VRP MEDICAL CENTER

Physical Medicine & Rehabilitation Department

Occupational Therapy Section

Special Topic Report: Hand Splints

Submitted by:
Biagtan, Czarina Mariel R.
Carpio, Inna Ysabelle H.
Palo, Hasmin B.
UST OT Interns Batch 2017 - September Batch

Introduction
A splint is an orthopedic device for immobilization, restraint, or support of any part of the body. While an orthosis is a force system
designed to control, correct or compensate for a bone deformity, deforming forces or forces absent from the body.
Types of splints: (Sprofit - hand splinting catalogue, Introduction to Splinting: A Clinical-Reasoning and Problem-Solving Approach
coppard and lohman)

SPLINT DESIGNS:
Static splints - has no moving parts and may be supportive, corrective or protective; can maintain a position to hold anatomical
structures at the end of available ROM, thus exerting a mobilizing effect on a joint.
Drop-out - Motion in one direction but blocks out the other motion. It allows another motion in one direction while blocking motion in
another
Articulated - has two static components; wire, rubber band, spring (elastic components)
Serial static splints - position soft tissues towards the end of their available range to help increase tissue length. Serial splinting
involves a series of adjustments to the same splint or the therapist making a series of splints; Capable of remodeling and
adjustments, If set, no movement is allowed, remodeling; usually classic splint
Dynamic Splints - consists of a static base onto which levers, springs or pulleys may be attached. They assist weak muscle function,
mobilize stiff joints or may substitute for lost muscle or nerve function; It also has self-adjusting or elastic components, which may
include wire, rubber, bands, or springs
Static Progressive Splints - involve the application of a low-load prolonged stretch at the end of the available movement, They often
involve the use of turnbuckles, screws, or non-elastic tape. They are sometimes classified as a dynamic splint; Inelastic components
(tapes, hinges, screws), use of inelastic components such as hook-and-loop tapes, outrigger line, progressive hinges, turnbuckles,
and screws.
Pre-fabricated Splints - frequently used by clinicians. They offer the user a quick, ready-made splint, which may be beneficial in
terms of time and cost effectiveness. They are available for many joints, in a variety of sizes, prices and colors. Most are adjustable
and require a thorough assessment by clinician prior to issue.
Properties:
1.)
Handling characteristics - when it is being heatened and softened
2.)
Performance Characteristics talks about the characteristic when it is set and cooled

1.

2.

3.

4.

Handling characteristics
Memory

Ability to return to its original shape, size and thickness when reheated

High memory for new practitioners

Not recommended for fine adjustments on splints

more translucent has higher memory (going back to its original form)
Drapability

Conforms to underlying shape without manual assistance

degree to which the material conforms (if you place it here, it will conform the shape of the bottle with the assistance of
gravity)

High drapability: gravity

Good for cooperative clients
Not recommended for new practitioners
Not recommended for large splints
Recommended for clients with painful or inflamed joints
Elasticity

Resistance to stretch and tendency to return to its original shape after stretch

High elasticity
Recommended for uncooperative clients
Recommended for clients that are spastic

resistance of material to being stretched (higher memory has higher elasticity=NO)

(if you have a higher memory, least elastic siya because resistance to being stretched)
Bonding

Degree to which the material will stick to itself when properly heated

High bonding: materials will overlap

Coated (low bonding)
Non-coated (high bonding)

Oil is used to prevent high bonding

Scoring: roughen the edges to easily put Velcro on the splint

5.
6.

higher memory splints can easily bond to another splint or materials (self-bonding: use Velcro)

put two classic together and two eco together

Self-finishing edges

Allows any cut edge to have a smooth texture

Other considerations

Heating Time
How long before it softens?

Working Time
How long before it hardens again?

Shrinkage
How long it takes for it to shrink, or not?
Performance Characteristics
1. Conformability- Ability to fit intimately into contoured areas
2. Flexibility- Can take stresses repeatedly
3. Durability- Length of time that the splint will last
4. Rigidity- Strong and resistant to repeated stress; can take stresses repeatedly
5. Perforations- Allows for air exchange, reduction in the weight of the splints; mini or micro or maxi type or non-perforated (the
bigger the perforation, it will cause the client to have pressure points) (to allow air to pass through the body)(also for lighter weight)
6. Finish- Texture of the end product; design of the splint (finger: use thin type of splint)
7. Color- May affect a clients compliance with the wearing schedule; design of the splint
8. Thickness- Typical thickness: 1/8 of an inch; Less than 1/8: faster softening and hardening (harder to work on) design of the
splint; common 1/8 inch ; finger 1.8 inch ; hand 2.4-3,2 inches ; LE 3.2 or 2x 3.2 inches

Review of Anatomy:

A total of 27 bones constitue the basic skeleton of the wrist and the hands, which are grouped into the carpals,
metacarpals and the phalanges. The wrist is the most complex joint in the body. It is formed by 8 carpal bones grouped in 2 rows
with very restricted motion between them. From radial to ulnar, the proximal row consists of the scaphoid, lunate, triquetrum, and
pisiform bones. In the same direction, the distal row consists of the trapezium, trapezoid, capitate, and hamate bones.

Fascial structure protects, cushions, restrains, conforms, and maintains the

hand arches
The deep fascia of the wrist and palm is thickened to form the flexor retinaculum
and the palmar aponeurosis.

Pulleys (Fingers)
A1-MCP joint
A2
C1
A3- PIP joint
C2
A4
C3
A5- DIP Joint

The Carpal Tunnel is formed

by the bones of the hand and
the flexor retinaculum.
contents of the carpal tunnel
tendons) - Middle and Ring
index and little finger, FPL (1

The
are: FDP (4 tendons), FDS (4
Finger tendons superficial to the
tendon) and median nerve.

The pulley system is critical to flexion of the

finger. The retinacular system for each of the
fingers contains 5 annular pulleys and 4
cruciate pulleys.[14] The thumb has 2 annular
pulleys and 1 oblique pulley. In the finger, the second and fourth annular pulleys (A2,
A4) are critical pulleys. The oblique pulley is the critical pulley in the thumb.

Zone of the Hand: Flexor Tendons

Zone 1 - consists of the profundus tendon and is bounded proximally by the insertion of
the superficialis tendons and distally by the insertion of the profundus tendon in the distal
phalanx
Zone 2 - no mans land, indicating the occurrence of restrictive adhesion bands around
lacerations in the area. At the level of the proximal third of the proximal phalanx, the
superficialis tendon split into two slips. These slips divide around the profundus tendon
and reunite at the dorsal aspect of the profundus, inserting in the distal end of the middle
phalanx. The split of the superficialis tendon is known as the Campers chiasma
Zone 3 - lumbrical muscles originate from this area and the distal palmar crease
superficially marks the end of Zone 3.
Zone 4 - carpal tunnel and its contents
Zone 5 - from the origin of the flexor tendons to the proximal edge of the carpal tunnel
Thumb T1 - from FPL insertion to A2 pulley
Thumb T2 - from Zone 1 to distal part A1 pulley. FPL tendon lacerations often retract into
the thenar area or wrist. Unlike other fingers, FPL lacks a vinculum and does not have a
lumbrical; therefore the tendon is free to retract.
Thumb T3 - from Zone 2 to carpal tunnel. Most time, injuries also involve damage to the
thenar muscles and recurrent motor branch of median nerve.

Extensor Zones of the Hand

Zone I: over the DIP

Zone II: middle phalanx
Zone III: over the PIP
Zone IV: proximal phalanx
Zone V: over the MCP
Zone VI: dorsum of hand/metacarpals
Zone VII: over the extensor retinaculum/carpals/CR/CMC
Zone VIII: proximal wrist
Up to the forearm, the odd-numbered zones all refer to dorsal surfaces of joints:
I distal interphalangeal [DIP];
III proximal interphalangeal [PIP]
V metacarpophalangeal [MP]
VII carpometacarpal [CMC] and radiocarpal [RC] joints
The even numbers are simply the intervening dorsal regions
The thumb has its own unique zone definition because it has fewer joints than the
fingers, but the same concept applies.
Using the "T" modifier, the odd-numbered zones all refer to extensor injuries in the
dorsal surfaces of the joints:
TI IP joint
TIII - MP joint
TV - CMC and RC joints
Arches of the Hand:

3 Arches:
longitudinal arch
distal transverse arch
proximal transverse
arch

Radial Nerve
It originates from the posterior cord of the brachial plexus
Arm: From the brachial plexus, it travels posteriorly and then enters the spiral groove of humerus. From the groove, it courses
inferiorly on the lateral aspect of the humerus. At the distal humerus, it passes anteriorly to the lateral epicondyle and continues to
the forearm.
Forearm: Branches into Superficial Branch of the Radial Nerve (divides into Lateral and Medial branches; serves as sensory supply
to the dorsum of the hand), and Deep Branch of the Radial Nerve (terminates below extensor retinaculum)
Sensory: supplies the dorsal surface of the lateral three and a half
digits (except the tips/nailbed)
Motor: all the extensor muscles in the posterior compartment of the forearm (ECRL, ECRB, ED, EDM, ECU, Anconeus, Supinator,
APL, EPB, EPL, EI)

Ulnar Nerve
It originates from the medial cord of the brachial plexus (C8 and
T1) then descends on the posteromedial aspect of the humerus
Forearm: enters the anterior (flexor) compartment of the forearm and courses alongside ulna, then travels inferiorly deep to the
flexor carpi ulnaris muscle. It branches off to muscular branches, palmar branch, and dorsal branch of ulnar nerve
Hand: enters the palm of the hand through the Guyons canal then it passes superficial to the flexor retinaculum. It branches off to
Superficial and Deep Branch of Ulnar Nerve.
Sensory: supplies the dorsum of the medial one and a half digits
Motor: Lumbricals (3rd and 4th), all the Interossei (Palmar and Dorsal)

Median Nerve
It arises from the medial and lateral cords of the brachial plexus. It passes vertically down and course on the medial side of the arm.
At the distal arm, it enters the cubital fossa
Forearm: from cubital fossa, it passes between two heads of pronator teres then travels between FDS and FDP. At the forearm, it
gives off two branches which are the Anterior Interosseus Branch and Palmar Cutaneous Branch (distal part of the forearm)
Hand: enters the hand through the carpal tunnel, deep to the flexor retinaculum. From here, it sends off several branches that
innervate the short muscles of the thumb (except adductor pollicis)

Sensory: supplies the dorsum of the tips of the lateral three and a
half digits
Motor: Lumbricals (1st and 2nd)

Dynamic Splints
Ulnar nerve palsy - caused by damage in the ulnar nerve that is usually due to a result of
illness, injury or too much pressure on the nerve. Symptoms may include loss of sensation in
the hand, specifically in the ring or little finger, tingling or burning sensations, pain, loss of grip
strength, etc.
Dynamic ulnar nerve splint
Position: 30-45 MCP flexion
Purpose: Blocks hyperextension of MCP joints and allows extension of
PIP joints. This position enables hand function, given that MCP joints
are in slight flexion and it permits phalangeal extension. It also
prevents possible PIP joint flexion contracture.
Wearing Schedule: It should be worn throughout the day except during
hygiene and exercise

Radial nerve injury/wrist drop - may be caused by physical trauma, infections, impingement,
etc. It may result to numbness, tingling or pain. The condition may cause weakness or
difficulty moving your wrist, hand or fingers.

Dynamic extensor assist splint (orfitube)

Position: Slight extension of wrist; 0 extension/neutral MCP and PIP; DIP is
free
Purpose: For early passive mobilization of extensor tendons
Wearing Schedule: Daytime use

Dynamic wrist extension splint

Position: Wrist in slight extension (20-30)
Purpose: This splint helps regain passive extension of MCPs.
Wearing Schedule: It should be worn throughout the day except
during hygiene and exercise.

Flexor tendon injury - may be caused by deep cut on palm side of fingers, hand, wrist,
or forearm. Bending fingers or thumb might not be possible when this injury occurs.
Sports such as football, wrestling, etc. as well as certain health conditions (rheumatoid
arthritis for example) may also cause this injury. Symptoms include numbness of
fingertip, tenderness along the palm side of the hand, pain and inability to bend one or
more joints of the finger.

Dynamic flexor assist splint

Purpose: This splint is to promote passive mobilization of long flexor
tendons. It produces passive flexion and allows some degrees of
extension.
Wearing Schedule: It should be removed during hygiene and
exercise.

Forms of ulnar nerve injury may be due to Cubital tunnel syndrome, Guyons canal
syndrome, etc. Common symptoms include weakness or tenderness of the hand,
sensitivity to cold, tenderness in the elbow joint, etc. On the other hand, median nerve
injury may be due to compression of the nerve in elbow or wrist. Forms of median nerve
injury may be carpal tunnel syndrome, pronator teres syndrome, etc.

Dynamic knuckle bender splint

Position: 90 flexion of MCP
Purpose: Dynamically flex MCP joints of hand while allowing active extension. It also prevents MCP from
hyperextension
Wearing Schedule: Removed during hygiene and exercise.

C6 injury - may result to problems in wrist extension, paralysis in hands, trunk and legs.
Persons with this injury may be able to bend wrist back and drive an adapted vehicle.

Tenodesis Splint
Position: Avoid hyperextension of thumb; Slight flexion of 2nd & 3rd
fingers
Purpose: This splint aims to promote functional pinch through reciprocal
wrist extension and finger flexion motion or tenodesis action.
Wearing Schedule: Worn throughout the day and should be removed
during hygiene and exercise.

Wrist and Hand Splints

Resting Hand Splint

Purpose:
-

to immobilize
to prevent further deformity
to position in functional alignment
to rest wrist and hand joints

Position:
Wrist: 20-30 deg extension
Thumb: 45 deg palmar abduction
MCP: 35-45 deg flexion
PIP DIP: slight flexion

Anti Spasticity Splint

Purpose:
Static positioning of the tendons at maximum extension in order to facilitate
lengthening of the tissue
Reduces muscle tone in wrist and digits
Position:
Wrist: slight extension
MCPs, PIPs, DIPs: full extension
Thumb: palmar abduction 45 degrees

Long/Forearm based thumb spica with thumb post

Purpose:
leaves IP joints free to prevent painful motions
Position:
Wrist: 15 deg extension, neutrally deviated (Coppard) / 20 deg
extension (Cooper)
CMC: palmar abd 40-45 deg
MCP: flexed 5-10 deg
Thumb IP: free for function (include if causing more pain)

Radial Gutter Splint

Purpose:
Fractures, Phalangeal and MCP and soft tissue injuries of the index and middle finger

Volar Wrist Immob Splint/ Wrist cock up splint

Purpose:
-

to regain functional wrist extension, provides protection and low load stress
slight wrist extension
after removal of cast and healing of fracture, wrist immob is used.
can be dorsal, volar, circumferential (if more support is needed) maximum passive extension
person can tolerate up to 30 deg.
for Carpal Tunnel syndrome and wrist fracture

Position:
Wrist: 20-30 deg extension

Dorsal Cock up Splint

Purpose:
High radial nerve palsy
Wrist drop
Immobilization of the wrist joint for restriction of motion, pain relief, joint alignment, functional
support, and/ or positioning for healing.
To create a limited tenodesis action to allow functional grip
Position:
Wrist: 30 deg extension
MCPs: neutral

Ulnar Gutter
Purpose:
Support, stabilize and immobilize dislocations and fractures of the hands, wrists and fingers
most especially the 4th and 5th fingers.
Boxers fracture (fracture of neck of 5th metacarpal)
An ulnar gutter splint typically extends along the ulna, the bone on the pinkie finger's side of
the forearm, partially covering the arm from just below the elbow to the palm or pinkie.
Position:
Wrist: 20 deg extension
MCPs: 70 deg flexion
PIP and DIPs: 5-10 deg flexion
Handbased ulnar nerve splint
Purpose:
splint for ulnar nerve lesion
This position corrects the clawhand posture of MCP hyperextension and PIP flexion
Position:
MCP: ring and little fingers in 30 to 45 degrees flexion

Short opponens thumb spica

Purpose:
For Gamekeepers thumb / UCL injury
To immobilize MCP of thumb where UCL is located; IP of thumb is not
immobilized
Position:
Thumb CMC: Radial abduction
Thumb MCP: Neutral/slight flexion
Note: Thumb CMC may not be exactly positioned as the suggested degrees but should be
in a position of comfort for the patient.

Finger Splints
Anti-claw hand - claw hand deformity is the flattening of the normal arches
of the hand with hyperextension of MCP and flexion in PIP and DIP of 4th and
5th digit. Unable to abduct and adduct fingers.
Hand-based ulnar nerve splint
Position: 4th and 5th digit 30-45 flexion
Purpose: Prevents attenuation of denervated intrinsic muscles
and MCP volar plates of ring and little fingers. This position also
corrects claw-hand posture of MCP hyperextension and PIP
flexion. It is also functional because with the MCPs blocked in
flexion, power of EDC is transferred to IP joints and allows them
to extend in absence of intrinsic muscles.
Wearing Schedule: Continue wear of splint with removal only for
hygiene and exercise

Figure of Eight Splint

Less bulky splint to keep from impeding palmar sensation and function of the hand
Design by Kiyoshi Yasaki

Boutonniere deformity - PIP in flexion and DIP in hyperextension. This deformity can result
from axial loading, tendon laceration, burns or arthritis. The central extensor tendon (central slip)
is disrupted, leads to an imbalance of the extensor mechanism as the lateral bands displace
volarly.

Dorsal PIP extension splint

Figure-of-8 splint

Capener Splint

Purpose: Maintain PIP joint in extension while keeping MCP and DIP joints free for about
6-8 weeks. Splinting is used during the time needed for central slip to re-establish tissue
continuity and for correction of deformity.
Wearing schedule: Day and night for up to 6 weeks. This is followed by 3 weeks of night
splinting.

Swan neck deformity: PIP hyperextension and DIP flexion. There are multiple possible causes
of this deformity that may occur at the level of the MCP, PIP or DIP joints. The lateral bands
displace dorsally. In addition to traumatic cases, people with rheumatoid arthritis may also
present with a swan neck deformity.

Dorsal Gutter with PIP joint in slight flexion (20)

If DIP demonstrates extensor lag, splint can cross DIP and a strap can be
added to support the DIP in neutral.
Purpose: Prevent PIP hyperextension and to promote DIP extension while not
restricting PIP flexion
Wearing Schedule: Since swan-neck is a challenging diagnosis, splinting may be
used indefinitely if it promotes improved function and eliminates painful snapping
with active flexion

PIP hyperextension block (swan-neck splints)

Mallet finger: digit with a droop of the DIP joint. This posture often occurs as a result of
axial loading with the DIP extended or flexion force to the fingertip. The terminal tendon
is avulsed, causing a droop of the DIP. A laceration to the terminal tendon may also
cause a mallet finger.

Stack Mallet Splint

Mallet Gutter Splint

Purpose: prevent DIP flexion.

Position: DIP joint in hyperextension or neutral DIP position. Do not impede PIP flexion
unless there are specific associated issues.
Wearing schedule: 6 weeks to allow terminal tendon to heal. After 6 weeks of continual
splinting, weaned off the splint but is usually worn at night for several week. If an extensor lag is
noted, consult physician to resume use of splint.

Trigger finger : a form of stenosing tenosynovitis that occur during

middle age and that has an increased incidence associated with
diabetes. It is a defect in the tendon causing a finger to jerk or snap
straight when the hand is extended.
Purpose: Keep finger in an extended position and restrict MP flexion

Buddy splint: Nondisplaced proximal/middle phalangeal shaft fracture and sprains which lead to chronic
swelling and stiffness and flexion contractures
Purpose: To promote motion and support injured digit and limit ROM of affected digit.

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References:
Coppard, B. & Lohman, H. (2008). Introduction to splinting. St. Louis: Mosby.
Johnson, D. & Pedowitz, R. Practical Orthopaedic Sports Medicine and Arthroscopy.
Snell, R. & Snell, R. (2008). Clinical anatomy by regions. Philadelphia: Lippincott Williams & Wilkins.
http://www.spinalinjury101.org/details/levels-of-injury. Retrieved on September 11, 2016
http://emedicine.medscape.com/article/1242387-overview. Retrieved on September 11, 2016
http://www.healthline.com/health/radial-nerve-dysfunction#Causes2. Retrieved on September 11, 2016
http://www.healthline.com/health/ulnar-nerve-dysfunction#Overview1. Retrieved on September 11, 2016