PPT – Orthotics

Definitions
Orthotics – science/practice of using orthoses
Orthosis – external device (brace/splint) to support/mobilize, etc
Orthoses – plural form of orthosis
Prefab – “off the shelf”, minimal adjustment
Custom fitted – prefab, but has more adjustment (ex: resting hand splint that needs to be
adjusted)
Custom fabricated – custom from A-Z for that client
Static – resting hand splint. Nothing moving. Just Velcro to hold it in place.
Serial static – no moving parts, but can be adjusted/remolded (ex: contracture)
Static progressive – tolerated better than serial static. Adjustable. Turnbuckles (straps) can
adjust tension.
(ex: elbow ccontracture, stretches). Wear 3x/day for 30 mins at a time. LOW LOAD.
Dynamic orthoses – elastic components to assist with mvmnt. (ex: radial nerve palsy)

Grasps
Lateral/key pinch: primary muscle adductor pollicis
3 jaw chuck/tripod pinch: flexor pollicis longus, flexor digitorum superficialis, FDP, opponens,
lumbricals
Tip prehension “OK”: flexor digitorum profundus, flexor pollicis longus
Cylindrical grasp: gross b/c whole hand is touching object
Spherical: gross. Fingers are abducted
Intrinsic plus: MCPs in flexion, IPs extension (ulnar nerve palsy = claw hand = intrinsic minus
position)

Purposes & Goals

• Mobilization
• To remodel long standing dense mature scar tissue
• To elongate soft tissue contractures
• To increase PROM
• To compensate or substitute for weak or absent
muscle(s)
• To provide resistance for exercise
• To maintain intraarticular fracture reduction

• Immobilization
• To protect and/or position healing structures/tissues
• To reduce pain/symptom relief
• To stabilize a body part; to block and/or transfer muscle
force as needed to improve function
• To preserve joint alignment
• Contracture management
• Maximize function

Clinical Reasoning
1/16” - 1/12” : Child/finger/hand-based
3/32” : arthritis, thumb/hand/wrist, static vs dynamic vs static progressive
1/8” : 1/6”: larger joint surfaces, contracture of large joint, spasticity, high tone
Document any redness. Take off immediately. Call office to take a second look or modify.
Document pre/post ROM, functional improvement, wear & care, precautions.

orthotics

Children: protocol for flexor tendon repair: immobilization 3-4 weeks is best

Children who cant’ understand/follow protocol, immobilize! (Intoxicated, low cognition,

Alzheimer’s)

Skin integrity/wound presence: use rolled washcloth was a good example if they have wounds
do NOT use orthotic. Modify or be creative

Steroids, HO diabetes = less healing time

Inflammatory phase - resting orthotic
proliferation phase - day 4-24, collagen phase. Calls/fobroblasts surroudning tissues and are
adding more tissues. Stretchy orthotic good idea to allow collagen to stretch
Remodeling phase - day 21-2 years - immature type 2 collagen, converted to more mature
collagen. Can be more active, allow for more movement to occur.

Most beneficial way to improve contracture is ????

TERT: total end range time. Way to document how long to wear orthotic. “Wear 3 hours
(TERT)”.

Forearm orthotic: 2/3 of forearm to offer enough range to counteract resistance on other side of
the joint. Distribute forces evenly. 1/3 would probably slip out of place

Angle of pull: 90*. If not, it has more torque and more wear & tear.

ULNAR INTERVENTIONS
Ulnar nerve injury = ulnar claw

Closer to wrist = more prominent claw

Often thenar atrophy
Intrinsic are unopposed
Orthotic allows for IP extension

MEDIAN NERVE INJURY

“Ape hand” - anything in thenar is damaged. Hard for thumb to move. Cannot
abduct/oppose??? Double check, slide 10
Opponents splint is good. Something to preserve the web space.

RADIAL NERVE
Radial nerve palsy (wrist drop)
“Saturday night palsy, honeymoon palsy, crutch palsy”
Higher level injury at axilla. Affects triceps, impacting elbow extension too.
Often caused by humerus fracture close to the elbow. If so, they would still have triceps.
Intervention: psychosocially disheartening. Patients & encouragement because it takes time!
Use a dynamic splint to allow wrist/finger extension for functional grip pattern.

CLIENT EDUCATION/DOCUMENTATION CHECKLIST:

Name/description of orthotics
Education about client’s condition and purpose
Detailed wearing schedule
Precautions
Constant info for practitioner
Take pic of the positioning for them to keep
Cleaning/care requirements/care
Compensatory strategies

CODING/BILLING
97760 - orthotic Mx & training
97763 - orthotic Mx and/or training, subsequent encounter
L code - hand clinic - specifics on orthotics/joints. Includes evaluation/fabrication/fitting. Cannot
ALSO bill with CPT codes.

Wrist/immobilization PPT
3 categories of wrist orthoses:
Protection, positioning, improving function
10-40* wrist ext allow fingers to move freely, allowing for balance between extrinsic flexor &
extensor forearm muscles

CARPAL TUNNEL
Median nerve compressed
Caused by: Swelling of synovial fluids, prolonged flexion, injury altering wrist anatomy, friction
caused by repetitive motions
Numbness/tingling in thumb,index,long fingers, radial half of ring finger, weakness with pinching
and gripping
Orthotics: 0-15* extension, minimizing median nerve compression.
Orthoses that includes MCP joints can decrease lumbrical movements, causing even more rest

Typical soft brace can be used full time until numbness, tingling, pain is gone. May have night
time use for severe night symptoms. Others may wear only during ax that aggravate symptoms.
No protocol for wearing schedules, but individualized.

POSITIONINGS:
Carpal tunnel - no more than 10-15* extension
Wrist sprain - ideally in neutral
Tendonitis - ideally in neutral, but they might need a slightly flexed or extended position to allow
rest of the affected tendons

WRIST FRACTURES
Most common: distal radius
AKA any carpal bone fx
Dementia/child = plaster cast
Often after sx, wrist orthoses is needed to Mx positioning and allow AROM exercises/light use of
hand
Instruction clients to use orthotic full time for several weeks after sx (6-8 weeks, then grade
down to just soft for a few weeks) (healing of bony structures indicates the need to stop wearing
orthoses)

DESIGNS FOR WRIST

See screenshots
Least favorite: circumferential design, because of difficulty to take on/off.
Velar/dorsal/thumbhole are commonly used

VOLAR WRIST ORTHOSIS

-carpal tunnel, used due to an odd shape of wrist styloids
-wrist fxs
Turn hand into supination while making this splint!
Material: very conforming, drapability to it

THUMB HOLD (VOLAR) WRIST ORTHOSIS

When you put thumb in hole, leave lots of room for thenar imminence
Use material with high drapability

DORSAL WRIST ORTHOSIS

Advantage: a lot of strong support, frees up Palmer surface for sensory input.
Good for muscular/bigger forearms.
Use more rigid material
MAKE SURE VOLAR side is proximal to distal palmar crease (functional use of hand!)
Pedretti Ch. 30

Distal transverse arch: goes across the metacarpal heads

Oblique = critical to ability for hand to adapt shape to hold objects
MCP = MP! All metacarpophalangeal

Orthotic should NOT go distal to the MC creases

Orthotic should NOT go past the MP creases on the ulnar border, limiting grasp of objects

Forearm rotation: if their arm is in supination during fabrication, the lines will be high on radial
border and low on ulnar border

Common problem when MPs are immobilized in extension: collateral ligaments shorten, volar
plate contractures and adheres (limits MP flexion and loss of fxnl grasp patterns)
Best way to prevent this: resting splint position:
wrist 25-35
MP 60-70 flexion
PIP/DIP 10-35 flexion
*prevents shortening, mx joints in midrange for fxn
Allow for 4th and 5th digits to have a little bit more flexion at MP joints

2 muscle groups that act on wrist/hand: extrinsics (flexors/extensors on wrist/digits) and

intrinsics (lumbricals, dorsal/palmar interossei, thenar/hypothenars)
Sites prone to nerve compression, use caution:
1) Ulnar nerve – elbow cubital tunnel and Guyon’s canal at ulnar border of wrist
2) Radial nerve – elbow, thenar snuffbox
3) Digital nerves – medial/lateral borders of digits

Neuro fabrication goal: prevent contractures, restore fxnl positioning. Must consider damage
prevention to sensory feedback and impaired sensation leading to skin breakdown

Superficial venous system (blood flow) lies dorsaly in hand. NOT TOO TIGHT!

Finger splints: consider “ring problem”

Common sites for pressure: ulnar styloid, distal radial styloid, thumb CMC joint

****padding adds pressure! Never add pads after the fact

ANGLE OF APPROACH
90 angle to the joint proximal to it??
< 90 = joint compression
>90 = joint distraction
Example: some outriggers need to be adjusted weekly as their contracture decreases

ORTHOTIC TYPES:
dynamic: 1 > component (elastics, rubber bands, springs) that produce motion
Increases PROM, augment AROM to assist through its range, substitutes for lost motion
Commonly used to get > finger range by adding dynamic MP extension or MP flexion
Components
Static: immobilizes
Rest/protect, reduces pain, prevents muscle shortening/contracture
Ex: resting hand splint
Serial static: slow, progressive increase in ROM by repeated remolding
No movable parts
Ex: cylindrical cast to reduce PIP joint flexion contracture
Static progressive: one static mechanism that adjusts the amount/angle of traction on another
part (turnbuckle, cloth strap, nylon line, buckle)
different from serial static bc it has a built-in adjustment system

ORTHOTIC PURPOSES:
Restriction: limits ROM (but doesn’t complete stop it)
Ex: oval 8 ring for arthritis
Immobilization: prevents injury, for rest for pain/inflammation, for positioning for healing
Ex: resting pan orthosis after CVA
Mobilization: increase limited ROM/restores or augments function, assists a weak muscle,
substitutes for motion lost due to nerve injury or muscle dysfunction
May balance the pull of unopposed muscles, or may also resist against weak muscles to
improve strength, may improve tendon gliding after surgery

ORTHOTIC DESIGNS
Single-surface: either volar/dorsal/ulnar/radial
Straps are used to add 3 points of pressure
Good post-CVA or peripheral nerve injury (any time there is weak/flaccid muscles)
Circumferential: cover all with = pressure
Uses thinner materials
Increased countours means that it has more rigidity
Need more air circulation? Use highly perforated materials
Good for painful joints or protecting soft tissue
3-point design: good for flexion contractures of 35 degrees or less (if more, use a hand or
forearm outrigger to use the 90* angle of attack OR use a serial static orthois)
One pointf proximal, one joint distal, other opposing force directly over the joint
** sum of 2 forces = force of central point
**surfaces as broad as possible, distribute pressure with padding, adjust to tolerance!
Loop design: mostly just for finger IP joints, wrapping loop around the joints to restore last
degrees of flexion

WHEN/WHEN NOT TO USE

Diaphoresis, excessive sweat = skin maceration, use ventilated plastics and absorbent padding
If there is issues, take the orthotic away!!!!!
Night time is for static splints designed to change ROM
Best to minimize day splinting for sensory and function.

FABRICATION NOTES
Depth: trim at midline! (ex: forearm splint, not too high or too low on the sides
“flare” the orthotic out to maintain midline (p. 746 picture)
To check forearm length, have them flex elbow and mark where forearm meets elbow, cut ¼”
below that

MATERIALS
Forearm & hand:
- Burns/trauma do not need conforming fit, can use low-drape materials
- Spasticity needs materials that resist stretch and tolerate aggressive handling
Large UE/LE:
- High resistance to stretch, lots of control.
- No need for highly conforming.
- Take care with bony prominences and pressure distribution needs padding
Circumferential orthoses:
- High degree of memory that tolerates stretching without forming thin spotshighly
perforated, thin, stretchable
- Good for fracture bracing and contracture reduction and stabilizing/immobilizing joints
- You COULD use semiflexible materials for easy donning/doffing
Serial orthoses:
- Needs frequent remolding
- Considerable memory or highly resistant to stretch (avoids thinning with remolding)
- Moderate-high rigidity when using for spasticity or contractures

TYPE OF TRACTION
Dynamic traction: springs, hinges, elastic
Static traction: straps, turnbuckles, or remolding

Spring coils: best for weak muscles or to substitute for paralyzed muscles
Will likely wear during ADLs, so low profile & lightweight is good
Good for long-term
Outriggers: good for post-op
Allow for frequent adjustments
Easily adjustable during rehab process (bandage changes, edema, healing, etc)
4-6 weeks usually
It’s bulky, but these clients don’t complete ADLS during that time usually
NEEDS to be self-donned to be able to remove it or switch with other orthotics (ex:
switching a flexion outrigger for an extension outrigger)
Also good for contracture reduction. Most effective during early stages of healing (pain
and inflammation, so they cannot tolerate a rigid static, but they can tolerate an
outrigger)
Static traction: purpose is to apply traction to immobilize or restrict motion to protect/rest/position
Can remodel scars
Serial static traction: end range every time, adjust frequently
Ex: cylindrical cast used for PIP extension changed every 1-3 days
Static progressive traction: mechanisms include Velcro, turnbuckles, buckles.
Rule of thumb: use the simplest one that reaches the goal

Serial static advantage: good for high tone/cognitive impairment/noncompliant/overly zealous

Disadvantage: must be remolded, opposing ROM can be lost
Static progressive advantage: only need to make 1 splint, reliable clients (with normal tone)
make more rapid progress.
Disadvantage: not for abnormal tone or unreliable

Techniques to avoid pressure areas/shear forces with dynamic orthoses:

1) Joints proximal to finger being addressed must be stabilized
2) Countor orthosis around the proximal phalanx to distribute pressure/prevent shearing
motion on dorsal finger
3) Use padding

Approaches to apply traction to lengthen soft tissue:

- Stress relaxation: position at end range, hold for short periods, then relax/reposition
frequently
- Apply force within its limits for long periods, then reposition it (low load over long time)
CHOOSING FOR GIVEN PURPOSES
Remodeling scar tissue/reduce contractures:
- Apply deep heat before application
- 3-point orthoses for flexion contractures
- Loop splints for IP joint extension contractures
- Outriggers for MCP extension contractures
- Dynamic outriggers are used to reduce early, soft tissue contractures
Pain reduction
- Acute = immobilizing
- Chronic = semiflexible restrictive
- Intermittent wear calls for lightweight, well-aerated materials
Burns
- Position at end range
Ended p. 751

PPT ZONES

5 flexion (volar) zones

3 zones for thumb

FLEXOR ZONE 1: anything distal to insertion of FDS

- FDP (profundus) goes all the way distal! “profound”
- FDS (superficialis) bifurcates going to the middle phalanx.
 - Zone 1 = distal phalanx
- Ex: jersey finger (injury to FDP)

PULLEYS OF HAND:
- Annular: circular fibers, hold flexor tendons in place, prevent bowstringing
- Cruciate: thinner: “cruciform” tiny pulleys, making a x shape across the finger
- A1-5: 1 is proximal, 5 is distal
- A2 pulley is very important to hold flexor tendons in place.
- A4 pulley is very important to hold FDS in its place

FLEXOR ZONE 2:
- Distal palmar crease (proximal A1 pulley) to FDS insertion (middle phalanx) (INCLUDES FDS
insertion)
- Ex: trigger finger (aka stenosing tenosynovitis) narrowing sheath around tendon. Likely at A1
pulley
CAMPER’S CHIASM: in flexor zone 2!
- This is the area between the bifurcation of the FDS.
- Provides stability/balance of the PIP.
- Prevents hyperextension of PIP

FLEXOR ZONE 3:
- Distal carpal tunnel to proximal A1 pulley
- Significance: lumbricals originate here (from the FDP)

FLEXOR ZONE 4:
- Carpal tunnel syndrome
- Carpal bones, flexor retinaculum
- Median nerve, FPL, 4 FDS, 4 FDPs (all flow through the carpal tunnel)

FLEXOR ZONE 5:
- Proximal to carpal tunnel
- Muscle bellies of the wrist flexors
- “home” to muscle/tendon interfaces
- Common for strain injuries in sports

THUMB PULLEYS
- A1, oblique, A2
- Oblique: most important because it prevents bowstringing of FPL
 - A1 (around head of MC)
- A2 (around head of proximal phalanx)

FLEXOR ZONE T1 THUMB:

- Insertion point for FPL

FLEXOR ZONE T2 THUMB:

- Considered to have poor outcomes
- A2 pulley to distal A1 pulley (including A1 pulley)
- Includes oblique pulley (MOST IMPORTANT pulley of the thumb)
- Oblique pulley: facilitates full excursion of FPL and prevents bowstringing of FPL

FLEXOR ZONE T3 THUMB:

- Just distal of A1 pulley to carpal tunnel
- Potential thenar musculature involvement

EXTENSOR ZONES (9)

- Odd #s: joints
 - Even #s: bone

EXTENSOR ZONE 1:
- DIP joint only
- Common injury: mallet finger (torn/strained extensor digitorum)

EXTENSOR ZONE 2:
- Middle phalanx
- Fractures: can involve tendon on that extensor side
- Extensor digitorum merges to become the extensor hood as you go distally  central slip
- Central slip: responsible for PIP extension
- Central slip bifurcates in to the lateral bands
- Central slip inserts at the BASE of middle phalanx.

EXTENSOR ZONE 3:
- PIP joint
- Central slip & complications that pull the rest of finger into deformity
- Boutonniere deformity: rupture of central slip (over PIP joint). PIP flexion/DIP extension

EXTENSOR ZONE 4:
- Proximal phalanx
- Easier to repair than zones 1-3

EXTENSOR ZONE 5:
- Follows MCP heads
- “fight”
- Punching while MCPs are taught (in flexion)
 - Sagittal bands (sheath surrounding extensor tendon (extensor digitorum)). Radial side thicker
than ulnar, BUT it tears more readily. Middle more likely to have injury

EXTENSOR ZONE 6:
- Metacarpal area
- Home of “juncturae tendinum”: connections between extensor digitorum communis tendons.
Disrubutes the force and mx space between the tendos and stabilizes MCP joint.
- Blood supply/nerve damage here
- Lesion proximal to juncturaw tendinum: LESS risk for adhesions

EXTENSOR ZONE 7:
- Extensor retinaculum (dorsal): keeps tendons in alignment, prevents bowstringing

EXTENSOR ZONE 8:
- Distal 1/3 of forearm
- Musculotendinous junction
- Place for lots of force: sprains, strains, breaks, nerve injuries
-

EXTENSOR ZONE 9:
- Proximal 2/3 of forearm
- Muscle belly area for extensor tendons

SUMMARY SLIDE:
- Focus on T2 (oblique pulley) flexor zone
- Know where flexor/extensor zones are
- Know pathologies for each (flex 1-5, ext 1-9)

ATHRITIS & OT POWERPOINT

OA: degenerative,
Primary: no known cause, localized to 1-2 joints OR generalized
Secondary: related causes (trauma, infection, necrosis)
Articular cartilage acts as a buffer, with synovial fluid between.
Doing PROM, hear clicking? STOP!

RA will have inflammation, OA will only have pain/stiffness

Osteophytes:
Bouchard’s notes: PIPs
Heberden’s nodes: DIPs (they go alphabetical!)

RA:
synovitis: inflammation of synovial membrane lining the capsule
p349 – stages
tenosynovitis: nodules in flexor tendon sheath, causing trigger finger

Rheumatoid nodule: cist development in elbows, etc. End stages of arthritis, no pain
Dr. guest recommends using the COPM for evaluation

Overarching goal for tx: decrease pain, protect joints, increase function
***CHART p. 958

Interventions:
- Recommend increased rest for the WHOLE body during acute stages
- Do NOT use PAMS for acute stage!!!
- DO use ice/gel pack for acute stage
- Use caution with ther. Ex. Avoid PROM, just do AROM during acute phase

Splints:
- OA thumb: thumb CMC orthotic
- Ulnar deviation/drifting hand splint: prevents progression
- Prefab wrist support : good for cane/walkers: wear while using them
- Oval-8

PEDRETTI CH 38

P 958, 961
- Acute (stage I) – resting splints day/night, GENTLE AROM, bedrest (MAINTAIN)
- Subacute (stage II) – night resting splints, daytime decreased splinting (MAINTAIN)
- Chronic active (stage III) – splint as needed, resistive exercises, cont. night splints (INCREASE)
- Chronic inactive (stage IV) – splint as needed, cont. night splints (INCREASE)
Ligamentous laxity:
- 5-10: slight
- 10-20: moderate
- 20 >: severe
JOINT PROTECTION/ENERGY CONSERVATION:
- Respect pain
- Mx muscle strength/ROM
- Use each joint in its most stable anatomic & functional plane
- Avoid positions of deformity
- Use strongest joints available
- Ensure correct patterns of movement
- Avoid staying in 1 position for long periods
- Avoid starting an ax that cannot be stopped immediately if it becomes stressful
- Balance rest & activity
- Reduce force & effort

PEDRETTI CHAPTER 39 – HAND/UE INJURIES

ADHESIVE CAPSULITIS:
- Loss of A/PROM shoulder with pronounced loss in ext rot, some loss in abd and int rot
- Capsular end feel to PROM
SUBACROMIAL IMPINGEMENT:
- Painful arc of motion between 80-100* elevation or at end AROM
- Early stages may show no pain
ROTATOR CUFF TENDINITIS:
- Painful AROM/PRO rotator cuff muscle
- Painful MMT of scapular abd/ext rot
- Pain-free PROM to end range
- Tenderness at supraspinatus or infraspinatus
ROTATOR CUFF TEAR:
- Significant substitution of scapula with arm elevation
- Positive drop arm test
- Very weak (less than 3/5) abd/ext rot
SHOULDER TESTS:
- Impingement tests: overpressure arm to end range. Positive if facial expression shows pain.
- Drop arm test: passive abd to 90 with palm down, ask to lower arm actively. Pain or inability is
positive

PEDRETTI CH 43
DESENTIZATION (to prep limb to tolerate initial socket)
- Implement tx after wound closure
 - Tapping
- Vibration
- Constant pressure
- Rubbing textures on limb (start with soft & smooth and grade up to rough/hand)
- Teach how to do these at home

PHANTOM LIMB PAIN:

- Analgesics
- Acupuncture
- Electric nerve stimulation
- Mirror therapy
- Isometric exercises (5-7 days after amputation) several times a day
- Active movement of muscles associated with phantom limb (if they describe phantom limb as
“stuck”)
- Mirror therapy
- Biofeedback
- TENS
- Ultrasound
- Progressive relaxation exercises
- Controlled breathing
- Massaging
- Tapping
- Pressure to residual limb
- Oral meds, surgery
- INTERDISCIPLINARY APPROACH!

NEUROMA:
- Local steroid injections
- Refabricate/modify residual limb socket

BIOMECHANICAL NOTES for UE:

- Daily strength & ROM is key for prosthetic training
- MOST IMPORTANT: ROM/strength of shoulder flexors, abductors, rotators, scapular
protactors/retractors
- Guide through HEP for this
- Focus on trunk symmetry: mirror, verbal/tactile cues,

MYOSITE TESTING/TRAINING:
- Myoelectric prosthesis (if early prosthetic fitting isn’t possible): uses EMG muscle signals
(myosites) to facilitate successful operation of the prosthetic.
- Finds TWO muscle sites in the socket that have the greatest volt difference between them
- Myotester can also be used to train muscles with feedback system (remember to give them rest
between sessions/ID fatigue!)
BODY-POWERED PROSTHESIS:
- Cable-driven, controlled by gross motor
- Pros: durable, prop feedback, low maintenance
- Cons: restrictive, force exerted on residual limb, difficult to control for high-level amputs,
decreased grip force
ELECTRIC POWERED PROSTHESIS:
- Aka myoelectric
- Pros: improves cosmesis (aesthetic), increased grip force, no harness, minimal effort, fitted early
- Cons: cost, mx/repair, no sensory feedback, bad with moisture, heavy
HYBRID PROSTHESIS:
- Body-power and myoelectric combined
- Common with transhumeral
- Pros: elbow/wrist simultaneous control, light, increased grip force
- Cons: harness at elbow, may be difficult to operate with short transhumeral or higher amput
(needs force at the elbow)
PASSIVE PROSTHESIS:
- Both cosmetic and functional (HAND)
- No active grasp
- Often passively positioned in to a grasp pattern
- Pros: aesthetic, no harness/controls, low mx, lightweight, grasp
- Cons: no active grasp, PVC stains easily
ACTIVITY-SPECIFIC PROSTHETIC
- Often with body-powered or electric ones that need MORE durability than the regular
- Sports, hobbies, tools
- Can interchange the terminal device
- Pros: participation, minimal harness/cables, durable, low mx, reduced wear & tear
- Cons: no active grasp, only for specific tasks

COMPONENTS:
SOCK:
- Wool, cotton, lycra
- Absorbs perspiration & protects from irritation, compensates for colume changes
- Improves fit and comfort
SOCKET
HARNESS/CONTROL SYSTEM
TERMINAL DEVICE
WRIST UNIT:
- Connects TD to prosthetic
- Provides supination/pronation
- Can be friction-held, locking, ball-and-socket
OTHER TYPS ON SPECIFIC PROSTHETICS -
TRANSRADIAL HINGES:
- On each side of the elbow
- Stabilize/align/distribute stress
- Styles: flexible (amp distal 1/3 of forearm) or rigid (amp at or above midforearm)
ELBOW UNITS:
- Internal (more durable): not appropriate for amp proximal to elbow
- External locking: for elbow disarticulation or amp within 2” above elbow
SHOULDER UNIT:
- …….. more to review on p. 1095-1097

TRAINING:
- ideally, initiate therapy with prosthetist and therapist for fitting and initiation
- Critical first step in training: donning/doffing (needs to be I ASAP)
- 2 most common donning/doffing: coat or pullover (sweater) method
- Make sure electric components are OFF during donning
- Silicone-based lotion before sock
- Experiment with lotion, sock materials, powder, and techniques
- Store with OFF and batteries removed.
- Hand fully opened when stored to keep thumb web space stretched

SCHEDULE:
- Establish & review first day of training
- Increase gradually
- Ideally worn 15-30 mins 3x/day initially, then inspect skin. Only increase if skin is ok.
- Increase in 30 min increments 3x/day
HYGEINE:
- Instruct in early phases
- Inspect skin EVERY time you remove
- Wash daily with mild soap and water, pat dry
- Use antiperspirants, socks, liners
OPERATIONAL KNOWLEDGE:
- Important for client to know the fancy words for communication with rehab team
PROSTHETIC CARE:
- Clean daily (ideally at night to allow to dry)
EAVLUATION MEASURES:
- Assessment of Capacity for Myoelectric Control
- Trinity Ampuation and Prosethesis Experience Scales-Revised
- Shouthampton Hand Assessment Procedure
- Orthotics and Prosthetics User Survey
- Activities Measure for Upper Limb Amputees