Upper Limb

orthotic devices
DEPT. OF PMR
AIIMS RISHIKESH
DR ADITI(JR 3)
Contents :
Definition and principles
Biomechanical and anatomic considerations of hand
Nomenclature
Classification
Diagnostic categories and orthotic devices
Making of orthosis
 DEFINITION AND PRINCIPLES
An externally applied device to an existing
body part used to modify the structural and
functional characteristics of neuromuscular-
skeletal system . 6) Prevent progression of fixed deformities
7) Adjustability

PRINCIPLES: 8) Maintenance and cleaning

1) Protection 9) Application

2) Correction 10) Sensation

3) Assistance with function 11) Gravity

4) Uses Of forces 12) Comfort

5) Limitation of movement 13) Utility

14) Cosmesis
Biomechanical and anatomic considerations of hand:
assessment of hand function
In regard to biomechanical motion, the hand has 7 maneuvers that make up most hand functions.

PRECISION GRASP
POWER GRASP
 Biomechanical and anatomic considerations of hand
Relaxed hand position: Wrist acts as base and is in slight flexion , ulnar deviation
MCP, PIP and DIP rest in slight flexion
Thumb is straight and relaxed
Functional hand position: Wrist in 10-30 degrees extension and 10 degrees ulnar deviation
MCP(45 degrees) PIP(30-45 degrees) and DIP (10-20degrees)flexion
Thumb is partially abducted and opposed with flexion at IP joint

Extension stability at wrist is required for optimal hand function

, the angle of pull needs to be perpendicular to the axis of bone that is being mobilized.
Total end range time (TERT) principle, is that the improvement in ROM is directly proportional
to the length of time a joint is held at its end range.
Thumb:- 40% of hand function
. Axis along trapezioMetacarpal joint
Pronation and flexion – 80°
Single digit amputation (with the exception of the thumb) will not result in the loss of essential
hand function
Fusion of small joints of hand decreases grip strength but prehension is preserved mostly.
ARCH SYSTEM: bone configuration and tension of muscles and ligaments is vital for
grasp and prehensions.
There are 2 transverse arches: the proximal transverse arch formed by the carpal bones and the
distal transverse arch formed by the metacarpal heads of the fingers. The longitudinal arches are
made up of the bones of the 5 digital rays
INTRINSIC HAND

Impairment can be due to intrinsic palsy

(intrinsic minus hand) or intrinsic contracture
(intrinsic plus hand).
Causes of intrinsic plus hand :- Causes of intrinsic minus hand;-
Trauma Traumatic injury to the ulnar nerve
metacarpal fractures or , compartment syndrome,
increased edema central nervous system diseases,
and vascular impairment, Leprosy (Hansen disease),
neurologic or spastic hand secondary to an Charcot-Marie-Tooth disease
upper motor neuron syndrome (cerebrovascular
accident, cerebral palsy, traumatic brain injury,
Parkinson’s disease)
, rheumatoid arthritis, osteoarthritis,
and arthrogryposis.
Nomenclature
On the basis of : joint they cover , the function they provide, condition they treat, by appearance,
name of the person who designed them.
Mainly three systems:
Common name
International Organisation for Standards(ISO): anatomic region wise name
American Society of Hand Therapists (ASHT): function and body part wise
Example:

Common name ASHT IOS

LONG ARM SPLINT 45 DEGREE ELBOW SHOULDER-ELBOW-
FLEXION WRIST-HAND
IMMOBILISATION ORTHOSIS
SWAN NECK SPLINT INDEX FINGER PIP FINGER ORTHOSIS
EXTENSION
RESTRICTION
Categories of Upper limb orthosis: ISO
CLASSIFICATION
NON ARTICULAR
STATIC: STATIC
SERIAL STATIC
STATIC MOTION BLOCKING
STATIC PROGRESSIVE
•DYNAMIC : DYNAMIC
DYNAMIC MOTION BLOCKING
DYNAMIC TRACTION
WRIST DRIVEN PREHENSIONS
CONTINUOUS PASSIVE MOTION
ADAPTIVE OR FUNCTIONAL USE
 NON- ARTICULAR
1)Provides support to a body part without crossing any joints and provides protection
Humeral fracture Sarmiento brace

2)Sugar-tong orthosis to immobilize

a proximal radius fracture

3)Gel shell orthosis to exert pressure over

a healing scar to prevent hypertrophic scarring
STATIC
STATIC: maintain a position to hold anatomical structures in place at the available end range.
Volar wrist orthosis for acute carpal tunnel syndrome reduces motion and rests injured tissues
-----
-
SERIAL STATIC : A static orthosis that is periodically changed to alter the joint angle
Provides a prolonged gentle stretch to involved structures, helping a stiff joint regain motion
STATIC MOTION BLOCKING: The static motion blocking orthosis permits motion in one
direction but blocks motion in another
swan neck splint
STATIC PROGRESSIVE Differ from serial orthoses by using non elastic components,
such as static lines, hinges, screws, and turn buckles, to place a force on a joint to induce
progressive change. Once the motion is increased tension is increased progressively.
DYNAMIC

Within elastic limits, the stress from a mobilization splint can positively affect the gradual
realignment of collagen fibers .

The ability to alter collagen formation is greatest during the proliferative stage of wound healing
Torque And Mechanical Advantage
Mechanical advantage involves the
consideration of various forces applied by the
splint base and the dynamic portion of the
splint.
Fa applied force and Fr resistance force. Fm is
the sum of the opposing forces (Fa+ Fr)
Length of the lever arm of the applied force (la)
Length of the lever arm of the applied resistance
(lr)
The goal of a splint is to maintain a mechanical
advantage of between 2/1 and 5/1.
Torque

●A correlation exists between the distance from a pivot

point and the amount of force required.

● To achieve the same results, a force applied close to the

pivot point (i.e., short moment arm) must be greater than
the force applied on a longer moment arm.
Application Of Force
●the force to a joint or finger is applied through
the application of nail hooks, finger loops, or a
palmar bar.

● direction of pull at a 90-degree angle to the

axis of the joint and perpendicular to the axes
of rotation.

●As range of motion increases, the therapist

must adjust the outrigger to maintain the 90-
degree angle
 Outriggers A turnbuckle

Velcro tabs used for static progressive tension

.
nylon string to attach finger loops to the source of tension
DYNAMIC: Finger extension orthosis, which uses a spring coil or wire tension assist
DYNAMIC MOTION BLOCKING: Allows certain motions but blocks others. It allows early
mobilization through passive movement to prevent contractures
DYNAMIC TRACTION: Offers traction to a joint although allowing controlled motion
WRIST DRIVEN PREHENSION/ TENODESIS: Active extension of the wrist produces
controlled passive flexion of the fingers against a static thumb post through a tenodesis action
CONTINUOUS PASSIVE MOTION: Electrically powered devices that mechanically move
joints through a desired range of motion
Adaptive or functional use: Adaptive or functional usage devices promote functional use of the
upper limb with impairment resulting from weakness, paralysis, or loss of a body part
DIAGNOSTIC CATEGORIES
MUSCULOSKELETAL

Tendonitis (inflammation of the tendon), tenosynovitis (inflammation of the tendon sheaths), and
enthesopathy (inflammation at a muscle or tendon origin or insertion) can all result from
excessive repetitive movement or external stressor.

The goal of fabricating an orthosis for these conditions is to immobilize the affected structures
so as to facilitate healing and decrease inflammation
 FRACTURES
These devices should immobilize the body part or joint sufficiently to promote healing while
also optimizing function
 NEUROMUSCULAR CONDITIONS
A distal median nerve injury, a simian hand deformity may occur, and the function most
affected is thumb palmar abduction and opposition.
The orthotic design holds the MCP joints in slight flexion but permits MCP extension. This
orthosis also has a portion to position the thumb in palmar abduction
An ulnar nerve palsy orthosis holds the MCP joints of the fourth and fifth fingers in slight
flexion by using a figure-of-eight splint design. The figure of-eight design assists MCP flexion
and permits extension of the MCP joints but blocks hyperextension
low median and ulnar nerve injuries, leaves the patient with no or weakened ability to place the
thumb in opposition and palmar abduction
With radial nerve injuries distal to the humeral spiral groove, the common presenting condition
is wrist and finger drop. The goal in this case is to enhance wrist and finger extension.
BRAIN INJURY AND STROKE
Depending on the area of brain injury and ensuing deficits, particularly if there is a change in
muscle tone, orthotic devices should be designed to prevent deformities and help adjust muscle
tone.
Postsurgical and Postinjury Orthoses
Many types of orthoses have been developed to help stiff joints regain motion
Joints that have a soft end feel do well with dynamic orthoses. Those with a rigid end typically
respond better to a static progressive approach that will maintain a constant joint position while
the tissue accommodates gently to the tension without the influence of gravity or motion.
EMERGENT TECHNOLOGIES
Concept of neural integration has recently been incorporated into upper limb orthoses.
These devices detect a myoelectric signals from an intact proximal muscle and then send a signal
to distal paralysed muscle.
The paralyzed musc;es are stimulated to contract via surface based electrical stimulation.
Orthotic material
Most splinting materials are low temperature thermoplastics.
They become soft and pliable when exposed to low temperatures and can be shaped in water bath
at temperatures 66to 82 degree celsius. Eg:- finger splinting
High temperature thermoplastics are more durable and require oven for heating ~177 degree
Celsius and placement over a mold for shaping. Eg:- management of spasticity.
CARBON COMPOSITES
THERMOPLASTICS
FOAMS AND GELS
 MANUAL FABRICATION METHOD

(A) Creating the negative cast of a person, (B) filling the negative cast with liquid plaster to produce the
positive cast, (C) applying additional plaster modifications, (D) refining plaster modifications, (E) vacuum
forming polypropylene over modified cast, (F) cutting the polypropylene AFO from the cast, (G) finishing the
AFO and (H) fitting the AFO to a person.
CAD/CAM
THANK YOU