Comparison of custom-made and prefabricated neoprene splinting In patients with the first...

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Disability and Rehabilitation: Assistive Technology, 2013; 8(3): 232–237© 2013 Informa UK, Ltd.ISSN 1748-3107 print/ISSN 1748-3115 onlineDOI: 10.3109/17483107.2012.699992

Aim: The objective of this study was to compare the effect of prefabricated and custom made thumb splints on pain, function, grip strength and key pinch in patients with basilar joint osteoarthritis. Method: Volunteer patients (n = 35) with first carpometacarpal joint osteoarthritis were assigned randomly to wear either a prefabricated or custom-made thumb splint or assigned to a control group. This was designed as a cross over study with two 4-week treatment periods, 2 weeks of wash out time for intervention groups between the test conditions and 10-weeks follow-up for the control group. All parameters were measured at the first visit and during the 4th, 6th and 10th weeks in the three groups. Results: In the control group, pain increased and pinch strength decreased but no statistically significant differences were found in function and grip strength. Both splints changed grip strength with no significant differences between them. Pain was reduced with the splints, and functions and pinch strength increased significantly as compared to the baseline and control groups. In comparing the two splints only significant differences were observed in pain. Conclusion: In comparing two splints, pain was the only significantly different parameter between tested parameters; with the custom-made splints demonstrating better results in pain reduction.

Keywords: First carpometacarpal joint osteoarthritis, prefabricated thumb splint, custom made thumb splint, function, grip strength

Introduction

Osteoarthritis is the most common joint disease that may result in loss of bone cartilage and is one of the main causes of disability and illness [1]. It can also result in a decreased joint space and significant deformity [2]. The most common site of

osteoarthritis in the upper extremity is in the joints of the hand [3,4]. Although these joints are less-commonly involved when compared to hip and knee joints, there is a high prevalence of this injury in people over 55 years of age. In the hand, after the distal finger joint, the most common site of osteoarthritis is the first carpo-metacarpal joint (otherwise known as the trapeziometacarpal or basilar joint) [5]. Thumb carpo-metacarpal joint arthritis affects 20% of men and women over 40 years of age [3]. The occurrence rate of this problem has been quoted as being 44–85% in people aged between 55 and 75 years old with one or more of their joints being affected [1]. Between 45% and 60% of hand functions involve the thumb, which means that any improvement in hand function helps patients to participate more effectively in activities of daily living and helps to improve their quality of life. A high level of disability has been reported in those patients with thumb carpometacarpal joint osteoarthritis [5,6].

Pain, joint stiffness and decreased function of the thumb are commonly seen symptoms of thumb carpo metacarpal joint osteoarthritis. These symptoms begin with stiffness or decreased range of motion [7]. Pain may be experienced in the

PRODUCTS AND DEVICES

Comparison of custom-made and prefabricated neoprene splinting in patients with the first carpometacarpal joint osteoarthritis

Monireh Ahmadi Bani1, Mokhtar Arazpour1, Reza Vahab Kashani1, Mohammad Ebrahim Mousavi1 & Stephen William Hutchins2

1Department of Orthotics and Prosthetics, University of Social Welfare and Rehabilitation Science, Tehran, Islamic Republic of Iran and 2 Faculty of Health and Social Care, University of Salford, IHSCR, Salford, UK

Correspondence: Mokhtar Arazpour, Student Research Committee, University of Social Welfare and Rehabilitation Science, Tehran, Islamic Republic of Iran. E-mail: [email protected]

Disability and Rehabilitation: Assistive Technology

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© 2013 Informa UK, Ltd.

10.3109/17483107.2012.699992

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Custom-made and prefabricated neoprene splinting in patients

M. Ahmadi Bani et al.

31May2012

• A high level of disability has been reported in those patients with thumb carpometacarpal joint osteoarthritis.

• Custom-made and prefabricated neoprene splinting is an effective method to improve pain, pinch strength and function by patients with the first carpometacar-pal joint osteoarthritis.

• The custom made splint demonstrated better results in pain reduction.

Implications for Rehabilitation

(Accepted May 2012)

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Custom-made and prefabricated neoprene splinting in patients 233


areas above and below the affected region. These symptoms are increased when undertaking activities such as pushing objects. Muscle atrophy and loss of power are other problems that cause reduced functional ability amongst patients, and 74% of patients with thumb carpometacarpal osteoarthritis have difficulty in performing their activities of daily living [4,8]. Different methods of treatment involve the use of drugs, surgery and conservative procedures [9,10].

The primary goals of conservative treatment in such patients are to reduce pain; improve joint space, improve thumb per-formance and function and increase both grip strength and pinch, in order to enable an increase in their activities of daily living and in their quality of life. This joint is the most com-mon site involved in surgery in the upper extremity [11], but many patients also suffer from chronic pain and instability even after successful surgery [12,13]. Conservative approaches may therefore be more effective than surgery in the treatment of early stage of osteoarthritis [13].

The use of splinting is one conservative method [9,10], which aims to stabilize the thumb carpo-metacarpal joint and prevent its movement during catching and pushing. Splints are not designed to alter the involved structure, but namely to increase the patient’s function; reduce pain and slow the degradation process [4]. Neoprene-prefabricated soft splints and short thermoplastic custom made splints are the most common type of splinting used in the treatment of basilar joint osteoarthritis [14,15].

Weiss and colleagues reported that a long prefabricated soft splint increased patient acceptance, reduced pain and increased performance in daily activities when compared to a short custom-made splint [15]. Buurke and colleagues stated that custom made splints interfered with the performance of the individual (especially in the elderly patients) and impeded the use of the hand [16]. McKee et al. and Colditz et al. both reported that immobilization of two adjacent joints is essen-tial to create sufficient stability to attain the optimal treatment outcome for carpometacarpal (CMC) joint osteoarthritis [13,17], but on the other hand, Colditz and colleagues, dem-onstrated that reduced patient compliance and acceptance can occur as a direct result of the joints being immobilized by an orthosis [17].

In addition, McKee and colleagues reported that wrist immobilization may cause fatigue syndromes and also overuse syndromes [13]. They therefore used a custom-made short thumb splint using low temperature molding material for the treatment of CMC joint osteoarthritis [13,17]. The study by Weiss and colleagues did not use a valid score to assess patients when using a 1-week intervention, nor did they use a control group. Kjeken et al. in a systematic review evalu-ated assistive technology in patients with hand osteoarthritis. They reported that the use of assistive technology significantly improved activity function and satisfaction of splint use in these patients, but they used only one type of splint in the study [18]. Rannou and colleagues, in randomized trial study, assessed the efficacy of a custom-made neoprene splint on patients with thumb osteoarthritis. They demonstrated that using a single splint design had no effect on pain at 1 month after being fitted, but improved pain and disability at 12

months [19]. A review by Egan et al. [20] demonstrated that CMC splints had not been evaluated against a control group, so there was no high quality evidence that they were effective in relieving symptoms at that time. However, two studies were carried out later [19,21] which did include control groups and provided high quality evidence that splints reduced pain, but did not seem to significantly affect function or pinch. The study by Gomes Carriera et al. demonstrated that a splint used for CMC osteoarthritis had a beneficial effect on pain but not on any other parameters measured such as function, grip strength or pinch strength [21].

Therefore, although several studies have been performed in this field, agreement on the most effective splint for this patient group does not therefore exist [14,15]. The objec-tives of this study were therefore to identify and compare the effect of neoprene soft prefabricated and low temperature custom-made thumb splints on pain, function, grip strength and key pinch in patients suffering from thumb CMC joint osteoarthritis.

Methods

Patients were referred with a diagnosis of grade 1 and 2 thumb carpometacarpal joint OA by an orthopedic surgeon to the Orthotics and Prosthetics department of University of Social Welfare and Rehabilitation Sciences. Referred patients were selected based on specific inclusion and exclusion criteria. Inclusion criteria were clinical and radiological diagnosis of thumb carpometacarpal joint OA grade 1 and 2 in either gen-der, with evidence of pain in the base of the thumb. Exclusion criteria included other deformities of the affected hand, defor-mities of thumb distal interphalangeal joint, use of a splint on the thumb during the previous 6 months, evidence of surgery on the studied hand in the previous 6 months, allergy to the splint material, or an inability to respond to a questionnaire or to perform the functional tests. Other exclusion criteria were evidence of injection therapy in the studied hand during the previous 6 months, and existence of other disease affecting the thumb or wrist (e.g. carpal tunnel syndrome, De Quatrains tendonitis, Dupuytren’s contracture, arthritis and fifth and sixth cervical vertebral disc herniation). Participants (n = 35) were randomly assigned to one of three groups; namely those using prefabricated thumb splints, custom made thumb splints or the control group. Subjects were randomized based on a computer-generated approach (block randomization, with variable sizes of the blocks, being 3 and 6). The random-ization codes were held by an independent observer to ensure masked blocking. The patients were randomly allocated to their groups after informed consent had been obtained and all baseline measurements were completed. The evaluator was not blinded to the treatment condition.

The study was designed as a cross-over with two 4-week treatment periods and a 2 week wash-out time for interven-tion groups [14,15] and a 10 week follow up period for those in the control group. The flowchart shows study design, and how patients received intervention and follow up in the groups (Figure 1). The Ethics Committee of University of Social Welfare and Rehabilitation Sciences approved the study.

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234 M. Ahmadi Bani et al.


The purpose of the splints was to stabilize the TMC joint, maintaining the pulp of the distal phalange of the index finger free for gripping with the other fingers and leaving the thumb in a functional position. In the prefabricated splint group according to patients hand size, we chose a previously manu-factured off the shelf (OTS) splint. The neoprene prefabricated thumb splint covered the first CMC and metatarsophalangeal joints and allowed a full range of motion in the other fingers. The material thickness of the splint was 3.5 mm.

The custom-made splint was constructed based on a pat-tern which matched the dimensions of the patient’s hand using low temperature-moulding material (Orfit Company, Inc Belgium) with a 1.6 mm thickness. After the splint had cooled, Plastazote with a 1.6 mm thickness was adhered to the inside the splint, and the splint then closed by Velcro on the patients’ hand. Patients in both groups received the splints on the first day after evaluation. The patients were asked to use the splints during their routine activities of daily living and to remove them during sleeping, bathing and in dangerous conditions which could be harmful for the splint material (e.g. when exposed to excessive heat). It was also explained how to clean the splints and how to use them. They were advised to call the therapist if they ever felt discomfort with splints.

Pain, function, grip strength and lateral pinch were mea-sured at the baseline and 4th, 6th and 10th weeks in the three groups. All tests conducted were by an orthosist who was trained to administer the tests. Pain was assessed using a visual analog scale (VAS). The average pain that the patients felt during the previous week was considered as a baseline point of pain. Function was measured via the Disability of the Arm, Shoulder and Hand (DASH) questionnaire. The DASH score has 30 questions that assess function and symptoms. It includes: physical function (two questions), symptoms of disease (six questions) and social aspects (three questions)

and two optional modules (four questions) for workers and athletes. Grip strength and key pinch were measured by dyna-mometer (Jamar Hydraulic Hand Dynamometer – PC 5030 J1) and Pinch Gauge (Jamar Hydraulic Pinch Gauge, model PC 7498-05). For assessment of patient’s grip and pinch strength, they were seated with the elbow at 90 degrees of flex-ion and with the wrist in a neutral position between pronation and supination.

To evaluate the effect of the two splints on pain, function, grip and pinch strength, a repeated measures analysis of vari-ance was used, and compared to the control group. For com-parison between two splints and to compare their effect to the control group, two- way ANOVA were used. To assess the effect of the two splints and following the result in the control group over the set time periods, one- way ANOVA were used. LSD pair wise multiple comparisons were performed when the ANOVA was significant. SPSS 16 was used for data analy-sis. The significant level considered α = 0.05.

Results

There were no significant differences in mean of age, BMI, time of splint using, dominant hand, affected hand, dura-tion of injury, pain, function, grip and pinch strength in the three groups at baseline. All parameters were uniform among three groups. All 35 patients who participated in this study continued their contributions to the end of the study. Table I shows the characteristics of patients participated in this study. Table II shows the mean and standard deviation of pain, func-tion, grip and pinch strength in the three study groups.

Control groupIn the control group, no significant differences in pain, func-tion, grip strength and key pinch were observed at the 4th

Figure 1. A flowchart of study design.

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week as compared with the initial assessment. In the 6th week, the only significant difference seen was in pinch strength (p = 0.000). In the 10th week as compared with the baseline significant differences were seen in pinch (p = 0.000) and pain (p = 0.05) parameters.

Comparison of test parameters at the end of week 4Both the prefabricated splint and the custom-made splint [(p = 0.000.), (p = 0.000) respectively] significantly reduced pain, and increased pinch (p = 0.000), (p = 0.001). DASH score increased with prefabricated splint (p = 0.018), but had no significant improvement with custom made splint (p = 0.232) compared to the control group at the end of the 4th week. No significant improvements in the grip strength were also demonstrated for both the prefabricated splint and the custom-made splint (p = 0.274) (p = 0.488) respec-tively; Table III.

Comparison of test parameters at the end of week 6At the end of the 2-week wash out period, some of the param-eters tested did not maintain their improvement compared to the control group. However, pain was still reduced compared to that experienced by the control group having used the cus-tom made splint (p = 0.049), but grip was not significantly dif-ferent compared to the control group for either of the splints. Both pinch strength was still significantly increased by pre-viously wearing either the prefabricated or the custom made splint [(p = 0.000), (p = 0.000) respectively]. The DASH score

was increased with custom made splint (p = 0.026) compared to the control group at the end of week 6 (Table IV).

Comparison of test parameters at the end of week 10Both the prefabricated splint and the custom-made splint sig-nificantly reduced pain and increased function as compared to the control group at the end of the 10th week (both p = 0.000). Significant differences in grip strength were not however observed by either orthoses when compared to the control group (prefabricated p = 0.130, custom p = 0.151), but significant dif-ferences were demonstrated in pinch strength and DASH score for both the orthoses (p = 0.000); Table II.

Comparing custom made splint and prefabricated splintIn comparing the two splints on function (p = 0.136), grip (p = 0.528) and pinch strength (p = 0.651), we found no sig-nificant differences between the prefabricated compared to the custom-made at 10 weeks, nor at the 4 or 6 week point (Tables III and IV). However, significant differences were indeed noted in pain levels (p = 0.024) at 10 weeks. The custom made splint therefore demonstrated a better performance in pain reduction at the end of the study period (Table II). However, after 4 weeks, the custom made splint was not as effective as the prefabricated splint in reducing pain, but there was no sig-nificant difference in pain levels demonstrated between them by the end of the wash out period after 6 weeks (p = 0.878). Grip strength was not significantly different between them throughout the study period [(p = 0.921) after 4 weeks, and (p = 0.884) after 6 weeks respectively].

Tables II, III and IV demonstrate the effect on the primary outcome measures at the 4th week, 6th week (following the 2-week wash out period) and at 10 weeks duration from com-mencement of the study.

Discussion

The main goal of this study was to assess the effect of a pre-fabricated neoprene thumb and custom-made thumb splints on carpometacarpal thumb joint osteoarthritis. Pain and decreased hand function reduces hand ability, and increases the difficulty in performing daily living activities and reduces quality of life. Therefore desired parameters to be analyzed in this study were pain, function, grip strength and pinch.

During the 10 weeks of observing the control group, signif-icant differences were demonstrated in pinch strength at the 6th week point and in pain in the 10th week. This finding is matched with the pathology of this injury [4]. Pinch as active force causes the posterior capsule of the first metacarpal to be thin and loose. This situation encourages posterior disloca-tion of the first metacarpal on the Trapezium. Inflammation and joint destruction, is seen in the anterior ligament which keeps the first metacarpal in the adduction position, which is thin. The first metacarpal may be subluxed on the radius. The thenar muscles are also involved in this process. Thenar muscle contraction, produces forward movement of the first metacarpal, and in this case, the loosening of the posterior capsule with an activated pinch may cause the upper end of metacarpal to shift posteriorly. The trapezium may also shift

Table I. Characteristics of the control and two intervention groups at baseline.

Prefabricated neoprene

thumb splint group

Custom made thumb splint

group Control group p valueNumber of subjects

12 12 11

Age 53.42 54.91 58.64 0.251Gender (female)

%66.7 %75 %72.7 0.316

Body mass index (kg/m2)

21.76 21.64 20.69 0.117

Index handRight 58.3 33.7 36.4Left 41.7 66.3 63.6Affected hand 0.405Right 58.3 66.7 81.8Left 41.7 33.3 18.2Time of splints using (hours/day)

8.4 8.2 0.105

Time of post up injury (months)

12.33 10.67 12.36

Pain 6.6 (1.9) 6.7 (2.0) 6.5 (0.9) 0/961Grip 7.4 (2.2) 7.3 (2.9) 7.5 (0.7) 0.989Pinch 5.4 (1.0) 4.6 (1.1) 4.1 (0.3) 0/717DASH 61.2 (4.9) 58.0 (6.5) 60.1 (13.1) 0/671

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and the resulting metacarpal articular cartilage damage causes joint pain associated with basilar arthritis [4].

In this study, both types of splint improved pain when compared to the control group. There was significant differ-ence between the two splints with the custom made splint producing better pain improvement. This effect could be due to the comfortable structure with the prefabricated splint and fewer restrictions when wearing the custom-made splint. Pain reduction may occur for several reasons when using a splint. The main reasons are immobilization of the covered joint, decreased inflammation, increased proprioception and creation of local warmth with splinting. In comparing results of the study with the previous studies in this field, Weiss and

colleagues [15], Sillem et al. [14] found similar results regard-ing pain among patients with OA of the basilar joint. McKee and colleagues compared two types of CMC joint stabilizer splints with one just covering the CMC joint and another cov-ering the CMC and MCP joints, and both of them reduced pain [13]. Wajon and colleagues demonstrated reduction of pain in this field, but how the decrease in pain occurred (i.e. by splinting or practice) was not obvious [22]. Pain reduction was also demonstrated by Swigert [10], but their study did not involve a control group.

Due to pain relief, increased function was expected [5]. This effect could have been due to increased joint stability and proprioception. Carreira et al. did not shown significant

Table II. Mean (SD) and comparison of variables in first CMC OA patients after 10 weeks.Baseline After 4 weeks After 2 weeks washout After 4 more weeks p value p value p value

C S1 S2 C S1 S2 C S1 S2 C S2 S1 1 2 3Pain 6.5

(0.9)6.6

(1.9)6.7

(2.0)7.0

(1.4)3.8

(1.8)3.0

(1.0)7.2

(1.1)6.1

(1.3)6.2

(1.2)7.5

(1.2)2.9

(1.7)2.1

(1.2)0.000 0.000 0.229

Grip 7.5 (0.7)

7.4 (2.2)

7.3 (2.9)

7.4 (0.7)

8.2 (2.1)

8.1 (3.0)

7.2 (1.1)

7.7 (2.8)

7.5 (2.3)

7.0 (1.2)

9.1 (1.8)

8.7 (2.7)

0.274 0.488 0.921

Pinch 4.1 (0.3)

5.4 (1.0)

4.6 (1.1)

4.1 (0.2)

6.2 (0.8)

5.7 (1.3)

3.5 (0.3)

5.0 (0.8)

5.6 (0.9)

3.5 (0.3)

6.8 (0.7)

6.4 (1.2)

0.000 0.001 0.359

DASH 60.1 (13.1)

61.2 (4.9)

58.0 (6.5)

56.8 (12.2)

66.6 (5.1)

62.0 (8.0)

54.4 (12.6)

63.4 (6.8)

61.3 (5.3)

53.5 (12.3)

75.2 (12.2)

73.1 (5.0)

0.018 0.232 0.110

P1: comparison between control group and Prefabricated splint group after 4 weeks.P2: comparison between control group and Custom made splint group after 4 weeks.P3: intra groups comparison between Prefabricated and Custom made splint groups after 4 weeks.

Table III. Mean (SD) and comparison of variables in first CMC OA patients after 4 weeks.Baseline After 4 weeks After 2 weeks washout After 4 more weeks p value p value p value


(0.9)6.6

(1.9)6.7

(2.0)7.0

(1.4)3.8

(1.8)3.0

(1.0)7.2

(1.1)6.1

(1.3)6.2

(1.2)7.5

(1.2)2.9

(1.7)2.1

(1.2)0.062 0.049 0.878

Grip 7.5 (0.7)

7.4 (2.2)

7.3 (2.9)

7.4 (0.7)

8.2 (2.1)

8.1 (3.0)

7.2 (1.1)

7.7 (2.8)

7.5 (2.3)

7.0 (1.2)

9.1 (1.8)

8.7 (2.7)

0.664 0.590 0.884

Pinch 4.1 (0.3)

5.4 (1.0)

4.6 (1.1)

4.1 (0.2)

6.2 (0.8)

5.7 (1.3)

3.5 (0.3)

5.0 (0.8)

5.6 (0.9)

3.5 (0.3)

6.8 (0.7)

6.4 (1.2)

0.000 0.000 0.130

DASH 60.1 (13.1)

61.2 (4.9)

58.0 (6.5)

56.8 (12.2)

66.6 (5.1)

62.0 (8.0)

54.4 (12.6)

63.4 (6.8)

61.3 (5.3)

53.5 (12.3)

75.2 (12.2)

73.1 (5.0)

0.060 0.026 0.418


Table IV. Mean (SD) and comparison of variables in first CMC OA patients after 6 weeks.Baseline After 4 weeks After 2 weeks washout After 4 more weeks p value p value p value


(0.9)6.6

(1.9)6.7

(2.0)7.0

(1.4)3.8

(1.8)3.0

(1.0)7.2

(1.1)6.1

(1.3)6.2

(1.2)7.5

(1.2)2.9

(1.7)2.1

(1.2)0.000 0.000 0.024

Grip 7.5 (0.7)

7.4 (2.2)

7.3 (2.9)

7.4 (0.7)

8.2 (2.1)

8.1 (3.0)

7.2 (1.1)

7.7 (2.8)

7.5 (2.3)

7.0 (1.2)

9.1 (1.8)

8.7 (2.7)

0.130 0.151 0.528

Pinch 4.1 (0.3)

5.4 (1.0)

4.6 (1.1)

4.1 (0.2)

6.2 (0.8)

5.7 (1.3)

3.5 (0.3)

5.0 (0.8)

5.6 (0.9)

3.5 (0.3)

6.8 (0.7)

6.4 (1.2)

0.000 0.000 0.651

DASH 60.1 (13.1)

61.2 (4.9)

58.0 (6.5)

56.8 (12.2)

66.6 (5.1)

62.0 (8.0)

54.4 (12.6)

63.4 (6.8)

61.3 (5.3)

53.5 (12.3)

75.2 (12.2)

73.1 (5.0)

0.000 0.000 0.136


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differences in functional improvement in the use of splint-ing in first carpometacarpal joint osteoarthritis patients [5], but in this present study these expectations were fulfilled. There was no significant difference between the two types of interventions in function. This confirmed the results from other studies in this field [13,14]. However, our results are at variance with that shown by Weiss and colleagues, who reported that a prefabricated splint produced a better per-formance than a custom made splint in function improve-ments [15].

Due to the fact that splinting can provide pain reduction and an increase in function, it may be argued that pinch and grip strength may be expected to increase with splint use. On the other hand, splints can cause muscular atrophy and decrease these parameters [5]. Both orthoses had a positive effect on grip strength in this study, but no significant dif-ference was noted between the two splint test conditions. Carreira and colleagues announced, however, that no change in pinch and grip strength was observed with a custom made thumb splint on the first CMC joint osteoarthritis patients [5]. Weiss and colleagues conversely reported that a prefabricated splint and a custom made splint both increased the ability of pinch strength. The results from the study by McKee and col-leagues agreed with the findings from this study in that pinch strength was increased compared to baseline by two types of splinting, but no significant differences were shown between them [13].

No significant difference was observed in wearing time between the groups. Average time of use of both splints was 8.3 h per day. Patients and therapist were not blinded to the two types of interventions; these problems were one of the limitations of this study. This was because all stages were explained to patients in the investigation by the therapists at beginning of the study. Future studies in this field should fol-low in order to examine effect of splints in the long-term. The effects of this type of splint can then be assessed on the quality of life and social participation in first CMC joint osteoarthri-tis patients.

One limitation of the study was that the evaluator was not blinded to the treatment conditions. However, it was thought that, this would not affect the results as the same tests were repeated for each volunteer subject in the study irrespective of test condition.

Conclusion

Both splints increased pain, pinch strength and function compared to baseline and control group. We found no evi-dence that splints improved grip strength as compared to control group. There were no significant differences in func-tion and pinch in comparing the splints. Pain was the only significant difference. The custom made splint demonstrated better results in pain reduction. It appears that these splints are helpful in the short-term in early CMC OA, particularly for pain.

Declaration of interest

The authors thank the University of Social Welfare and Rehabilitation Science for financial support for this research. The authors report no conflicts of interest.

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Comparison of custom-made and prefabricated neoprene splinting In patients with the first...

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