Buddy strapping or taping
Metacarpophalangeal (MCP) ulnar drift
Upon completion of this chapter, you will be able to:
1. Describe the clinical conditions and goals for prescribing a hand-based orthosis.
2. Identify pertinent anatomical structures and biomechanical principles involved in a hand-based 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 a pattern for two different types of hand-based orthoses.
5. After reviewing the instructional videos:
a. Outline the steps involved in the fabrication of a hand-based orthosis.
b. Complete the molding and fabrication steps of a hand-based orthosis.
c. Evaluate the fit and function of a completed hand-based orthosis and identify and address all areas needing adjustment.
6. Identify elements of a client education program following provision of a hand-based orthosis.
7. Describe special considerations of hand-based orthotic design and fabrication for pediatric and geriatric clients.
Box 8-1. Common Goals of Hand-Based Orthoses
- Support and protect the metacarpals and proximal and/or middle phalanges of digits II through V following a metacarpal or proximal phalanx fracture.
- Offer pain relief for injured, edematous joints or soft tissues.
- Support and protect unstable joints from arthritis or injury (e.g., sagittal band rupture).
- Position the digits to prevent development of joint or soft tissue contracture following injury or surgery (e.g., Dupuytren’s contracture release).
- Position the digit(s) to limit movement of the flexor tendon to enhance healing from trigger finger.
- Position the fourth and fifth metacarpophalangeal (MCP) joints in flexion to prevent development of soft tissue and/or joint contractures following injury to the ulnar nerve.
- Substitute for loss of muscle function and facilitate muscle balance in the affected digit(s) following ulnar nerve injury.
- Improve the alignment of the joints affected by a disease process or injury (e.g., rheumatoid arthritis).
Clients with a variety of different clinical conditions may benefit from a hand-based orthosis. These orthoses are commonly prescribed following injury to the bones of the hand (metacarpals and digit phalanges); joints (MCP, proximal interphalangeal [PIP], and distal interphalangeal [DIP]); supporting ligaments, tendons, and muscles; and other soft tissue structures. Other indications include positioning the digits following surgery or injury to prevent development of joint or soft tissue contractures or limiting tendon movement following tendon repair or trigger finger. The choice of orthotic type and design depends on the clinical condition and physician preference, therapist experience, and client needs. 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 clinical and personal needs of the client.
Goals for Use of a Hand-Based Orthosis
The goals of a hand-based orthosis will depend on the condition or diagnosis for which the orthosis is being prescribed, the order from the referring physician, the therapist’s experience and clinical judgement, and the client’s needs (Box 8-1).
When fabricating hand-based orthoses, the practitioner must consider the specific diagnosis and the purpose of the orthosis and use clinical reasoning to select the most appropriate design. As discussed, the particular design chosen depends on multiple factors. The orthosis can be volar, dorsal, radial, ulnar, or circumferential in design, depending on the involved structures and the client’s needs (Figure 8-1).
Practitioners treating clients with hand injuries (fractures, sprains, ligament injuries, or other pathologies) must recognize the benefits that immobilization orthoses can offer their clients. These benefits include relief from pain, provision of stability, prevention or correction of deformity, positioning during healing, and improved functional ability. It is critical to perform an ongoing assessment of a client’s current status, particularly in relation to his or her functional ability. A custom-made hand orthosis may require adaptations to meet the client’s changing needs. Inflamed or injured swollen joints require rest and immobilization; however, prolonged immobilization may lead to loss of range of motion (ROM) due to joint stiffness. This is especially true for the MCP, PIP, and DIP joints of the digits. The use of orthoses helps prevent the development of soft tissue or joint contractures and improve function, allowing the client to maintain independence.
Clinical Conditions and Wearing Schedules
This section describes common clinical conditions where a hand-based orthosis is typically prescribed, recommended wearing schedules, 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.
Hand fractures are the most common fractures of the human skeleton. Metacarpal fractures collectively account for 30% to 50% of all hand fractures, with fractures of the fourth and fifth metacarpal neck occurring most often. These are commonly referred to as boxer’s fractures when they involve the fifth metacarpal bone (Figure 8-2). These fractures are extra-articular in nature, meaning the fracture does not involve the articulating surface of the metacarpal head. These fractures frequently occur as a result of direct impact from a hard object on the metacarpal head. The force from the impact is then transferred to the metacarpal neck, causing displacement of the metacarpal head volarly. The majority of these fractures do not require surgery and are treated conservatively with hand-based ulnar gutter design immobilization orthoses. The position of protection for a metacarpal fracture is with the MCP joints positioned in 70 degrees of flexion. Inclusion of the wrist, PIP, or DIP joints depends on fracture stability, presence of edema or pain, and surgeon preference. If included, the PIP and DIP joints should be in full extension to prevent stiffness. Fractures involving the second or third metacarpals are immobilized in the same position, but with a hand-based radial gutter design.
Metacarpal shaft fractures are typically classified as either transverse or oblique and are subject to considerable deforming forces from the interossei muscles, which can result in dorsal angulation at the fracture site, where the fracture “ends” move dorsally (Figure 8-3). Treatment of these fractures depends on the degree of angulation and fracture stability. Stable fractures are typically treated with immobilization in a hand-based metacarpal orthosis that employs the three-point fixation concept: one pressure point over the fracture site and two pressure points on either side of the fracture (Figure 8-4). The MCP joints are left free to move in this orthosis. Buddy strapping of the adjacent uninjured digits may be used in conjunction with this orthosis to prevent rotation at the fracture site (Figure 8-5).
Metacarpal neck and shaft fractures heal rapidly. Immobilization for 3 to 4 weeks is recommended. Active PIP and DIP joint motion, both flexion and full interphalangeal (IP) joint extension, are encouraged within the orthosis. The IP joints can be placed in an extension orthosis at night if an extension lag develops (loss of active PIP and/or DIP joint extension).
- Harding, I. J., Parry, D., & Barrington, R. (2001). The use of a moulded metacarpal brace versus neighbor strapping for fractures of the little finger metacarpal neck. Journal of Hand Surgery (British and European Volume), 26(3), 261-263.
- This prospective, randomized, single-blind study compared the use of a hand-based thermoplastic metacarpal brace with use of neighbor strapping of the fourth and fifth digits for treatment of nondisplaced, minimally angulated fifth metacarpal neck fractures. Outcome measures included pain evaluation using a verbal rating scale, active and passive flexion and extension at the fifth MCP joint, and total ROM of the fifth digit. Participants also rated their overall satisfaction during the 3 weeks of immobilization. Participants in the brace group complained of significantly less pain during immobilization and had slightly better digit mobility following healing as compared with the strapping group; the brace group returned to work earlier and reported higher levels of satisfaction. A hand-based custom orthosis is an acceptable treatment option for minimally displaced fifth metacarpal neck fractures.
- Gülke, J., Leopold, B., Grözinger, D., Drews, B., Paschke, S., & Wachter, N. J. (2018). Postoperative treatment of metacarpal fractures—Classical physical therapy compared with a home exercise program. Journal of Hand Therapy, 31(1), 20-28.
- The authors designed a prospective, cohort, randomized, controlled trial to evaluate whether a home exercise program or traditional physical therapy was more effective in the postoperative management of metacarpal fractures. Their study included 60 patients suffering from digital metacarpal fractures. Fractures of the first metacarpal were not included. All patients were prospectively randomized into either the physical therapy group or the home exercise group. Follow-up evaluations occurred at 2, 6, and 12 weeks postoperatively. After 2 weeks, the ROM in both groups was still severely reduced. Twelve weeks after surgery, the total digital flexion ROM of the involved digit improved to 245 degrees (physical therapy group) and 256 degrees (home exercise group). Grip strength after 6 weeks was 68% (physical therapy group) and 71% (home exercise group) when compared with the noninjured hand, improving to 91% (physical therapy group) and 93% (home exercise group) after 12 weeks. The results indicate that both home exercise programs and traditional therapy visits are effective in the postoperative management of metacarpal fractures.
- Gulabi, D., Avci, C., Cecen, G., Bekler, H., Saglam, F, & Merih, E. (2014). A comparison of the functional and radiological results of Paris plaster cast and ulnar gutter splint in the conservative treatment of fractures of the fifth metacarpal. European Journal of Orthopedic Surgery and Traumatology, 24, 1167-1173.
- In this retrospective comparative study, the authors compared two methods of immobilization of fifth metacarpal neck and shaft fractures: a short arm of Paris cast and a short arm ulnar gutter splint. Both groups were immobilized for an average of 30 days. Outcome measures included fourth and fifth digit mobility using goniometric measurements, grip strength, and radiographic evaluation. No statistical difference was found in both groups when all three outcome measures were compared. The plaster of Paris treatment group did experience pressure sores and pain during the immobilization period, whereas the ulnar gutter splint group did not. The authors found that immobilization in an ulnar gutter orthosis/splint is an acceptable conservative treatment option for fifth metacarpal neck and shaft fractures.
- McNemar, T. B., Howell, J. W., & Chang, E. (2003). Management of metacarpal fractures. Journal of Hand Therapy, 16(2), 143-151.
- This comprehensive review article outlines the different fractures that occur at the metacarpals and the conservative and operative treatment options for each. The authors outline the importance of orthoses as part of the management of these fractures. Orthoses include custom-fabricated forearm- and hand-based designs for metacarpal head, neck, and shaft fractures and use of prefabricated varieties for stable shaft fractures. The majority of metacarpal fractures can be treated conservatively, and some degree of angulation following fracture healing is acceptable as long as it does not interfere with hand function. The authors recommend immobilizing the MCPs in 70 to 90 degrees of flexion with the wrist in neutral to slight extension. Also important is a dorsal component that allows for IP joint extension positioning between exercise periods and at night but allows for full IP joint flexion within the orthosis.
PROXIMAL PHALANX FRACTURES
Proximal phalanx fractures, similar to metacarpal fractures, commonly involve the neck or shaft. Due to the close relationship of the anatomical structures on the dorsal and volar surfaces of these bones, proximal phalanx fractures can pose more of a challenge for the practitioner. This type of fracture of the proximal phalanx is more susceptible to adhesions of either the extensor or flexor tendon(s) over the fracture site, which can result in loss of active extension or flexion at the PIP joint of the injured digit. Proximal phalanx fractures and PIP joint injuries are also subject to deforming forces at the time of injury and can result in volar or dorsal angulation due to the pull of the intrinsic muscles across the fracture site (Figure 8-6). A hand-based orthosis is typically used to help protect the fracture and promote protected tendon gliding during healing. The MCP joint is positioned at 60 to 70 degrees of flexion with the PIP and DIP joints in full extension (safe position). For stable fractures, the PIP and DIP joints may be left out of the orthosis to promote active tendon movement across the fracture site during healing, helping to discourage development of adhesions.
The wearing schedule of an orthosis prescribed for a proximal phalanx fracture depends on fracture stability and surgeon preference. Proximal phalanx fractures typically heal quickly. Immobilization for 2 to 4 weeks is recommended, with active PIP and DIP joint motion, both flexion and full IP joint extension, encouraged within the orthosis for stable fractures. As with metacarpal fractures, the PIP joint can be placed in an extension orthosis at night if an extension lag, or loss of active PIP and/or DIP joint extension, develops.
DUPUYTREN’S CONTRACTURE/DUPUYTREN’S DISEASE
Dupuytren’s disease is an irreversible connective tissue disorder that results in progressive fibrosis, or thickening of the palmar fascia that causes development of contractile cords and nodules in the palm of the hand (Figure 8-7). Dupuytren’s is characterized by progressive thickening of the fascia below the skin, which draws the digits in toward the palm. Consequently, the client is unable to place his or her hand flat on a table surface. This condition occurs more frequently in men of European descent and affects up to 20% of men over the age of 65 years. Flexion contractures of the MCP and/or PIP joints of the affected digits is common and can significantly affect an individual’s ability to perform daily activities. Surgical intervention with excision of the diseased fascia and release of the contracted joint(s) is the most common treatment. Nonoperative techniques, including needle fasciotomy and collagenase injection with manipulation, are becoming popular due to decreased complications and faster recovery. In needle fasciotomy, the surgeon uses a needle to repeatedly pierce the skin and diseased cords. The affected digits are then passively extended until the cord is ruptured. With collagenase injection with manipulation, the surgeon injects collagenase into the diseased cord(s) in order to disrupt the collagen bonds and weaken the cord. The client returns the following day to have the affected digit passively extended, rupturing the cord. Researchers are studying the long-term effects of these procedures; however, long-term outcomes are currently unknown. Readers are strongly encouraged to seek out current literature as it becomes available.
Hand-based orthoses are commonly used following both surgery and nonoperative procedures to maintain the digit extension achieved and prevent recurrence of flexion contractures. The involved digits are positioned in extension, with care taken to avoid excessive tension on the wound for the first 1 to 2 weeks following surgery (Figure 8-8). Wide variability exists in the frequency in which these orthoses are used, the force and position of the involved digits in the orthosis, and the duration of orthosis use following surgery. The therapeutic effect of orthoses to deliver controlled stress to diseased fascia following surgery is currently unknown, particularly the use of orthoses at night following the initial healing period. The reader is encouraged to refer to current literature as it becomes available.
The wearing schedule of an orthosis following treatment, both surgical and nonoperative, of Dupuytren’s disease depends on disease severity, surgeon preference, and degree of preoperative joint contracture. As discussed, the duration of orthosis use for this population remains widely variable. Some surgeons recommend full-time wear until the wounds have healed, with removal on a regular basis for active digit flexion and extension, combined with consistent night wear for 4 to 6 months. Others recommend orthosis use as needed based on maintenance of digit extension following surgery.
- Jerosh-Herold, C., Shepstone, L., Chojnowsi, A. J., Larson, D., Barrett, E., & Vaughan, S. P. (2011). Nighttime splinting after fasciotomy or dermo-fasciectomy for Dupuytren’s contracture: A pragmatic, multi-centre, randomized controlled trial. BMC Musculoskeletal Disorders, 12, 136.
- This prospective, randomized, controlled trial evaluated the effectiveness of use of a night digit extension immobilization orthosis following surgery to treat Dupuytren’s contracture. Outcome measures included Disabilities of the Arm, Shoulder, and Hand scores, digit ROM, and self-reported patient satisfaction. No statistical differences were noted in all outcome measures at 12 months postsurgery. The authors recommend use of a hand-based digit extension orthosis only if loss of digit extension is observed following surgery and report that routine use of a night orthosis is not necessary.
- Kemler, M. A., Houpt, P., & van der Horst, C. M. (2012). A pilot study assessing the effectiveness of postoperative splinting after limited fasciectomy for Dupuytren’s disease. Journal of Hand Surgery (European Volume), 37(8), 733-737.
- This study examined the effectiveness of postoperative splinting following surgery for Dupuytren’s contracture. All 54 participants had a PIP flexion contracture of at least 30 degrees. PIP extension served as the primary outcome measure; secondary measures included visual analog scale (VAS) for pain, perceived comfort of the splint, and compliance with splint wear. All participants were evaluated at 1 year postsurgery. No statistically significant results were noted in all outcome measures between the two groups. The authors suggest that use of an orthosis following surgery for Dupuytren’s disease is not beneficial but note that further study is needed to support their preliminary pilot data.
- Brauns, A., Van Nuffel, M., De Smet, L., & Degreef, I. (2017). A clinical trial of tension and compression orthoses for Dupuytren contractures. Journal of Hand Therapy, 30(3), 253-261.
- The authors devised a randomized clinical trial on two patient groups with Dupuytren’s disease to evaluate how much improvement two different types of orthoses (tension and compression) can provide to a patient with a Dupuytren’s contracture. They wanted to find whether a compression orthosis contributed to better results than a tension orthosis. The trial included 30 patients with measurable flexion contractures of the fingers. Each treatment group consisted of 15 patients. One group received a standard tension orthosis and the other group received a newly designed silicon compression orthosis. Patients were instructed to wear their orthoses 20 hours per day for 3 months. Outcome measures were collected at the initial visit and again after 3 months of orthotic treatment. Primary outcomes were active extension deficit of each joint and total active extension of the digit. Secondary outcomes included patient satisfaction, and a VAS score of function and esthetics (0 to 10 points). The results of this trial showed that, for all patients, the flexion contracture was reduced at least 5 degrees. After 3 months, total active extension was significantly reduced in both groups (both P < .001). The mean change in total active extension was 32.36 degrees in the tension orthosis group and 46.47 degrees in the compression orthosis group. Although reduction of total active extension deficit was bigger in the compression group, this difference was not statistically significant (P = .39). The VAS score of esthetics and functionality was significantly increased in both treatment groups. The functional VAS after 3 months was 11% higher in the compression group than in the tension group (P = .03). A major complication of the tension orthotic was skin ulcers. The authors concluded that both tension and/or compression orthoses can be used as a nonoperative treatment of Dupuytren’s disease in both early proliferative untreated hands and aggressive postsurgery recurrence. Although there was no statistically significant difference, compression orthoses appear to be more effective and are better tolerated.
ULNAR NERVE INJURIES
Both high and low injuries to the ulnar nerve can cause significant motor and sensory impairments in the hand. As discussed in Chapter 1, the ulnar nerve innervates the majority of the hand intrinsic muscles, hypothenar muscles, and adductor pollicis. Paralysis or weakness of these muscles causes considerable imbalance of forces across the MCP and IP joints of the fourth and fifth digits, impairment in prehensile function, and sensory impairment on the ulnar aspect of the hand and digits. Ulnar claw hand develops due to the unopposed contraction of the extensor digitorum across the MCP joints and loss of intrinsic muscle power across the IP joints. The ulnar claw hand postures with the fourth and fifth MCP joints in hyperextension and concurrent flexion of the PIP and DIP joints with all attempts at active digit (Figure 8-9). A hand-based orthosis (Figure 8-10) that positions the fourth and fifth MCP joints in flexion helps to transfer the force from the extensor digitorum communis at the MCP joints to the IP joints to prevent MCP hyperextension, as well as prevent development of fixed contractures. For burns or other longstanding injuries with IP flexion contractures, a hand-based orthosis that positions the fourth and fifth MCP joints in flexion with the IP joints in maximum extension is recommended.