introduction to orthotics tammy j. lesage mot otr/l, cht elisabeth mcgee dpt, mot, pt, otr/l, cht,...
TRANSCRIPT
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 of Orthoses for OT
How can you use ?
Client-Centered Bio-occupational Approach
Rehabilitation of the Hand and Upper Extremity, 2011
History of OrthoticsPhysical rehab – WWII (1939 – 1945)Sterling Burnell MDSplints/orthotic devices commercially
available – 1940’sSplints/ orthotic devices for function –
1950’s polioLow temperature thermoplastics
(temps 135 – 180 degrees) 1960’s
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 LigamentsJoints
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 JointsMetacarpals – 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 PhalanxBoth are hinge joints – flexion/
extensionLigaments
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 LigamentsJoints
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 HandTwo groups: Extensor muscle group
Flexor muscle group
Each has a retinacular system
Extensor retinacular system Flexor retinacular system Digital pulley system
Extrinsic Extensor TendonsAPL, EPBECRL, ECRBEPLEDC, EIPEDMECU
Extrinsic Flexor Tendons
FDS index – smallFDP index – smallFPL
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 HandOrganize them in three compartments
Thenar 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 DigitsExtrinsic Flexor Tightness
What is it? How would you position it?Extrinsic Extensor Tightness
What is it? How would you position it? Intrinsic Tightness
What is it? How would you position?
Nerve Supply Considerationswith 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 pressureWhen fabricating an orthosis, you want
to avoid applying pressure over sites where the nerve is superficial and prone to compression. Ulnar nerve – a) elbow b) guyon’s canal Radial nerve – a) elbow b) dorsal/ radial
anatomical snuffbox Digital nerves – lateral borders of fingers
and thumb
Decrease Sensation Peripheral Nerve Disruption
Sensory Nerve Distribution Radial, Ulnar, Median Nerves
Care 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. How would you position?
Ulnar Nerve – Flat hand, claw hand ring and small fingers
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 HandUlnar Artery, Radial ArterySuperficial Palmar Arch, Deep Palmar
ArchCommon digital arteries, digital arteriesCare 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 row of carpal bones Fixed arch without much motion
Distal Transverse Arch 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 PatternsPrehensile 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