Because the purpose of this chapter is to introduce basic concepts to beginning splinters, there are many types and variations of pediatric hand splints that will not be covered. A number of children may respond best to a splint designed to reduce spasticity (see Chapter 14). Children with traumatic injuries or burns can be approached in a manner similar to adults [Hogan and Uditsky 1998], which is described in previous chapters. Other children may benefit from the use of plaster or pneumatic splints for the elbow or hand (see Chapter 14). Some splints are part of interventions in advanced areas of practice, such as the neonatal intensive care unit. These complex or specialized splints are beyond the scope of this chapter. Readers are encouraged to read articles cited in the references at the end of this chapter for more information. Those who desire additional skills in these areas should explore continuing education courses or arrange for advanced study.

The previous chapters have described basic splinting principles, designs, and fabrication techniques that need not be repeated here. However, examples and applications in previous chapters focused primarily on adults. Successfully splinting a child is different from splinting an adult in many respects, including the following:

• Abnormal muscle tone has been present since birth or infancy and may differ qualitatively from abnormal muscle tone acquired after disease or injury.

• The child experiences the dynamic process of maturational and neurologic development, which has a continuous effect on the acquisition of functional hand skills. It is also important to realize that because of the plasticity and immaturity of the child’s systems inappropriate splints can result in harmful effects [Granhaug 2006].

• Muscles and tendons undergoing growth respond differently to stretch [Wilton 2003].

• Children experience continued growth of the upper extremities. As children grow, splints fit tighter and create pressure. During a growth spurt, the risk of deformity or skin breakdown may increase as a result of bone growth that exceeds growth or lengthening of muscles and soft tissues because of spasticity. Deformity may also occur secondary to a splint that has been outgrown and no longer fits properly.

• Many children must rely on adults, such as parents or teachers, to apply and remove their splints. Therefore, the level of understanding and cooperation of these adults is a factor.

• Children have a low tolerance for interference by adults and the imposition of a piece of equipment (splint) unfamiliar to them. Their cognitive level may be insufficient for them to understand abstract concepts such as prevention or to comprehend cause-and-effect relationships (if you wear this splint, then your hand will work better). They may resist holding still, become fearful and cry, or be able to cooperate only for brief periods of time because of a short attention span. Any or all of these factors may create greater challenges to the fabrication and application of the splint(s) for children. In addition, as the child asserts his or her autonomy, a power struggle may develop with adults and the child may resist donning or removal of the splint at home or school.

• The placement and molding of a splint on a child is more difficult than on an adult because the child’s hand is much smaller in proportion to the therapist’s hand.

Diagnostic Indications

The focus of this chapter is on splinting the child with a developmental disability or congenital anomaly. However, many of the principles and splints described also apply to adults with developmental disabilities. According to the Centers for Disease Control and Prevention (CDC), developmental disabilities are a diverse group of chronic conditions that result from a mental and/or physical impairment and interfere with major life activities [CDC 2006]. Many developmental disabilities, such as cerebral palsy, are accompanied by central nervous system dysfunction and abnormal muscle tone.

Central nervous system dysfunction can be the result of many types of brain injury, such as an intracranial hemorrhage, hypoxia, infections, tumors, or trauma. Abnormal muscle tone can include increased, decreased, or fluctuating tone and presents a number of splinting challenges. Lower motor neuron dysfunction may also occur at birth as the result of excessive stretch to the brachial plexus during delivery. Depending on the nature and extent of the nerve damage, this may result in developmental arm and hand dysfunction.

Other diagnoses in children for which splinting may be indicated include brachial plexus injury or congenital defects or anomalies of the hand or upper extremity, which are generally due to malformations of the musculoskeletal system. Malformations include finger flexion contractures, soft-tissue or bony fusion (syndactyly), and dysplasia of the ulna or radius. Children with brachial plexus injury (Erb’s palsy) may require splinting or casting of the hand and the entire upper extremity, especially after surgery. Another congenital or birth defect that may require orthotic intervention is arthrogryposis multiplex congenita.

According to Banker, “Arthrogryposis multiplex congenita is not a specific disorder but rather a symptom complex of congenital joint contractures associated with both neurogenic and myopathic disorders.…The main feature shared by these disorders appears to be the presence of severe weakness early in fetal development, which immobilizes joints, resulting in contractures” [Banker 1985, p. 30]. Programs that involve early passive stretching and serial splinting of contracted joints are recommended [Bayne 1986, Donohoe 2006, Palmer et al. 1985, Sala et al. 1996, Williams 1985]. Splints, such as a dynamic elbow flexion splint, have also been developed to compensate for lost muscle power [Kamil and Correia 1990].

Children with developmental disabilities or congenital anomalies often present with indwelling thumbs (thumbs held adducted into the palm). This may be the result of abnormal muscle tone, weakness, or abnormal anatomy of the hand. To effectively grasp and manipulate objects, it is crucial that the thumb be positioned in opposition. Splinting, along with active movement, is often required to effectively position the thumb in opposition for grasp and optimal hand function.

Juvenile rheumatoid arthritis (JRA) is a systemic rheumatic disease that causes major disabilities in children younger than 16 years. Children with JRA may present with pain, fatigue, and reduced range of motion (ROM). These symptoms often result in difficulty performing school tasks and activities of daily living. In addition to medical management and interventions to promote participation, treatment for JRA may include splinting and passive and active ranging of the joints [Rogers 2005]. In summary, a number of pediatric diagnoses may indicate a need for splinting. However, rather than strictly on a specific diagnosis the final splinting decision is made on the basis of the limitations in specific movements, the type and severity of abnormal muscle tone, the extent of soft-tissue and bony involvement, the child’s functional level, the child’s environment, and the frame of reference guiding therapy.

Assessment

Before fabricating a splint, the therapist must complete a comprehensive assessment. According to the American Occupational Therapy Association (AOTA) Occupational Therapy Performance Framework, the therapist should consider performance in areas of occupation first and then evaluate performance skills, performance patterns, context, activity demands, and client factors [AOTA 2002]. This chapter discusses areas of assessment in the categories of areas of occupation, client factors, performance skills, and context.

Understanding the possible physiologic mechanisms for the formation of a contracture can assist the therapist in splint design and establishment of wearing schedules. Hogan and Uditsky [1998], McClure et al. [1994], and Watanabe [2004] provided useful discussions of this topic. Briefly, when a joint is held in a fixed position (for example, wrist flexion) the result “is a decrease in the functional length of the periarticular connective tissues and associated muscles that have been held in this shortened position.…The muscle then accommodates to this shortened immobilized position through biological changes that take place such as a loss in the number of sarcomeres” [Hogan and Uditsky 1998, p. 71].

Preventing contractures, or minimizing their severity, is one of the most important functions of splinting for children with developmental disabilities or congenital anomalies. Even with ongoing intervention, prevention of all contractures in children who have severely increased tone can be difficult and may not be possible. However, even if an existing contracture cannot be improved splinting should be done to prevent the contracture from becoming worse. A moderate contracture is better than a severe contracture because the latter can result in problems with skin breakdown and can make care much more difficult. When working to decrease a contracture it is important to keep in mind that “soft tissue connective tissue responds better to low-load prolonged stress (LLPS) than high-load brief stress (HLBS)” [Granhaug 2006, p. 419].

Integrity of Skin, Bones, and Circulatory System

In severe cases, the therapist should use extreme caution when splinting a child with osteoporosis because stress to the bones could cause a fracture. Osteoporosis in children occurs as a result of lack of weight bearing while bones are growing. Children with tightly fisted hands are at risk of developing maceration or skin breakdown in the palms or between the fingers, and maintenance of skin hygiene becomes a priority.

Some children experience pain in certain positions or have very sensitive skin. Other children have poor circulation, which necessitates careful monitoring of the color and temperature of the skin during splint wear. Finally, some children who have developmental disabilities also have significant feeding problems and may be underweight. Children with little subcutaneous fat probably have more difficulty tolerating pressure on bony areas, thus affecting the splint’s design and wearing schedule.

Performance Skills

The therapist should evaluate components of reach, grasp, manipulation, release, bilateral hand use, and tactile and proprioceptive reactivity and discrimination. It is important to evaluate upper extremity function in various positions, such as supported sitting, unsupported sitting, and prone, supine, and side lying. This gives crucial information about the proximal stability needed for effective distal function of the hand. Sensory system modulation should be observed. Hyperreactivity or hyporeactivity to sensory stimuli affects how the therapist approaches the child and influences splint selection and fabrication.

The child’s level of cognitive ability also affects hand use, and the therapist should obtain information about the child’s cognitive level. Because one of the most important determinants of a successful splint is the improvement of hand function, the therapist should use an objective measure of hand function such as a criterion-referenced assessment tool. This allows the therapist to periodically reevaluate and compare the child’s performance over time. A qualitative description of how the child moves and performs should also be included to complete the functional assessment.

Context

Children with disabilities live, rest, play, and are productive in a variety of environments—including home, school, child care centers, and sometimes hospitals. The fabrication and monitoring of splints may occur in any of these environments. When selecting and designing a splint, persons who are responsible for donning the splint must be considered. Simplicity of design is desirable and may be a necessity in cases where the child interacts with multiple care providers in a variety of environments. Compliance with using the splint is likely to decline as the complexity with the donning and wearing schedule increases. In the hospital setting, care must be taken to obtain information from family members and the treating therapist (if applicable) about home and school settings that will influence splinting decisions.

Careful planning must be made when splinting in the intensive care units of the hospital because splints must be fabricated with minimal handling of the infant or child and while navigating carefully around life-supporting tubes and monitors. Consideration must be given to incorporation of the use of the splints in the daily medical care provided by nursing staff. The therapist must also be familiar with the child’s medical condition and be able to recognize signs of stress that can be harmful to the child. Practice in the neonatal intensive care unit requires advanced competencies, and therapists considering practice in this environment should obtain training beyond entry level [Hunter 2005].

When a splint is used in the school environment, it must contribute to the child’s ability to benefit from a specially designed program of instruction such as special education. It is important for a child to be able to reach, grasp, manipulate, and release learning materials and other objects in order to function in the classroom, lunchroom, playground, hallways, library, and gymnasium.

The therapist should include the purpose of a splint as a part of educationally related occupational therapy described by the individualized education plan (IEP) if the child is 3 to 21 years of age or the individualized family service plan (IFSP) if the child is under 3 years of age. Remember, the splint is a means to an end and not the end itself. Therefore, the IEP or IFSP goal would be a measurable statement describing the child’s performance skills, patterns, or client factors and not the fabrication of the splint. The splint is part of the intervention that allows or facilitates participation in educational programming. This distinction is important if personnel at the school question whether splinting is an educational or a medical intervention.

Information about the home environment should be obtained from interviews with the parents and caretakers, and if possible via a home visit. Splints with wearing schedules incompatible with family schedules or splints that family members do not understand will not be used effectively. The family should not be expected to follow a “one size fits all” splinting protocol. Rather, the therapist must individualize the splint design and wearing schedule not only to fit the child’s needs but to fit the family’s strengths and needs. The therapist should always bear in mind that families are expected to carry out other therapeutic, educational, or medical interventions in addition to meeting the challenges of day-to-day life with a child who has a disability.

After an assessment is completed, the therapist can establish therapeutic goals and intervention strategies for the child. A splint may be a component of this treatment plan. According to Schoen and Anderson, orthotic devices (like adaptive equipment) are an important part of intervention because they reinforce neurodevelopmental treatment therapeutic goals: “If preventative measures such as adaptive equipment and orthotic devices are provided, then the child will receive consistent input to prevent or reduce the occurrence of deformities and limitations” [Schoen and Anderson 1999, p. 107]. Once a decision is made to provide a splint for a child, the splinting process is initiated.

Overview of the Splinting Process

Prepare the Child

Position the child so that the effects of abnormal tone and postural reflexes on the arm and hand are at a minimum. This position depends on the results of the assessment of the individual child and may be different from how the child is typically positioned. It is important to provide external stability through equipment or handling for children who have not acquired internal stability of proximal joints. This may involve a seating system or other adaptive equipment. For the infant or young child, it may be possible for the parent to hold the child and provide external stability with the therapist’s instructions.

It is also important to reduce the child’s fearfulness and maximize his or her cooperation. If the therapist does not already have a relationship with the child, time must be provided to allow the child to warm up to a stranger. Even if the child knows the therapist, a brief time should be provided to allow the child to acclimate to the equipment and setup for splinting. The therapist should have toys, music, books, stickers, or other materials to establish a reciprocal interaction with the child before starting the fabrication process. With an infant, the therapist can talk in a soothing voice and touch the child in a playful manner before fabrication. With an older child, the therapist can show the child what to expect by first fabricating a “splint” on a doll or stuffed animal or by making “thermoplastic jewelry” or other play objects.

When appropriate, the child should be given the opportunity to touch and feel the material while it is warm and soft and again after it becomes cool and hard. The child’s response to tactile stimuli should be noted, and if signs of tactile defensiveness occur the therapist should follow sensory processing guidelines for improving sensory system modulation. If colored thermoplastic material is available, the child should be encouraged to select a color. Decorating the splint with stickers or leather stamps also encourages the acceptance of the splint for some children.

Giving children a role to play in the fabrication process may increase their cooperation. This could include keeping time by counting, holding the tail of the Ace wrap, or any other role the therapist can invent to keep them involved. However, if associated reactions are present it is best for the child to be involved without exerting effort—because this may increase tone. Although preparing the child may take a few extra minutes at the beginning of a splinting session, it can save hours of frustration in having to reschedule or remake a splint because of lack of cooperation.

Prepare the Environment

Thoughtful preparation is especially important when splinting children because of their short attention spans. In addition to having splinting and play materials close at hand, it is recommended that the therapist plan to have a second pair of adult hands to help with the fabrication process [Armstrong 2005]. This additional person might be a parent, teacher, paraprofessional, or another therapist. This is especially important if the child has increased tone, is not able to follow verbal instructions, or is likely to be uncooperative. The therapist must clearly explain the helper’s role so that efforts assist the process and not hinder it. This usually involves maintaining the child’s overall position, calming or entertaining the child, holding the arm just proximal to the joint being splinted, or stabilizing the material once in place and while it is cooling.

Selection of Splinting Materials

Pediatric splints may be made of many different types of materials, depending on the purpose of the splint and the age and needs of the child. Thermoplastic materials are commonly used for the fabrication of static splints or those that require restricting motion at certain joints. Soft splints are commonly made of materials such as neoprene. Soft splints may not totally immobilize a joint, but they provide support and allow greater freedom of movement. Children with athetosis or involuntary flailing movements should be protected from possible harm from the splint by selection of a soft material or by covering a thermoplastic material with a mitt or sock.

When splinting with neoprene, the therapist should be alert to the possibility of skin irritation or rash. According to Stern et al. [1998, p. 573], “skin contact with neoprene poses two dermatological risks: allergic contact dermatitis (ACD) and miliaria rubra (i.e., prickly heat).” Although neoprene hypersensitivity is rare, the authors recommend that therapists screen patients for a history of dermatologic reactions; instruct clients to discontinue use and inform the therapist if a rash, itching, or skin eruptions occur; and report cases of adverse skin reactions to the manufacturer of the neoprene material. They also recommend that therapists limit their own exposure to neoprene and neoprene glue because of the exposure to thiourea compounds that are thought to contribute to allergic reactions.

Thermoplastic materials range in conformability (and in stretch, thickness, and rigidity) and are described in Chapter 3. Generally, thermoplastic materials with a high plastic content have more conformability—whereas materials with a high rubber content have less stretch but are less likely to be indented with fingerprints during fabrication or stretch out of shape. When making a splint that counteracts the forces of spasticity, it is especially important to select a thermoplastic material that resists stretch (i.e., one with a high rubber content) because it is necessary for the therapist to apply considerable pressure to obtain the desired position of the wrist, thumb, and fingers [Armstrong 2005].

There are also products that combine the properties of plastic and rubber. Usually the rubberlike (or combination) thermoplastic material is necessary when one is splinting against spasticity, even though it is less rigid than the plastic type. If necessary, a reinforcement component can be added to the splint. Selecting a material with a high degree of memory is helpful when one is working with a child whose movements may be unpredictable and require the therapist to start over (sometimes more than once!). These plastics are elastic-like and self-adhere easily. This latter characteristic can also be problematic.

One way to reduce the stickiness is to add a tablespoon of liquid soap or shampoo to the hot water [Hogan and Uditsky 1998]. When splinting a neonate or young infant, the standard -inch material may be too thick and heavy. Rather, the therapist should use material that is 1/16-inch or 3/32-inch in thickness. The therapist’s experience and preferences also affect the choice of thermoplastic material. (See Chapter 3 for a review of splinting material.)