dynamic splinting

Philippe DEPONT

Masseur-kinsithrapeute

TOURS - FRANCE

Centre MainLEONARD DE VINCI

In 1984, Professor ROBERT from the hospital of TOURS

(FRANCE), proposed to set up a conservative treatmentincluding wearing dynamic splints after plastic surgery of handfor children with Recessive Dystrophic Epidermolysis Bullosa inorder to reduce recurrence and to prevent repeated interventions

Until then, treatments were establishment of bandages, possiblyassociated with static splints.

Recurrences appeared often extremely quickly, with a total loss of surgical benefit in a few months or even weeks.

Despite the difficulties of adapting to the technical equipment in this condition, results were immediately very satisfactory

A few years later, the EBAE association allowed anagreement of different practitioners interested in thispathology and Dr. BLANCHET- BARDON proposed to use thesame protocol for the prevention of deformities at non-operated

Children.

Results observed:

- Improvement of mild forms

- Maintain intermediate forms

- Decreasing of severe forms

Two points to fight:

- synechiae- retractile healing of blisters

synechiae gradually fill commissural spaces

- synechiae

- Retractile healing of blisters

Successive scarring gradually decrease the surface of the skin

Two points to fight:

A complete range of motion is possible only if the length of the outer

skin is sufficient

For a long finger, transition from extended position to

a flexed position induces lenghthening of the dorsal

skin of +/- 3cm.

"Reserves of skin"

In case of healthy skin, there are

reserves materialized by skin folds

facing joints.

In R.D.E.B. successive recurrence-

remissions gradually decrease

reserves of skin

With progressive exhaustion of reserves, skin retraction allows less and

less mobility.

Skin retractions will then induce more or less anarchic deformities and

unpredictable deformities based on localization of blisters

To fight against these incessant attacks of blisters it is necessary to stress

the whole skin tissue, often and during a long time, to induce healing

without retractions on the principle of guided healing .

Active Mobilization by the patient, frequent and with maximum amplitudes

may be sufficient but :

- during a normal activity , maximum amplitudes of extension and flexion of

the fingers are almost never used

- In the context of R.D.E.B. pain associated with bullous lesions limits

movement significantly .

- night is a long time without stretching during which contractures can

settle.

External assistance is needed

=> Dynamic splinting

Dynamic splinting has two parts

Synechiae

Bandages

24 / 7

Retractile healing

Dynamic splint

Night wearing

+ physiotherapist

Every injury has a risk of loss

but

A chance to gain too

Guided healing

Bandage has several functions

- to protect against synechiae and

filling of commissures

-To protect against injury during

activities

- to Improve hand function

=> fundamental element of

psychomotor development of

children

- to be a pad for the splint

Coating with nonadherent strips

(sofra-tulle, silicone coated tulle, etc)

Base of commissure

large Overflow on the palm and

back of hand

On any wound

Making of bandage

Making of bandage

Wrapping with gauze bandage

-Small width (2-3cm)

-Thin to limit bandage volume

- Slightly elastic=>possibility of pressure

Apply tension between the fingers

=> Pressure at the base of commissures

Avoid circular clamping

=> tourniquet, oedema

=> hand Growth

Bandage the forearm ++

=> Balance pressure

=> best protection

=> best hand position

use always the same way of bandage

the same volume of bandage

=> position and adaptation of splint

Making of bandage

Dynamic splint

Support:

Thermoplastics molded on the bandage

motor elements on thermoplastics

difficult to achieve in young children

cooperation ? => time and patience

Wrist extension (20-30)

- Avoid bad position of wrist

- Best positioning

- Balance the stress

There are generally

MP stop

on the support

- avoid hyperextension of MP

- traction on the PIP

abutment

traction

abutment

traction

More rarely

extended to P2

Dynamic splint

piano wire spring

small section 0.5 0.7 mm

low traction

minimum size

easy to modify direction of traction

traction force not infleunces by flexion of fingers

easy replacement

springs are attached on the splint

at the back of the hand

attached to each finger individually

velcro ring ( +/- lastic )

Traction improve extension of fingers

Motor elements of long fingers

Dynamic splint

Adult => blades Levame type

stronger traction forces

larger size

more precise axis

less fragiles

Gauntlet Support + MP stop

is sometimes enough

Dynamic splint

Motor elements of long fingers

Mild formes cause

single lsions

So we use classic splints

Dynamic splint

The opposition is ensured by the joint

trapezometacarpal (T.M.) witch allows itself a

satisfactory use of the thumb

- Place the thumb facing each other fingers

- perform the opening and closing grip or pinch

Metacarpophalangeal joint ( M.P.) requires

pratically no mobility

- has to be stable

- flexion approximately 20

Interphalangeal joint ( I.P.) adjusts grips and

remains fonctional with little mobility

- Approximately 25

particular case, the thumb = opposition

Almost all gripare in opposition

Skin surfaces mobilized by the function of the thumb are in relation

with trapezometacarpal joint and are placed in front of the thumb and

wrist:

- Surface larger +++ than surface of long fingers

=> large reserves of skin

- Area generally less affected by blisters

- better maintenance frequent use +++

=> conservation of T.M. mobility is often easier than that of long fingers

MP and IP joints ot the thumb have problems

similar to long fingers

particular case, the thumb = opposition

usually => static splint

sometimes adduction tendency ++

=> dynamic splint

If bandage is enough => thumb free

bandage avoiding filling of the first commissure is the primary and often

sufficient element to maintain a good function of the thumb

particular case, the thumb = opposition

early bandages ++

- prevention

- protection

Indication of splint before any loss of range of motion

Supervision by physiotherapist

- making of splint

- changes in the splint

- instructions for changing

Flexion mobilities are not influenced by the splint

It is the daily use of the hand, assisted by rehabilitation,

witch will keep them

Filling commissures

=> splint impossible

=> rapid worsening

=> repairing surgery

Indications of surgery

Localized problem

limited surgery

conservative treatment

Keeping outcome of surgery is determined by the quality of healing

control

Setting up the splint:

open wounds

pain

synechiae

cicatricial retractions

=> Too soon

=> Too late

Outcome at 1 month = morphology restored but without reserve of skin

Immediat post surgery

Functional range of motion

In pratice, full extension of fingers

is not used in a regular activity

Useful ranges are :

M.P. 60 P.I.P. 60 D.I.P 40

70% to 80% of the function of finger

Is dependent on the P.I.P.

Mobilities to preserve in priority

T.M. joint

Good Positions of ankylosis

M.P. long finger : flexion 30

D.I.P. long fingers and I.P. thumb: flexion 25

M.P. thumb: flexion 20

P.I.P. long fingers

Conclusion

Faced with incessant and unpredictable blisters attacks, it is essential

to develop a strategy of defense extremely vigilant.

The importance of general daily care does not allow enough time for

the exclusive problem of hands.

Dynamic splints allows continuous response and overcomes this lack

of time.

However, its effectiveness is dependent on the quality of supervision

and proper integration into the plan of care of the physiotherapist who

must be trained in these specialized techniques.

Quality of results is dependent on the severity of the injury but the goal

remains to avoid surgery that will occur earlier in childhood and will

therefore certainly iterative.

Eminence hypothnar