaw chuck prehension.

v  Indications

o    Used for maintaining thumb ROM in patients who have had burns

o    Used to restrict motion in patients with arthritis

o    Used for serial static stretching, such as in contractures and burns

o    Used to stabilize the thumb in opposition for 3-point chuck pinch in patients with peripheral nerve lesions, cerebrovascular disease, C5-level spinal cord injury (SCI), and other upper motor neuron lesions

o    Used in patients who have had tendon transfers/repairs, arthroplasty, and de Quervain's tenosynovitis 

FOREARM-WRIST-HAND ORTHOSES

The basic types of forearm-wrist-hand orthoses include the resting hand splint, functional resting splint, and static hand splint.  

• • Placement may be dorsal, volar, or circumferential and extends from the tips of the fingers to two thirds of the distal forearm. The dorsal type of splint is particularly useful in patients who demonstrate palmar hypersensitivity and grasp reflex.

• The position of the wrist is neutral or in slight dorsiflexion.

• Functions of the forearm-wrist-hand orthoses include the following:

  • Immobilization in patients with hand flexor and extensor tendinitis or who are undergoing tendon, nerve, or fracture repair

  • Maintenance of passive ROM in patients with upper motor neuron lesions, burns, and contractures

• More specific types of forearm-wrist-hand orthoses include the following:

  • Functional resting splint

  • Static hand splint

  • Burn splint

  • Weightbearing splint

  • Resting hand splint

HAND ORTHOSES

Static orthoses serve to protect, immobilize, and help prevent or correct contractures.

• The proximal interphalangeal (PIP) orthosis is used to immobilize PIP joint hyperflexion deformities in patients with Boutonniere deformities or to prevent hyperextension of the PIP joint in swan-neck deformities, both of which are found in patients with rheumatoid arthritis.

• The distal interphalangeal (DIP) orthosis is used to immobilize the DIP joints in extensor tendon and collateral ligament repairs.

• The MP orthosis is used to maintain a functional position for the distal phalanges while preventing hyperextension of the MP joints. These devices are used in patients with burns, scleroderma, or nerve injuries.

• The static thumb orthosis is used to support the carpometacarpal joint, the IP joint, or the MP joint in patients with traumatic or arthritic conditions and in patients with thenar muscle weakness, by providing static support for the thumb.

Dynamic hand orthoses are used to maintain support while providing dynamic corrective force in positioning the fingers, assisting weak motor finger-extensor function. These devices are used with outrigger supports, cuffs, elastic threads, rubber bands, and hook applications for their function of providing dynamic assistance.

• The MP joint dynamic orthosis is used to assist with flexion of the DIP joint in swan-neck deformities and to act as a substitute for weakness of the flexor digitorum superficialis muscle. The MP joint dynamic orthosis also can be used in correcting or maintaining contractures of the MP joints.

• A dynamic PIP joint extension with an MP extension stop device is made up of a bar placed across the dorsum of the hand. The orthosis, which is used in patients with ulnar nerve palsy with claw hand deformity, allows extension while resisting flexor deformity pull.

• A thumb IP dynamic orthosis is used to assist in IP joint extension of the thumb while maintaining the position of the other hand joints. This device is used to substitute for weakness of the extensor pollicis longus muscle.

• A reciprocal wrist-extension finger-flexion orthosis is used in patients with C6 tetraplegia who, given their level of injury, can extend their wrists but cannot flex their fingers. By using the wrist extension force, finger flexion at the MP joints of the second and third digits is attained. Wrist extension is used to flex the MP joints of digits 2 and 3 through tenodesis. Preservation of extensor carpi radialis longus and brevis normally is observed in C6-level spinal cord injury (SCI). Use of this device allows for a 3-point pinch.

• The MP extension splint has the same mechanism as the MP flexion splint; however, it is placed on the dorsal side and serves mainly as a splint in patients with weak wrist extensors and for traction of MP flexion contractures.

UPPER EXTREMITY ORTHOSES WITH SPECIAL FUNCTIONS

Tenodesis orthoses are used to facilitate 3-jaw chuck prehension use of the natural tenodesis action of the wrist.

This action requires that the wrist extensor motor strength be at least a 3+/5 (on a 0-5 muscle grade scale).

When the wrist extends, the thumb is pulled in opposition with the second and third digits, movement that is particularly useful in patients with C6-level tetraplegia who can manage radially deviated wrist extension.

Examples of tenodesis splints include the following:

• The wrist-driven flexor hinge splint has a design that includes an MP spring-activated ratchet lock that functions to sustain the pinch after the wrist relaxes.

• The Rehabilitation Institute of Chicago orthosis is composed of 3 separate pieces: a short opponens, an index and middle finger dorsal plate, and a wristlet.

• The externally powered tenodesis orthosis uses myoelectric or switch control and/or an electric motor to power the device.

Tone reduction orthoses

• These devices are used for flexor tone reduction in patients with significant spasticity, as is commonly observed in cerebrovascular accidents, multiple sclerosis, traumatic brain injury, and cerebral palsy.

• The more common tone reduction orthoses include the Bobath splint, cone splint, and antispasticity ball splint.