Pediatric Splinting

Objectives
 At the end of the lecture the student will:
» Understand the history of splinting
» Understand classification and nonmenclature of
splints and splint components.
» Understand the mechanical, design, construction, fit
principles of splinting.
» Understand the goals of splinting a pediatric patient.
» Understand specific splints used with patients
diagnosed with JRA.
 Definition and Purpose of
Splinting
 Splint, brace or orthosis-terms are many
times used interchangeably.
– Rationale for splinting application:
1) Increase function
2) Prevent deformity
3) Correct deformity
4) Protect healing structures
5) Restrict motion
6) Allow tissue growth or remodeling
Functional Splint
Prevent Deformity; Functional
Correct deformity; Protect healing structures; Functional
Protect Healing Structures; Prevent deformity
Restrict Motion; increase function; protect; prevent deformity
 General History
 In early years, splints were used to immobilize
fractures.
– Splints were made from bamboo sticks,leaves, rods,
and bark padded with linen.
– In medieval times (1000 AD) plaster-like substances
were made from flour dust and egg whites, and
vegetable concoctions were made of gummastic, clay,
pulped fig, and poppy leaves.
– The Aztecs (1400 AD) made use of wooden splints and
large leaves held in place by leather straps
 Continue with History
 By 1517-joint contractures were treated with turn-
buckle and screw-driven metal splints
 By 1592-armor-based splints were designed.
 1750’s-1850’s-surgeons worked closely together
with appliance makers, or mechanics to design and
build custom braces and splints.
 Early 1900’s plaster of paris was widely used.
 20th Century
 1924-the “functional” splint or position for
hand infections was advocated.
 The use of Plastic Materials for
Splinting
 Late 1930’s-early 1940’s-high temperature
thermosetting material
 Late 1960’s-early 1970’s-low temperature
thermoplastic material
 Mid-late 1970’s-Polyform and Aquaplast
 Early 1990’s splinting material proliferation
took off
 History-Conclusion
 Between 1967 and 1971-publications, seminars, and
grants significantly affected splinting practice in
terms of therapist being involved in an evolving
field of expertise.
 By the 1970’s therapists enthusiastically embraced
splinting. Splinting vs. orthotics
 Therapists started building tighter and tighter
alliances with physicians, ASHT was formed, hand
certification took hold
 Splinting was the impetus for opening many doors
for therapists today.
 Anatomy and Kinesiology
 As therapist’ splinting the upper and lower
extremity, it is imperative to have a
working knowledge of anatomy and
kinesiology.
 Anatomy of the forearm, wrist and hand is
essential
Why is it important to understand
Anatomy?
The application of an external device on a
body part may change the dynamics of the
working or non-working system. As
therapists, we need to know what those
changes can and will be.
 Anatomy we need to know
 Skeletal structures
 Joints
 Musculotendinous units
 Blood supply
 Nerve supply
 Surface anatomy
 Tissue Remodeling
Quick Review
Extensor Tendons of the hand
Flexor muscles and tendons
Arteries of the hand Veins of the hand
Nerves of the hand
Peripheral Nerve Distribution and Dermatomes
Surface Anatomy
Splint Classification and
Nomenclature
S p li n t C la s s i f i c a t i o n S y s t e m

S p li n t s / o r t h o s is

A r t i c u la r N o n - a r tic u la r

L o c a tio n L o c a tio n

D ire c tio n

I m m o b i li z a ti o n m o b i li z a ti o n r e s tr ic tio n T o r q u e tr a n s m is s io n

ty p e ty p e ty p e ty p e
 Upper Extremity Assessment
 Posture  Edema
 Skin and  ROM
Subcutaneous tissue  Muscle strength
 Bone  Sensation
 Joint  Pain
 Muscle and Tendon  Grip and pinch strength
 Nerve  Coordination and
dexterity
 Vascular status
 ADL’s
 Function  Patient satisfaction
 Splint Evaluation Criteria
 Need
 Design/Pattern
 Mechanics
 Construction
 Fit
 Client Education
 General Design Principles
 Patient factors  Consider
 Length of time splint will splint/exercise
be used
regimen
 Strive for simplicity and
pleasing appearance  Patient-associated risk
 Allow optimal function of factors
extremity
 Allow optimal sensation
 Allow for efficient
construction and fit
 Provide for ease of
application and removal
 Specific Design Principles
 Age, intellect,  Adapt for anatomic variables
location,economic status,  Integrate medical and surgical
general health, lifestyle intervention variables
 Identify primary joint segments  Use mechanical principles-
 Determine kinematic direction length/width/size
 Purpose, immobilization,  Consider kinetic effects-altered
mobilization, restriction, torque forces
transmission  Decide whether or not to employ
 Identify secondary joints inelastic or elastic forces
 Determine if wrist, forearm,
 Determine surface for splint
and/or elbow should be application
included  Identify insensate areas
 Choose appropriate material
 Fit Principles
 Mechanical considerations  Maintain arches
 Anatomic considerations  Consider ligamentous
– Adapt to skin/soft tissue stress
alterations  Use optimal rotational
– Use skin crease as force
boundaries
– Mechanical principles to
 Align splint forces to joint
protect skin/soft tissue rotational axis and bone
» Reduce pressure longitudinal axis
» Eliminate shear and  Consider vascular and
friction
» Protect bone prominences
neural status
» Use optimum leverage  Consider kinematics
 Technical considerations to fit
principles
 Develop patient rapport
 Work efficiently
 If your pattern fits, your splint will fit
 Change method according to properties of
materials used
 Adapt prefabricated splints when
appropriate
 Assessed finished splint
 Construction Principles
 Strive for good cosmetic effect  Consider information data
 Match material to construction on material safety data
circumstances sheets
 Use equipment appropriate to  Round corners and smooth
material edges
 Use type of heat and  Analyze and integrate
temperature appropriate to effective mechanical
material
principles
– Wet/dry
 Stabilize joined surfaces
 Use safety and ergonomic
precautions and work efficiency
 Provide ventilation as
necessary
 Secure padding and straps
 Mechanical Principles
 Understand basic force – Consider reciprocal parallel
forces
systems
– Use appropriate outrigger
– Increase area of force systems
application – Increase material strength
– Increase mechanical by contouring
advantage – Eliminate friction
– Use optimal rotational – Avoid high shear stress
force
– Consider torque effect
– Control reaction effect
of secondary joints
 Goals for Pediatric Splinting
 Maximize hand function  Compensate for muscle
 Provide protection and support imbalance
to weak muscles and joints  Substitute for muscles that are
 Provide proximal support and not functional
stability for improved distal  Increase joint ROM
function  Improve joint alignment
 Normalize tone  Decrease edema
 Provide positioning of a joint,  Prevent/ or correct deformity
which allows overall limb use  Make skin care/hygiene easier
and improved body movement
and function
 Assist in task performance
 Pediatric conditions that might
require splinting
 CP  Radial or Ulnar deficiency
 Hemiplegia  Ostiogenesis imperfecta
 Quadriplegia  Charcot-marie-tooth
 Duchene MD disease
 Rett Syndrome  Arthogryposisi
 Polio  Brachial plexus palsy
 Thumb hypoplasia  Radial ulnar synostosis
 JRA  Brachydactyly
 Thumb duplication  Camptodactyly
 Myelodysplasia  Clinodactyly
Neonatal Splinting and Positioning
Neonatal
Splinting and positioning
Ideas to consider and aid in splint
construction for children
 Muscle tone
 Presence of primitive reflexes
 Splint size
 Short attention span
 Lack of ability or desire to cooperate
 May want to make splint with two therapists
 Functional hand position
 Splint consideration for Adults
 What is the purpose of the splint?
 Protect healing structures: follow specific
protocol
 Increase function: wearing time according
to patient needs
 Correct deformity: wearing time according
to deficit
 Materials to use
 Rubber-based thermoplastic-very easy to work with-good
with spasticity-good for larger splints- not very durable
 Plastic-based thermoplastic-good conformability-difficult
with spasticity or difficult behaviors-not great for beginner
therapists
 Elastic-based thermoplastic-good for serial splinting-very
durable
 Rubber-plastic-based thermoplastic-not good fro increased
tone
 Neoprene
 Elastomer
 Ideas to assist with wearing
compliance for children
 Make wearing schedule compatible  Issue bilateral hand-based neoprene
to child’s typical routine and if splints
appropriate protocol  Splint a teddy bear or doll so child
 Provide information to care giver can don and doff on their toy when
about the application of the splint they have to wear theirs
and wearing time and use  Have child decorate splint with
 Let child pick color of material stickers or markers
and/or straps if possible  Provide written and verbal
 Decorate splint instructions to care giver
 Call the splint a “fun” name i.e.; a  Label splint R or L
neoprene splint can be called a
“scuba divers glove”
 Donning on and off (depends on
the purpose of splint)
 Precautions to remember for
children
 Make sure object adhered to splint are not too small
for child to swallow
 Make sure splinting material is not too hot for patient’s
skin
 Patient who might be tactile defensive
 Avoid glues or adhesives that may be toxic
 Allergies to latex-high risk groups: myelodysplasia or
spina bifida; CP; bladder extrophy (reaction will be
rash, hives, edema, watery eyes, and respiratory
symtoms)
 Should not use outriggers
 Common problems associated with
splinting the pediatric patient
 Elbow flexion
 Limited supination
 Wrist flexion
 Ulnar or radial deviation
 Thumb in palm positioning
 Hand fisting
 Difficulty weight bearing
 Inability to grasp
 Difficulty with finger isolation tasks
 General types of pedi splints
 Elbow extension for elbow contractures
 Supination positioning splint/strapping
 Wrist extension
 Ulnar gutter
 Thumb spica
 Thumb opponens
 Anti-spasticity
 Weight bearing splints
 Functional hand
Functional “safe” resting hand
Splint or Intrinsic Plus Position
– Functional or “safe” position to protect:
» Traumatic hand (burn; crush; infection):
 Wrist: 30-35 wrist extension
 MCP: 60-90 flexion
 IP’s: 0 extension
 Thumb: between palmar abduction and opposition
 Functional Resting Hand
Splint(for neurological deficits)
 Wrist: 30 extension
 MCP: 45 flexion
 PIP: 30 flexion
 DIP: 10 flexion
 Thumb: abduct and opposed
 Arthritis Resting Hand Splint
 Wrist: 0-30 extension
 MCP: 30 flexion
 IP’s slight flexion
 Thumb: abduction and opposition
 Splinting the patient with JRA
 Immobilize
 Stabilize
 Protect
 Decrease pain
 Increase function
 Use in conjunction with medical and surgical
treatment
 Usually implemented during an exacerbation
 Specific splints for JRA
 Arthritis resting
 Wrist extension
 Thumb
 Ankle
 Finger
 Dynamic
 Adaptive devices
 Common problems associated
with JRA
 Elbow contractures
 Wrist deformity (radial deviation)
 MCP deformity (ulnar deviation)
 Finger deformity (swan neck and
boutonniere)
 Thumb deformity (swan neck)
 Ankle instability
 Pattern Making
 Wrist cock-up spling
 Thumb opponens
 Finger
 Decide on creative ways to decorate splint
 Creative ways to keep splint on
 References
Coppard, B. M., Lohman, H. (2008). Introduction to splinting: A
clinical-reasoning & problem solving approach, (2nd ed).
St. Louis, MI: Mosby.

Fess, E. E., Gettle, K. S., Philips, C. A., Janson, J. R. (2004). Hand and
upper extremity splinting: Principles & methods, (3rd ed). St. Louis,
MI: Mosby.

Jacobs, ML., Austin, N. (2003). Splinting the hand and upper extremity:
Principles and process. Philadelphia, PA: Lipponcott Williams &
Wilkins.