orthosis description and types

1. ORTHOSIS OF HAND
SUBMITTED TO : Dr. SHABNAM JOSHI
SUBMITTED BY : MANOJ PUROHIT
170171720001

2. ORTHOSIS
• A force system designed to control, correct or
compensate bone deformity, deforming forces or
forces absent from the body.
• Derived from the Greek word ORTHO meaning
straight, upright or correct.
• Orthoses are devices applied externally to
restore or improve functional and structural
characteristics of the musculoskeletal and nervous
systems.

3. General Classification
Orthosis Type
• Static
• Dynamic
• Hybrid
Regional Classification
• Volar or Dorsal
• Joints crossed
 Finger / thumb splint
 Wrist Splint
 Wrist Hand Orthosis

4. Functional
• Corrective
• Supportive
• Protective
• Orthosis which strengthen certain group of muscle
E.g. Tenodesis Splint
• Relief of pain
• Prevent weight bearing
• Facilitate Motion

5. BIOMECHANICAL PRINCIPLES
1) Three Point Pressure
2) Mechanical Advantage
3) Torque
4) Degree and Duration of Stress
5) Repetitive stress
6) Control Normal force across the joint
7) Control Axial Force across the joint
8) Control line of action of Ground reaction force

6. 1) THREE POINT PRESSURE: (JORDAN’S Principle)
• A three-point pressure system consists of three
individual linear forces in which middle force is directed
in opposite direction to the other two forces.
• It is multiple direction force where one force
immobilize one joint and mobilize the other joint.
Example: cock-up splint

8. 2) MECHANICAL ADVANTAGE:
• Splint incorporate lever system, which incorporate
forces, resistance, axes of motion and movement arm.
• Example:
Volar based wrist cock-up splint for mechanical
advantage forearm length is made longer so that splint
has better pressure distribution support and
comfortability.

9. 3) DIRECTION OF STRESS:
• There are three direction of force to act:
 Tension
 Compression
 Shear

10. 4) TORQUE:
• It is biomechanical principle defined as rotational effect
of mechanism.
• Torque is the production of the applied force multiplied
by perpendicular distance from the axis of rotation to the
line of application.
• Most important for dynamic splint.

12. 4) DEGREE AND DURATION OF STRESS :
• Generally low stress can be tolerated for longer period
of time, whereas high stress over long period of time
cause damage.
• Therapist must remember the least stress is tolerated
by the skin.
•Skin become ischemic if load increases.
• Distribution of stress is most important for long term
wearing of orthosis.

13. 5) REPETITIVE STRESS:
•If repetitive stress is applied in moderate amount may
lead to breakdown and damage to skin.
• So to avoid that traction must be release to avoid
unnecessary tension and well distributed pressure.
6) CONTROL NORMAL FORCE ACROSS THE JOINT:
Now two free, body load carrying bones when subjected
to ground reaction force are free to rotate that are
maintained in extension this is normal joint is
maintained by capsule and ligaments.
But in abnormal joint we require orthosis to correct it.

14. 7) CONTROL AXIAL FORCES ACROSS A JOINT:
• In normal healthy individual load is carried through
bony structures and layers of articular cartilage which
have immense strength to bear this weight.
• Now due to some degenerative change the integrity of
this structure is lost which will cause excessive
compression on joint.
• So, orthosis is used to offload the joint. This process of
offloading
depends on two thing:
 How the orthosis is fitted
 Orthosis and body segment interface

15. 1) The orthosis here is incorporated as rigid orthosis
framework and strapping it at the end of two limb
segment which would divide the force into half.

16. 2) The second criteria is the transfer of load across skin
and orthosis solely depend on friction of orthosis and
underlying skin.

17. 8) CONTROLS ACTION OF GROUND REACTION FORCE:
• This principle is only applicable to lower limb orthosis.
In normal joint line of gravity passes from front of Hip,
back of knee, front of ankle.
• Now due to some asymmetric movement for this
pattern, GRF is altered so we need a orthosis for its
correct alignments.
• In this case orthosis management would be moving the
line of gravity to center that is close to joint line.
•Which can be achieved by modifying the limb movement
during gait.

18. COCK-UP SPLINT
It is static in nature.
• Common Name:
1) Volar/Palmar Wrist splint
2) Volar Wrist Cock up splint
3) Wrist Immobilization Splint
4) Drop Wrist Splint
5) Carpal Tunnel Splint
6) Wrist Extension Immobilization Splint
• Objectives:
1) To reduce Pain and Inflammation
2) To protect against joint damage
3) To promote hand function
4) To prevent or correct contractures
5) To provide base for Outriggers

19. • Indications:
1) Tendinitis/Tenosynovitis of wrist tendons
2) Joint Inflammation such as Rheumatoid Arthritis
3) Skin Graft
4) Unstable Wrist Joint
5) Wrist Sprain
6) Weak/Paralyzed Wrist Extensor
7) Congenital Hand Deformity
8) Volar style for flexion outriggers
9) Dorsal style for extension Outriggers

21. GAUNLET IMMOBILIZATION SPLINT
Common Name: Circumferential working Splint
• Objectives:
1) Greater wrist stability
• Indications:
1) An evaluation tool before wrist arthrodesis
2) To immobilize and stabilize a fracture of radius or
base of Metacarpal

22. DYNAMIC WRIST EXTENSION SPLINT
• Objectives:
1) To Passively extend the wrist while allowing active
wrist flexion
2) To prevent contracture of unopposed innervated wrist
flexors
• Indications:
1) Weak or Paralyzed wrist Extensors (e.g.. Radial Nerve
Palsy)

23. STATIC WRIST WRITING/PAINTING ORTHOSIS
Common Name: Wrist Splinting
• Objectives:
1) To enable writing, drawing or painting by positioning
wrist in functional extension and providing attachment
of pen, pencil , eraser etc.
• Indications:
1) Spinal Cord Injuries at level C5 or above where wrist
extensors Paralyzed

24. RADIAL THUMB GUTTER SPLINT
• Objectives:
1) To immobilize wrist, thumb CMC, MCP Joints, which
are crossed by inflamed tendons
2) To rest and reduce inflammation
• Indications:
1) De Quervain’s tenosynovitis: Inflammation of tendon
of abductor polices longus and extensor polices brevis in
their synovial sheath.

25. DYNAMIC MCP FLEXION SPLINT
• Objectives:
1) To gently stress the MCP collateral ligaments to
promote desired growth and increase flexion range
• Indications:
1) Extension contracture of MCPs caused by
shortened collateral ligaments

26. RESTING HAND ORTHOSIS
It is Static or Serial Static type of splint.
• Objectives:
1) To immobilize the wrist, MCPs, and IPs of Finger and
thumb
2) To reduce or prevent contractures
3) Reduce pain and inflammation
• Indications:
1) Scleroderma
2) Dupuytren’s release
3) Boxer’s fracture (Base of 5 MCP fracture)
4) Burns
5) Inflammatory joint disease
7) Crush injury

28. ANTISPASTICITY SPLINT
Common Name: dorsal volar hand splint
• Objectives:
1) To immobilize wrist, MCP, IP
2) To prevent and reduce contracture
3) To reduce tone of hypertonic muscles
• Indications:
1) Hand Trauma or surgery

29. TENODESIS SPLINT
• Objectives:
1) To train a tenodesis grasp
2) To promote tripod pinch
• Indications:
1) Quadriplegia at level of C6 with at least grade 3
strength of the wrist extensors
• This splint is a functional aid for such patient which
uses extensor carpi radialis muscle giving potential grasp
by reciprocal wrist extension and finger flexion.

31. KLEINERT SPLINT
It allows protective flexion of MCP and IP and Blocks
Extension of MCP.
• Objectives:
1) To position wrist in static flexion and passively flex
the MCP and IP while permitting limited active
extension of wrist and MCP and full extension of IP.
• Indications:
1) Flexor Tendon Laceration in zone 2.

33. EXTENSOR TENDON REPAIR SPLINT
• Objectives:
1) To position wrist in static extension and passively
extend the MCP and IP while permitting limited active
flexion of MCP.
• Indications:
1) Extensor tendon Laceration.

34. METACARPAL FRACTURE BRACE
Common Name: Metacarpal(fracture) Brace
• Objective: To stabilize MC fracture to promote healing.
• Indication: Midshaft fracture of third, fourth or fifth
metacarpal.

35. STATIC ULNAR DEVIATION SPLINT
Common Name: MCP protection splint, static ulnar
drift/deviation splint, metacarpal ulnar deviation
orthosis, trigger finger splint, blocking splint
1)Joint Inflammation: To promote restabilization of
tendon to restraints at MCPs, To prevent or correct ulnar
drift of MCP
2) Trigger Finger: To block MCP Flexion and limit
excursion of long finger flexor. By subsiding irritation at
A1 pulley and inflammation subside.

36. 3) Surgical release of Dupuytren’s Contracture
To maintain surgical gained extension.
4) Intrinsic muscle tightness and extension contracture:
To block MP joint so FDP and FDS can actively stretch IP
joint and intrinsic muscle.
5) MC head fracture for stabilization.

37. DYANAMIC MCP EXTENSIION SPLINT
• Objectives: To passively extend MCP to 0* extension
and allow active flexion movement and IP movement.
• Indication: Radial nerve injury when reinnervation
reach to wrist
•Repair of extensor tendon rupture, extensor
contracture

38. STATIC ANTICLAW DEFORMITY SPLINT
Common: Static Anticlaw deformity splint, static ulnar
nerve splint
• Objective: To stabilize the fourth and fifth MCPs in
flexion.
To correct fourth and fifth MCPs hyperextension
To prevent shortening of MCP Collateral Ligament
To promote active IP Extension
• Indication: Ulnar Nerve Lesion

40. DYNAMIC MEDIAN-ULNAR NERVE SPLINT
Common Name: Dynamic anticlaw deformity splint,
dynamic median/ulnar nerve splint, spring wire knuckle
bender.
• Objectives: To passively flex the MCP of fourth and fifth
finger and to allow active extension.
To correct Hyperextension
To prevent shortening of MCP
To promote active IP Extension
• Indication: Combined median and ulnar nerve lesion at
level of wrist.

42. FLEXION BLOCKING SPLINT
Common Name: Blocking Splint
• Objective: To Block MCP and PIP so that the flexor
digitorium profundus can actively stretch DIP to
increase the flexion range of motion
• Indication: Extension contracture of DIP Joint

43. FINAL FLEXION SPLINT
Common Name: Final Flexion Splint
• Objectives: To progressively flexion MCPs IPs in
composite flexion applying gentle
prolonged stretch to contracted tissue.
• Indication: Contracture of extrinsic Extension Tendon,
IP Extension Contracture.

45. SHORT DORSAL OUTRIGGERS
• Objective: To apply gentle prolonged stretch to the
contracted PIP capsule and ligaments to promote growth
of the shortened tissues and restore extension ROM.
• Indication: Flexion Contracture Of PIP joint

46. TRAPPER
Common Name: Buddy splint, trapper
• Objectives: To strap affected finger to an unaffected
finger at proximal middle phalanges
To stabilize finger
To provide passive movement of affected joint by moving
unaffected finger
• Indication: PIP Collateral ligament injury
flexor tendon reconstruction and PIP flexion

48. PIP EXTENSION SPLINT
It is a extension blocking static splint.
Common Name: Swan Neck Deformity splint, PIP
hyperextension splint, Fiqure of eight splint
• Objective: Index finger PIP extension restriction
• Indication: Swan Neck Deformity, (caused by: RA,
Trauma, intrinsic muscle tightness, Dorsal migration of
extension mechanism,)
Trigger finger

49. CAPENER SPLINT
• Objective: Index finger pip extension mobilization
• Indication: PIP flexion contracture, PIP dislocation,
Volar plate injury, flexor tendon repair partial or
complete tear of collateral ligament,
• Boutonniere Deformity

50. SHORT OPPONENCE ORTHOSIS
• Objective: To relieve CMC pain
To immobilize CMC and MCP
To position the thumb in functional opposition
To correct first web space
• Indication: Inflammation of CMC or injury
CMC Arthroplasty, Median nerve injury, Quadriplegia

52. GENERAL PRINCIPLES
• Use of forces:
• Orthosis utilises forces to limit or assist movements
 Rigid material spanning a joint prevents motion,
e.g posterior tube splint
 A spring in a joint is stressed by one motion and
then recoils to assist, the opposite desired motion.
E.g. leaf spring orthosis
• Limitation of movement: Limiting motion may reduce
pain.
• Correcting a mobile deformity: a flexible deformity may
be corrected by an orthosis. Corrective forces must be
balanced according to principle of Jordan.

53. • Fixed deformity: if the fixed deformity is
accommodated by an orthosis, it will prevent the
progression of deformity.
•Adjustability: orthotic adjustability is indicated for
children to accommodate their growth and for patients
with progressive or resolving disorders.
• Maintenance and cleaning: the orthosis should be
simple to maintain and clean.
• Application: the design should be simple for easy
donning and doffing.
• Sensation: An orthotic device does not provide
sensation, in fact it often covers skin areas and decreases
sensory feedback.

54. • Comfort: The Orthosis should be comfortable. Pressure
should be distributed over the largest area possible.
• Utility: the Orthosis must be useful and serve a real
purpose.
• A well functioning opposite extremity is a major
deterrent to the use of an upper extremity orthosis as
most activities can be performed with the good hand.
• Gravity: Gravity plays an important role in upper limb
orthosis, especially in those joints where the heaviest
movement masses are present.
• Cosmesis: Cosmesis is important especially in hand
orthosis. A functional but unsightly orthosis is often
rejected if the patient values appearance over function.

55. CONTRAINDICATIONS
• Skin infections.
• When the muscle power is very much affected by the
weight of the orthosis.
• In case of severe deformity which cannot be
accommodated in the orthosis.
• If it limits the movement at other normal joints.
• Where the orthosis interferes grossly with clothing or
limits other functions.
• Lack of motivation or other psychological problems
• Very young or old patients.

56. PHYSICAL THERAPY INTERVANTION
• Assessment
• Pre-orthotic assessment and prescription evaluate:
• Joint mobility
• Sensation
• Strength and motor function
• Functional level
• Psychological status
• Orthotic prescription
• Consider the patients abilities and needs
• Level of impairments, functional limitations, disability
• Status: consider if the patient’s condition is permanent
or changing

57. • Consider level of function, current lifestyle.
• Consider if the patient is going to be a community
ambulator versus a household ambulator.
• Consider recreational and work related needs.
• Consider overall weight of orthotic devices, energy
capabilities of the patient. Some individuals abandon
their orthoses quickly in favor of wheelchairs because of
the high energy demands of ambulating with orthosis.
• Consider manual dexterity, mental capacity of the
individual. The donning and use of devices may be too
difficult or complicated for some individuals.

58. Orthotic Assessment check out
• Ensure proper fit and function; construction of the
orthosis.
1. Static assessment
2. Dynamic assessment
• Fit and function during activities of daily living,
functional mobility skills.
• Fit and function during gait.
• Consider the pressure tolerance of the skin and tissues.
• Consider use of a temporary orthosis to assess
likelihood of functional independence, reduce costs.

59. ORTHOTIC TRAINING
• Instruct the patient in procedures for orthotic
maintenance: routing skin inspection and care.
• Ensure orthotic acceptance
• Patients should clearly understand the functions,
limitations of an orthosis.
• Can use support groups to assist
• Teach proper application (donning-doffing) of the
orthosis, teach proper use of the orthosis.
• Balance, gait and functional activities training.
• Reassess function and construction of the orthosis at
periodic intervals; assess habitual use of the orthosis.

60. RECENT ADVANCES
1.) Pilot Study Combining Electrical Stimulation and a Dynamic
Hand Orthosis for Functional Recovery in Chronic Stroke.
Barbara M. Doucet and Joni A. Mettler
OBJECTIVE. We investigated the effect of a combined
neuromuscular electrical stimulation (ES) and dynamic hand
orthosis (DHO) regimen with a group of people with chronic stroke
to improve performance on specific daily tasks.
METHOD. Four people with chronic stroke participated in an ES–
DHO regimen using the affected upper extremity 5×/wk for 6 wk.
Outcome measures included grip strength, range of motion (ROM),
and analysis of muscle activation–deactivation during release of
grasp through electromyography. Ability to perform specific daily
living tasks was assessed using the Assessment of Motor and Process
Skills (AMPS).

61. RESULTS. Results suggested that improvements in strength, ROM, and
grasp deactivation are possible with the combined ES–DHO regimen. All
participants’ AMPS motor scores improved.
CONCLUSIONS. An ES–DHO regimen may improve motor skills needed for
functional task performance in people with chronic stroke. Results should
be interpreted cautiously because of the pilot nature of the study and the
small sample size.

62. Introduction: People with Duchenne muscular dystrophy are
currently in need of assistive robotics to improve their hand
function and have a better quality of life. However, none of
the available active hand orthoses is able to address to their
specific needs.
Methods: In this study, the use of hydraulic technology is proposed
in the design of an active hand orthosis.
Commercially available components were used to identify where
customization is necessary for a new electrohydraulic hand orthosis.
2.) Design of an electrohydraulic hand orthosis for people with
Duchenne muscular dystrophy using commercially available
components
Ronald A. Bos1, Kostas Nizamis2, Dick H. Plettenburg1, Member,
IEEE, and Just L. Herder3, Member, IEEE

63. The presented prototype was able to move four finger modules with
a single actuator. The finger modules were separable and had a total mass of
only 150 g, whereas the valve manifold added another 250 g.
Results revealed that the prototype was able to function well with full
flexion/extension cycles up to 2 Hz, but with hysteretic losses between 37–
81% of the total input energy. Specialized valves and slave cylinders are
required to increase efficiency at higher speeds and to obtain more robust
sealing performance.

64. REFERENCES
• Textbook of Rehabilitation: S Sunder
• Physical Rehabilitation: Susan B. O’Sullivan
• Orthotics in Rehabilitation: Pat Mckee and Leanne
Morgan
• Splinting: Brenda M Coppard and Helene Lohman
• Orthotics and Prosthetics Rehabilitation: Michelle M
Lusardi and Milgros George
• DELISA’S physical medicine & rehabilitation
PRINCIPLES AND PRACTICE 5th EDITION

65. THANK YOU