COMMON HAND INJURIES, SPLINTING, AND THERAPY

COMMON HAND INJURIES,SPLINTING, AND THERAPYSTEPHAN KULZER, OTR/L, CHTANDREA RANSOM, OTR/L, CHTJune 10th , 20162:45-3:30pm

Objectives Become familiar with splint materials and educationOverview of common sport related upper extremityinjuries seen by Occupational Therapy.Overview of treatment for upper extremity injuriesrelated to sport.Overview of splinting for upper extremity injuriesrelated to sport.Understand the rules for athletics regarding the useof playing casts/splintsRecognize splint treatment options for commonathletic injuries

Splinting Put in picture of splints?

Splinting Orthoplast Splints-Questions-What’s the Diagnosis?-What position?-Are there any pins to avoid or protect?-Forearm Based, Hand Based,Finger Based, Long Arm?

Splinting Splint materials are 1/16”, 3/32” or 1/8” thick.Minimal/mod/max resistantSplint materials vary in character – vary bymemory, amount of drape, rigidity, perforated orsolid.Lastly, they come with almost any color.

SplintingCommon Static Splints Tip Protector Splint- Used for distal finger injuries forprotection and support.Used for distal finger injuries forprotection and support- Used for fractures of thehand/forearm, sprains/strainsClam Shell SplintUsed for greater support andprotection of the wrist/forearm.DIP Hyperextension Splint- Percutaneous pinning at distalfingerWrist Cock Up/Neutral WristResting Splint DIP Extension Splint- Mallet fingersUlnar/Radial Gutter Splint-Used for fractures of the hand,sprains/strains Thumb Spica SplintUsed for thumb fracture, sprains/strainsfor protection and support

Splinting Wear and Care Wear schedule per doctors orders and/or therapist’srecommendations-May depend on if static vs dynamic vs static progressive-Caution to observe for skin tolerance and splint fit Care-Wash with warm water and antibacterial soaps-Use of alcohol based products to clean splint and decrease smellworks the best-Education on what to avoid with the splints – hot weather summer, in car dash, do not put in dishwasher, etc.

Splints in AthleticsSDHSAAVolleyball:Rule 4, Article 1: A guard, cast or brace made of hardand unyielding leather, plastic, pliable (soft) plastic, metalor any other hard substance shall not be worn on thehand, finger, wrist or forearm, even though coveredwith soft padding.Rule 4, Artcle 2: Hard and unyielding items (guards, casts,braces) on the elbow, upper arm or shoulder must bepadded with closed-cell, slow recovery foam padding noless than ½-inch thick. An elbow brace shall not extendmore than halfway down the forearm.

Splints in AthleticsSDHSAABasketball:Rule 3-5-2 a,b:a.Guard, cast or brace must meet the following guidelines:A guard, cast or brace made of a hard and unyieldingsubstance, such as, but not limited to, leather, plaster,plastic or metal shall not be worn on the elbow, hand,finger/thumb, wrist or forearm; even though coveredwith soft padding.b.Hard and unyielding items (guards, casts, braces, etc.) onthe upper arm or shoulder must be padded with a closedcell, slow recovery foam padding no less than ½ inch thick.

Splints in AthleticsSDHSAAFootball:Hard and unyielding items(guards, casts, braces, etc.)on the hand, wrist,forearm, elbow or upperarm are illegal unlesscovered with a padded,closed-cell, slow recoveryfoam padding no lessthan ½ inch thick.

Splints in AthleticsSDHSAATrack: If a guard, cast, brace, splint, etc. is worn anddetermined by the referee that padding is required,such padding shall be closed-cell, slow recovery foamno less than ½ inch thick. Knee and ankle braceswhich are unaltered from the manufacturer’s originaldescription do not require any additional padding.Wresting: Illegal in all cases.

Splints in Athletics NCAA/NAIA Similaras previous rules Always check with governing body Communication with athletic trainers

Common Hand Injuries in Athletes Mallet FingerTuft/Distal Phalanx FractureBoutonniere DeformityPIP Jt Dorsal DislocationProximal Phalanx FractureMetacarpal FractureThumb FractureScaphoid FractureDistal Radius Fracture

Mallet FingerMallet Finger Injury

Mallet Finger Most common closed tendon injury found in athletesUsually the result of a jam against any surfaceCaused by disruption of terminal tendon on distalphalanxPresent with pain, swelling and extensor lag at DIPjt.

Mallet FingerManagement-without pinning-6 wks - DIP hyperextension splint-custom orthoplast, alumifoam, Stack, serial cast-followed by 4-6wks of night wear or weaning from splint-AROM – PIP and MCP 1st 6wks**No DIP bending allowed – not even one time.-with pinning-same as above – splint is moresupportive/protective because of pin

Mallet Finger Management of splint Remove daily to check skin Clean splint and finger with alcohol Dry finger prior to splint placement Use of paper tape with splints

Mallet Finger Case Study – Football player jammed finger whentrying to make a tackle – noted DIP extensor lag –assessed at after hours orthopedic clinic – sent toorthopedic hand surgeon for further evaluation.Evaluation of acute mallet fingerOrders sent to hand therapy for DIP hyperextensionsplint x 2Education provided on wear/care, playing withsplint during football – buddy tape, SDHSAA ruledpadding – discuss with athletic trainer

Mallet FingerCase Study Combo Mallet finger and tuft fracture Recreational play with dodgeball 6 weeks wear time and then return to doctor

Mallet Finger

Mallet Finger

Mallet Finger

Tuft/Distal Phalanx Fracture Common fracture – smashing or crushing injury –caught in jersey, b/w helmetsUsually treated conservativelyIf K-wire – removed approx. 3wks – AROM to DIPjt is then startedTip protector splint/volar DIP extension splintHypersensitivity can be a problem Desensitizationprogram

Tuft Fracture/Distal Phalanx Fracture AROM – MCP/PIPSwelling Control Elevation,ice, compression wrap/finger sleeve

Tuft Fracture/Distal Phalanx Fracture

Tuft Fracture/Distal Phalanx Fracture

Tuft Fracture/Distal Phalanx Fracture

Tuft Fracture/Distal Phalanx Fracture

Boutonniere Deformity

Boutonniere Deformity

Boutonniere Deformity Athletes usually injured by forced hyperflexion atthe PIP jt. - “jammed” fingerCentral slip is disrupted at dorsal insertion atmiddle phalanx and lateral band migratesanteriorly

Boutonniere Deformity Management - AcuteFull time volar based PIPextension splint with DIPfree for 6 weeks andthen night time wear for4 weeksDIP free to allow dorsalmovement of lateralbands and ensureoblique retinacularligament does not gettight

Blocking ExercisesFocus on DIP blockingand reverse blockingexercises DIP BLOCKING

Boutonniere Deformity REVERSE BLOCKING MCP’sflexed with activeextension of IP’s,

Boutonniere Deformity Management - Chronic Chronicor PIP flexion contracture Focus is on regaining passive PIP extension throughdynamic, static progressive splint or serial casting Once PIP joint passive extension established – initiateor continue with emphasis on reverse blocking andactive DIP blocking motion Continued focus on swelling reduction

PIP joint dorsal dislocationVolar Plate Disruption- Hyperextension injury - Jammed Finger injury

PIP joint dorsal dislocation Orthoplast dorsal blockingsplint at 20-30 degreesDecrease restriction ofsplint by 10 degrees eachweek starting at 2 to 3weeks per orders; splint x6wksSplint fabricated out of1/16” materialDistal strap removed toallow patient to performAROM of IP’s within splintfrequently during the day.

PIP joint dorsal dislocationEdema controltechniques Edema wrap,compressionwrap/finger sleeves

PIP joint dorsal dislocation Strengthening – 4 to 6wks or when orderedby doctorIsometrics, therapyputty/ball

Proximal Phalanx Fracture Volar angulation, limited rotation usually occurs withproximal phalanxNeed to have a balance between treating fractureand limiting adhesions/promoting gliding of thetendons

Proximal Phalanx Fracture Management Splinting--MCP’s in flexion andIP’s extended “intrinsicplus” positioning – safepositionForearm based or handbased gutter splint Positionof MCP joints- collateral ligament- stablility

Proximal Phalanx Fracture

Proximal Phalanx Fracture ManagementROM initiated per doctors orders and/or at 2-4 weeks withsplint utilized up to 6 weeks. Athlete to wear splint that is least confining for protectionper doctor and wrapped with approved ½” closed cellfoam If reduction not maintained then closed reduction with pinningfollowed by open reduction and fixation – followed withAROM per doctor orders, edema and incision/dressingmanagement

Proximal Phalanx Fracture Case Study 10 y.o. playing football. Caught the ball and overextended smallfinger Seen by orthopedics with closed reduction Order for custom FA based intrinsic plus positioned splint RICE principles Return to doctor in 1 week for recheck Initiate arom of hand as ordered

Metacarpal Fracture Metacarpal neck Fracture-Boxer’s Fracture-Common metacarpal Fx-Allows for angulationnot rotation

Metacarpal FractureManagement Splint - hand or forearmbased splints – 4-6 wks Edema control ROM started at 2-4 wks Strengthening 4-6 wks oras ordered Return to play upondoctors orders or whenevidence of healing isshown

Metacarpal Fracture MCP’s placed in flexedposition in splints Maintainlength of MCPcollateral ligaments Provide stability

Metacarpal Fracture

Metacarpal Fracture Young male with SalterHarris II fracture –neck fractureInjured playingfootballInitiated with ulnargutter splint and aromSplinted x 4wks andthen as needed

Metacarpal Fracture3 weeks post injury

Distal Radius Fracture

Accelerated Protocol Days 3-5 Post-OpOrthoplast Splint – Patient may remove splint for Light ADLactivities - hygiene, dressing, eating, computer work

Accelerated Protocol Case Study:3-5 Days Post-Op AROMfor wrist andforearm Ensure patients areflexing/extendingwrist with correctmuscles by keeping MPjoints bent with motion AROM/PROM EdemafingersControl Lifting Restriction – 5lbs.

Active Range of Motion .

AcceleratedDistal Radius Fracture Protocol Reinforce that wrist extensors – not – fingerextensors are used for motion

Accelerated Protocol 2 Weeks Post-Op PROMWrist and Forearm Isometric LightExercisesPutty Exercises Liftingrestriction – 10 lbs.

Accelerated Protocol 3 Weeks Post-Op Wean Return from Splintto sport – varies by Physician4 Weeks Post-Op ConcentricWrist Strengthening Medium Putty Strengthening Splint Discontinued ** LiftingRestriction – 40 lbs.

Orthoplast Wrist Splint

Radial or Ulna Shaft Fracture

Ulnar or Radial Collateral LigamentThumb Injury

Ulnar Collateral Ligament Thumb InjuryUlnar Collateral Ligament Injury – forceapplied to digit in radial direction

Thumb Collateral Ligament SprainConservative Management 0-4 Weeks – Hand basedthumb spica splint4-6 Weeks – AROM of thumb– painfree range6-8 Weeks – Unrestrictedrange of motion Splint for sport activity andprotectionGentle Strengthening.Weeks8 Weeks – Splintdiscontinued for light ADLactivities, continued for Sportactivities**dependent on jointtenderness.

Thumb Collateral Ligament InjurySurgical Management Initial Treatment – Wristthumb Orthoplast Splint4 Weeks – Pin Removal andAROM/AAROM to thumb andwrist.6-7 Weeks – PROM to thumb,* Avoid lateral strain to thumb8 weeks – Splint discontinuedfor light ADL Use.Possibly continued splint usefor heavy hand use and sport

Splinting Options

Scaphoid Fracture Can be missed on initial X-raysecondary to edemaNoted by tenderness withpalpation at Anatomical snuffboxPreviously typically withsurgical intervention andextended period ofimmobilization – leading todecreased range of motionand loss of ADL function ofthe hand

Scaphoid Fracture

Scaphoid FractureInternal fixation increases position of healingand decreases immobilization time