Management of the child who has sustained an injury or undergone surgery to the upper extremity poses a unique challenge to the surgeon-therapist-patient team. Most upper extremity surgery and reconstruction require a high degree of cooperation and participation on the part of the patient to achieve optimal results. The child is unable to participate on this level. Parents are asked to participate for and with the child. Together, the treatment team is challenged to new limits of creativity to accomplish the desired result with the child. Splinting is often a large part of the management of a child’s hand problem because of the difficulty in cooperation.
The child population with upper extremity problems consists of three groups: infants with congenital or birth injuries that require splinting to prevent development of deformity or to correct existing deformities, children with congenital defects who have undergone corrective surgery, and those who require treatment secondary to trauma.
Splinting may be designed to prevent development of deformity, correct an existing problem, position for function, or protect an injured or repaired structure. Within these groups, static ( Fig. 120-1 ), serial static ( Figs. 120-2 and 120-3 ), or dynamic ( Fig. 120-4 ) splinting options may be used.
The specific problems associated with splinting a child vary considerably with the age and developmental level of the individual. The infant cannot actively cooperate. The young child who is aware of his or her environment and has begun interacting with it but cannot yet be reasoned with poses the greatest challenge.
Parental Involvement
The ability or inability of the child to cooperate with splint fabrication is the key and is related to the age and specific abilities of the child and to the parents’ ability to work with the child. Communication with parents or caregivers is important before, during, and after splint application. Parents often communicate so much anxiety to children nonverbally that the children can do nothing but become fearful or anxious themselves. Parents often have more difficulty dealing with an injury or disability than does the child because of underlying guilt or other unknown factors. It is helpful to begin by establishing a working relationship with the parents.
The clinician should reassure the parents as much as possible. They should be shown a sample of the type of splint their child will be receiving and informed about the fabrication process. They may feel that they have to remember every bit of information from the session; for reassurance, they should be told ahead of time that written instructions will be provided.
Splinting Materials
In the past, it was necessary to use thin splint materials by rolling them to obtain a thickness that could be molded accurately to the contour of tiny arms. Recently, several manufacturers have introduced a 
-inch thickness of their materials that is more appropriate for use in children. These materials are also available in perforated form. When nonperforated material is used, it sometimes is necessary to introduce a limited number of strategically placed perforations into the splints after fabrication to prevent maceration and to increase comfort.
For long-arm splints, standard-thickness material usually is acceptable ( Fig. 120-5 ). Good conformation is still important, and a material with this quality must be chosen.
