Upper extremity orthotics

Upper Extremity Orthotics
Restoring Mobility and Quality of Life www.cpousa.com
P R E S E N T E D B Y :
COMPREHENSIVE PROSTHETICS AND
ORTHOTICS

Upper Extremity Orthotics
Overview
• Common upper extremity related orthoses
• Upper extremity orthotic components
• Common upper extremity pathologies requiring orthotic
intervention
• Upper extremity fracture/post operative orthoses

Our Goals
With upper extremity orthoses, our main goals usually
revolve around…
• Maintain or maximize functionality of the upper limbs
• Prevent deformity or contractures
• Improve positioning or range of motion of upper limbs
• Allow protection and positioning for proper healing and recovery
• Improve mobility and quality of life

Key Components of the Upper Limb
 Shoulder: Positioning and support critical
 Elbow: Emphasis on flexion
 Wrist: Achieve most optimal placement and ROM
 Fingers: Proper positioning for patient goals
 Thumb: Primary emphasis for prehension and grasp

Shoulder
 In the normal shoulder, the articulating surfaces of the
humerus and glenoid provide minimal stability of the
shoulder
 The contact area between the two articulating surfaces is
relatively small, with only 25-30% of the humeral head in
contact with the glenoid surface in most anatomical positions
 Due to a lack of bony stability, it relies mostly on capsular,
ligamentous, and dynamic muscular activity for constraint
(resist joint translation)

Elbow
 Elbow flexion remains the biggest importance in
regards to movement and stabilization
 Extension usually aided by gravity
 Constant positioning in extension increases tension
on shoulder joint
 Elbow flexion imperative for positioning of wrist and
hand.

Wrist
 Wrist positioning key for achieving
therapeutic goals
 Neutral positioning or 30 degrees
extension is optimal for static orthoses
 Wrist flexion very imperative for
prehension and grasp with dynamic
orthoses

Fingers
 Increased finger range of motion directly proportional
to increased functionality and independence
 For dynamic orthoses, control over the 2nd and 3rd
finger remain primary target for grasp and prehension
 The MP joints are the most important for and function
as they contribute 77% of total arc of finger flexion as it
is a diathroidal joint contributing to ab/adduction,
critical for prehension.
 PIP joints are of importance as they produce 85% of
intrinsic digital flexion and contribute 20% to the
overall arc of finger motion. (Arc from 45-90 deg
provides normal function relatively)

Thumb
 Thumb is top priority for prehension as it
provides 40% of overall hand function in
uninjured patient. (50% in injured)
 The ability to grasp is the pinnacle of
importance in regards to the thumb
 Positioning, functionality, and
optimization of web space are the top
concerns

Upper Limb Components
 Upper limb orthoses are more widely accepted by
a patient if the therapeutic purpose is well defined
or the orthosis provides a desired function that
cannot be accomplished otherwise.
 Therapeutic orthoses tend to be optimized for
specific purposes or activities.
 Often these purposes are divided into static and
dynamic purposes.
 Orthoses are even further divided into therapeutic
or functional purposes.

Static Orthoses
 Classified as therapeutic orthoses
 For support and positioning of weak or paralyzed upper extremities
 Used to prevent contractures and further deformity
 Can also serve as a platform for other therapeutic attachments
 Classified into levels of involvement:
 WHO: Wrist-hand orthosis
 HdO: Hand orthosis
 EO: Elbow orthosis
 SEWO: Shoulder-elbow-wrist orthosis
 SEO: Shoulder-elbow orthosis

Static WHO
 Supports the wrist joint, maintains the functional
architecture of the hand, and prevents wrist-hand
deformities.
 Patient Populations:
 Severe weakness or paralysis of the wrist and hand
musculature.
 Prevention of contractures or deformities
 Often used for post CVA or C1-5 Quadriplegics with zero wrist
extensors and an intrinsic minus hand

Static Hand Orthosis
 Maintains the functional position of the hand and
prevents development of deformities.
 Serves as a vehicle for other therapeutic attachments
 Patient Population:
 Patients with weakness or paralysis of the hand intrinsic
musculature and strong wrist extensors
 Without this orthosis these patients are at risk for developing flat
hand with the thumb carpometacarpal joint in extension
 The C7 neurosegmental level quadriplegic exhibits this weakness

Static Elbow Orthoses
 Designed for reducing soft tissue contractures.
 Must be custom designed and custom fabricated with cuffs and
straps.
 Application of low magnitude, long duration forces is preferable for
reducing contractures.
 Contracture reduction should be done slowly and incrementally in a
therapeutic setting.
 Can result from trauma or disease
 Largest population affected is SCI who depend on full ROM of the elbow to propel
a wheel chair or bring the hand to the face

Static Shoulder Elbow Orthoses
 Commonly seen for support of a painful shoulder or traumatized brachial
plexus-injured limb for long term use as opposed to simple sling.
 The coupling between the forearm trough and the iliac cap can be
customized to permit a variety of motions for the glenohumeral joint.
 Common examples include: “gunslinger,” forearm trough, or shoulder
abduction orthosis.
 Brachial Plexus injury
 Painful or subluxing glenohumeral joint
 Intrinsic plus hand and wrist C7-8 Spared
 Can have a an WHO extension is weak hand/wrist

Shoulder Elbow Wrist Orthosis
Restoring Mobility and Quality of Life
www.cpousa.com
 Frequently prescribed to protect soft tissues or to prevent
contractures of soft tissues or to correct an existing deformity.
 Can be utilized for static placement or designed to allow for
maximum mobility.
 These orthoses also known as a shoulder stabilizer or airplane
orthosis.
 Post rotator cuff repairs
 Anteroposterior capsular repairs
 Postmanipulation
 Axillary burns

Functional Upper Limb Orthoses
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 Protects and assists weak musculature to perform selective
tasks
 Often uses internal or external power sources to achieve
increased functionality of upper limb
 Often used for patient populations with long standing
limitations who would benefit from increased function of
hand through use of orthoses

Functional WHO
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 Wrist Driven WHO: “Flexor hinge WHO”
 Dynamic prehension orthosis for transferring power from the wrist extensors to the
fingers.
 Active wrist extension provides grasp, and gravity assisted wrist flexion enables the
patient to open the hand.
 The proximal and distal IP joints of fingers 2 and 3 are immobilized along with the
carpometacarpal and MCP joints of the thumb.
 An adjustable actuating lever system at the wrist joint allows the user to fine-tune the
wrist joint angle at which prehension occurs.
 Paralysis or severe weakness of the hand
 Wrist extensor strength must be 3+ with functional proximal strength
 Indicated for SCI C5 and some C6 return or C6, C7 levels

Functional WHO
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 Ratchet wrist-hand orthosis: Enables the patient to grasp and release
objects using external power
 Power is manually controlled and substitutes for finger flexor and extensor
muscles that are less than grade 3
 A ratchet system is used so that the hand can be closed in discrete
increments.
 Pinch is achieved by applying force on the proximal end of the ratchet bar
or by using the patients own chine, other arm, or battery power to flex the
fingers to form 3 jaw chuck.
 SCI with weak or no hand or wrist extension, C5 quadriplegics
 Patient should have grade 2shoulder flexion, abduction, external/internal rotation.

Elbow Orthoses
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 Functional EO’s usually incorporate an elastic device with a locking
mechanism to assist elbow flexion with multiple angular lock points.
 The user initiates elbow flexion with residual musculature or using body
mechanics.
 The elastic device (i.e. spiral spring) assists the flexion until one of the
flexion stops is reaches. A release on the stop permits the elbow either to
advance to a new greater angle or fall back into extension
 Selective loss of elbow flexion secondary to a brachial plexus injury or congenital defect
 Bilateral applications may be more successful than unilateral (so no dominance)

Mobile Arm Supports
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 MAS is a shoulder elbow orthosis that supports the weight of the
arm and provides assistance to the shoulder and elbow motions
through a linkage of bearings joints.
 Using gravitational forces and occasionally tension from rubber
bands or springs to substitute for or supplement loss of strength in
shoulder and elbow musculature
 Mounted on wheelchairs and comprised of forearm trough and
optional pivoting and tilting of the proximal arm.
 M.S., Polio, Guillain-Barre, Amyotrophic lateral sclerosis
 Specific evaluation for deltoids, elbow flexors, and external rotators most
important for function of MAS

Resting Wrist-Hand Orthosis
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 Designed to maintain the arches of the hand, keep the thumb
abducted and flexed, and maintain the wrist in a functional position
(30 degrees)
 Most often used to preserve the hand architecture but also used to
reduce hypertonicity by abducting the fingers
 Also used to alleviate wrist or hand pain by immobilizing the
muscles and tissues and suitable for preventing loss of motion after
acute trauma.
 CVA, hemiplegia, SCI, traumatic injury
 Either volar or palmar design to accommodate for patient needs

Hand Orthoses
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 Maintains palmar arch and web space
 Useful for acute intervention in a painful hand or when
thumb contracture is threatening.
 Used to position the thumb in opposition, leaving the
hand in functional position for use.
 Several different attachments for therapeutic uses to
achieve patient specific goals.

Hand Orthoses Attachments
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 MCP Extension Stop: Used for intrinsic weakness of the
hand to prevent MCP hyperextension. MCP stop placed
just proximal to the IP joints. Used for median and radial
nerve injury causing weakening of the transverse arch
 Thumb Adduction stop: Positions thumb in opposition
and maintains thumb web space leaving the hand in a
functional position for use. Allows IP flexion of the
thumb and flexion of the second MCP joint.

Hand Orthoses Attachments
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 Thumb post: Used for Absence of active opposition and
thumb flexion or a flail thumb with no volitional control
that needs complete positioning and placement. Positions
thumb for prehension and grasp.
 IP extension assist: Used for assisting opening of the
fingers to aid in grasp and release. Used for weakness of the
intrinsic muscles of the hand with adequate finger flexion.

Upper Limb Fracture Orthoses
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 Primary fracture orthoses for Humerus and Ulna
 Provides micro-motion (increased osteo-genesis), easier
donning and doffing than casts, improved hygiene,
adjustability for swelling, adjustability in limb
positioning, Maintain limb mobility, and most
importantly total contact and soft tissue compression
 Requires several follow up visits to ensure optimal fit and function

Humeral Fracture
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 Primarily used for fractures of the mid shaft and
distal 1/3 of humerus
 Usually applied after 2nd week post fracture
 Indications for use:
 Less than or equal to 30 degrees varus angulation
 Less than or equal to 20 degrees A/P
 Less than or equal to 25 mm of shortening

Humeral Fracture
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 Humeral Fx orthoses usually come pre-fabricated but
also require trimming and modifications to individualize
for patients.
 Regular follow ups for tightening and cleaning
mandatory
 Fitting protocol:
 25 mm inferior to axilla medially
 15 mm proximal to medial epicondyle
 Immediately distal to acromion
 Proximal to lateral epicondyle
 Allows for full ROM

Ulnar Fracture Orthosis
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 Also called “night stick fracture”
 Involves distal 2/3 of ulna
 Applied first week of fracture
 Orthotic Indications:
 Angulation less than or equal to 10 degrees
 Distal 2/3 of ulna

Ulnar Fracture Orthosis
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 Full elbow and wrist motion made available to patient
 Usually flare distal aspect for wrist motion and proximal
aspect if patient has a lot of soft tissue
 Usually provides compression of the majority of the
forearm with adjustable straps for increased compression
 Makes use of interosseus membrane of forearm

Colle’s Fracture
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 Usually involves a fall on outstretched hand
(females>males)
 Involves distal 20 mm of radius
 Orthosis applied second week after fracture
 Orthosis positioned so that elbow is bent slightly and
wrist is ulnarly deviated

Fracture Orthosis Contraindications
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 Angulation or deformity is greater than orthosis can correct for
 Soft tissue loss
 Instable phase of healing
 Insensate, dysvascular, neruological patient
 Polymer sensitivity
 Open fractures
 Intra-articular or close to it
 Non Compliant patients

Post Operative Care
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 Post operative orthoses used in conjunction post
surgery to facilitate proper healing
 Usually will involve continued soft tissue
compression and selective positioning
 Can incorporate ROM dial locks for therapeutic
purposes to prevent or allow physician specified
movements.

Post Operative Care
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Commonly Seen Orthotic UE Pathologies
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 Carpal Tunnel Syndrome
 Rheumatoid Arthritis
 Post CVA/SCI
 Swan Neck/Boutanniere Deformity

Carpal Tunnel Syndrome
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 Main cause is compression of median nerve
 Main objective is to position wrist in neutral but
preferably slight extension (approx 30 degrees) to get
pressure off of median nerve
 Static low profile wrist supports often used to position
wrist accordingly
 Usually accompanied by hypertrophied thenar eminence
 Assessment: Phalen Manuever (praying hands)
 Tinnel Sign (tapping on palmar side of wrist)

Rheumatoid Arthritis
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 Inflammation of wrist, usually accompanied by
Carpal Tunnel and thenar atrophy
 Boutonniere/swan neck deformity and ulnar
deviation commonly seen
 Orthotic Goals:
 Decrease pain and swelling
 Maintain joint mobility/prevent deformity
 Position MCPs in 25 deg flexion, PIPs slight flexion
 Wrist in neutral or 10 to 15 deg flexion

Post CVA/SCI
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 Main objective is to position to prevent contractures and
prevent wrist and finger flexion due to high tone
 Usually involves a static volar resting hand orthosis
 Can incorporate ROM dial lock to gradually increase ROM
if contractures/tightness already present
 Prefabricated models often involve modifications for
personalization and optimized use

Swan Neck Deformity
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 PIP hyperextension and DIP flexion
 Stretching of Palmar Plate
 Lateral band Dorsal Shifting
 Ruptured Superficialis Tendon, lateral sides of phalanx
 Can use finger orthoses to prevent PIP hyperextension
and/or DIP flexion

Boutonniere Deformity
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 Consists of PIP flexion and DIP hyperextension
 Ruptured Central Slip
 Subluxed Lateral Band
 PIP flexion caused by extensor tendon
 DIP extension caused by shortening of extensor tendon
 Can use finger orthoses to encourage PIP extension and
prohibit DIP hyperextension

Casting for UE Orthoses
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 Goal is to get hand in functional position
 Align wrist with third MCP for “neutral” alignment
 Position thumb for prehension directly under index finger
 Thumb can be casted separately or included in cast of arm and
hand all together
 Indicate bony prominences with indelible pencil and include
bicipital mark (where forearm touches bicep when arm flexed)
to indicate proximal trim line.

Problems With UE Orthoses
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 Upper extremity orthoses some of the most difficult for compliance
 Many patient lack the ability to self don orthoses and require additional
assistance
 Cosmesis is a big concern as many upper extremity orthoses are bulky and
cumbersome
 High functionality and mobility of the hand make UE orthoses hard to keep
in desired position
 Upper extremity orthoses often require patience and practice in order to
achieve patients goals
 If the orthoses help a patient achieve their goals, compliance increases
exponentially

Questions?
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Upper extremity orthotics

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