4.position of safe immobilisation
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4.position of safe immobilisation
- 1. The Position of Safe Immobilisation (POSI) Juliet Schneemann Occupational Therapist Bachelor of Science (Psychology) Masters of Occupational Therapy julietchapman@hotmail.com
- 2. Overview of Presentation What is the POSI? Why is it important? When should it be used? How to splint a POSI? Key points Questions References
- 3. What is the POSI? A position to rest the hand during periods of immobilisation James (1962, 1970) - Joint position can influence risk of contractures MCP joints are safe when immobilised in flexion & most unsafe in extension PIP joints are safe when immobilised in extension & most unsafe in flexion Also known as: The intrinsic plus position Table top position The James position Edinburgh position Clam digger “The MCPJs are safe from contracture in flexion & most unsafe in extension; the PIPJs, conversely, are safe in extension & exceedingly unsafe if immobilised in flexion” (James, 1970)
- 4. MCP flexion 60-90° PIP in full extension DIP in full extension Wrist extension 10-45° What is the POSI?
- 5. Why is it an Important Position? Excessive immobilisation, incorrect positioning, trauma, inflammation, infection, tumor, CNS disease, joint destruction can all lead to joint stiffness & intrinsic contractures Joint stiffness & contractures can lead to deformities & functional disability Immobilising the hand in the POSI can minimise/prevent joint stiffness & intrinsic contractures
- 6. Basic Anatomy of the Finger (excluding tendons) Bones: Metacarpal, Proximal Phalanx, Middle Phalanx, Distal Phalanx Joints: Metacarpal Phalangeal (MCP), Proximal Interphalangeal (PIP), Distal Interphalangeal (DIP) Support Structures of the Fingers Joint capsule, Volar plate, Collateral ligaments, Palmar ligaments, Extensor hood Collateral ligaments provide lateral joint stability whilst the hand is being used for functional activities The length of the collateral ligaments are critical in allowing normal joint motion Why is it an Important Position?
- 7. Anatomy of the Metacarpal Joint MCP joint is a condyloid/ellipsoid joint MCP Flexion Collateral ligaments are stretched & tight Greater bone surface area contact causing more joint stability MCP Extension Collateral ligaments are lax & loose Less bone surface contact causing less joint stability Why is it an Important Position? “It is well known that the MCP develop an extensor contracture if they are held in extension for as little as 3 weeks” (James, 1970)
- 8. Anatomy of the IP Joints IP joints are hinge joints IP Flexion: Collateral ligaments are lax & loose Fibers between the collateral ligament & palmar plate contract IP Extension Collateral ligaments are stretched & tight Volar plate is maximally stretched Why is it an Important Position? “It is easier to regain flexion than extension at the PIPJ after a period of immobilisation” (Hardy,2004)
- 9. When should it be used? Fractures Metacarpals (neck, head, shaft) Phalanges (proximal, excluding volar plate injuries) Tendon Injuries Flexor tendon (wrist in flexion not extension) Extensor tendon (depending on zone, surgery & surgeon’s advice) Nerve injuries (depending on level & type of injury) Burns (all hand burns unless indicated otherwise) Preventing scar contractures (following soft tissue injury & surgery) Hand replants (position depends on structures involved & surgeon’s advice) Corrective Splinting “MP joint stiffness with loss of flexion is the most common post operative soft tissue complication of P1 fractures. Therefore, protective splinting must rest the MCPJ in flexion.” (Hardy, 2004)
- 10. When should it be used?
- 11. How to splint in the POSI? Apply back slab or cast in usual manner then place one hand on the volar aspect of forearm and the other hand on the dorsum of the hand The splint should usually be applied to the volar surface (exception may be if a patient has a burn on the volar surface) Aim to achieve an ideal POSI as soon as possible, as changes to soft tissue can begin after just 3 days “Simple errors in the plaster for a Colles’ fracture which block flexion at the MCP joints, and similar minor errors give imperfect results in these patient. It cannot be stressed too much how rapidly these joints stiffen in the dangerous position even in young people, how irreversible the situation is even with activephysiotherapy, and how simple are the mistakes that lead to these difficulties” (James, 1970)
- 12. How to splint in the POSI?
- 13. Key Principles for Effective Splinting REDUCE Reduction of the fracture is maintained Eliminate contractures through positioning Don’t immobilise fractures more than 3 weeks Uninvolved joints should not be splinted in stable fractures Creases of the should should not be obstructed by the splint Early active tendon gliding is encouraged Unpublished work by Greer, 1998. Splinting for closed metacarpal fractures. 4th International Congress of IFSHT. Vancouver, BC: International Federation of Societies for Hand Therapy. As cited in Hardy, 2004)
- 14. Key Points to Take Home Incorrect positioning during periods of immobilisation can lead to shortening of the collateral ligaments, which results in hand stiffness & contractures Hand stiffness & contractures can lead to significant loss of hand function The POSI allows the collateral ligaments to be in a position of stretch, which limits shortening The POSI can be used for a wide range of hand related injuries & conditions The hand should be placed in the POSI as soon as possible to prevent stiffness & contractures Early referral for hand therapy is vital in preventing unnecessary hand stiffness & contractures
- 15. Any Questions? “Any hand injury is incomplete without appropriate rehabilitation in the post repair/reconstruction period” (Karunadasa, 2015)
- 16. References Boscheinen-Morrin, J., & Conolly, B. (2003). The Hand: Fundamentals of Therapy (3rd ed.) Elsevier Science Limited, Avon, Great Britain. Bueno, E., Benjamin, M., Sisk, G., Sampson, C., Carty, M., Pribaz, J., Pomahac, B., & Talbot, S. (2014). Rehabilitation following hand transplantation. Hand. 9, 9-15. Bruner, J. (1963). Problems of postoperative position & motion in surgery of the hand. Journal of Bone & Joint Surgery. 35A(2), 355-366. Cooper, C. (2007). Fundamentals of Hand Therapy: Clinical Reasoning & Treatment Guidelines for Common Diagnoses of the Upper Extremity. Mosby Elsevier, Missouri, USA. Dean, B., & Little, C. (2010). Fractures of the metacarpals & phalanges. Orthopaedics & Trauma. 25(1), 43-56. Hardy, M. (2004). Principles of metacarpal & phalangeal fracture management: A review of rehabilitation concepts. Journal of Orthopaedic & Sports Physical Therapy. 34(12), 781-799. James, J. (1970). Common, simple errors in the management of hand injuries. Proceedings of the Royal Society of Medicine Journal. 63, 69-71. Karunadasa, K. (2015). Management of the injured hand- basic principles in rehabilitation. The Sri Lanka Journal of Surgery. 33(2), 25-28. Kucynski, K. (1968). The proximal interphalangeal joint: Anatomy & causes of stiffness in the fingers.The Journal of Bone & Joint Surgery. 50B(3), 656-663.
- 17. References Markiewitz, A. (2013). Complications of hand fractures & their prevention. Hand Clinic. 29, 601-620. Moran, C. (1989). Anatomy of the hand. Journal of the American Physical Therapy Association. 69, 1007-1013. Rath, S. (2011). Hand kinematics: Application in clinical practice. Indian Journal of Plastic Surgery. 44(2), 178-185. Schreuders, T., & Prosser, R. (No Date). Fractures, luxation & ligament teasr of the hand & wrist. Erasmus University Rotterdam the Netherlands & Sydney Hand Therapy & Rehabilitation Centre Australia. Retreievd from www.handweb.nl/uploads/files/docus/fractures_and_luxation.pdf on 31st August, 2015. Schreuders, T., Brandsma, J., & Stam, H. (2006). The intrinsic muscles of the hand: Function, assessment & principles for therapeutic intervention. Physikalische Medizin Rehabilitationsmedizin Kurortmedizin . 16, 1-9. Sprague, M. (1975). Proximal interphalangeal joint injuries & their initial treatment. The Journal of Trauma. 15(5), 380-385. Taams, K., Ash, G., & Johannes, S. (1996). Maintaining the safe position in a palmar splint. Journal of Hand Surgery, British & European Volume. 21B(3), 396-399. Tavassoli, J., Ruland. R., Hogan, C., & Cannon, D. (2005). Three cast techniques for the treatment of extra-articular metacarpal fractures: Comparison of short-term outcomes & final fracture alignments. Journal of Bone & Joint Surgery, American Volume. 87, 2196-201.
- 18. 1- Main Collateral Ligament; 2- Accessorry Collateral Ligament; 3- Volar Plate
Notes de l'éditeur
- The POSI position refers to a position used to rest the hand during periods of immobilisation. It was identified as an important position by John Ivor Pulsford James, a Professor of orthopaedic surgery. He recognised in the early 1960’s that the MCP joints recover better from a period of immobilisation when placed in flexion and the IP joints recover better when in extension. Since then, there have been many different names used to refer to this particular position and extensive research emphasising the importance of this position.
- The POSI Position is where the wrist is held in moderate extension (10-45), MCP joints in flexion (70-90) and PIP joints in neutral. The exact degrees can vary slightly depending the on reason for splinting and conditions of the persons hand (e.g. injury, surgery, existing problems) Can I get everyone to hold their hand up in this position?
- Who is familiar with this type of hand position? What can you tell me about it? When might you see this happen? What are the problems with this? We know that excessive immobilisation, incorrect positioning, trauma, inflammation, infection, disease, joint degeneration can all lead to joint stiffness and contractures. One of the biggest problems with joint stiffness and contractures is that it can result in significant deformities that can lead to functional disability. That is, a person may no longer be able to do their day to day activities independently and can end up having to rely on someone else for assistance. As Professor James recognised, by using the intrinsic plus position for periods of immobilisation, we are able to minimise and prevent joint stiffness & contractures from occurring. When active motion is not permitted after an injury or surgery and oedema is present, preventing the development of contractures is critical We know that swollen joints predictably move into positions that permit the greatest expansion of the joint capsule & collateral ligaments, and that injured hands will tend to rest in its weakest position. Therefore, as oedema increases the hand typically moves into a position of wrist flexion, MP extension, IP flexion & thumb adduction. (Hardy, 2004) This position is also referred to as the claw and it can be extremely difficult and sometimes even impossible to correct, especially the longer the hand is in this position. This should never really be a position that an injured hand should be held in. Can I get everyone to make a claw position and now the POSI position?
- To understand why the POSI position is important for preventing contractures and deformities during periods of immobilisation, we must understand several key things about the anatomy of the fingers. As a very quick overview of the basic anatomy, we know that The bones include the MC, PP, MP, and DP. The joints involved are the MCPJ, PIPJ and DIPJ The structures that provide support to these joints include the joint capsule, volar/palmar plate, collateral ligaments and the extensor hood I’m going to focus on the collateral ligaments and volar plates as they are the key structure involved in the POSI position
- The metacarpal joint is shaped in a way that allows movement in two planes, allowing for abduction, adduction, and rotation, as well as flexion and extension. Because of this movement it is classified as an ellipsoid joint. The collateral ligaments are positioned laterally and dorsal to the axis of rotation of the MCP joint. This particular positioning of the collateral ligaments allows for variable degrees of tightness on the ligaments based on the position of the joint. When the joint is in extension, the collateral ligaments are lax. In flexion, the collateral ligaments span a greater distance and are tight Evidence has shown us that MCP joints recover well from being in a position of flexion because the ligaments are held in a position of stretch which prevents shortening But also because of the stable position the metacarpal head & volar plates are in when in flexion. (as you can see in the top diagram)
- Whilst a position of flexion is required to prevent MCP joint stiffness, the opposite if required to prevent IP joint stiffness. Again, this is due to the shape of the phalangeal head, volar plate & collateral ligament anatomy. The IP joint is a hinge joint, allowing only flexion and extension. In comparison to the MCP joints, The PIP joint collateral ligaments originate close to the axis of rotation, providing a smaller change in length with joint position and providing lateral stability. The trochlear shape of the PIP joint also adds to its lateral stability. Research performed on cadavers' has shown that the volar plate of the IP joint is maximally stretched when in extension, and this prevents the volar plate from moving proximally which can lead to further joint complications (Splinting- Final) The final position involved in the POSI position, although it is not as significant as the MCP and IP joints, is that of the wrist. Research has shown that by keeping the wrist at an angle of 30 extensions it facilitates maintaining the POSI position as it relaxes the long extensor tendons and the dorsal skin of the hand (Hand Kinematics) allowing the MCPs to remain in a flexed position more easily. If the wrist is in flexion it is harder to achieve MCP flexion. Let’s try this. Hold your hand up with you wrist in extension, now make a fist. Pretty easy right? Now relax your hand and move your wrist into flexion, now make a fist. There is much more tightness over the dorsal part of the hand and it is harder to make a tight fist. So you can see that having the wrist in extension makes it easier to maintain MCP flexion
- The POSI position is used for many different types of hand conditions and injuries due to it’s ability to prevent stiffness and contractures during periods of immobilisation. It can be used for many fractures of the Metacarpals and Phalanges and soft tissue injuries Metacarpal neck fracture- MCP 70° flexion – tight collateral ligaments will stabilise MCP head in place Flexor tendon- depends on specific protocol – approximately wrist 20-30 flexion, MCP 50-60 flexion, IPs neutral
- Here is an interesting case study from Professor James, 1970, the surgeon who identified the IPP. It goes to show how important positioning is even if the period of immobilisation is only relatively short Examples of when we don’t use it: when we are resting the joints due to pain caused by arthritis or CRPS, after Dupuytren’s release (hand is in full extension to counteract scar contracture),
- Splinting in the POSI position can be achieved several different ways and using different types of materials. But the key thing to remember is that the hand must have the MCPs flexed and the IPs in extension, to ensure that the collateral ligaments are being stretched. Incorrect immobilisation can lead to shortening of the collaterals, and if you feel the person’s hand is not in an ideal intrinsic plus position it is important to correct the position as soon as possible. As changes to soft tissue can begin after 3 days. It is recommended to apply the splint to the volar surface of the hand and to use your own hands to emphasis and achieve the position.
- Here are some examples of splints used to achieve an IPP for different situations The metal splint used for fracture of the proximal phalanx of the finger (James, 1970)