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An ulnar boost splint for midcarpal instability
PRACTICE FORUM
An Ulnar Boost Splint for Midcarpal Instability Our understanding of the wrist, and its intricate network of ligaments, has improved significantly in the last decade. Any alteration in this network may alter one’s functional ability. Good proximal stability is necessary for distal mobility. These authors have designed a splint to help improve stability in one example of wrist dysfunction.—PEGGY L. FILLION, OTR, CHT, Practice Forum Editor
AN ULNAR BOOST SPLINT FOR MIDCARPAL INSTABILITY
Shrikant Chinchalkar, OTR, CHT Sean Ah Yong, OTR, MSc (OT) Hand and Upper Limb Centre St. Joseph’s Health Care London London, Ontario, Canada
One form of midcarpal instability is associated with an abnormally volarflexed lunate. This is also known as a volar intercalated segmental instability (VISI) deformity. In a healthy, uninjured wrist, the lunate naturally volarflexes because of its attachment to the scaphoid, by the scapholunate interosseous ligaments, or secondary to its innate shape with detachment from the scaphoid and/or the triquetrum.1 However, with trauma to the ligamentous structures of the midcarpal joint, the lunate can become hyperflexed volarly, resulting in pain and dysfunction. Symptoms of midcarpal instability include a prominent ulnar head, tenderness over the triquetrohamate joint, and a positive midcarpal shift test.1
Materials 1. Thermoplastic, conforming, splinting material, preferably 1⁄8 inch thick (e.g., Ezeform or Kaysplint). 2. Self-adhesive Velcro hooks. Cut approximately two pieces of 1-inch-wide by 2-foot-long strips for the wrist component and two pieces of 1-inchwide by 11⁄4 -inch-long strips for the hand component. 3. Velcro loop-nonadhesive. Cut one approximately 7-inch-long by 1-inch-wide piece. This will pull the hand and wrist components together. 4. Two-inch Velfoam. Cut one approximately 3-inchlong piece. This will secure the wrist portion. 5. One approximately 2-inch piece of closed-cell, adhesive-backed foam. 6. Measuring tape.
Fabrication The hand component is fabricated as follows (Figure 1):
Purpose Our ulnar boost splint addresses type I or II midcarpal instability. With this type of instability, symptoms usually occur on the ulnar side of the wrist.1 Chronic midcarpal instability can progressively worsen and result in limitations in wrist function. Our ulnar boost splint follows the recommendations of splinting to support the pisotriquetral area.2,3 Correspondence and reprint requests to Shrikant Chinchalkar, OTR, CHT, Senior Hand Therapist, Hand and Upper Limb Centre, St. Joseph’s Health Care London, London, Ontario, Canada N6A 4L6; e-mail:. doi:10.1197/j.jht.2004.04.013
FIGURE 1. Materials needed to fabricate the ulnar boost splint.
July–September 2004 377
FIGURE 2. Hand component with foam build-up on the pisotriquetral area.
FIGURE 5. The complete ulnar boost splint on a subject’s hand (palmar and ulnar-sided view).
FIGURE 6. The complete ulnar boost splint on a subject’s hand (palmar and radial-sided view).
FIGURE 3. Wrist component with distal end cushioned with foam.
1. Measure the circumference of the distal palmar crease. This will become the distal measurement. 2. Cut a piece of thermoplastic material that includes the above measurement and covers the thenar eminence. Make sure your piece covers the pisiform (Figure 2). 3. Form the above piece to the hand. This should be a continuous cuff around the hand. Make sure to follow the natural creases of the hand and finish your edges. The digits, thumb, and wrist should be able to flex and extend without any restrictions. 4. Cut and apply the foam to conform to the area covering the thenar eminence. Make sure to have the majority of coverage over the pisiform. To fabricate the wrist component (Figure 3):
FIGURE 4. Velcro strap demonstrating the dorsal force on the pisotriquetral area.
378
JOURNAL OF HAND THERAPY
1. With the measuring tape, measure just proximal to the ulnar and radial styloids. 2. Subtract approximately 2 inches from the above measurement to allow for the volar wrist opening.
3. Cut a piece of thermoplastic material with the aforementioned dimensions. 4. Form this piece on the dorsal forearm just proximal to the ulnar styloid. Make sure to flare and cushion the distal end to help protect the ulnar head. 5. Apply your 1-inch by 2-inch Velcro-hook, adhesive-backed pieces to the radial and ulnar aspects of this component and secure with the Velfoam piece. To fabricate the pisotriquetral force component (Figures 4–6): 1. Place the 1-inch by 11⁄4 -inch Velcro-hook, adhesive-backed piece on the volar surface, ulnar side of the hand component. 2. Place the other piece of 1-inch by 11⁄4 -inch Velcrohook, adhesive-backed piece to the radial aspect of your Velfoam piece. 3. Using the 1-inch Velcro loop strap, attach one end to the ulnar side of the hand component and
apply moderate tension as you pull it dorsally to the radial wrist component (Figures 5 and 6).
Wearing Time The splint should be worn continuously for six weeks, in conjunction with extensor carpi ulnaris strengthening and educating the client regarding activity modification.2
REFERENCES 1. Caputo AE, Watson HK, Weinzweig J. Midcarpal instability. In: Watson HK, Weinzweig J (eds). The Wrist. Philadelphia, PA: Lippincott, Williams & Wilkins, 2001, pp 511–20. 2. Wright TW, Michlovitz SL. Management of carpal instability. In: Mackin EJ, Callahan AD, Skirven TM, Schneider LH, Osterman AL (eds). Rehabilitation of the Hand and Upper Extremity. 5th ed. St. Louis, MO: Mosby, 2002, pp 1185–94. 3. Ambrose L, Posner MA. Lunate-triquetral and midcarpal joint instability. Hand Clin. 1992;8:653–68.
Modification to a Pediatric Thumb Splint Splinting a child has always been a challenge, even for the best therapist. We frequently consider the correct fabrication and positioning of the splint to be our success, only to find moments later that the child has removed the splint. This author has incorporated a simple clasp into a frequently used pediatric splint to help address this problem.—PEGGY L. FILLION, OTR, CHT, Practice Forum Editor
MODIFICATION TO A PEDIATRIC THUMB SPLINT
Marc Willey, PhD, OTR/L University of Central Arkansas Conway, Arkansas Arkansas Children’s Hospital Little Rock, Arkansas
In the pediatric population, it is frequently difficult to maintain a desired splint and/or splint position. A frequently used splint in our clinic is one that encircles the thumb as well as assists in maintaining the web space (Figure 1). This splint typically is applied to patients with hypertonicity (Figure 2). The
design of the splint encircles the thumb, thus providing some warmth to the thumb. By providing neutral warmth, this splint has the potential of reducing tone.1 To prevent the child from removing this splint, we secured a small plastic clasp to the wrist portion of the splint.
Material You will need the following materials (Figure 3): 3-cm 3 40-cm Neoprene wrist strap 2-cm 3 20-cm Neoprene thumb strap 1-inch 3 2-inch piece of nonadhesive Velcro hook Small plastic clasp (can be obtained from a small pet collar for approximately $3.00)
Procedure Correspondence and reprint requests to Marc Willey, PhD, OTR/L, 2945 Baxter, Conway, AR 72034; e-mail:. doi:10.1197/j.jht.2004.04.014
1. Measure and cut the wrist strap, making sure it has adequate length to wrap around the child’s wrist.
July–September 2004 379
An Ulnar Boost Splint for Midcarpal Instability Our understanding of the wrist, and its intricate network of ligaments, has improved significantly in the last decade. Any alteration in this network may alter one’s functional ability. Good proximal stability is necessary for distal mobility. These authors have designed a splint to help improve stability in one example of wrist dysfunction.—PEGGY L. FILLION, OTR, CHT, Practice Forum Editor
AN ULNAR BOOST SPLINT FOR MIDCARPAL INSTABILITY
Shrikant Chinchalkar, OTR, CHT Sean Ah Yong, OTR, MSc (OT) Hand and Upper Limb Centre St. Joseph’s Health Care London London, Ontario, Canada
One form of midcarpal instability is associated with an abnormally volarflexed lunate. This is also known as a volar intercalated segmental instability (VISI) deformity. In a healthy, uninjured wrist, the lunate naturally volarflexes because of its attachment to the scaphoid, by the scapholunate interosseous ligaments, or secondary to its innate shape with detachment from the scaphoid and/or the triquetrum.1 However, with trauma to the ligamentous structures of the midcarpal joint, the lunate can become hyperflexed volarly, resulting in pain and dysfunction. Symptoms of midcarpal instability include a prominent ulnar head, tenderness over the triquetrohamate joint, and a positive midcarpal shift test.1
Materials 1. Thermoplastic, conforming, splinting material, preferably 1⁄8 inch thick (e.g., Ezeform or Kaysplint). 2. Self-adhesive Velcro hooks. Cut approximately two pieces of 1-inch-wide by 2-foot-long strips for the wrist component and two pieces of 1-inchwide by 11⁄4 -inch-long strips for the hand component. 3. Velcro loop-nonadhesive. Cut one approximately 7-inch-long by 1-inch-wide piece. This will pull the hand and wrist components together. 4. Two-inch Velfoam. Cut one approximately 3-inchlong piece. This will secure the wrist portion. 5. One approximately 2-inch piece of closed-cell, adhesive-backed foam. 6. Measuring tape.
Fabrication The hand component is fabricated as follows (Figure 1):
Purpose Our ulnar boost splint addresses type I or II midcarpal instability. With this type of instability, symptoms usually occur on the ulnar side of the wrist.1 Chronic midcarpal instability can progressively worsen and result in limitations in wrist function. Our ulnar boost splint follows the recommendations of splinting to support the pisotriquetral area.2,3 Correspondence and reprint requests to Shrikant Chinchalkar, OTR, CHT, Senior Hand Therapist, Hand and Upper Limb Centre, St. Joseph’s Health Care London, London, Ontario, Canada N6A 4L6; e-mail:
FIGURE 1. Materials needed to fabricate the ulnar boost splint.
July–September 2004 377
FIGURE 2. Hand component with foam build-up on the pisotriquetral area.
FIGURE 5. The complete ulnar boost splint on a subject’s hand (palmar and ulnar-sided view).
FIGURE 6. The complete ulnar boost splint on a subject’s hand (palmar and radial-sided view).
FIGURE 3. Wrist component with distal end cushioned with foam.
1. Measure the circumference of the distal palmar crease. This will become the distal measurement. 2. Cut a piece of thermoplastic material that includes the above measurement and covers the thenar eminence. Make sure your piece covers the pisiform (Figure 2). 3. Form the above piece to the hand. This should be a continuous cuff around the hand. Make sure to follow the natural creases of the hand and finish your edges. The digits, thumb, and wrist should be able to flex and extend without any restrictions. 4. Cut and apply the foam to conform to the area covering the thenar eminence. Make sure to have the majority of coverage over the pisiform. To fabricate the wrist component (Figure 3):
FIGURE 4. Velcro strap demonstrating the dorsal force on the pisotriquetral area.
378
JOURNAL OF HAND THERAPY
1. With the measuring tape, measure just proximal to the ulnar and radial styloids. 2. Subtract approximately 2 inches from the above measurement to allow for the volar wrist opening.
3. Cut a piece of thermoplastic material with the aforementioned dimensions. 4. Form this piece on the dorsal forearm just proximal to the ulnar styloid. Make sure to flare and cushion the distal end to help protect the ulnar head. 5. Apply your 1-inch by 2-inch Velcro-hook, adhesive-backed pieces to the radial and ulnar aspects of this component and secure with the Velfoam piece. To fabricate the pisotriquetral force component (Figures 4–6): 1. Place the 1-inch by 11⁄4 -inch Velcro-hook, adhesive-backed piece on the volar surface, ulnar side of the hand component. 2. Place the other piece of 1-inch by 11⁄4 -inch Velcrohook, adhesive-backed piece to the radial aspect of your Velfoam piece. 3. Using the 1-inch Velcro loop strap, attach one end to the ulnar side of the hand component and
apply moderate tension as you pull it dorsally to the radial wrist component (Figures 5 and 6).
Wearing Time The splint should be worn continuously for six weeks, in conjunction with extensor carpi ulnaris strengthening and educating the client regarding activity modification.2
REFERENCES 1. Caputo AE, Watson HK, Weinzweig J. Midcarpal instability. In: Watson HK, Weinzweig J (eds). The Wrist. Philadelphia, PA: Lippincott, Williams & Wilkins, 2001, pp 511–20. 2. Wright TW, Michlovitz SL. Management of carpal instability. In: Mackin EJ, Callahan AD, Skirven TM, Schneider LH, Osterman AL (eds). Rehabilitation of the Hand and Upper Extremity. 5th ed. St. Louis, MO: Mosby, 2002, pp 1185–94. 3. Ambrose L, Posner MA. Lunate-triquetral and midcarpal joint instability. Hand Clin. 1992;8:653–68.
Modification to a Pediatric Thumb Splint Splinting a child has always been a challenge, even for the best therapist. We frequently consider the correct fabrication and positioning of the splint to be our success, only to find moments later that the child has removed the splint. This author has incorporated a simple clasp into a frequently used pediatric splint to help address this problem.—PEGGY L. FILLION, OTR, CHT, Practice Forum Editor
MODIFICATION TO A PEDIATRIC THUMB SPLINT
Marc Willey, PhD, OTR/L University of Central Arkansas Conway, Arkansas Arkansas Children’s Hospital Little Rock, Arkansas
In the pediatric population, it is frequently difficult to maintain a desired splint and/or splint position. A frequently used splint in our clinic is one that encircles the thumb as well as assists in maintaining the web space (Figure 1). This splint typically is applied to patients with hypertonicity (Figure 2). The
design of the splint encircles the thumb, thus providing some warmth to the thumb. By providing neutral warmth, this splint has the potential of reducing tone.1 To prevent the child from removing this splint, we secured a small plastic clasp to the wrist portion of the splint.
Material You will need the following materials (Figure 3): 3-cm 3 40-cm Neoprene wrist strap 2-cm 3 20-cm Neoprene thumb strap 1-inch 3 2-inch piece of nonadhesive Velcro hook Small plastic clasp (can be obtained from a small pet collar for approximately $3.00)
Procedure Correspondence and reprint requests to Marc Willey, PhD, OTR/L, 2945 Baxter, Conway, AR 72034; e-mail:
1. Measure and cut the wrist strap, making sure it has adequate length to wrap around the child’s wrist.
July–September 2004 379