Splinting the paediatric hand.
Generell introduksjon
Griet van Veldhoven – Margareta Persson
Big difference between an adult hand
and a child’s hand
• The small size can be a challenge
But the child’s hand is MORE than a
small hand.
Big differences with the adult :
-”Anatomical /biological”
- Development
- Behavioural
Anatomical differences with the adult hand:
Other proportions than the adult hand
Adult splint patterns can’t just be copied in a smaller size
Anatomical differences with the adult hand:
Tissue healing
Tissue healing is going faster.
Adult splint- and treatment programs
can’t just be transferred to the child.
Anatomical differences with the adult hand:
bone formation
Dynamic splints ??!!
Position - duration for immobilisation ??!!
”Developmental” difference with the adult hand:
Psycho-motoric development
 Capabilities of the hand are dependent on the stage of
mental- and motor development
 Important interaction between brain – hand function –
eyes – sensibility – body perception …
”behavioural” difference with the adult:
The child is more dependent on others
Donning and doffing of the splint:
 some children are real Houdini’s
 needs to be easy for the ”caregivers”
”behavioural” difference with the adult:
Exploration with the mouth
…mmm this splint tastes good …..
”behavioural” difference with the adult:
Design - Motivation
”behavioural” difference with the adult:
Fabrication of the splint
Take care of both the parents and the child
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Explanation about what's going to happen
Showing a sample
Written information
Establishing a working relationship
Practice donning and doffing at the clinic
Picture, (colour) coded fixation straps
Trail wear during 15 minutes before leaving the clinic
Telephone number
”behavioural” difference with the adult:
Fabrication of the splint
Establishing an optimal collaboration with the child
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Child decide where to take place
Showing some funny splints
Play with the splinting material
Making a splint on a favourite toy or parent
white coat? a funny hat or mask?
Choice of coloured material
Music, “story”
Making the splint while the child sleeps
Honest information and agreements
Allow the young child to participate in donning and doffing the
splint
 (Separate from parents)
Hånd ortoser til barn med CP
Griet van Veldhoven – Margareta Persson
What’s the point of using a splint?
Each splint needs a clear and measurable
aim/goal.
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Increasing function (which function in what kind of activity?)
Preventing/correcting contractures
Help during treatment/training
Post operative – post Botulintoxin
Decreasing pain / improve hygiene
To
What’s the point of using a splint?
Increasing function:
 which function in what kind of activity?
 Splint used during daytime.
 No gain = no wear
What’s the point of using a splint?
Preventing/correcting contractures = keep the
length of the spastic muscles
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Avoid ingrowth of fibrotic fibres
 Avoid lengthening of the antagonists
What’s the point of using a splint?
Help during treatment/training:
 Elbow extention + Wrist extenstion + Fingerextention
 In order to train shoulder stability
What’s the point of using a splint?
Post operative – post Botulintoxin
 Protect healing tissue
 Keep muscles in length
 Training assistance
What’s the point of using a splint?
Decreasing pain \ improve hygiene
General «spastic splinting rules»
 The hand must find rest in the splint
 Use splint material, straps, color, etc acceptable for the
patient
 Only support what need’s support… a day orthosis
should help positioning the hand for better hand
function
 The joints should be in relaxed non stressful
positions, not hyper extended or in max flexed
position
 Use material washable in the washing machine on
wool program 40°
Ha ALLTID et kritisk blikk ved bruk av prefabrikerte ortoser
MEN OGSÅ på den ortose du har laget selv. Ta avstand å ta
fram ditt kritiske blikk
Night splints for spastic hands
Night splints for spastic hands
The optimal resting position
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Neutral position of the wrist
MCP i almost full extension
IP joints in just a bit of flexion
Thumb extended in palmar abduction with slightly MCP
Flexion
Central support point at the wrist has to be broad
and slightly elastic
Central support point at the MCP joints 2-5 has to be broad
and slightly elastic
The central support point to control ulnar deviation of
the wrist has to be broad and slight elastic band NO hard
splinting material NO hard edge. Keep the ulnar side
low.
Make the radial side high for stability and for
comfortable support points (distal MC and proximal
forearm).
When the adductor is tight: try to slightly flex the MCP
and IP 1 joint
Don’t pull or push the MCP 1 joint
into hyperextention or radial
deviation in an attempt to correct
adduction
A prefabricated soft wrist support with a cylinder of pipe
insulation can be an alternative to a static night splint
En myk håndleddsstøtte med palmar
forsterkning kan bygges ut med en
skumm gummi rulle (vann rør
isolasjon) for å støtte fingrene (og
tommel)
Som alternativ for en rigid natt ortose kan man utvide en
fleksibel prefabrikert håndleddsortose med en skumm
gummi sylinder for å støtte fingrene. Dette er et
kompromiss men bedre det enn ingenting ;-)
For babies a HandAid thumbsplint with a cylinder
of pipe insulation attached with a V-shaped
velcro on the dorsal side of the wrist-thumb
support can be used as a night orthoses
Pucci Air: bruk din kritisk refleksjon
Houdinni barn?
Sklir hånden ut av en rigid semi sirkulær ortose kan man feste
fabrifoam med velcro på innside av ortosen. Den hvite side med
høy friksjon peker mot huden.
Dorso palmare ortoser er enklere å ta på, lettere å
lage men bare brukbar ved litt større barn
Functional wrist splints
Stability: distal row of carpal
bones and CMC II-III
Mobility: CMC I – CMC IV-V and
MCP II-III
The MCP joint III is the highest point of the distal arc
- Important both for function and for rest.
- Without the distal arch no strength and
reduced ability to manipulate objects.
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Ulnar pull in flexion
Radial pull in extension
Check:
Are the fingers more flexed with the wrist support on
or can they extend as much as without the splint?
Replace the rigid support by a
custommade support (on the
outside OR the inside of the prefabricated
flexible wrist support)
A wrist with a tendency to some ulnar deviation
can be counteracted with a piece of double
sided velcro attached to ulnar side on the inner
layer of a Fabrifoam thumb support
Spectra wrist support – change the metal stay to a
plastic for better comfort,
gives some flexibility to the wrist.
Fabrifoam håndledds ortose med Orfit forsterkning ulnar
Finn feilen??!!
Functional thumb splints
Tommel stillinger
OR
Functional thumb support: try to expose the tactile
area of the thumb = pulpa.
The thumb should reach the lateral side of the tip of
the index finger
Grip initiated by adductor policis.
Positioning the thumb to stimulate grip with FPL.
Rigid orthoses if a firm,
non elastic support is
needed
A cylinder of pipe insulation / rubbermaterial on the
thumb strap to gain web space and positioning of the
thumb
Supinasjonsortose
Pro- og supinasjon skjer mellom
radius og ulna
Ved å ta tak rundt tommelen drar man på
både tommelens grunnledd og håndleddet
Man skal feste draget distalt på underarmen.
Tommelen kan inkluderes men draget skal ikke festes på tommelen.
Fest noe spennende på palmar side av en ortose.
Dette kan stimulere supinasjon.
En supinasjons bandasje kan kombineres med for eks
en håndleddsortose, tommelortose og palmar
nattortose
Todelt konstruksjon gir flere muligheter (dag, natt).
Forarmen endrer form ved pro-supinasjon
Forarmsortosen i rigid material må derfor lages i den stillingen
ortosen skal bli brukt i.
Vær sikker at pårørende vet i hvilken
retning armen skal
”wrappes”!!!!!!!!!!
Om nødvendig sett merker på
bandasjen.
Fabrifoam = anti skli =
ingen strangulering 
Neoprene = tekstil =
strangulering 
Elbow Splints
Elbow splints
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Prevent flexion contracture
Correct flexion contraction
Stimulate support / stabilisation of the shoulder
Elbow extension splint made of 2-3 layers of
Fabrifoam wrapped on top of a standard hand
resting splint.
If a more rigid splint is needed Fabrifoam can be
reinforced with a piece of dry heated Orfit.
Dry heated Orfit Classic 1.6mm sticks to the fabric layer.
Finger splints
Spastic hand with swan neck deformities. Often it’s enough with one
single extension block
• Vær kritisk ved valg av prefabrikerte ortoser
• Myk (Rehband, DeRoyal, Spectra, MedSpec)
håndleddsstøtte kan forsterkes palmar, dorsal, ulnar eller
sirkulær med plast inn- eller utvendig.
• Innvendig dekkes plast med polstring. Utvendig dekkes
plasten med lær som sys på.
• Ved spastisitet av FDP og eller FDS: feste en rull på
håndledds støtte slik at fingrene kan legges rundt
rullen.
• Ved tommel adduksjon: rørhylse over tommelløkken.
 Palmar ortose: bred og myk bånd over håndledd og
håndrygg
 masse masse hyll i plasten (Margareta Persson)
 Strømpe under plasten (microfiber strømpe fra
Rehband/Knite rite) (Griet van Veldhoven)
 Håndleddsbandage type Spectra (Össur) er veldig bra den
klemmer ikke radio ulnair men dorsopalmair.
Barnestørrelse???
• En metall forsterkning skal helst erstattes med en plast
forsterkning som har litt fleksibilitet
• En fabrifoam håndledds ortose kan bli forsterket med orfit
classic eller dobbelsidig rigid borrelås
 Ved spastisitet av FDP og eller FDS: feste en rull på
håndledds støtte
 Ved tommel adduksjon: rørhylse over tommelløkken
 Rullen dekkes med splintpolstering eller en ”stoffhylse”
 pasienten får to ortoser slik at de kan vaskes
 Elastisk borrelås fra DeRoyal eller Otto Bock er veldig myk
og billig, kan klippes uten at den rakner.
”myk elastisk bånd med karbordbånd funksjon”
 Inhibering før ortoselaging:
OK for å gjøre det enklere å lage en ortose
IKKE for å oppnå en bedre stilling!!!
 Bruk Theraband (kjøleskap) når man lager en ortose
kleber ikke i plasten , lager ikke merker
kald Theraband kjøler plasten ned ganske fort
 Bred borrelås over handryggen = for bred i første
webspace:
borrelåsen brettes sammen og holdes på plass med en bit
Orfit
 Farget plast, farget borrelås, små klistremerker i
morsomme farger og mønstre…
 Bånd som hindrer tommelen å dra mot volar eller rad.
abd. Skal gå over MCP ALDRI over IP eller PP!!!
 forskjellige ortoser for dag og nattbruk
 (Redusere spastisitet med is eller en gellpose som man
legger i fryseren)
 Stabil og trygg sittestilling, stimuli fattig omgivelse
Vi skal lage denne listen lengre i løp av diskusjonen