- Which orthosis would BEST support the affected joint during activity while maximizing hand function?
Answer: A hand-based thumb spica splint that immobilizes the CMC joint.
A hand-based thumb spica splint is the best option because it specifically supports and immobilizes the painful CMC joint while leaving the wrist and fingers free for movement. This provides stability to the thumb during functional tasks like gardening, reduces pain, and allows for maximum participation in the desired occupation.
- What is the OPTIMAL position for the glenohumeral joint that the orthosis must maintain?
Answer: 90-100° of abduction, 20-30° of horizontal adduction, and neutral rotation.
The position of comfort for an axillary burn is adduction and internal rotation, which is the position of contracture. The anti-deformity position requires placing the shoulder in 90-100° of abduction and slight horizontal adduction to place the healing tissue on maximal stretch. This is typically achieved with an airplane splint or axillary conformer. The other positions would either be insufficient to prevent contracture or place the client in a position that encourages it.
- Which orthosis provides the MOST effective immobilization for the involved tendons?
Answer: A rigid, forearm-based thumb spica splint including the wrist and thumb MCP joint.
De Quervain's tenosynovitis involves the tendons of the first dorsal compartment (abductor pollicis longus and extensor pollicis brevis), which cross the wrist. To effectively rest these tendons, both the wrist and the thumb (CMC and MCP joints) must be immobilized. A rigid, forearm-based thumb spica provides this necessary immobilization. A hand-based splint (B) or a wrist-only splint (C) fails to immobilize all the joints crossed by the inflamed tendons. A soft splint (A) would not provide sufficient support for an acute, painful exacerbation.
- Which orthotic modification is MOST appropriate to facilitate active tendon glide and manage the developing adhesions?
Answer: Transition to a dorsal blocking splint with a wrist hinge and add a component for place-and-hold exercises.
At 4 weeks post-op, transitioning to an early active motion protocol is appropriate, especially with signs of adhesion formation. A dorsal blocking splint with a wrist hinge allows for controlled active wrist extension, which facilitates differential gliding of the flexor tendons. Incorporating place-and-hold exercises (active contraction in a passively placed position) is a key component of this stage to gently load the tendon and break up adhesions without risking rupture.
- What is the MOST appropriate orthosis for this client at this stage?
Answer: A volar wrist cock-up splint for support, which can be removed for exercises.
After cast removal for a stable fracture, the goal is to transition to active motion while providing support and protection to the healing bone and weak wrist. A removable volar wrist cock-up splint provides external support, reduces pain during functional activities, and can be easily removed for prescribed wrist mobility and strengthening exercises. It offers a balance of protection and mobilization.
- What is the MOST appropriate orthosis to fabricate for this client's stage of healing?
Answer: A dorsal blocking splint with the wrist in 20-30 degrees of flexion and MCPs in 50-70 degrees of flexion.
A dorsal blocking splint is the standard of care for a Zone II flexor tendon repair. It protects the repaired tendon by preventing full wrist and finger extension, which would put excessive tension on the repair. The specified joint positions (wrist and MCP flexion) place the flexor tendons in a shortened, slackened position, minimizing stress during healing and controlled motion exercises.
- What is the MOST likely reason the prefabricated splint is ineffective, and what modification should the OTR make in the custom orthosis?
Answer: The splint is ineffective because the wrist is in excessive extension; the custom orthosis should position the wrist in neutral (0-2° extension).
Research on carpal tunnel pressures has shown that the position of least pressure within the tunnel is neutral to very slight extension (0-2°). Positioning the wrist in significant extension (or flexion) decreases the volume of the carpal tunnel and increases pressure on the median nerve, which can exacerbate symptoms. The prefabricated splint's position of 25° extension is likely worsening the client's condition. The most crucial design feature of the custom orthosis is to position the wrist as close to neutral as possible to maximize space for the median nerve.
- Which orthosis is BEST suited to balance the competing needs of mobilizing the repaired tendon while protecting the healing fracture?
Answer: A dynamic extension outrigger for the 4th digit, mounted on a forearm-based volar wrist splint.
This complex injury requires protecting the healing extensor tendon from overstretching while allowing motion to prevent adhesions and stiffness. A dynamic extension outrigger provides passive extension to the digit via a rubber band, protecting the repair. The client can actively flex the finger against this gentle resistance, promoting tendon glide. The forearm base provides stability for the healing metacarpal fracture. The other options are either contraindicated (B), regressive (A), or provide insufficient protection and mobilization (C).
- Which type of orthosis would be MOST effective for this child?
Answer: A serial casting or static progressive stretching orthosis program for the wrists.
In a young child with fixed contractures from arthrogryposis, the initial priority is to gain passive range of motion. A serial casting program, where casts are changed weekly to gradually stretch the wrist into a more extended and radially deviated position, is the most effective method for lengthening contracted tissues. A static progressive orthosis could also be used to achieve this low-load, prolonged stretch. Once a more functional wrist position is achieved, other orthoses for functional use can be considered. Soft splints (B) would be ineffective against the contractures, and dynamic splints (A) are inappropriate until passive range is improved.
- Which type of orthosis is MOST suitable for this child?
Answer: A soft thumb abduction splint or strap.
For a mild, flexible congenital thumb-in-palm deformity, a soft thumb abduction splint is often the first choice. It is less restrictive than a rigid forearm-based splint, is generally better tolerated by infants and young children, and gently positions the thumb in abduction to stretch the tight adductor and flexor muscles, encouraging more functional use.
- Which type of orthosis is the BEST choice for increasing elbow extension for this client?
Answer: A static-progressive or dynamic elbow extension splint.
For a chronic contracture with a hard end-feel, an orthosis that applies a low-load, prolonged stretch is most effective. Both static-progressive and dynamic elbow extension splints achieve this. They apply a constant, gentle force to the tissue at its end range, stimulating tissue growth and gradually increasing joint range of motion over time.
- What is the MOST appropriate orthosis to reduce symptoms of trigger finger?
Answer: A splint that blocks the MCP joint in slight flexion, preventing full flexion.
Trigger finger is caused by inflammation of the flexor tendon sheath at the A1 pulley, located at the level of the MCP joint. An orthosis that blocks the MCP joint from flexing fully prevents the inflamed nodule on the tendon from passing through the pulley, thus allowing it to rest and the inflammation to subside. The PIP and DIP joints are left free to move.
- Which orthotic intervention is MOST appropriate during this phase of rehabilitation?
Answer: A static forearm-based orthosis that maintains the wrist in extension and the thumb in opposition.
To develop a tenodesis grasp, the finger flexors must be allowed to shorten slightly to create passive tension. Aggressively stretching them (D) is contraindicated. The priority in the early stages is to position the hand to facilitate this shortening while preventing overstretching. A static orthosis that holds the wrist in extension (the functional position for tenodesis) and the thumb in opposition preserves the arches and promotes the ideal posture for a future passive grasp. A complex wrist-driven orthosis (A) is typically considered later, once the passive grasp pattern is established.
- Which orthosis is MOST appropriate for this client to facilitate functional hand use?
Answer: A dynamic wrist and MCP extension outrigger splint.
The most appropriate orthosis is a dynamic wrist and MCP extension outrigger splint. This orthosis provides passive extension to the wrist and digits, substituting for the paralyzed extensor muscles. This allows the client to use their intact flexor muscles to grasp objects and then relax to allow the dynamic component to open the hand for release, thereby improving functional use of the hand during recovery.
- What is the MOST appropriate orthosis to recommend for this client's primary complaint?
Answer: A wrist cock-up splint in 0-10 degrees of extension to be worn at night.
For carpal tunnel syndrome, a wrist cock-up splint worn at night is the standard conservative intervention. Positioning the wrist in a neutral to slightly extended position (0-10°) maximizes the space within the carpal tunnel, which reduces pressure on the median nerve and alleviates nocturnal symptoms of paresthesia.
- Which combination of material properties is MOST suitable for this client's needs?
Answer: High rigidity, high memory, and good resistance to surface scratches.
An athlete requires a durable and strong orthosis. High rigidity ensures the splint will not bend or break under stress. High memory allows the material to be reheated and reshaped multiple times (as edema changes) and return to its original flat sheet form, which is useful for significant modifications. Good resistance to scratches adds to its durability. High drapability (A) and low resistance to stretch (B) often correspond with less rigid materials that may not be durable enough for sports.
- Which type of orthosis would be MOST effective for improving this client's hand function?
Answer: A figure-8 or silver ring splint.
A figure-8 or silver ring splint is designed specifically to address swan neck deformity. It works by preventing PIP hyperextension while allowing full PIP flexion. By blocking the hyperextension, it corrects the joint's alignment and allows for a smoother, more functional arc of motion for grasping objects.
- Which type of orthosis is MOST appropriate to manage tone and improve hygiene for this client?
Answer: An anti-spasticity ball splint or cone splint.
An anti-spasticity ball splint or a cone splint is designed to manage flexor tone. These splints position the hand with the fingers abducted and extended over a curved surface, which can help reduce the stimulation that triggers a strong grasp reflex. This positioning maintains the palmar arch and can make it easier to perform passive range of motion and hygiene care for the palm.
- Which orthosis is MOST appropriate to fabricate for this client?
Answer: A volar-based hand splint with the affected fingers in full extension.
Following a Dupuytren's fasciectomy, the primary goal of the orthosis is to maintain the length of the surgically released tissues and prevent flexion contractures from recurring. A volar-based hand splint that holds the wrist and affected digits in maximal comfortable extension is the standard of care. This position provides a continuous stretch to the healing palmar fascia.
- What is the correct orthotic intervention for this condition?
Answer: Immobilize the DIP joint in full extension or slight hyperextension continuously for 6-8 weeks.
Mallet finger is an injury to the terminal extensor tendon at the DIP joint. The standard treatment is continuous immobilization of the DIP joint in full extension or slight hyperextension for 6-8 weeks to allow the tendon to heal. The PIP joint should be left free to move to prevent stiffness.
