Thumb Thumb immobilization splintsimmobilization splints

Somaya Malkawi, PhDSomaya Malkawi, PhD

IntroductionIntroduction

The most common thumb splint is the The most common thumb splint is the thumb palmar abduction thumb palmar abduction immobilization splint (Thumb Spica, immobilization splint (Thumb Spica, short/long opponens splint or thumb short/long opponens splint or thumb gauntlet splint) gauntlet splint)

The purpose is to immobilize, protect, The purpose is to immobilize, protect, rest and position one, two or all of the rest and position one, two or all of the thumb CMC, MCP and IP joints while thumb CMC, MCP and IP joints while allowing other digits to be free allowing other digits to be free

IntroductionIntroduction

TIS are divided into:TIS are divided into:1.1. Forearm based splintsForearm based splints

2.2. Hand based splints Hand based splints Forearms based- and hand splints are Forearms based- and hand splints are

used to help manage different conditions used to help manage different conditions that affect the thumbthat affect the thumb

F-TIS: Stabilizing the wrist is beneficial for F-TIS: Stabilizing the wrist is beneficial for a painful wrist as the splint provides a painful wrist as the splint provides support support

IntroductionIntroduction FTIS FTIS people who have de Quervain’s people who have de Quervain’s

tenosynovitis will benefit from it which tenosynovitis will benefit from it which provides rest, support, protection of the provides rest, support, protection of the tendons across the radial side of the tendons across the radial side of the wrist into the thumb jointwrist into the thumb joint

FTIS FTIS after joint arthrodesis or after joint arthrodesis or dislocation, post surgery RAdislocation, post surgery RA

HTIS HTIS Muscle imbalance after median Muscle imbalance after median nerve injury to maintain the web space nerve injury to maintain the web space

HTIS is also used to position the thumb HTIS is also used to position the thumb before surgery before surgery

Functional and anatomic Functional and anatomic considerations for thumb considerations for thumb

splintingsplinting The thumb is essential for hand The thumb is essential for hand

functioning (grip, pinch and fine functioning (grip, pinch and fine manipulation) manipulation)

High mobility due to being a saddle High mobility due to being a saddle jointjoint

Sensory input of the tip of thumb is Sensory input of the tip of thumb is essentialessential

You have to understand that the most You have to understand that the most crucial aspect of the TIS is the CMC crucial aspect of the TIS is the CMC joint (because it allows opposition and joint (because it allows opposition and abduction) abduction)

Features of the TISFeatures of the TIS

TIS prevents motion for one, two or TIS prevents motion for one, two or all thumb joints all thumb joints

Numerous designs:Numerous designs: It can be volar, dorsal or radial.. See It can be volar, dorsal or radial.. See

fig 8-1, 8-2, 8-3 fig 8-1, 8-2, 8-3

Features of the TISFeatures of the TIS

Usually the C bar and thumb are in some Usually the C bar and thumb are in some degree of palmar abduction degree of palmar abduction

The Thumb post could The Thumb post could immobilize the MP joint alone immobilize the MP joint alone or with the IP joint or with the IP joint The position of the thumb The position of the thumb varies according to the varies according to the diagnosis, (palmar/ radial diagnosis, (palmar/ radial Abduction) Abduction)

Opponens bar

C bar

Thumb post

Features of the TISFeatures of the TIS

The TIS may do one of the following:The TIS may do one of the following:

1.1. Stabilize only the CMC jointStabilize only the CMC joint

2.2. Include the CMC and MP jointInclude the CMC and MP joint

3.3. Encompass the CMC MCP and IP joints Encompass the CMC MCP and IP joints

The Judgment goes back to you! You should The Judgment goes back to you! You should fabricate a splint which gives the MOST fabricate a splint which gives the MOST support with the LEAST movement restrictionsupport with the LEAST movement restriction

IP included: thumb replantation, tendon IP included: thumb replantation, tendon transfer, tendon repair transfer, tendon repair

Diagnostic indicationsDiagnostic indications TIS are prescribed for (but not limited TIS are prescribed for (but not limited

to): scaphoid fractures of the proximal to): scaphoid fractures of the proximal phalanx of the 1phalanx of the 1stst MC, tendon transfers, MC, tendon transfers, radial or ulnar collateral ligament radial or ulnar collateral ligament strains, repair of the MCP joint collateral strains, repair of the MCP joint collateral ligaments, ligaments, RARA,, OA OA, , de Quervian’s de Quervian’s tenosynovitistenosynovitis, median nerve injuries, , median nerve injuries, MCP joint dislocations, capsular MCP joint dislocations, capsular tightness of the MCP and IP joints after tightness of the MCP and IP joints after trauma, posttraumatic adduction trauma, posttraumatic adduction contracture, extrinsic flexor or extensor contracture, extrinsic flexor or extensor muscle contracture, FPL repair, muscle contracture, FPL repair, uncomplicated EPL repairs, uncomplicated EPL repairs, hypertonicity, and congenital adduction hypertonicity, and congenital adduction deformity of the thumb deformity of the thumb

Splinting for Splinting for De Quervain’s TenosynovitisDe Quervain’s Tenosynovitis

It results from repetitive thumb It results from repetitive thumb motion and wrist ulnar deviation motion and wrist ulnar deviation

Affects the AbPL and EPB muscles in Affects the AbPL and EPB muscles in the first dorsal compartment the first dorsal compartment

Splinting for De Quervain’s Splinting for De Quervain’s TenosynovitisTenosynovitis

How did this condition developHow did this condition develop??Repeatedly performing wrist deviation and thumb motions Repeatedly performing wrist deviation and thumb motions such as grasping, pinching, squeezing, or wringing such as grasping, pinching, squeezing, or wringing (construction: painting, scraping, hammering) may lead (construction: painting, scraping, hammering) may lead

to the inflammation of tenosynovitisto the inflammation of tenosynovitis . .

This inflammation can lead to swelling, which hampers the This inflammation can lead to swelling, which hampers the smooth gliding action of the tendons within the tunnel. smooth gliding action of the tendons within the tunnel. Arthritic diseases also cause tenosynovitis in the thumbArthritic diseases also cause tenosynovitis in the thumb

Forearm based TISForearm based TIS

Splinting for De Quervain’s Splinting for De Quervain’s TenosynovitisTenosynovitis

During the acute phase During the acute phase immobilization of the immobilization of the thumb and the wrist for symptom control thumb and the wrist for symptom control wrist wrist extension thumb CMC palmar abduction and MP extension thumb CMC palmar abduction and MP flexion ISflexion IS

Wrist in 15 extension Wrist in 15 extension Neutral wrist deviation Neutral wrist deviation 40-45 degrees of palmar abduction of the CMC 40-45 degrees of palmar abduction of the CMC

thumb joint thumb joint 5- 10 degrees of flexion in the MP joint 5- 10 degrees of flexion in the MP joint IP free, unless patient overuses thumb or fights the IP free, unless patient overuses thumb or fights the

splint splint Continuous wearing with removal for hygiene and Continuous wearing with removal for hygiene and

exercise within a pain free range exercise within a pain free range A prefabricated splint is indicated when pain A prefabricated splint is indicated when pain

subsides for sport and work activitiessubsides for sport and work activities Post surgical management, same splint worn for 7-10 Post surgical management, same splint worn for 7-10

days days

Splinting for RA and OASplinting for RA and OA

RA often affects the thumb joints (CMC and RA often affects the thumb joints (CMC and MCP) MCP)

splint reduces pain, slows deformity and splint reduces pain, slows deformity and stabilizes the joints stabilizes the joints

RA involves three stages:RA involves three stages:1. The inflammatory stage: splinting is used 1. The inflammatory stage: splinting is used

for resting the joint and reduce inflammation for resting the joint and reduce inflammation 2. Disease progression, help the stability of 2. Disease progression, help the stability of

painful moving joints during activities painful moving joints during activities 3. Grossly deformed splints, aid in putting the 3. Grossly deformed splints, aid in putting the

hand in a more functional position hand in a more functional position

Splinting for RA and OASplinting for RA and OA

The best splint during the periods on The best splint during the periods on inflammation is: Forearm based TIS inflammation is: Forearm based TIS

immobilizing the thumb in a forearm immobilizing the thumb in a forearm based splint, with wrist in 20-30 degrees based splint, with wrist in 20-30 degrees of extension, CMC in 45 degrees of of extension, CMC in 45 degrees of palmar abduction or midway, MCP in 5 palmar abduction or midway, MCP in 5 flexion flexion

““wrist extension thumb CMC palmar wrist extension thumb CMC palmar abduction and MP flexion immobilization abduction and MP flexion immobilization splint!” splint!”

Splinting for RA and OASplinting for RA and OA

You should always fabricate a splint You should always fabricate a splint in a position of comfort in a position of comfort

Use 1.8 mm or less material Use 1.8 mm or less material Watch out for bony prominences Watch out for bony prominences

such as ulnar head radial styloid, such as ulnar head radial styloid, scaphoid and pisiform bonesscaphoid and pisiform bones

Splinting for RA and OASplinting for RA and OA

CMC OA is a common thumb condition CMC OA is a common thumb condition Causes subluxation of the joint radially Causes subluxation of the joint radially

and dorsally and dorsally loss of extension loss of extension compensated by adduction compensated by adduction

In this case, splinting is used to In this case, splinting is used to manage pain, provides stability and manage pain, provides stability and preservation of the web spacepreservation of the web space

Hand based TISHand based TIS

Splinting for ulnar collateral Splinting for ulnar collateral ligament injuryligament injury

A common injury that occurs at the A common injury that occurs at the thumbthumb

Gamekeepers or skier’s thumb Gamekeepers or skier’s thumb The UCL helps stabilize the thumb by The UCL helps stabilize the thumb by

resisting radial stresses across the MCP resisting radial stresses across the MCP jointjoint

The UCL is injured when the thumb is The UCL is injured when the thumb is forcefully abducted or forcefully abducted or

hyperextended hyperextended

Splinting for ulnar collateral Splinting for ulnar collateral ligament injuryligament injury

Injuries are classified to I, II, III Injuries are classified to I, II, III For level I: hand based TIS with the For level I: hand based TIS with the

CMC in 30-40 degrees of palmar CMC in 30-40 degrees of palmar abduction with MCP in neutral or abduction with MCP in neutral or slight flexion (3-4 weeks)slight flexion (3-4 weeks)

For level II: same as above but worn For level II: same as above but worn for 4-5 weeks for 4-5 weeks

For level III: requires surgery For level III: requires surgery

Splinting for scaphoid Splinting for scaphoid fracturesfractures

Second most common fractureSecond most common fracture Comes from falling on an Comes from falling on an

outstretched hyperextended/ outstretched hyperextended/ dorsiflexed hand more 90 degrees dorsiflexed hand more 90 degrees

If a result of a sports injuryIf a result of a sports injury volar volar FB-TIS FB-TIS

Splinting for scaphoid Splinting for scaphoid fracturesfractures

VF-TISVF-TIS Thumb in palmar abdThumb in palmar abd MCP in 0 -10 flexMCP in 0 -10 flex Wrist in slight flex and radial dev or Wrist in slight flex and radial dev or

neutral depending on the physician neutral depending on the physician preference preference

Splinting for HypertonocitySplinting for Hypertonocity

Thumb loopThumb loop Figure of 8 thumb wrap Figure of 8 thumb wrap