Splinting the paediatric hand. Generell introduksjon. Griet van Veldhoven Margareta Persson

Transkript

1 Splinting the paediatric hand. Generell introduksjon Griet van Veldhoven Margareta Persson

2 Big difference between an adult hand and a child s hand The small size can be a challenge

3 But the child s hand is MORE than a small hand. Big differences with the adult : - Anatomical /biological - Development - Behavioural

4 Anatomical differences with the adult hand: Other proportions than the adult hand Adult splint patterns can t just be copied in a smaller size

5 Anatomical differences with the adult hand: Tissue healing Tissue healing is going faster. Adult splint- and treatment programs can t just be transferred to the child.

6 Anatomical differences with the adult hand: bone formation Dynamic splints??!! Position - duration for immobilisation??!!

7 Developmental difference with the adult hand: Psycho-motoric development Capabilities of the hand are dependent on the stage of mental- and motor development Important interaction between brain hand function eyes sensibility body perception

8 behavioural difference with the adult: The child is more dependent on others Donning and doffing of the splint: some children are real Houdini s needs to be easy for the caregivers

9 behavioural difference with the adult: Exploration with the mouth mmm this splint tastes good..

10 behavioural difference with the adult: Design - Motivation

11 behavioural difference with the adult: Fabrication of the splint Take care of both the parents and the child Explanation about what's going to happen Showing a sample Written information Establishing a working relationship Practice donning and doffing at the clinic Picture, (colour) coded fixation straps Trail wear during 15 minutes before leaving the clinic Telephone number

12 behavioural difference with the adult: Fabrication of the splint Establishing an optimal collaboration with the child Child decide where to take place Showing some funny splints Play with the splinting material Making a splint on a favourite toy or parent white coat? a funny hat or mask? Choice of coloured material Music, story Making the splint while the child sleeps Honest information and agreements Allow the young child to participate in donning and doffing the splint (Separate from parents)

13 Hånd ortoser til barn med CP Griet van Veldhoven Margareta Persson

14 What s the point of using a splint? Each splint needs a clear and measurable aim/goal. Increasing function (which function in what kind of activity?) Preventing/correcting contractures Help during treatment/training Post operative post Botulintoxin Decreasing pain / improve hygiene To

15 What s the point of using a splint? Increasing function: which function in what kind of activity? Splint used during daytime. No gain = no wear

16 What s the point of using a splint? Preventing/correcting contractures = keep the length of the spastic muscles Avoid ingrowth of fibrotic fibres Avoid lengthening of the antagonists

17 What s the point of using a splint? Help during treatment/training: Elbow extention + Wrist extenstion + Fingerextention In order to train shoulder stability

18 What s the point of using a splint? Post operative post Botulintoxin Protect healing tissue Keep muscles in length Training assistance

19 What s the point of using a splint? Decreasing pain \ improve hygiene

20 General «spastic splinting rules»

21 The hand must find rest in the splint Use splint material, straps, color, etc acceptable for the patient

22 Only support what need s support a day orthosis should help positioning the hand for better hand function The joints should be in relaxed non stressful positions, not hyper extended or in max flexed position

23 Use material washable in the washing machine on wool program 40

24 Ha ALLTID et kritisk blikk ved bruk av prefabrikerte ortoser MEN OGSÅ på den ortose du har laget selv. Ta avstand å ta fram ditt kritiske blikk

25 Night splints for spastic hands

26 Night splints for spastic hands

27 The optimal resting position Neutral position of the wrist MCP i almost full extension IP joints in just a bit of flexion Thumb extended in palmar abduction with slightly MCP Flexion

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29 Central support point at the wrist has to be broad and slightly elastic Central support point at the MCP joints 2-5 has to be broad and slightly elastic

30 The central support point to control ulnar deviation of the wrist has to be broad and slight elastic band NO hard splinting material NO hard edge. Keep the ulnar side low. Make the radial side high for stability and for comfortable support points (distal MC and proximal forearm).

31 When the adductor is tight: try to slightly flex the MCP and IP 1 joint

32 Don t pull or push the MCP 1 joint into hyperextention or radial deviation in an attempt to correct adduction

33 A prefabricated soft wrist support with a cylinder of pipe insulation can be an alternative to a static night splint

34 En myk håndleddsstøtte med palmar forsterkning kan bygges ut med en skumm gummi rulle (vann rør isolasjon) for å støtte fingrene (og tommel)

35 Som alternativ for en rigid natt ortose kan man utvide en fleksibel prefabrikert håndleddsortose med en skumm gummi sylinder for å støtte fingrene. Dette er et kompromiss men bedre det enn ingenting ;-)

36 For babies a HandAid thumbsplint with a cylinder of pipe insulation attached with a V-shaped velcro on the dorsal side of the wrist-thumb support can be used as a night orthoses

37 Pucci Air: bruk din kritisk refleksjon

38 Houdinni barn? Sklir hånden ut av en rigid semi sirkulær ortose kan man feste fabrifoam med velcro på innside av ortosen. Den hvite side med høy friksjon peker mot huden.

39 Dorso palmare ortoser er enklere å ta på, lettere å lage men bare brukbar ved litt større barn

40 Functional wrist splints

41 Stability: distal row of carpal bones and CMC II-III Mobility: CMC I CMC IV-V and MCP II-III

42 The MCP joint III is the highest point of the distal arc - Important both for function and for rest. - Without the distal arch no strength and reduced ability to manipulate objects.

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44 Radial pull in extension Ulnar pull in flexion

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46 Check: Are the fingers more flexed with the wrist support on or can they extend as much as without the splint?

47 Replace the rigid support by a custommade support (on the outside OR the inside of the prefabricated flexible wrist support)

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50 A wrist with a tendency to some ulnar deviation can be counteracted with a piece of double sided velcro attached to ulnar side on the inner layer of a Fabrifoam thumb support

51 Spectra wrist support change the metal stay to a plastic for better comfort, gives some flexibility to the wrist.

52 Fabrifoam håndledds ortose med Orfit forsterkning ulnar Finn feilen??!!

53 Functional thumb splints

54 Tommel stillinger

55 OR

56 Functional thumb support: try to expose the tactile area of the thumb = pulpa. The thumb should reach the lateral side of the tip of the index finger

57 Grip initiated by adductor policis. Positioning the thumb to stimulate grip with FPL.

58 Rigid orthoses if a firm, non elastic support is needed

59 A cylinder of pipe insulation / rubbermaterial on the thumb strap to gain web space and positioning of the thumb

60 Supinasjonsortose

61 Pro- og supinasjon skjer mellom radius og ulna

62 Ved å ta tak rundt tommelen drar man på både tommelens grunnledd og håndleddet

63 Man skal feste draget distalt på underarmen. Tommelen kan inkluderes men draget skal ikke festes på tommelen.

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65 Fest noe spennende på palmar side av en ortose. Dette kan stimulere supinasjon.

66 En supinasjons bandasje kan kombineres med for eks en håndleddsortose, tommelortose og palmar nattortose Todelt konstruksjon gir flere muligheter (dag, natt).

67 Forarmen endrer form ved pro-supinasjon Forarmsortosen i rigid material må derfor lages i den stillingen ortosen skal bli brukt i.

68 Vær sikker at pårørende vet i hvilken retning armen skal wrappes!!!!!!!!!! Om nødvendig sett merker på bandasjen.

69 Fabrifoam = anti skli = ingen strangulering Neoprene = tekstil = strangulering

70 Elbow Splints

71 Elbow splints Prevent flexion contracture Correct flexion contraction Stimulate support / stabilisation of the shoulder

72 Elbow extension splint made of 2-3 layers of Fabrifoam wrapped on top of a standard hand resting splint.

73 If a more rigid splint is needed Fabrifoam can be reinforced with a piece of dry heated Orfit. Dry heated Orfit Classic 1.6mm sticks to the fabric layer.

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76 Finger splints

77 Spastic hand with swan neck deformities. Often it s enough with one single extension block

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79 Vær kritisk ved valg av prefabrikerte ortoser Myk (Rehband, DeRoyal, Spectra, MedSpec) håndleddsstøtte kan forsterkes palmar, dorsal, ulnar eller sirkulær med plast inn- eller utvendig. Innvendig dekkes plast med polstring. Utvendig dekkes plasten med lær som sys på. Ved spastisitet av FDP og eller FDS: feste en rull på håndledds støtte slik at fingrene kan legges rundt rullen. Ved tommel adduksjon: rørhylse over tommelløkken.

80 Palmar ortose: bred og myk bånd over håndledd og håndrygg masse masse hyll i plasten (Margareta Persson) Strømpe under plasten (microfiber strømpe fra Rehband/Knite rite) (Griet van Veldhoven) Håndleddsbandage type Spectra (Össur) er veldig bra den klemmer ikke radio ulnair men dorsopalmair. Barnestørrelse??? En metall forsterkning skal helst erstattes med en plast forsterkning som har litt fleksibilitet En fabrifoam håndledds ortose kan bli forsterket med orfit classic eller dobbelsidig rigid borrelås

81 Ved spastisitet av FDP og eller FDS: feste en rull på håndledds støtte Ved tommel adduksjon: rørhylse over tommelløkken Rullen dekkes med splintpolstering eller en stoffhylse pasienten får to ortoser slik at de kan vaskes Elastisk borrelås fra DeRoyal eller Otto Bock er veldig myk og billig, kan klippes uten at den rakner. myk elastisk bånd med karbordbånd funksjon Inhibering før ortoselaging: OK for å gjøre det enklere å lage en ortose IKKE for å oppnå en bedre stilling!!!

82 Bruk Theraband (kjøleskap) når man lager en ortose kleber ikke i plasten, lager ikke merker kald Theraband kjøler plasten ned ganske fort Bred borrelås over handryggen = for bred i første webspace: borrelåsen brettes sammen og holdes på plass med en bit Orfit Farget plast, farget borrelås, små klistremerker i morsomme farger og mønstre Bånd som hindrer tommelen å dra mot volar eller rad. abd. Skal gå over MCP ALDRI over IP eller PP!!! forskjellige ortoser for dag og nattbruk (Redusere spastisitet med is eller en gellpose som man legger i fryseren) Stabil og trygg sittestilling, stimuli fattig omgivelse

83 Vi skal lage denne listen lengre i løp av diskusjonen