Elbow, Wrist, and Hand Immobilization Orthoses

Learning Outcomes

Upon completion of this chapter, you will be able to:

1. Describe the clinical conditions and goals for prescribing an elbow, wrist, and hand immobilization orthosis.

2. Identify pertinent anatomical structures and biomechanical principles involved in an elbow, wrist, and hand immobilization orthosis and apply these concepts to orthotic design and fabrication.

3. Identify the most commonly selected orthotic designs and describe the rationale for choosing one design over another.

4. Design suitable patterns for the two common types of elbow, wrist, and hand immobilization orthoses and one forearm-based orthosis and identify the pertinent anatomical landmarks.

5. After reviewing the instructional videos:

a. Outline the steps involved in the fabrication of an elbow, wrist, and hand immobilization orthosis.

b. Complete the molding and finishing of an elbow, wrist, and hand immobilization orthosis.

c. Evaluate the fit and function of a completed elbow, wrist, and hand immobilization orthosis and identify and address all areas needing adjustment.

6. Identify elements of a client education program following provision of an elbow, wrist, and hand immobilization orthosis.

7. Describe special considerations of an elbow, wrist, and hand immobilization orthotic design and fabrication for pediatric and geriatric clients.

Introduction

Clients with a variety of different clinical conditions may benefit from an elbow, wrist, and hand immobilization orthosis. These orthoses are commonly prescribed following traumatic injury to the distal humerus, radius, and ulna and supporting ligaments, muscles, and other soft tissues surrounding the elbow, wrist, and hand. Other indications include supporting unstable or painful joints (osteoarthritis [OA] or rheumatoid arthritis [RA]), restricting movement to protect and rest structures (the ulnar nerve in the cubital tunnel), and providing controlled stress to contracted tissues to improve joint motion (joint stiffness following trauma). Elbow, wrist, and hand orthoses might also be use in constraint-induced movement therapy (CIMT), a treatment intervention that restricts motion in the unaffected limb and encourages or promotes active movement of an involved limb in patients following stroke or other neurological disorders. CIMT is a treatment strategy often also used with children with cerebral palsy. Sometimes elbow, wrist, and hand orthoses are used to prevent clients from hurting themselves with harmful or disruptive habits such as biting themselves or mouthing their hands. The choice of orthotic type and design depends on the clinical condition and physician preference, therapist experience, and needs of the client. A thorough assessment of the client’s current functional status must always be done in conjunction with orthotic provision to ensure that the orthotic design chosen meets the needs of the client.

Goals for Use of an Elbow, Wrist, and Hand Immobilization Orthosis

The goals of an elbow, wrist, and hand immobilization orthosis are outlined in Box 7-1.

Clinical Conditions and Wearing Schedules

This section describes common clinical conditions where an elbow, wrist, and hand immobilization orthosis is typically prescribed; recommended wearing schedules; and the current evidence supporting this type of orthosis as an appropriate intervention strategy. Readers are encouraged to review the references provided for additional details regarding each clinical condition and search current research databases for updated evidence as it becomes available.

ELBOW FRACTURES AND JOINT DISLOCATION

Fractures of the elbow can involve the distal humerus, proximal radius, proximal ulna, and/or the radial head. Fractures may be nondisplaced, where the bony alignment is maintained even with partial or full break of the involved bone, or displaced, where movement of the bone segments has occurred. Concurrent injury to soft tissue structures, such as the muscles, nerves, blood vessels, and ligaments, can occur with these injuries and may complicate recovery. Joint dislocation, where the articulating surfaces of a joint are no longer in contact with each other, can also occur with or without associated fractures and is often associated with injuries to the joint capsule and ligaments.

DISTAL HUMERUS FRACTURES

Fractures of the distal humerus account for approximately one-third of all elbow fractures. They occur commonly as a result of a fall on an outstretched hand (FOOSH) or a direct blow or hit to the elbow. Extra-articular fractures, indicating fractures that do not involve the articulating surface of the distal humerus, typically occur above the condyles (supracondylar) and are treated conservatively or with surgical intervention (Figure 7-1).

Intra-articular fractures, indicating fractures that do involve the articulating surface, are usually treated surgically with open reduction internal fixation (ORIF) (Figure 7-2).

A posterior elbow, forearm, and wrist immobilization orthosis may be used instead of a cast to protect the injured structures to promote healing. The advantages of an orthosis over a cast is that the orthosis can be removed for periodic wound care and skin checks. It is also is critical for initiating early range of motion (ROM) exercises to avoid stiffness of the elbow joint. The elbow is typically positioned at 90 degrees of flexion, with the forearm in neutral and wrist at 0 degrees (Figure 7-3).

Wearing Schedule

The wearing schedule for this orthosis will depend in part on the healing time of the involved structures, the health of the client, and the severity of the injury. The practitioner must collaborate with the referring physician to determine the appropriate wearing schedule, but typically, a period of 4 to 6 weeks is recommended. Protected movement of the elbow and forearm is strongly encouraged as soon as possible to minimize the risk of joint and soft tissue stiffness that is commonly encountered following elbow trauma.

Evidence

Level V

• Casmus, R. J. (2010). Traumatic distal-third humeral fracture in a collegiate football player: A case review. Athletic Training and Sports Health Care, 2(1), 39-42.
  
  
  
  • The author describes a case study in which a collegiate football player sustained a traumatic distal-third humeral fracture while tackling an opponent, a high-impact activity. Fractures of the humerus are commonly due to blunt trauma, high-speed collisions, motor vehicle accidents, or falls from heights. Because of the location of the fracture and the degree of angulation, the decision was made to perform distal humerus ORIF. The surgical procedure was performed 48 hours post-injury. Postoperatively, the athlete wore a posterior splint and sling for 2 weeks, followed by a humeral brace for 6 weeks. Due to an intense postoperative therapy regimen, full active ROM of the elbow for flexion and extension was achieved 10 weeks postoperatively. Active ROM for supination and pronation was equal bilaterally at 12 weeks.

PROXIMAL RADIUS FRACTURES

Fractures of the proximal radius are the most common fractures that occur at the elbow and are often a result of FOOSH with the forearm positioned in pronation and the elbow in slight flexion. Most fractures occur at the radial head and/or radial neck. Simple, stable fractures are often treated with a posterior elbow, wrist, and hand immobilization orthosis with early active mobilization out of the orthosis. Comminuted or displaced fractures may be treated with ORIF or prosthetic replacement of the radial head if the fracture cannot be repaired. These fractures can also be managed with an elbow, wrist, and hand immobilization orthosis with graded mobilization out of the orthosis. The practitioner must collaborate with the referring physician to determine the ROM that is safe for the client to perform without risk of further injury or disruption of the injury site or surgical repair.

Wearing Schedule

The orthosis wearing schedule will depend in part on the healing time of the involved structures, the health of the client, and the severity of the injury. The practitioner must collaborate with the referring physician to determine the appropriate wearing schedule. For stable, simple fractures, typically a period of 1 to 3 weeks is recommended. Protected movement of the elbow and forearm is strongly encouraged as soon as possible to minimize the risk of joint and soft tissue stiffness that is commonly encountered following elbow trauma.

PROXIMAL ULNA FRACTURES

The majority of proximal ulna fractures occur at the olecranon or at the coronoid process of the ulna. These fractures can be associated with concurrent injury to the triceps insertion. Most are treated with ORIF and immobilized in an elbow, wrist, and hand orthosis with the elbow at 30 to 40 degrees of flexion to avoid stress on the triceps tendon. Fractures of the coronoid process are often associated with significant joint instability and are typically treated with cast immobilization or surgical intervention.

Wearing Schedule

The orthosis wearing schedule will depend in part on the healing time of the involved structures, the health of the client, and the severity of the injury. The practitioner must collaborate with the referring physician to determine the appropriate wearing schedule. For stable fractures, typically a period of 4 to 6 weeks is recommended. As with other fractures involving the elbow, protected movement of the elbow and forearm is strongly encouraged as soon as possible to minimize the risk of joint and soft tissue stiffness that is commonly encountered following elbow trauma.

COMPLEX FOREARM FRACTURES

Complex forearm fractures are those that involve both the radius and ulna and may also include injury to the proximal radioulnar and/or distal radioulnar joints. The interosseous membrane, a fibrous membrane that unites the radius and ulna together, is also susceptible to injury. The following are three such fractures:

• Galeazzi: Fracture of the middle shaft of the radius with distal radioulnar joint disruption
  
• Monteggia: Ulna fracture with anterior dislocation of the radial head
  
• Essex-Lopresti: Radial head fracture with interosseous membrane disruption and distal radioulnar joint dislocation

Managing these injuries involves controlling the amount of available forearm, elbow, and wrist motion during the healing process with the use of appropriate orthoses. Clinicians can use one of two different orthoses to limit forearm rotation to allow for adequate healing of structures: a sugar tong orthosis design or a Muenster design. Both of these designs limit full forearm rotation while allowing elbow flexion and extension during the healing process (Figure 7-4).

Wearing Schedule

The orthosis wearing schedule will depend in part on the healing time of the involved structures, the health of the client, and the severity of the injury. The practitioner must collaborate with the referring physician to determine the appropriate wearing schedule. For stable fractures, typically a period of 4 to 6 weeks is recommended. As with other fractures involving the elbow, protected movement of the elbow and forearm is strongly encouraged as soon as possible to minimize the risk of joint and soft tissue stiffness that is commonly encountered following elbow trauma.

Evidence

Level II

• Levy, J., Ernat, J., Song, D., Cook, J. B., Judd, D., & Shaha, S. (2015). Outcomes of long-arm casting versus double-sugar-tong splinting of acute pediatric distal forearm fractures. Journal of Pediatric Orthopedics, 35(1), 11-17.
  
  
  
  • This prospective comparative study examined the effectiveness of a double sugar tong orthosis versus a long arm cast in maintaining distal radius or double forearm bone fractures in a pediatric population. Seventy-one subjects participated in the study; 37 with a long arm cast and 34 in a double sugar tong orthosis after fracture reduction. The double sugar tong orthosis was described as a sugar tong orthosis fabricated from plaster and bivalved that was then converted into a long arm cast after the initial swelling had decreased. The long arm cast group had significant risk of loss of reduction throughout the study, but no difference between groups was apparent following cast removal. The authors concluded that both the long arm cast and double sugar tong orthoses are comparable and effective methods of immobilization for this population.
  
  
• Kim, J. K., Kook, S. H., & Kim, Y. K. (2012). Comparison of forearm rotation allowed by different types of upper extremity immobilization. Journal of Bone and Joint Surgery, 94, 455-60.
  
  
  
  • This prospective comparative study examined the degree of allowable forearm rotation of five elbow, wrist, and forearm immobilization devices: short arm splint, short arm cast, sugar tong splint, long arm splint, and long arm cast. Forty healthy subjects participated in the study, 20 men and 20 women. Active forearm pronation and supination with and without each of the five immobilization orthoses was measured with a custom goniometer, and results were compared between each orthosis, as well as between men and women. The long arm cast was the most effective at limiting forearm rotation (less than 10% of allowable motion); no significant differences were found between the sugar tong, short arm splint, long arm splint, and short arm cast in the degree of allowable forearm rotation (each averaging approximately 30% to 40% of allowable motion). The authors recommend use of a long arm cast if complete forearm immobilization is required.

Level IV

• Slaughter, A., Miles, L., Fleming, J., & McPhail, S. (2010). A comparative study of splint effectiveness in limiting forearm rotation. Journal of Hand Therapy, 23, 241-248.
  
  
  
  • This case series study compared the effectiveness of four orthoses that are designed to limit forearm rotation: Muenster, sugar tong, wrist immobilization, and anti-pronation. Five healthy, uninjured subjects participated in the study. All four orthoses were fabricated for each participant with the forearm in neutral rotation. Outcome measures included the degree of active forearm rotation to the point of sensory feedback and forearm supination and pronation to the point of maximum force for each of the four orthoses. Results indicated statistically significant differences in active ROM for all four orthoses. The sugar tong design was more restrictive than the Muenster orthosis for forearm pronation, and the anti-pronation orthosis was more restrictive in pronation compared with the wrist orthosis. None of the orthoses immobilized the forearm completely. The authors recommend the sugar tong design to restrict forearm pronation and note that further study is warranted to assess orthoses effectiveness when the forearm is positioned in supination (to limit pronation) and pronation (to limit supination).

DISTAL BICEPS AND TRICEPS INJURIES

Injuries to the distal biceps and or triceps tendons are typically avulsion injuries and may be treated conservatively or surgically. Clients may include workers, weight lifters, and professional athletes, and these injuries occur most commonly in males aged 40 to 60 years. Typically, the mechanism of acute injury involves an eccentric load placed across a contracting muscle belly. Both the triceps and biceps muscles span two joints, and they can be particularly at risk when placed in an unfavorable loading condition such as lowering a very heavy object.

Both operative and nonoperative treatments have been reported, but recommendations for surgical repair are supported in the literature. Nonoperative treatment typically includes splinting the elbow at 90 degrees for several weeks and, if needed, using physical agents for pain relief.

Biceps repairs are immobilized initially in a long arm splint positioning the elbow in 90 degrees of flexion, the forearm in neutral rotation, and the wrist supported. Following triceps repairs, the elbow is typically immobilized in a long arm splint, initially positioning the elbow in 30 to 45 degrees of elbow flexion, the forearm in neutral, and the wrist often supported.

Evidence

Level V

• Blackmore, S. M., Jander, R. M., & Culp, R. W. (2006). Management of distal biceps and triceps ruptures. Journal of Hand Therapy, 19(2), 154-169.
  
  
  
  • The authors outline the management of distal biceps and triceps ruptures and describe in detail the clinical presentation, evaluation, surgical management, and nonoperative management protocols. They describe therapeutic interventions and orthotic options for these injuries. Although they highlight the numerous surgical procedures and techniques used by surgeons to repair tears and list the postsurgical complications, the more interesting components to this article for therapists are the postoperative time tables for rehabilitation procedures and orthotic design options for both immobilization and mobilization orthoses.

CUBITAL TUNNEL SYNDROME

Cubital tunnel syndrome, the second most common compressive nerve syndrome in the upper extremity (UE) after carpal tunnel syndrome, is defined as compression of the ulnar nerve at the elbow as it courses through the cubital tunnel, a bony canal formed by the medial epicondyle and olecranon. Tension on the ulnar nerve in this area can occur secondary to compression, friction, or elongation. Some examples include resting the elbow on a hard surface such as a desk or car door, holding the elbow in a fully flexed position for a prolonged period, or moving the elbow in a repetitive manner, such as seen with individuals who use a manual wheelchair for mobility. Elbow flexion in particular narrows the space within the cubital tunnel. Clients with this condition often present with symptoms of pain, dysesthesias (reports of pain from normally nonpainful touch), and paresthesias (numbness/tingling) on the volar and dorsal aspects of the ulnar half of the ring finger and entire small finger, along with impaired grip and pinch strength. In more advanced cases, clawing of the ring and small fingers may be observed due to weakened fourth and fifth digit lumbricals and volar and dorsal interossei and loss of balance between the extrinsic flexor and extensor muscles of the fingers. This position is characterized by hyperextension of the metacarpophalangeal (MCP) joints of the ring and small fingers, with concurrent flexion of the proximal interphalangeal and distal interphalangeal joints, and is commonly referred to as ulnar claw hand (Figure 7-5).

An elbow immobilization orthosis is commonly prescribed for clients with cubital tunnel syndrome to reduce tension and rest the ulnar nerve at the cubital tunnel. The elbow is positioned between 30 and 45 degrees of flexion, and the orthosis is typically worn at night to prevent full elbow flexion while sleeping. An elbow pad may also be prescribed for use during the day to protect and pad the ulnar nerve (Figure 7-6).

Wearing Schedule

When an orthosis is used as part of conservative treatment of cubital tunnel syndrome, a minimum of 3 months of consistent use of the orthosis at night is recommended, along with avoiding provocative activities during the day such as repetitive elbow flexion and direct pressure on the ulnar nerve/medial epicondyle during daily tasks.

Evidence

Level III

• Shah, C. M., Calfee, R. P., Gelberman, R. H., & Goldfarb, C. A. (2013). Outcomes of rigid night splinting and activity modification in the treatment of cubital tunnel syndrome. Journal of Hand Surgery, 38, 1125-1130.
  
  
  
  • This prospective quasi-experimental study analyzed the effectiveness of a 3-month course of night splinting and activity modification for cubital tunnel syndrome. Nineteen subjects (25 extremities) participated in the study with a diagnosis of idiopathic cubital tunnel syndrome; 85% of the participants had positive nerve conduction studies. Treatment consisted of a 3-month course of education on activity modification to reduce “daytime aggravation of the ulnar nerve” and rigid night time splinting with the elbow at 45 degrees of flexion. Outcome measures included the Disabilities of the Arm, Shoulder and Hand score, self-report of splint compliance, the Short Form 12, grip strength, and ulnar nerve provocative testing. All were measured at baseline, 6 weeks, 3 months, and 1 and 2 years. A total of 24 of the 25 extremities were available at final follow-up; 21 of the 24 extremities demonstrated significant improvement in all outcomes measured. The authors conclude that rigid splinting, along with activity modification, is an effective intervention for clients with mild to moderate cubital tunnel syndrome.

Related posts:

Orthotic Fabrication: Principles and Practice Orthoses for Mobilization The Basics Wrist Immobilization Orthoses Wrist and Hand Immobilization Orthoses Anatomical and Biomechanical Principles of Orthotic Intervention

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