orthosis
used to describe a custom molded, custom fitted and prefabricated orthoses fabricated and/or dispensed by therapists
HCPCS Level I codes
developed by the American Medical Association and includes codes such as Therapeutic Exercise (97110),
HCPCS Level II
represent supplies or equipment (L codes)
L-codes
codes used to describe orthotics and prosthetics ie/ L3906 WHO, C/F (wrist hand orthosis, custom-fit)
Three-point pressure
single force is placed at the area of correction. two additional forces counter the force in the opposite direction usually above and below the primary area of correction.
Wider orthotic components ______ pressure and ______ comfort
decrease pressure and increase comfort
orthotics should always be _____ the width of the body part
½ the width (on the sides) of the body part
Longer orthotics components ______ pressure and _______ comfort
Longer orthotics components = decrease pressure and increase comfort
Orthotics should be ________ the length of the forearm
Orthotics should be 2/3 the length of the forearm
Optimal line of pull is _______ degrees
Optimal line of pull is 90 degrees
Angle of pull is great or less than ________ can cause ________ or _________ forces on the joint
Angle of pull is great or less than 90 can cause shearing or compressive forces on the joint
The ______ _______ from the main focus joint a force is applied the ________ the torque on the joint
The further away from the main focus joint a force is applied the greater the torque on the joint—be careful not put too much shearing force on a joint
When utilizing a mobilization orthotic ensure that _______ and _______ joints are appropriately stabilized
When utilizing a mobilization orthotic ensure that proximal and distal joints are appropriately stabilized
In a three-point pressure system the middle reciprocal pressure equals ______________________________
0
Outriggers must be strong enough to support pull from________ devicesAs joint motion changes, change your outrigger to maintain the ___________ line of pull from the____________ of the bone
Outriggers must be strong enough to support pull from traction devices As joint motion changes, change your outrigger to maintain the 90 degree line of pull from the long axis of the bone
Incorporate articulated components appropriately
Carefully align orthotic joints/hinges with corresponding anatomical joints
contoured material provides increased _____ on the orthotic
increased strength to the orthotic
How to eliminate fraction
1. Design orthotics in accordance to key skin creases to ensure the orthotic material doesn't impede desired joint motion 2. Ensure straps are wide enough and good orthotic fit to avoid orthotic migration/slippage
How to avoid high shear areas?
Shearing/compressive stress can damage joint surfaces Monitor for excessive pressure from orthotic edges—widen and flare as necessary
mechanical advantage of a lever system
defined by the relationship between the length of the effort arm (EA) and the length of the resistance arm (RA).
If you lengthen the resistance arm the __________ force is required to support a joint and if you shorten the resistance arm _______ force is required
If you lengthen the resistance arm the less force is required to support a joint and if you shorten the resistance arm more force is required
Forearm trough should be _______ the length of the forearm
Forearm trough should be 2/3 the length of the forearm
Trough should come up_________
Trough should come up half way on sides
Upward Force couple
upper trapezius, serratus anterior, lower trapezius
Downward Force couple
levator scapulae, pectoralis minor, rhomboids
Men's carrying angle in elbow/forearm
0
Women's carrying angle in elbow/forearm
10-15 degrees
Ligaments of the Elbow =
Annular ligament (encircles head of radius)Ulnar (medial) collateral ligament complex (UCL)Lateral (radial) collateral ligament complex
Elbow forearm fabrication
be careful of pressure on Lister's tubercle and, radial notch, and ulnar styloidbe careful of epicondyles
Radius moved around ulnaPronation ulna more distal and prominent - what clinical significance does this provide?
wrist cock up- fully pronate towards therapist to allow for comfort during pronation when splint is on
Mobile row vs taut row in carpals
Proximal: scaphoid, lunate, triquetrum, pisiform—Mobile rowDistal: Trapezium, trapeziod, capitate, hamate—Taut row
Gripping force
80% radial20% ulnar
Angulation
Volar angulation 11* tilt (more flexion than extension)Radial inclination 22* (more ulnar deviation than radial deviation)
_____ and ______ for wrist extension
Slide and roll for wrist extension
Triangular Fibrocartilage Complex
shock absorber for the wrist
Head of MCP is not symmetrical, therefore what should be done when splinting?
intrinsic plus position to maintain the length of the collateral ligament.
MCP fracture and fingers are left extended what can happen?
ligament can tighten over time and lose length. Difficulty bending their MCP joint.
Intrinsic plus position
ligaments are now fully lengthened all the way out as they attach,little bit of wrist extension. MCP joints at 80 to 90 degrees if possible. And then the IP joints completely straight
Intrinsic minus position or (extrinsic plus position):
would be slack if the bone was up here. And then those would tighten over time and kind of scar into place, and then they would lose MCP motion over time
median nerve distribution
thumb, index, long, and one half of the ring finger
ulnar nerve distribution
small finger on both the front and the back, and the other half of the ring finger
radial nerve distribution
dorsal part right here, excluding the fingertips
no excessive pressure where the nerve is more superficial
1. the ulnar nerve= limited pressure on cubital tunnel and guyon's canal2. radial nerve= limited pressure on spiral groove and dorsal radial anatomical snuff box3. median nerve= carpal tunnel area4. Digital nerves= Sides of fingers
ulnar nerve laceration
oval weight, putting their small and ring fingers into flexion at the MCP joint
median nerve laceration
thumb in an opposed position
maintain _____ and don't put pressure on _______ areas
maintain arches and don't put pressure on blood supply areas
if we want the joint to be free,
we want to make sure that we can see that crease and that it's completely clear.
flexor tendon orthotic =
we need to include all of the fingers and have them in a protected position as tendons want to retract since nothing is holding it down
FLEXOR ZONES
Zone 1 = FDP only Jersey finger Zone II used to be called "no man's land" Camper's chiasm (where FDP goes through FDS) Zone 3 = palm of hand Zone 4 = carpal tunnel Zone 5 = wrist
EXTENSOR ZONES
Zones I & II • Mallet finger - immobilize DIP Zones III & IV • Central slip injury - finger gutter splint (often IP can be free) • Lateral bands involved - IP needs to be immobilized Zones V, VI, VII • Full wrist and digit extension (sometimes can stop with P1 block) Zone VIII • Often wrist musculature - can often use wrist controlOdd numbers of are on the joints1- Mallet fingers3 - boutonniere deformity5- fight bite.
Precision grasp
uses opposition of the thumb to the fingertips
Power grasp
uses the whole hand with thumb flexion or abduction according to the control needed for the task
Shift
object that is being held on the radial aspect of the hand is moved linearly on the finger surface in order to reposition it on the finger pads
Rotation
Rotating a pen to use the eraser
In-hand manipulation with stabilization
Picking up coins while holding them in their palm
conformability or drape
ability of the material to just kind of fall into place and use gravity
resistance to stretch
opposite of drape
high conformability, low resistance to stretch =
material is very drapy. So you can use gravity and just kind of get it to fall into place. light handling. material of choice for more skilled therapists. Used for more of a painful condition where minimal handling is the best approach. material can really conform around that joint to give a nice, good, precise fit as well. And it's also recommended for smaller orthotics, such as a finger or hand
low conformability, high resistance to stretch =
take you working it and using your hands to mold it till it's completely firm- not drapy. easier if you're a newer therapist
Memory =
is the degree to which a material is able to return to its original shape once molded and then reheated. ranges from 100% to 0%, no memory
high memory material is often recommended when
you're fabricating an orthotic that requires frequent remolding, cost effective
rigidity
stiffness or the strength of a material, or the degree to which a molded orthotic is able to resist deformation when external forces are applied. Thicker materials are typically more rigid.
circumferential design
more rigid support. Used for comminuted fracture or ulna fractures
Bonding
ability of a material to adhere to itself once heated
coated materials
don't bond to itself, unless it's overheated, overstretched, scratched, or a little abrasion, or treated with a solvent. wet paper towel or lotion can be used to prevent adherence.
general orthotic split pan temperature
usually between 140 to 170 degrees
heating time
is between 30 seconds to 2 minutes
Working time
generally 1 to 7 minutes
if the skin is hypersensitive
use a stockinette
thickness
1/8th for arm, forearm, elbow, and wrist orthotics.3/32nd or 1/16th for hand based or pediatric orthotics (thinner material for the hand based or the finger based)
Perforation
range from 1% to 42% perforation. help with air exchange. Rash prevention.
plastic materials
polyform (high conformability and the minimal resistance to stretch) - very drapy so have to be very gentle with it
rubber like materials
Easyform (low conformability and high resistance to stretch) good control but high amount of work to form. Better for larger orthotics
combo of both plastic and rubber like
tailor (moderate resistance to stretch)
elastic materials
good when you have to remold the orthotic frequently, because it has high memory
A normal hand at rest assumes a posture of
10 degrees wrist extension • 15 degrees mp flexion • 10 degrees ulnar deviation
assessments
The Moberg would be a fine motor control assessmentFinkelstein's is your basic provocative pain test for de Quervain's.Froment's, another provocative testPhalen's, often used with carpal tunneTinel's, also a nerve provocative tesGrip testing with a JamarSensory testing with Semmes-WeinsteinAllen's test is for vascular integrityDASH is a good instrument to use to get a quick assessment of functional activity
relatively thin or highly perforated _________working times
relatively thin or highly perforated shorter working times
Wrist cock up
-Carpal tunnel-ligaments injuries (scaphoid lunate)-Colles fracture-lower-level wrist fracture-OA of the wrist
short thumb spica
-skiers thumb-MCP fracture-Dypharens
Resting Hand Orthotic
-CVA-Burns
static and dynamic orthosis
Static splints have no moving components and provide support and immobilization, while dynamic splints employ traction devices such as rubber bands, springs, cords, or Velcro strips to alter the range of passive motion of a joint or joints
if a joint is stiff using a _____ over a ____ is best
low load, long time
Client reports pain around the styloid process- what should you do?
flare the area around the styloid
what position puts the maximum stretch on the extrinsic flexors?
MCP extension, IP extension
the immobile portion of the longitudinal arch follows which digits?
2nd/3rd metacarpals
advantages of intrinsic plus position include
maintain MCP collateral ligament lengthmaintain the arches of the handis safe position after burns and other injuries