Ape hand deformity
Carpometacarpal (CMC) joint
de Quervain’s tenosynovitis
Interphalangeal (IP) joint
Metacarpophalangeal (MCP) joint
Radial collateral ligament
Thumb boutonniere deformity
Thumb swan neck deformity
Ulnar collateral ligament
Upon completion of this chapter, you will be able to:
1. Describe the clinical conditions and goals for prescribing a forearm-based thumb orthosis.
2. Describe the clinical conditions and goals for prescribing a hand-based thumb orthosis.
3. Identify pertinent anatomical structures and biomechanical principles involved in forearm- and/or hand-based thumb orthoses and apply these concepts to orthotic design and fabrication.
4. Identify the most commonly selected orthotic designs and describe the rationale for choosing one design over another.
5. After reviewing the instructional videos:
a. Outline the steps involved in the fabrication of forearm- and hand-based thumb orthoses.
b. Complete the molding and finishing of forearm and hand-based thumb orthoses.
c. Evaluate the fit and function of completed forearm- and hand-based thumb orthoses and identify and address all areas needing adjustment.
6. Design suitable patterns for the three common types of forearm- and hand-based thumb orthoses and identify the pertinent anatomical landmarks.
7. Identify elements of a client education program following provision of forearm- and hand-based thumb orthoses.
8. Describe special considerations of forearm- and hand-based thumb orthotic designs and fabrication for pediatric and geriatric clients.
Box 6-1. Common Goals of Forearm- and Hand-Based Thumb Orthoses
- Support and protect the thumb CMC, MCP, and/or IP joints following surgical repair of structures.
- Support and protect the thumb after a fracture or ligament injury.
- Offer relief and joint protection from a painful tendinitis or arthritis.
- Position the thumb to maintain the web space to prevent contracture.
- Support and position the thumb in abduction and opposition to improve prehensile hand function due to muscle paralysis or weakness.
- Use the thumb orthosis as a base for outrigger attachments to create mobilization orthoses or adaptive equipment.
The thumb is a key component of hand function. When a clinical condition affects the thumb, an orthosis for immobilization may be important for stability and/or pain relief. Orthoses for the thumb may include the wrist or may be designed to keep the wrist free.
There are several different design options for these orthoses. The design chosen will depend on multiple factors, including the client’s clinical condition, his or her functional needs, and specifications set by the referring physician.
GOALS FOR USE OF FOREARM- AND HAND-BASED THUMB ORTHOSES
The goals of forearm- and hand-based thumb orthoses will vary depending on the individual client’s needs and clinical condition. Box 6-1 reviews common goals.
When fabricating forearm- and hand-based thumb orthoses, the practitioner must consider each client’s specific clinical condition or diagnosis, the expected clinical outcome following orthotic use, and use of sound clinical reasoning to select the most appropriate design for the client. As discussed, the particular design chosen depends on multiple factors. A forearm-based thumb orthosis (also called a long opponens or long thumb spica) immobilizes the wrist, carpometacarpal (CMC) joint, and/or the metacarpophalangeal (MCP) and interphalangeal (IP) joints (Figure 6-1).
A hand-based thumb orthosis (also called a short opponens or short thumb spica) immobilizes the CMC joint and most often includes the MCP joint as well. The thumb IP joint may also be included if this joint is involved (Figure 6-2).
Practitioners treating clients with arthritis of the thumb joint(s), fractures, sprains, ligament injuries, or other pathologies recognize the benefits that orthoses can offer their clients. These benefits include pain relief, stability, prevention or correction of deformity, positioning during healing, and improved functional ability. It is critical to perform an ongoing assessment of the client’s current status, particularly in relation to his or her functional ability during the time the orthosis is part of the intervention. Custom-made thumb orthoses may require adaptations to meet the client’s changing needs. Inflamed or injured swollen joints require rest and protection; however, prolonged immobilization may lead to loss of range of motion (ROM) due to joint stiffness. Use of orthoses may help prevent the development of soft tissue and/or joint contractures and may improve function, allowing the client to maintain independence.
Clinical Conditions and Wearing Schedules
The following section describes common clinical conditions where a thumb orthosis is prescribed and the current evidence supporting this 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.
RHEUMATOID ARTHRITIS AND OSTEOARTHRITIS
Both rheumatoid arthritis (RA) and osteoarthritis (OA) can affect the thumb with decreased motion, pain, joint instability, and weakness. Radiographic evidence of both OA and RA demonstrates significant changes in bony alignment and structure (Figure 6-3).
The thumb CMC and MCP joints are often affected in clients with RA, and the most commonly seen thumb deformities are thumb boutonniere deformity, which is MCP joint flexion with IP joint hyperextension, and thumb swan neck deformity, which is MCP joint hyperextension with or without IP joint flexion (Figure 6-5). Both deformities can affect a client’s prehensile function.
In addition to the thumb joint pathology, clients with RA will likely have multiple joint pathologies that affect both the wrist and digit MCP joints, necessitating orthoses that address these joints as well.
OA is a wear-and-tear degenerative condition where the cartilage lining the articular joint surfaces is affected by repeated stresses placed on it due to age, repetitive activities, and past injury. The most common site of OA in the hand is the first CMC joint. This joint is subject to considerable stress during prehensile tasks, which can lead to degenerative changes with aging. OA is a common condition, affecting up to 20% of men and women over the age of 40 years. A family history of OA, postmenopausal women, hypermobility of the CMC joint, and history of repetitive grasping and resistive pinching activities predispose individuals to this condition. With time, the repetitive pinching forces and strong pull of the adductor pollicis and intrinsic thumb muscles causes the base of the first metacarpal to sublux dorsally and radially on the trapezium. This causes considerable pain, instability, and loss of prehensile function. OA may affect only one joint in the body, but it is more common to have the condition on both sides.
Forearm- and hand-based thumb orthoses can alleviate symptoms of both RA and OA by supporting the wrist (forearm-based orthosis) and thumb in a resting and comfortable position to reduce pain, facilitate pinch-and-release thumb function, improve pinch strength, provide joint stability, and protect the thumb joints during activities of daily living (ADL). For clients with OA of the first CMC joint, orthoses are the mainstay in conservative management. The specific goals of an orthosis for this condition are pain reduction, joint protection during ADL, optimization of functional use of the affected hand by stabilizing the thumb, and prevention of adduction contractures of the first web space.
A recommended wearing schedule for a thumb orthosis for a client with arthritis is to wear it as needed during periods of inflammation, swelling, and pain. The client can be encouraged to remove the orthosis periodically to perform gentle ROM exercises and hygiene. When the inflammatory episode has resolved or diminished, the client can reduce orthosis use. For some clients, wearing the orthosis only during activities or only at night may be the appropriate schedule. Use clinical reasoning and discussion with the client to develop an individual treatment plan.
- Valdes, K., & Marik, T. (2010). A systematic review of conservative interventions for osteoarthritis of the hand. Journal of Hand Therapy, 23, 334-351.
- This systematic review of conservative treatments for OA of the hand found 11 studies that described orthotic intervention. The studies indicated that a thumb-based orthosis can improve function and decrease pain. Moderate to high evidence exists to support this intervention.
- Amini, D. (2011). Occupational therapy interventions for work-related injuries and conditions of the forearm, wrist, and hand: A systematic review. American Journal of Occupational Therapy, 65, 2936. doi:10.5014/ajot.2011.09186
- This systematic review of interventions therapists use to treat work-related injuries found that orthotic intervention for thumb-based pain due to OA is an effective intervention regardless of specific design.
- Bani, M. A., Arazpour, M., Kashani, R. V., Mousavi, M. E., & Hutchins, S. W. (2013). Comparison of custom-made and prefabricated neoprene splinting in patients with the first carpometacarpal joint osteoarthritis. Disability and Rehabilitation: Assistive Technology, 8(3), 232-237.
- This crossover design study compared the use of custom-made orthoses with neoprene prefabricated orthoses for immobilization of the base of the thumb in patients with CMC OA. Key outcome measures were pain, function, grip strength, and pinch strength. The authors found that custom-made orthoses were better at pain reduction.
- Cantero-Téllez, R., Valdes, K., Schwartz, D. A., Medina-Porqueres, I., Arias, J. C., & Villafañe, J. H. (2018). Necessity of immobilizing the metacarpophalangeal joint in carpometacarpal osteoarthritis: Short-term effect. Hand (N Y), 13(4), 412-417.
- In this study conducted on the use of orthotic intervention for the conservative management of CMC joint OA, the authors note that different types of orthoses have been used to improve patients’ symptoms. However, there are no guidelines specifying if inclusion of the thumb MCP in an orthosis is required in the treatment of thumb CMC joint OA. The main objective of this study was to determine the effectiveness of two different thumb CMC joint orthotic designs on pain reduction and improved hand function: one design immobilized both the MCP joint and the CMC joint, and the other design immobilized only the CMC joint. A total of 66 patients were included in the study. One group of 33 patients received a short thumb orthosis with the MCP joint excluded, and the other group of 33 patients received a short thumb orthosis with the MCP joint included. Outcomes measures included the visual analog scale for pain and the Quick Disabilities of the Arm, Shoulder and Hand (Spanish version) for function. In both patient groups, the orthoses contributed to decreased pain levels and improved functional abilities. However, there was no significant difference between the two groups regarding pain or improvement in daily activities. The authors concluded that there are benefits of either thumb orthotic design on pain reduction and functional improvement, even after 1 week of using the orthoses as the sole conservative treatment.
- Beasley, J. (2012). Osteoarthritis and rheumatoid arthritis: Conservative therapeutic management. Journal of Hand Therapy, 25, 163-172.
- This paper presents conservative treatment options for managing arthritis. Orthoses are a method of providing stability to weakened structures of the thumb and help maintain joint alignment. Patients prefer a hand-based short thumb orthosis, and nighttime use appears to help relieve symptoms and decrease disability after wear for 12 months.
DE QUERVAIN’S TENOSYNOVITIS
De Quervain’s tenosynovitis, also called de Quervain’s disease and de Quervain’s syndrome, is a condition that involves the two tendons of the first dorsal compartment of the wrist (refer to the extensor tendon compartments in Chapter 2), the abductor pollicis longus and extensor pollicis brevis. These tendons run in a small compartment along the radial aspect of the wrist and thumb and are subject to repetitive stress with movement of the wrist and thumb together, such as wringing a towel, opening jars, and cutting with scissors. This condition is more commonly seen in women, and symptoms often appear in the early postpartum period (6 to 9 months after delivery). Swelling of the abductor pollicis longus and extensor pollicis brevis tendons and their tendon sheath causes pain on the radial side of the wrist near the radial styloid and is often aggravated with movement of the thumb. An orthosis that immobilizes the wrist and thumb CMC and MCP joints minimizes movement of the abductor pollicis longus and extensor pollicis brevis tendons, which can help reduce inflammation and pain during functional tasks (Figure 6-6).
For a client presenting with symptoms of de Quervain’s tenosynovitis, an appropriate wearing schedule for the forearm-based thumb immobilization orthosis is full-time for a period of 4 to 6 weeks or until symptoms have diminished considerably or resolved.
- Cavaleri, R., Schabrun, S. M., Te, M., & Chipchase, L. S. (2016). Hand therapy versus corticosteroid injections in the treatment of de Quervain’s disease: A systematic review and meta-analysis. Journal of Hand Therapy, 29(1), 3-11.
- Although corticosteroid injections are often cited as the best conservative treatment intervention for clients with symptoms of de Quervain’s disease, there are no reviews that have compared their effectiveness with other interventions commonly used in hand therapy clinics. The purpose of this systematic review was to compare the effectiveness of corticosteroid injections with that of hand therapy interventions alone and also with a combined hand therapy/corticosteroid injection approach in the treatment of de Quervain’s disease. The authors conducted a search of key databases to identify experimental studies published between January 1950 and November 2014. Outcome measures included treatment success, pain, quality of life, and function. Results: Both corticosteroid injections and hand therapy interventions were shown to improve pain and function from baseline, but the between-group differences were not significant (across six studies). However, significantly more participants were treated successfully when a combined approach was used, including an orthosis, corticosteroid injection, and hand therapy, compared with either just orthoses or just injections alone.
- Menendez, M. E., Thornton, E., Kent, S., Kalajian, T., & Ring, D. (2015). A prospective randomized clinical trial of prescription of full-time versus as-desired splint wear for de Quervain tendinopathy. International Orthopaedics, 39(8), 1563-1569.
- The authors tested whether patients with a diagnosis of de Quervain’s tendinopathy wearing a splint full-time did better, worse, or the same as patients who wore their splint when they chose to do so. Because many authors feel that complete rest of the involved tendons will aid in healing, it is important to determine the best wearing schedule of the long opponens splint used to treat this condition. The authors conducted this randomized clinical trial of 8 weeks of full-time splint wear versus wearing the splint when desired. The authors found no significant difference in symptoms between the two groups. However, at the end of the trial, only 70% of the patients were contacted for final outcomes, and there was no clear method to determine patient compliance with the splinting protocol.
- Smith, M. (2009). Literature review: Splinting and education in the treatment of de Quervains disease: Effect and practability. Irish Journal of Occupational Therapy, 37(1), 38-46.
- The authors reviewed studies on different treatment strategies for de Quervain’s disease and concluded that splinting is effective for mild cases and for patients post-pregnancy; splinting with injections can reduce symptoms; splinting the wrist in neutral may be effective, yet there is no reported optimum thumb position; and there is no specific splint wearing schedule, but 2 to 6 weeks of wear is suggested.
- Cavaleri, R., Schabrun, S. M., Te, M., & Chipchase, L. S. (2016). Hand therapy versus corticosteroid injections in the treatment of de Quervain’s disease: A systematic review and meta-analysis. Journal of Hand Therapy, 29(1), 3-11.
- The authors reviewed the evidence to determine the best treatment options for de Quervain’s disease, considered a work-related upper limb disorder, and included six studies in this systematic review. The included studies evaluated the effectiveness of hand therapy treatment and corticosteroid injections and also looked at the effectiveness of either treatment alone. Three studies compared corticosteroid injections with wrist/thumb orthoses, three studies compared a combined orthosis/corticosteroid injection approach with orthoses or injections alone, and one study compared acupuncture with corticosteroid injections. The authors concluded that splinting is effective when combined with corticosteroid injections as compared with splinting alone as a treatment.
- Huisstede, B. M., Coert, J. H., Fridén, J., & Hoogvliet, P. (2014). Consensus on multidisciplinary treatment guideline for de Quervain disease: Results from the European HANDGUIDE study. Physical Therapy, 94(8), 1095-1190.
- A Delphi consensus strategy was used to determine the best multidisciplinary treatment guidelines for patients with de Quervain’s disease. A systematic review of surgical and nonsurgical interventions was published, and 35 experts in the field (surgery and rehabilitation) from participating European countries participated in the discussions. Patient instructions with other interventions such as non-steroidal anti-inflammatory drugs and splinting or injections and splinting were considered suitable treatment options. Splinting choices should be either a long, lower arm–based (wrist immobilized) splint including the IP joint of the thumb or a long, lower arm–based (wrist immobilized) splint excluding the IP joint of the thumb. The recommended wearing schedule dictated that the splint should be worn for 3 to 8 weeks, 24 hours per day, excluding grooming and except for brief periods of pain-free ROM.
ULNAR COLLATERAL AND RADIAL COLLATERAL LIGAMENT SPRAIN/INJURY
An ulnar collateral ligament sprain is an injury to the ligaments supporting the thumb MCP joint (Figure 6-7). This joint and its supporting ligaments can be injured during sports activities or during a fall on an outstretched thumb. This injury is often referred to as gamekeeper’s thumb or skier’s thumb. Although the terms are used interchangeably, the mechanism of injury for each one differs. The term gamekeeper’s thumb originated from the repetitive stress placed on the ligament by Scottish gamekeepers as they euthanized rabbits. Skier’s thumb, in contrast, is a more acute injury to the ligament resulting from a fall that forces a ski pole from the hand, rupturing the ligament. In addition, a small piece of bone can avulse off the thumb metacarpal head along with the ligament. Consequently, the thumb MCP joint becomes unstable, and pinching and other prehensile tasks become difficult to perform. A hand-based thumb orthosis can help maintain the ligament/bony fragment in a position for healing and stabilize the thumb MCP joint.
The radial collateral ligament can also be injured during sports activities or following a fall on an outstretched thumb (Figure 6-8). This type of injury is much less common than the ulnar collateral ligament injury. A hand-based thumb orthosis can help maintain the radial-based ligaments in a position for healing. A hand-based thumb orthosis can protect and stabilize the thumb MCP joint to facilitate healing after joint injury.
The appropriate wearing schedule for a hand-based thumb orthosis for a client with ulnar or radial collateral ligament injuries is to wear it full-time as protection and support until the ligaments have healed and the joint is considered stable. The client is typically allowed to remove the orthosis for periods of gentle ROM exercises and hygiene.
- Leggett, J., & Meko, C. (2006). Acute finger injuries: Part II. Fractures, dislocations, and thumb injuries. American Family Physician, 73(5), 827-834.
- The authors discuss various finger and joint injuries and appropriate treatment and interventions. Stable ulnar collateral ligament injuries are treated with a thumb orthosis or cast. If a fracture dislocation or Stenar lesion is suspected, then surgery is required. A Stenar lesion occurs when part of the ulnar collateral ligament is trapped outside of the adductor aponeurosis and constitutes a more serious injury.
- Michaud, E. J., Flinn, S., & Seitz, W. H. (2010). Treatment of grade III thumb metacarpophalangeal ulnar collateral ligament injuries with early controlled motion using a hinged splint. Journal of Hand Therapy, 23(1), 77-82.
- The authors of this article suggest an alternative design for a custom-made hinged thumb orthosis to allow early motion in the healing ulnar collateral ligament injury. They base their suggestion on evidence pointing to the use of custom-made hand-based orthoses for thumb ulnar collateral ligament injuries of the MCP joint and the fact that 85% to 90% of patients achieve good to satisfactory results with an early active motion home program.
Fractures can occur in any of the thumb bones (metacarpal, proximal, or distal phalanges). Use of a custom-fabricated forearm- or hand-based thumb orthosis is often prescribed to stabilize and protect the bone(s) during the healing process, either with conservative management or following surgery. An orthosis is also commonly prescribed following cast removal to provide protection while the client works on regaining joint mobility.
Although not considered a bone of the thumb, fractures involving the scaphoid require immobilization of the wrist, thumb CMC, MCP, and perhaps the IP joint. The scaphoid is the most commonly fractured carpal bone and accounts for 60% to 70% of all carpal fractures and 11% of all hand fractures. Most scaphoid fractures occur in the middle of the bone, or waist, followed by the proximal pole and tubercle (Figure 6-9). The vascularity of the scaphoid significantly affects the outcome of these fractures. Up to 90% of the blood vessels that supply the scaphoid are distal to the waist, or middle of the bone. Consequently, these fractures frequently require a longer period of immobilization, as long as 3 to 6 months. Forearm-based thumb orthoses are often prescribed following cast removal for protection or initially to immobilize and protect the fracture.
The appropriate wearing schedule for a thumb orthosis for a client with thumb fractures is to wear it full-time for protection and support until the fracture has healed. An orthosis is also commonly used following cast removal and is worn for protection while the client regains wrist and thumb mobility. The client may be permitted to remove the orthosis for periods of gentle ROM exercises and hygiene if the fracture is stable.
- Doornberg, J. N., Buijze, G. A., Ham, S. J., Ring, D., Bhandari, M., & Poolman, R. W. (2011). Nonoperative treatment for acute scaphoid fractures: A systematic review and meta-analysis of randomized controlled trials. Journal of Trauma and Acute Care Surgery, 71(4), 1073-1081.
- The authors completed a systematic review of the literature from 1966 to 2010 looking at studies involving nonoperative management of acute scaphoid injuries to determine the best treatment. In total, 523 patients were included in four trials, including two evaluating below-elbow casting versus above-elbow casting; one trial comparing below-elbow casting including the thumb versus excluding the thumb; and one trial comparing fractures with a below-elbow cast with the wrist in 20 degrees of flexion to 20 degrees of extension, with both types excluding the thumb. There were no significant differences in union rate, pain, grip strength, time to union, or osteonecrosis for the various nonoperative treatment methods. The authors concluded that no specific casting or immobilization method exists that is better than others.
- Mallee, W. H., Doornberg, J. N., Ring, D., Maas, M., Muhl, M., van Dijk, C. N., & Goslings, J. C. (2014). Computed tomography for suspected scaphoid fractures: Comparison of reformations in the plane of the wrist versus the long axis of the scaphoid. Hand (N Y), 9(1), 117-121.
- The authors conducted a multicentered, single-blind, randomized, controlled, clinical trial comparing outcomes in patients given one of two forms of immobilization: with the thumb included or without the thumb included. Computed tomography 10 weeks after injury revealed that when immobilization had excluded the thumb, 85% of scaphoid fractures had healed, but when immobilization had included the thumb, 70% of such fractures had healed. Differences in wrist motion; grip strength; or arm, shoulder, or hand disability between the two patient groups were insignificant. Other authors have also concluded that immobilization including the thumb does not offer a clear advantage over immobilization excluding the thumb.
- Lawton, J. N., Nicholls, M. A., & Charoglu, C. P. (2007). Immobilization for scaphoid fracture: Forearm rotation in long arm thumb-spica versus Munster thumb-spica casts. Orthopedics, 30(8), 612-614.
- The authors report on a study demonstrating healing of scaphoid fractures in 9.5 weeks versus 12.7 weeks with conservative management of a nondisplaced scaphoid fracture when treatment was initiated with a long arm thumb spica cast that includes the elbow. The reported advantage to a long arm cast is a decrease in the shearing motion of the volar radiocarpal ligaments accompanying forearm rotation. A disadvantage of using a long arm cast to immobilize a patient with a scaphoid fracture is the additional potential for elbow joint stiffness and muscle atrophy that can occur during the required period of immobilization.
- Mulligan, J., & Amblum, J. (2014). Diagnosis and treatment of scaphoid fracture. Emergency Nurse, 22(3), 18-23.
- The authors provide a literature review of manuscripts describing evaluation techniques for determining if a scaphoid fracture is present. They also examine the description of different methods of immobilization, including the usage of above-elbow versus below-elbow casts and the position of the wrist inside the cast. In studies that compared the use of above-below casting with the thumb included versus below-elbow casting without the thumb, there do not appear to be significant differences in healing rates or nonunion rates. Variables to consider in immobilization for management of scaphoid fractures include above- versus below-elbow, the inclusion or exclusion of the thumb, and the wrist positioned in extension versus flexion.
- Hart, R. G., Kleinert, H. E., & Lyons, K. (2005). A modified thumb spica for thumb injuries in the emergency department. American Journal of Emergency Medicine, 23(6), 777-781.
- The authors describe the various injuries to the thumb seen in the emergency room of a hospital that require immediate immobilization. Although an orthosis applied in the emergency room is typically fabricated from plaster, the information provided in this article discusses the different diagnoses involving the thumb that are typically seen, including fractures, ulnar collateral ligament injuries, and general trauma to the thumb. Positioning in the immobilization splint is described in detail.
- Carlsen, B. T., & Moran, S. L. (2009). Thumb trauma: Bennett fractures, Rolando fractures, and ulnar collateral ligament injuries. Journal of Hand Surgery, 34(5), 945-952.
- This Level V background article provides relevant information on a variety of diagnoses involving the thumb. It does not include specific information on the provision of orthoses but may be helpful at describing the different diagnoses and the anatomical structures involved in each case.