Brachial plexus palsy
Functional hand position
Intrinsic plus position
Open-packed position/position of deformity
Position of safe immobilization (POSI)
Upon completion of this chapter, you will be able to:
- Describe three to five common clinical conditions and goals for a wrist and hand immobilization orthosis.
- Identify pertinent anatomical structures and biomechanical principles involved in a wrist and hand immobilization orthosis and apply these concepts to orthotic design and fabrication.
- Identify the four most commonly selected orthotic designs and describe the rationale for choosing one design over another.
- Design suitable patterns for the four common types of wrist and hand immobilization orthoses and identify the pertinent anatomical landmarks.
- Outline the steps involved in the fabrication of a wrist and hand immobilization orthosis.
- Complete the molding and finishing of a wrist and hand immobilization orthosis.
- Evaluate the fit and function of a completed wrist and hand immobilization orthosis and identify and address all areas needing adjustment.
- Identify elements of a client education program following provision of a wrist and hand immobilization orthosis.
- Describe special considerations of wrist and hand orthotic design and fabrication.
Immobilization of the wrist and hand is necessary for treatment of certain conditions. Traumatic injuries that involve multiple joints and soft tissues may cause significant edema and pain and require immobilization of the entire hand and wrist. Painful arthritic episodes may also require immobilization of the wrist and hand. Other situations may arise where a client has little volitional control of the distal upper extremity (UE) and may also benefit from an orthosis that immobilizes the wrist and hand, often described as a wrist and hand immobilization orthosis. Such situations include multiple sclerosis, cerebral vascular accidents, traumatic brain injuries, and spinal cord injuries. Children with a wide range of congenital conditions, such as juvenile rheumatoid arthritis (RA), radial club hand, brachial plexus palsy, cerebral palsy, and others, may need the support of a wrist hand immobilization orthosis at various stages in their development.
Proper hand and wrist positioning in a wrist and hand immobilization orthosis is critical for healing of involved structures and preventing contractures of the involved joints and shortening of the tissues. In the absence of disease or injury, the hand and wrist assume a typical resting, or functional, position. This position, often referred to as the functional resting hand position, is characterized by wrist extension, metacarpophalangeal (MCP) joint flexion, slight proximal interphalangeal (PIP) and distal interphalangeal (DIP) joint flexion, and thumb abduction (Figure 5-1). When the digit and thumb flexor muscles are relaxed (flexor digitorum superficialis, flexor digitorum profundus, and flexor pollicis longus), this is the natural position that the digits and thumb assume when the wrist extends. This is known as the tenodesis effect. Following injury, the hand often assumes an open-packed position, or position of deformity (Figure 5-2). This is a position where the articular surfaces of a joint are in minimal contact with each other and the collateral ligaments and joint capsule are lax, or loose. This is opposed to the close-packed position, where the articular surfaces of the joint are in maximum contact with each other and the joint capsule and collateral ligaments are taut, or tight. The hand often assumes the open-packed position following injury due to pain and development of edema. This position is characterized by wrist slight flexion, extension of the MCP joints, flexion of the PIP and DIP joints, and adduction of the thumb web space. This can lead to development of joint and soft tissue contractures if not corrected early. The two most common positions used for wrist and hand orthoses are the resting hand position (or functional hand position) and the antideformity position, also known as the intrinsic plus position (Figure 5-3). Some clinicians refer to this as the position of safe immobilization (POSI). A summary of the different hand positions is shown in Box 5-1.
The position chosen for the orthosis will depend on the client’s condition and goals of the orthosis.
Wrist and hand immobilization orthoses are used for a wide variety of diagnoses and conditions. It is important to design and mold these orthoses properly so that they fit each individual client appropriately. The basic design for the wrist and hand orthosis takes into account the client’s clinical condition, his or her functional needs, specifications set by the referring physician, and the most appropriate low-temperature thermoplastic material (LTTM). Some examples include the following:
- When a client presents with severe edema of the involved extremity, it is preferable to select an LTTM with full memory because the orthosis may need to be remolded when the client’s edema decreases over time.
- If the client’s hand is large and presents with increased tone, the LTTM must have enough rigidity to support the weight of the involved extremity.
- If the client is elderly and frail, a lightweight, less rigid, and highly moldable LTTM may conform best to the anatomy and be less heavy for the client to support.
- When working with a pediatric client, it is important to consider that children grow at times more rapidly than at other times. The orthosis must be checked regularly for proper fit, especially if the child complains of pain or discomfort due to the orthosis suddenly becoming too tight or too small.
Box 5-1. Hand and Wrist Positions
OPEN-PACKED POSITION/POSITION OF DEFORMITY
- Wrist: 10 to 20 degrees of flexion
- MCP joints: extension
- PIP and DIP joints: flexion
- Thumb: adduction
RESTING HAND POSITION
- Wrist: 10 to 20 degrees of extension
- MCP joints: 50 to 55 degrees of flexion
- PIP and DIP joints: 10 to 20 degrees of flexion
- Thumb: full palmar abduction (perpendicular to the second digit)
- Wrist: 20 to 30 degrees of extension
- MCP joints: 70 to 90 degrees of flexion
- PIP and DIP joints: full extension, or 0 degrees
- Thumb: full palmar abduction (perpendicular to the second digit)
Box 5-2. Common Goals of Wrist and Hand Immobilization Orthoses
- Support and position the wrist, hand, digits, and thumb following surgery, trauma, or injury to protect and rest injured structures.
- Support and position the wrist, hand, digits, and thumb to provide pain relief.
- Provide joint protection for arthritic joints and minimize further joint deformity.
RESTING HAND POSITION
- Prevent joint and soft tissue contractures following surgery, trauma, or injury to the hand and wrist.
- Prevent contractures during healing following burn or other injuries.
- Position the wrist and hand to prevent shortening of muscles and tendons due to changes in muscle tone.
- Position the wrist and hand to maintain or achieve best joint alignment for function.
Goals for Use of a Wrist and Hand Immobilization Orthosis
The goals of a wrist and hand immobilization orthosis will vary depending on the individual client and his or her condition. The most common goals of wrist and hand immobilization orthoses are presented in Box 5-2.
When fabricating a wrist and hand immobilization orthosis, the practitioner must have a thorough understanding of the specific clinical condition or diagnosis and the expected outcome following orthotic use. It is important that the practitioner use sound clinical reasoning when selecting the most appropriate design and material to meet the client’s particular needs.
Clinical Conditions and Wearing Schedules
This section describes common clinical conditions where a wrist and hand immobilization orthosis is often prescribed. Readers are encouraged to review the references provided for additional details regarding each clinical condition. Current evidence available supporting the use of wrist and hand orthoses as an intervention strategy is also discussed.
Orthotic intervention plays a critical role in preventing contractures and maintaining length of tissues in the burned hand. Immediately following a burn injury, it is common for the hand and wrist to assume an open-packed position due to pain and edema formation, particularly on the dorsal aspect of the metacarpals (Figure 5-4). The wrist and hand immobilization orthosis is typically used, but the positioning of the hand may vary from the normal resting hand position to the antideformity position (see Box 5-1). This involves placing the wrist in 30 to 50 degrees of extension, the MCP joints in 70 to 90 degrees of flexion, and the PIP and DIP joints in full extension; this is referred to as the intrinsic plus position, or antideformity position, as mentioned previously. The thumb is placed in full palmar abduction due to the risk of adduction contractures of the first web space. This orthosis may be used immediately following a burn injury, ideally during the inflammatory and fibroplastic phases of wound healing (0 to 6 weeks), to prevent development of joint or soft tissue contractures as the burn scar heals and matures. The skin, scar tissue, and orthosis must be periodically checked for proper fit and adjustments. When allowed, active range of motion (ROM) is initiated and encouraged.
- Fufa, D., Chuang, S., & Yang, J. (2015). Post burn contractures of the hand. Journal of Hand Surgery America, 39(9), 1869-1876. doi:10.1016/j.jhsa.2015.03.018
- These authors describe current surgical and therapeutic intervention strategies following burn injuries to the hand and wrist. Principles of acute burn care include use of resting hand orthoses in an intrinsic-plus or antideformity position to prevent or minimize joint and skin contractures. Following hand burn reconstructive surgery, similar orthotic principles are employed to maintain proper joint positioning.
- Dewey, W. S., Richard, R. L., & Parry, I. S. (2011). Positioning, splinting, and contracture management. Physical Medicine and Rehabilitation Clinics North America, 22, 229-257.
- In this narrative review, the authors recommend use of resting hand immobilization orthoses in all stages of burn rehabilitation (acute, intermediate, and long term) for maintenance of functional hand joint positioning, prevention of tissue shortening due to scar tissue deposition, skin graft protection and positioning, and correction of existing joint and/or soft tissue contractures. Hand position recommended is 15 to 25 degrees of wrist extension, 60 to 70 degrees of MCP joint flexion, full PIP and DIP joint extension, and thumb palmar abduction.
MULTIPLE FRACTURES AND TRAUMA
Crush and compression injuries and multiple fractures of any of the carpal bones, the radius and/or ulna at the wrist, the metacarpals, and the phalanges may require a wrist and hand immobilization orthosis for support, protection, and positioning. The positioning of the wrist and hand in this orthosis may be in the functional hand or antideformity position depending on the injury itself, the extent of the edema, the wounds, and the overall pain level.
Both osteoarthritis (OA) and RA can affect the wrist and hand by causing impaired motion, pain, and weakness. RA typically affects the UE joints symmetrically, and the wrist, MCP joints, and PIP joints are commonly involved. Deformities include ulnar deviation of the wrist and volar subluxation of the carpus, along with associated ulnar drift and volar subluxation of the MCP joints, resulting in what is commonly referred to as zig-zag deformity (Figures 5-5 and 5-6).
OA typically affects the wrist, PIP and/or DIP joints, and MCP joint of the thumb. The MCP joints of the digits are rarely affected. Wrist and hand immobilization orthoses can help decrease both RA and OA symptoms by supporting the wrist and hand in a resting and comfortable position to reduce pain, which can secondarily help prevent further deformity and improve hand function (see Figure 5-6).
- Beasley, J. (2012). Osteoarthritis and rheumatoid arthritis: Conservative therapeutic management. Journal of Hand Therapy, 25(2), 163-172. doi:10.1016/jht.2011.11.001
- Use of wrist and hand immobilization orthoses for RA patients can help reduce pain and reduce joint deformity. Care should be taken to address all involved joints if the client presents with zig-zag deformity, specifically the carpometacarpal joints of the digits. Positioning the MCP joints in an anti-ulnar drift position can worsen the radial deviation deformity seen at the carpometacarpal joints and metacarpals.
- Chim, H. W., Reese, S. K., Toomey, S. N., & Moran, S. L. (2015). Update on the surgical treatment for rheumatoid arthritis of the wrist and hand. Journal of Hand Therapy, 27(2), 134-142. doi:10.1016/j.jht.2013.12.002
- Use of wrist and hand immobilization orthoses following MCP joint arthroplasty surgery rather than a dynamic MCP joint extension orthotic design is now recommended for clients with RA. The authors note that compliance is improved with these orthoses and clients have an easier time donning and doffing the orthosis during the rehabilitation phase.
In the absence of disease or injury, muscles have resting tone, or resistance to passive stretch. This is created by connective tissues present in muscle, as well as input from the central and peripheral nervous systems. A common physical impairment in the UE following brain trauma or stroke is the development of abnormal muscle tone. There are different terms used to describe abnormalities in tone. These include flaccidity, hypertonicity, hypotonicity, and rigidity. Flaccidity is characterized by absence of both muscle tone and deep tendon reflexes. No active movement in the extremity is observed. Flaccidity typically presents immediately following a traumatic injury or event in the brain or spinal cord. It can also occur following injury to a lower motor nerve or peripheral nerve. Hypertonicity typically develops a few weeks later but may also be present immediately following injury. In contrast to flaccidity, hypertonicity is an increase in muscle tone with resistance to active and passive movement. Injury to upper motor neurons in the brain or spinal cord interrupts the normal pathway between these neurons and the lower motor neurons. Stretch reflexes become hyperactive, resulting in increased muscle tone. In hypertonicity, changes can also occur in the connective tissue of the involved muscles and surrounding joints, resulting in soft tissue and joint contractures. Rigidity is also an increase in muscle tone, but muscles on both sides of a joint are affected, resulting in loss of voluntary movement in all directions that a joint moves. This is in contrast to hypertonicity, where muscles on one side of a joint demonstrate increased tone and muscles on the other side become inactive, or weak. Hypotonicity, or less-than-normal muscle tone, is characterized by muscle weakness and impaired ability to resist the force of gravity during active movement. Wrist and hand immobilization orthoses can help support hypotonic or flaccid muscles, help prevent the development of joint and soft tissue contractures, and temporarily reduce hypertonicity of the wrist and digit flexor muscles (Figures 5-7 and 5-8).
- Ivy, C. C., Smith, S. M., & Materi, M. M. (2015). Upper extremity orthoses use in amyotrophic lateral sclerosis/motor neuron disease: A systematic review. International Journal of Physical Medicine & Rehabilitation, 3(2), 264.
- These authors examined the current literature to determine common orthotic interventions for individuals with amyotrophic lateral sclerosis/motor neuron disease. Available evidence to support orthotic intervention for this population is limited to Level IV (case reports) and Level V (expert opinions). Such evidence suggests that wrist and hand immobilization orthoses can help reduce pain, provide rest to fatigued musculature, and prevent development of joint and soft tissue contractures.
- Copley, J., Kuipers, K., Fleming, J., & Rassafiani, M. (2013). Individualized resting hand splints for adults with acquired brain injury: A randomized, single blinded, single case design. Neurorehabilitation, 32(5), 885-898.
- These authors investigated the effects of a wrist and hand immobilization orthosis on wrist and digit spasticity following brain injury in adults using a randomized, single-blinded, single-case design. Results support use of orthotic intervention in positively influencing wrist and digit flexor spasticity, tissue stiffness, and passive digit motion in individuals without joint or soft tissue contractures.
- Pizzi, A., Carlucci, G., Falsimi, C., & Verdesca, S. (2005). Application of a volar static splint in post-stroke spasticity of the upper limb. Archives of Physical Medicine and Rehabilitation, 86, 1855-1859.
- These authors conducted a pretest-posttest trial study to assess the effectiveness of a volar-based resting hand immobilization orthosis on spasticity, wrist and elbow passive ROM, pain, and spasms in clients with post-stroke upper limb spasticity. Wrist and elbow pain, passive ROM, and flexor carpi radialis spasticity were positively affected by use of an orthosis for 90 minutes per day for 3 months. The orthosis was well tolerated by the study participants.
Children may benefit from wrist and hand immobilization orthoses for conditions such as radial deficiencies and brachial plexus palsy. A brief overview of these conditions is provided here. Radial deficiencies (Figure 5-9) refer to all congenital hand anomalies with failure of formation along the radial border of the UE. Orthotic intervention may be started immediately after birth. A program of passive stretching along with orthotic intervention is introduced. A wrist and hand immobilization orthosis can help centralize the hand, maintain digital alignment, and prevent flexion contractures of the digits. The orthosis may be worn full-time until the baby begins to use the hands. Particular attention must be addressed to the increased prominence of the ulnar styloid. The LTTM can be carefully formed so as to not put pressure on this bony prominence.
- Takagi, T., Seki, A., Takayama, S., & Watanabe, M. (2017). Current concepts in radial club hand. The Open Orthopaedics Journal, 11, 369-377.
- These authors provide an overview of current treatment considerations for radial club hand. Use of orthoses is recommended soon after birth and should continue for at least 6 months, with the goal of stretching tight soft tissues and aligning the hand and wrist with the ulna. The authors also recommend inclusion of the elbow due to the small size of the arm. Continued use of orthoses combined with stretching is advised until 2 to 3 years of age.