upper limb

1. Upper Limb
orthotic devices
DEPT. OF PMR
AIIMS RISHIKESH
DR ADITI(JR 3)

2. Contents :
Definition and principles
Biomechanical and anatomic considerations of hand
Nomenclature
Classification
Diagnostic categories and orthotic devices

3. DEFINITION AND PRINCIPLES
An externally applied device to an existing body part used to modify the structural and
functional characteristics of neuromuscular- skeletal system .
PRINCIPLES:
1) Protection
2) Correction
3) Assistance with function

4. Biomechanical and anatomic
considerations of hand
In regard to biomechanical motion, the hand has 7 maneuvers that make up most hand
functions.
PRECISION GRASP

5. POWER GRASP

6. 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 20 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

7. When increasing joint ROM with splinting, the angle of pull needs to be perpendicular to the
axis of bone that is being mobilized.
Total end range time principle, is that the improvement in ROM is directly proportional to the
length of time a joint is held at its end range.

8. 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

9. INTRINSIC HAND
Impairment can be due to intrinsic palsy (intrinsic minus hand) or intrinsic contracture (intrinsic
plus hand).
Trauma is the most frequent cause of intrinsic contracture, which can be associated with
metacarpal fractures or increased edema and vascular impairment, as happens with
compartment syndrome. This causes lead to adhesion formation and fibrosis of the intrinsic
muscles and tendons.
Other causes of intrinsic contractures include neurologic or spastic hand secondary to an upper
motor neuron syndrome (cerebrovascular accident, cerebral palsy, traumatic brain injury,
Parkinson’s disease), rheumatoid arthritis, osteoarthritis, and arthrogryposis.
Traumatic injury to the ulnar nerve is the most frequent cause of intrinsic palsy. Other causes
include nervous entrapment along its path in the arm (compression neuropathy), compartment
syndrome, central nervous system diseases, rheumatoid diseases, Leprosy (Hansen disease),
rheumatoid arthritis, Charcot-Marie-Tooth disease, and prolonged immobilization, failure to
splint a crush-injured hand using intrinsic plus posture.

11. 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(IOS): 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
FLEXION IMMOBILISATION
SHOULDER-ELBOW-WRIST-
HAND ORTHOSIS
SWAN NECK SPLINT INDEX FINGER PIP
EXTENSION RESTRICTION
FINGER ORTHOSIS

12. 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

13. 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

14. 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

15. 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

16. STATIC MOTION BLOCKING: The static motion blocking orthosis permits motion in one direction
but blocks motion in another
swan neck splint

17. 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.

18. DYNAMIC
Within elastic limits, the stress from a mobilization splint can positively affect the gradual
realignment of collagen fibers (resulting in increased tensile strength of the tissue) without
causing microscopic tearing of the tissue. The ability to alter collagen formation is greatest
during the proliferative stage of wound healing but continues to a lesser degree for several
months during scar maturation.

19. 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 refers to the applied force and Fr refers to
the resistance force. Fm is determined by 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, meaning
that the lever arm of the applied force is at
least twice as long as the lever arm of the
applied resistance

20. Torque is defined as the effect of force on the rotational
movement of a point.
The amount of torque is calculated by multiplying the
applied force by the length of the moment arm.
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. This force is called torque because it acts on the
rotational movement of a joint.

21. Application Of Force
In dynamic splinting, the force to a joint or
finger is applied through the application of nail
hooks, finger loops, or a palmar bar.
 When applying force to increase passive
joint range of motion, the therapist must keep
the 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

22. Outriggers
nylon string to attach finger loops to the source of tension.
A turnbuckle
Velcro tabs used for static progressive tension

23. DYNAMIC: Finger extension orthosis, which uses a spring coil or wire tension assist

24. DYNAMIC MOTION BLOCKING: Allows certain motions but blocks others. It allows early
mobilization through passive movement to prevent contractures

25. DYNAMIC TRACTION: Offers traction to a joint although allowing controlled motion

26. 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

27. CONTINUOUS PASSIVE MOTION: Electrically powered devices that mechanically move joints
through a desired range of motion

28. 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

29. 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

31. FRACTURES
These devices should immobilize the body part or joint sufficiently to promote healing while
also optimizing function

32. 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

33. 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

34. low median and ulnar nerve injuries, leaves the patient with no or weakened ability to place
the thumb in opposition and palmar abduction

35. 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.

36. 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.

37. 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.

39. 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.

40. 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.

41. CARBON COMPOSITES

42. THERMOPLASTICS

43. FOAMS AND GELS

46. 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.

47. CAD/CAM

48. THANK YOU