HAND SPLINTING IN CHILDREN

HAND SPLINTING IN CHILDREN!

HELEN S. BLAIR, M.A.P.A., M.C.S.P.

Lecturer in Paediatric Physiotherapy, South Australian Institute of Technology.

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Normal hand function is essential to carryout all the activities of daily living indepen­dently. The child using his hands in play pre­pares himself for this independence.

Soon after birth the infant sucks his fingerslustily but at this stage his grasp is purely re­flex and purposeless. Eye hand control deve­lops early, so that by five months the handsmeeting together in the midline begin to graspwith purpose. This grasp is palmar and ulnarbut as reaching becomes more co-ordinatedthe infant grasps between the palm and baseof the thumb. By eight months the inferiorpincer grasp develops and small objects areheld between the side of the index finger andthumb. At the end of the first year the normaladult pincer grasp is present.

Release develops later than grasp and isnot well adjusted to the size of the object untilthe end of the first year. The child continuesto develop power and dexterity of the handlearning by touch and manipulation through­out his growth period.

To develop normal hand function he needsbeth normal hone and soft tissues and mustdevelop normal synergic action between thevarious muscle groups of the hand. Normalsensation is also necessary for the develop­ment of normal hand use.

ABNORMAL HAND FUNCTION

Any abnormality of hand function is adisturbing factor in the normal growth pro­cess. The child may not develop a normalpower grip or the ability to handle objectsdelicately using the thumb and finger tips.When sensation is abnormal hand function isdisturbed or even absent.

lReceived July, 1971.

Common Causes 0/ Abnormal Function

1. Congenital defects.(a) Arthrogryposis where severe and

disabling deformities are present athirth, with limitation of joint rangesand weak fibrotic muscles. Thewrists and fingers are usually flexedwith little movement present.

(b) Absent radius or ulnar usuallyassociated with a small deformedclub hand laterally flexed to the sideof the missing bone. Finger move..ments are often poor due to abnor..mal muscle and bone formation.

(c) Other defects which include themany hand defonnities of a mixednature. These are very variable withno two alike.

2. Paralytic causes.Here muscle weakness and con­

sequent imbalance results in inability touse the hand normany. Contractures anddeformity occur with growth and con­stant abnormal use. Poliomyelitis, peri­pheral neuritis and cerebral damage mayall cause varying degrees of paralysis..

3. Systemic Diseases..In rheumatoid arthritis the inflam­

matory condition of the connectivetissue causes inability to use the hand inthe early stages because of pain andmuscle spasm. Later structural changesoccur due to progressive fibrosis andjoint damage causing disabling deform"ities.

4. Traumatic causes.Many accidents occurring in chilid..

hood result in damage to the hand.

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Burns which affect the skin and softtissue develop contractures during thegranulating phase. Even after skin graft..ing, shrinkage occurs and in the child'shand, severe deformity can result.

Tendon injuries, fractures and nervelesions are all common mishaps. Oftenfollowing satisfactory repair fibrosis mayresult in tendon adherence, contracturesand stiff joints.

In all these conditions contractureof the soft tissues of the hand is a com­mon factor contributing to abnormalhand function. Any contracture cancause disabling deformities which pre­vent the development of normal handfunction. Growth during childhood causesdeformities to increase unless they aretreated with effective and continuoustherapy.

Frequently contractures can beavoided with careful management andmany deformities can be corrected with­out surgical interference. This neces­sitates the use of effective splinting overa long period of time"

TfIE ROLE OF SPLINTS IN TREATING THE HAND

Treatment of the hand aims to restorefunction and particularly the grip in all itsvarious forms. A useful grip needs sufficientwrist extension to give power to the fingerflexors, and flexible opposable digits. Becauseof the initial deformity this is not alwayspossihle hut surprisingly useful function canbe ohtained with treatment.

Many therapeutic measures will be involvedbut are often ineffective unless used in con..junction with suitable splinting.

The use of splints depends on the cause ofthe malfunction and varies accordingly.

I. Resting Splints"These allow recovery of paralysed

muscles to take place in a physiologicalresting position, i.e. near the mid-positionof the normal movement range of thej oint. They are also used to reduce painfrom mnscle spasm and inflamed tissuesas occurs in the rheumatoid hand..

Aust.!.Physiother., XVIII, 4, December, 1972

2~ Splints to stretch tissues.These are used where contracted

tissues are present as in congenital defectsor if this has occurred for any other rea·SOD. They are also used to prevent con­tractures occurring. Serial fixed or re­movable splints are most effective.

3. Functional splints.Active or lively splints help func­

tion as recovery is occurring and havea place in paediatric work. However, asmuch of the splinting used during child­hood is concerned with prevention orcorrection of deformity, splinting is oftenmore passive and rigid. It must be usedin conjunction with other active physio­therapeutic measures.

Materials used and their method of applicatio1n

It is essential that all hand splints be lightand confortable. Heavy cumbersome splintsare not well tolerated by the child. They willnot remain in position or he as effective.

l~ Plaster of Paris.This is probably the cheapest mate­

rial available and is easily and quicklyappfied. Specially prepared low plasterloss bandages are used when making thesesplints, and the most common methods ofsplinting with this are:

(a) Serial fixed plasters. A light fixedplaster is applied initially with asmuch correction as possible withoutcausing circulatory changes. This ischanged at first at frequent intervals(every three or four days) anld laterat weekly or fortnightly intervals ac­cording to the correction gained,and is generally used over a sixweek period.

To apply the plaster, the forearmand hand are covered with stocki­nette and a thin layer of sheet woolevenly applied. Half a plasterbandage (of 2", 3" or 4" width ac­cording to limb size) is soaked inthe usual way and bandaged firmlyand smoothly. Only enough band­age is applied to hold the position

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while correction is obtained. It isthen completed but kept as light aspossible as a heavy plaster will slipon a small malformed arm.

The elbow may he included to pre­vent the plaster slipping, e.g. cor..recting a small club hand with nothumb. In this instance the arm isplastered from the axilla to justabove the wrist with the elbow in90 0 flexion. When this part is setthe plaster is completed while thewrist is held in a corrected position.Care must be taken not to causepressure from plaster edges.

If the plaster is moulded into aslightly eliptical rather than cylin..drical shape over the soft tissues ofthe forearm it is less likely to slip(Fig. 1).

FIGURE I

Fixed plaster for club hand showing eliptical shapedmoulding of the forearm.

It is not usually necessary to rein­force the plaster but a collar andcuff sling will prevent damage dur­ing the drying period.

(b) Removable plaster splints. These aremade from plaster slabs of 4" or 6"width according to the size of thehand. For light effective splints only

four thicknesses of plaster are usedin their making. These can be rein­forced with rolled plaster strips,moulded duralium, the plastic cen­tres of plaster bandages softened inhot water and then moulded,celastic or glassona. A light butdurable splint can be made froman intelligent combination of thesematerials.

The slab extends from just beyondthe middle finger to I'" below theelbow crease in a full hand splintand to the finger webs in a cock upsplint. A thumb hole is marked atthe base of the first metacarpal andat the fold of its web as the handrests in place on the slab. An ovalhole is cut shaped to clear the thenareminence and allow correct position­ing of the thumb. If the thumb is tobe included, a three thickness slabwide enough almost to encircle thethumb and extending from the tipof the thumb along the web and asfar as the tip of the index finger ismeasured. A narrow two thicknessslab is made to mould over the webarea (Fig. 2).

Where there is hair growth, the limbis lightly greased. The wet slab fromwhich excess water is carefully re..moved is applied to the forearm andhand moulding it to the appropriateposition.

The use of a thumb hole gives agood fit to the splint and helps holdthe slab in place during making.The thumb slab is applied over thepalmar and medial surface, acrossthe web and along the side of theindex finger. This ensures goodmoulding into the web. The narrowslab placed across the web holds thethumb slah in place (Fig. 3). Unlessthe area of the thumb web is wellmoulded the thumb will not fit satis..factorily into the splint and hyper..extensiCJD of the metacarpophalan..geal joint occurs.

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The slab is bandaged, using one lay..er of plaster, only if the child is veryrestless or the position hard tomaintain, e.g. a spastic hand.

FIGURE 2Plaster slabs-note thumb hole in arm slab.

The making of a palmar or dorsalsplint is essentially the same withthe thumb inserted appropriatelythrough the hole. Strips of plastermay also he added to separate thefingers.When the splint is set the edges aremarked for cutting down. Unless theplaster is cut low at the wrist jointand along the sides of the fingers itwill slip off. It must allow comfort..able elbow flexion. The strap posi­tions are marked to hold the fingers,thumb, wrist and forearm in posi­tiODII

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The splint is finished in the usualway_ When dry, velcro straps areapplied using glassona to hold themin place and the splint is reinforcedas necessary_ The wrist strapsmay he more effective if crossedwith straps over the dorsum ofthe hand. In the posterior handsplint an encircling strap passingover the web of the thumb acrossthe lower palm and then around thesplint and the wrist to attach post­eriorly at the thumb web area pre­vents the splint from slipping (Fig.4). Straps holding the fingers inplace avoids the palmar crease in aspastic hand. All straps are moreeffective if felt pads are used overskin areas to ensure a firm grip.

FIGURE 3Moulding of the thumb piece in the posterior hand

splint.

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2. Plastic Materials.Although these materials are light

and often easily moulded directly to theskin it is not always possible to get aneffective correction with a small deform­ed hand. Some materials are both lightand semirigid and make more comfort..able splints especially where spasm ispresent. They also allow a little movementwhich may assist hand function in thecongenitally deformed limb.

FIGURE 4Posterior hand sphnt showing velcro straps in place.

They are easily cleaned, withstandplay in cold water and tolerate an amaz­ing amount of abuse.

Some can be remoulded for furthercorrection or to accommodate growthand will not need renewing over a longperiod of time.

(a) PrenyL This semirigid plastic isavailable in varying weights andmakes a light comfortable splint~ Itis fairly easy to cut with scissors andis pliable when put into hot water.It is directly applied to the skin andcan he stretched and moulded to thepart. It must he held in positionuntil set which takes several minutesand this is a disadvantage in a youngchild.

It can however he easily remouldedand adjusted as necessary. It maycause skin irritation and discomfortfrom sweating and punch holes willhelp prevent this hut slightly lessen

its rigidity. Lining with a fine lemonhide helps reduce these discomforts.

Application: A slab is measured byoutlining the hand and forearmallowing l/l..!" extra. A thumb holeis cut for a cock up splint which onlyextends to just beyond the metacar..pophalangeal joints. In the full hand~plint the thumb is separated fromthe finger piece by a slit cut to thethumb web.

Immersion in very hot water for afew seconds makes the material veryeasy to use, but it must be cooled toa comfortable temperature beforeapplying to the skin. It is mouldedinto the position and held in place,vith a crepe bandage, which must bebandaged lightly.

In the posterior hand splint thethumb piece is swung around to fitover the web of the thumb andthenar eminence. A thumh slahmoulded in the same way as theplaster splint is joined to the pos..terior slab with Prenyl cement.

As soon as the splint is set sufficient­ly to hoLd its shape it is removedand immersed in cold water to in­crease its rigidity quickly. It maybe reinforced using moulded stripsof prenyl or prenyl ribbing cement..ed in place.Velcro straps hold the splint in placeand are attached by rivets or sewnon through small punch holes.

Isoprene, a more recently availableplastic can be used in a similar man­ner and has the advantage of heingmore malleable and becomes rigidmore quickly..

(b) Polythene. This plastic materialneeds heating to 300-400° in anoven. It can he applied directly tothe limb over felt padding but isbetter moulded onto a plaster castin paediatric work..The splint is both light and durableand well tolerated although a little

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more cumbersome and fits lesssnugly on a small hand. Being amore rigid splint it stands up tohard wear" It cannot be alteredsatisfactorily to allow for growth orimprovement of the hand.

The positive cast is made from thenegative, in the usual way, by thephysiotherapist, and the splintmakeruses this for the moulding of thesplint. The splint is then fitted andsuitably trimmed. Leather or velcrostraps are riveted in place. Punchholes help prevent excessive sweat­ing and adhesive felt, pressure onany bony areas (Fig. 5).

FIGURE 5

Modified cock up splints-top left prenyl-top rightpolythene-lower plaster.

3. Metal Splints.Plastic materials, especially prenyl

and isoprene are largely replacing the useof metal in splint making. They are, how..ever, useful in strapping some contractedfingers and can he serially adjusted.Varying gauge duralium is used accord­ing to the size of the limb. The splint..maker cuts the splint from an accuratepaper pattern made by the physiotherap..ist.

When used for serial correction it isapplied with an adhesive felt cover andstrapped directly to the hand. Felt isused to increase the corrective forcewithout traumatic pressure to the skin.

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Types of Splints Used

Any of these materials can be used inmaking a splint. The choice depends on thecondition being treated, the child's age, thelength of time the splint is to be used or whenit is llsed. Each patient is carefully consideredand often a variety of splinting material isused during the course of treatment.

1. The Cock up Splint. (See case historyLisa.)

This may be used on the palmarsurface (Fig. 7) or dorsal surface (Fig.14) .

2. The Resting Splint. (See case historyRonnie.)

This is usually worn on the palmarsupface of the arm and is made in thephysiological resting position of semi..grasp with the thumb directly below theindex finger.

In the rheumatoid hand this positionof rest will vary if deformity is occur..ring. The fingers may he more extendedbut it is important to maintain the func ..tional cupping of the hand.

~3. The Posterior Hand Splint. (See case his­tory Cathie,,)

This extends from just beyond thefinger tips to liN below the flexed elbow.The thumb is held in the reflex inhibitoryposition of extension and abduction withthe splint well moulded over the web andthenar eminence (Fig.. 4). A hand shakegrasp used in making the splint inducesreflex relaxation of the hand and accuratemoulding over the thumb web.

An overextended wrist positioncauses uncomfortable pressure on theback of the wrist and the splint will notbe tolerated. It may be necessary to usea felt strip along the first metacarpalwhen making the plaster splint.

4~ The Thumb Splint. (See case historyCathie.)

This also aims to induce reflex re..laxation of the hand and an elongation of

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the contracted web. It fits over the webof the thumb and extends partway alongthe first phalanx of the thumb and indexfinger and is usually padded with felt. Itis moulded over the posterior and ante..rior aspects of the first interosseus spaceand held in place by a velcro straparound the wrist. It is a useful sprint inthe hemiplegic infant and may helpfunction in the older child (Fig. 17).

5. Varions modifications of these splintscan be devised to improve hand func­tion.

CASE HISTORIES

Lisa, aged 6 weeks was referred for treat­ment of arthrogryptic type flexion deformitiesof her hands. The right hand could be passive­ly extended fully at the wrist and fingers, theleft only to neutraL The left elbow was fullyextended at rest hut could be passively flexedto 75° (:Fig. 6). Both shoulders were limitedin external rotation and elevation. Some graspreflex was present in both hands.

Splinting

Cock up splints were used including thefingers but leaving the thumbs free, these be­ing abducted with felt (Fig. 7). In a monthwith increasing correction of the deformitythese were remade and the thumbs included inthe splints. The splints were of plaster re­inforced with glassona. A left prenyl armsplint including the hand held the elbow inmaximal flexion and was used alternativelywith the hand splint (Fig. 8) .

Progress

Active dorsiflexion of the right wrist andfingers improved to almost normal over athree month period and this splint was thenused at night only. The left elbow gained anincreasing amount of passive and a smallrange of active flexion. The left wrist still lack­ed sufficient extension to give an effective gripand as tactile grasp was developing a smallprenyl cock up splint was made. At 15 monthsher active control of the arms is good (Fig. 9) .

ProblemsThe cock up splints which included the

thumbs tended to slip and needed crossedstraps to hold them is place.. Remoulding ofthe elbow splint to increase elbow flexion wasnot well tolerated and needed readjusting.This splint soon needed reinforcing to counter­act the overacting triceps. With increasinghand awareness the splint actively encouragedsome elbow flexor exercise as the baby suckedher thumb protruding through its hole.

FIGURE 6Lisa showing deformities of arms at 6 weeks.

The velcro straps were sewn in place asrivets would have caused pressure.

Paul, aged 6 days had severe arthro­gryptic deformities of both hands and feet.The fingers were tightly clenched with thethumbs adducted and flexed in the palm (Fig.10) .

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Splinting

Serial prenyl splints gave the most com~fortahle early correction of these small grosslydeformed hands. Later serial plaster splintswere used to splint the thumb and fingers moreadequately. The fingers were separated bynarrow plaster ridges to correct curving andulnar deviation (Fig. II).

FIGURE 7Plaster cock up splints reinforced with glassona.

FIGURE 8Prenyl arm splint.

Progress

This child has gained considerable func~tional use of his hands although their appear­ance is not normal (Fig. 12). He can crawl onaIr fours and is now pulling up to standing inan attempt to walk.

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Problems

These hands have been difficult to splint an\din the initial stage only felt and z.o. strap..ping could be used. The severe almost spasticlike flexion deformity of the metacarpopha~langeal joint has been difficult to correct andhold in the sprint and caused some hyper­extension of the interphalangeal joints. Thesplints eventually were kept satisfactorily inplace by using a long strap which crossedover the back of the hand and encircled thesplint and wrist.

FIGURE 9LIsa aged 15 months.

Barbara, aged 8 years was born withsevere flexion deformities of both hands. Thethumbs lacked a metacarpal and were smalland useless. Muscle development to the handswas abnormaL The second metacarpal waswidely spaced from the third. The rest of thearms were normal.

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Splinting and Progress

The hands were treated with serial plastersplints that were changed frequently and in­itially reinforced with Z.O. adhesive tape.This also held the splints in place using gauzeor felt over skin areas.

FIGURE 10Paul-gross hand deformities.

When the flexion deformities were suffi­ciently corrected and hand use improving, thefirst finger was splinted into an opposableposition with a plaster splint at night and alight duralium one for day use.

FIGURE 11

Plaster night splint with ridges for fingers.

The rudimentary thumbs were removed at4 years. Night splints were continued until 7years. The left hand then had good functionahd was left free.

The right wrist lacked dorsiflexion beyondneutral. This hand was stretched in serial fix ..ed plasters for 8 weeks~ These included the

wrist but left the fingers free 80 as to not inter­fere with the flexion of the metacarpophalan­geal joints. After removal of the plaster ananterior prenyl cock up splint was made fornight use and a dorsal cock up splint for func­tional use. In this latter splint the three lateralfingers were inserted through a srit in theprenyl and this palmar piece controlled dor­siflexion, fitting just below the metacarpopha­langeal joint. The plasticity of prenyl givesconsiderable latitude in moulding.

FIGURE 12Paul-Hand function at 2 years.

ProblemsThe splints needed a lemon hide lining to

prevent skin irritation.. The child needed per­suasion to persevere with the hand splintwhich does increase ftulction and has main..tained a stronger and better range of dor­siflexion (Figs. 13 and 14).

Kelvin was referred at 3 weeks for serialplaster splinting for deformities of bothhands. These lacked thumbs and normalmuscle and joint function and were initiallyflexed at the wrist and fingers. Both removableplaster and duralium splints were used.

At 3 years the child had no further treat..ment until re..referred, aged 6 years, becauseof flexion and ulnar deviation of the left wrist.Because of very poor active finger flexion andno opposable digits, objects were held betweenthe palm and forearm ..

Serial fixed plasters on this hand increasedrange and were followed by plaster nightsplints and a fight prenyl day splint.

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Progress

Lack of finger flexion and opposable digitsis a serious disability but the young con~genitally deformed child develops surprising­ly functional hand use. This child has increas­ed function of the hand when using the splint(Fig. 15).

FIGURE 13Barbara-use of spoon without splint.

Ronnie aged 8 years was ordered restingsplints during the early acute stages of rheu­matoid arthritis. These were made with ex­tended fingers but slight cupping of the palmas the finger flexors were painful and con~tracting with spasm. Plaster reinforced withglassona was used.

Problems

With continued use the child developedsome skin irritation and was given cottonstockinette to wear under the splints.

Aust./.Physiother., XVIII, 4, December, 1972

Progress

He quickly regained full extension becamepain free and has gained increasing fingerflexion with regular physiotheraphy and suit­able medication.

Ellen aged 10 years suffered full thick~ness burns to both hands and forearms. Ante~rior metal cock up splints were used overdressings in the initial stage. Despite earlyskin grafting she developed gross hyperexten­sion deformities of the metacarpophalangealjoints.

Splinting and Progress

SanspIint dorsal splints were made to holdthe fingers in flexion and remoulded with im­provement of range. The left hand was more

FIGURE 14

Improved function in dorsal cock up splint. Note useof opposable index finger.

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difficult to control and serial fixed plasterswere used for three weeks in an attempt toflex the metacarpophalangeal joints. The lefthand was regrafted across the metacarpopha..langeal joints dorsally and the thumb freedand the web grafted. The right hand wasmanipulated at the same time. Both hadfurther serial plasters with frequent changesalthough the left was not changed except fordressing until the grafts were satisfactorilyhealed.

FIGURE 15Kelvin-Increased hand function using cock up splint.

Eventually the hands were left free to en­courage function hut dorsal splints which nowhad thumb pieces were used part time in theday and at night. The right hand was left com..pletely free one year after injury. The splinton the left was changed to a prenyl anteriorone with the fingers as flexed as possible andthe thumb web stretched.

Problems

The serial splinting in fixed plaster wasdifficult because of poor skin and lack of nor­mal sensation. Adhesive felt was used in at..tempt to protect vulnerable areas and also tostretch the finger webs. In between changes ofplasters it was at times necessary to leave thehands free of plaster for 24 hours using salinebaths and the plastic splints to control theposition.

The left hand was strapped to a curvedduralium splint which was serially remouldedto gain further correction of the 4th and 5thfingers and allow function of the others at astage when skin areas were particularly vul-

l1erable. Strapping over tulle grass \vas usedand healing occurred satisfactorily.

Tony aged II! years suffered a severe in­jury to his right hand with degloving but notendon or nerve injury. He was referred forserial splinting because of the flexion deform­ity of the 4th finger, untit healing of the handwas complete.

Splints.Serial removable plaster splints which in­

cluded the wrist and splinted the fourth fingeronly were used. These needed reinforcing withglassona and later a duralium strut to main­tain finger extension without hyperextensionof the metacarpophalangeal joint (Fig. 16).

FIGURE 16

Plaster splint reinforced with glassona used to gainfinger extension.

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Progress

A full range of passive movement of thefourth finger was gained and good function ofthe rest of the hand. The fourth finger lackedflexion at the interphalangeal joints probablybecause of adherence of the flexor tendons,and is to be surgically investigated.

Kathie was horn by Caesarian sectionand found to have a right hemiplegia at 8months. She has an athetoid type lesion andhas some use of the right arm but co..ordina­tion is poor and associated with movementsof this limb are a problem.

Splinting

She was unable to tolerate a plaster nightsprint but finds the prenyl one very comfort­able. She has had this for one year and it wasrecently completely remodelled to accom­modate growth (Fig. 4).

A sansplint thumb splint was made twoyears ago in an attempt to improve the useof her hand (Fig. 17).

CONCLUSION

Although splinting may give much im­proved hand function it is not always welltolerated by an active child who prefers hisown trick movements which are quicker andeasier. The physiotherapist needs muchpatience in helping both the parents and thechild to appreciate the value of splintingwhich must always be as light, comfortahleand effective as possible. However, the gratify­ing results that can he gained, as illustratedhy the above case histories, more than ade­quately compensate for the demands placedupon the children, parents and physio..therapists.

SUMMARY

The development of normal hand functionand its importance in attaining independencehas been discussed. Abnormalities of handfunction and the various causes have beenmentioned. The various splints, the materialsused and their construction have also beendescribed, and illustrated in the case histories.

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Case histories and photographs have illus..trated the use of the splints, their effectivenessand the gratifying results that can be gained.

FIGURE 17Cathie-using prenyl thumb splint.

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