Transcript
josh MacDonald: I'm Josh McDonald.
Miranda Materi: And I'm Miranda Macerey and we are Hand Therapy Academy.
josh MacDonald: We're gonna talk a little bit about dynamic splinting. I know it's an area that when we both learned, there was all kinds of work in both OT school and lots and lots of focus on dynamic splints and these outriggers and wires and bending things and all that.
josh MacDonald: But what do we do in clinics today? What are we what are we spending our time with dynamic splinting today? So Miranda, do you use, let's start with outriggers. Do you use outriggers much? And if so, what for?
Miranda Materi: I will occasionally use like an outrigger, like if we're doing an MC arthroplasty or something that has to be really exact or precise. And I like to use the Phoenix outrigger because it's really adjustable.
Miranda Materi: With that being said, though, um I have done them out of thermoplastic as well. But if i if I could choose, I would choose that one. I think it's easier to put together and easier to get the correct alignment. Just sometimes, you know, like I think i was at a clinic last time where they didn't have one, so i had to make one myself. So that was an option. But so for MCP arthroplasty, I would prefer Phoenix outrigger. If it's like a radial nerve palsy splint or something like that, then I'm probably making the outrigger out of thermoplastic.
josh MacDonald: Okay.
Miranda Materi: How about you?
josh MacDonald: is Is there a reason you won't do the outrigger out of a Phoenix outrigger for radial palsy?
Miranda Materi: Yes, cost.
josh MacDonald: Okay. Okay.
Miranda Materi: I think the you last time I ordered the outriggers were like $90 and I'm like, you know, we just need to keep your fingers extended extended in a good position.
josh MacDonald: Because... Yeah. Yeah.
josh MacDonald: Yeah.
Miranda Materi: It doesn't have to be perfect. You know, if we're off radial or only a couple of degrees, it's not going to be detrimental to this patient. Versus with the EMC arthroplasty, it could be. So I think for costs alone, and because sometimes like, well, sometimes, you know, we don't, you don't get paid a lot or, you know, even the insurance will turn around and deny it.
Miranda Materi: And then you're out, you're out a hundred bucks for the outrigger that, you know, they maybe didn't really need.
josh MacDonald: Yeah, yeah. um So I have a very similar approach to you on that one. For MCP arthroplasties, I will use a Phoenix outrigger. um And you know you're dialing in your 90 degree angle of pole. And it's there's so much more like going into that to make sure you don't change the kinematics of that joint as it heals and as that bone cement sets. But for like a radial palsy or an extensor tendon injury, if they want an outrigger, I am typically doing that low profile one. We've got videos out there on it where it's just basically a low profile thermoplastic across the dorsum of the hand and forearm out to the level of the PIPs and then Velcro strapping like three quarter or one inch wide Velcro elastic strap that runs like between the fingers and loops so they can activate against that elastic strapping, but then it pulls them back up because the line of pole is not nearly as significant.
Miranda Materi: Yeah.
josh MacDonald: Yeah.
Miranda Materi: Yeah. And I think those are better tolerated by the patient as well. There's not like this big metal thing sticking off of their hand.
josh MacDonald: Yeah, yeah, for sure. um I feel like for extensor tendon injuries, that used to be kind of the standard. You were putting in stops for the 30 degree mark and you were you were lining everything up and you getting all your lines of pull right.
josh MacDonald: And I just don't feel like the, that of I've heard this, that the juice wasn't worth the squeeze. It's just so hard to do all of that that you're just not getting the return out of it. Yeah.
Miranda Materi: Right. And then there's no clinical study saying that, right? Like this is how many, it's all based on theory. So we think in theory, but in reality, it probably doesn't really matter.
josh MacDonald: Yeah. Yeah. um So I will use out, excuse me, I will use dynamic splints because we're talking about dynamic in general, not just outriggers. I will use dynamic splinting much more often for trying to regain flexion, passive range of motion after metacarpal fractures and digit injuries where the patient's just not gaining that range of motion into flexion. I'll use dynamic, maybe static progressive with fishing line instead of rubber bands to reestablish joint flexion in a passive way so hopefully gain more active range of motion as a result. I'm doing that all the time with the forearm base splint and those, you know, Velcro loops that come down to pulleys that attach to the forearm, that kind of thing.
Miranda Materi: Yeah. What about for, what are you, are you using any type of outrigger when you're working on wrist extension for the line of, because you know, that's a hard one because the line of pull, especially as they get more, you know, when you first start off, there's not really that good leverage.
Miranda Materi: So I've seen a lot of people where they'll build up a huge, like dinosaur looking T-Rex, you know, with the little divots in it, where you put the rubber band in.
josh MacDonald: Yeah.
josh MacDonald: Yes. And I don't know why i just have this aversion to those things. And I think for me, like I try to figure out why, and I think it's because it is this obtrusive thing for the patient. And I think the more obscure and obtrusive it is for the patient, the less likely they are to use it. And that may be me imposing that and projecting that onto the patients. I'm not a big fan of those.
josh MacDonald: I feel like if a patient doesn't have the first, I'll say 20 degrees one direction or the other, I don't know that they're right yet for a dynamic splint, that there is more joint capsule tightness. And so even if I have the right line of pull on someone who only has five degrees, if I'm torquing that joint, the joint capsule does not have enough pliability to respond to that in a healthy way.
josh MacDonald: And so I need to get them kind of like, I'll say rocked loose a little bit in concept first, but that's just a personal preference. There's no research that goes behind that. That's just kind of like, I want to get them to that stage first.
josh MacDonald: And there's been some patients where I'll go with a Dynasplint or a Jazz or something like that, just because I don't know that I can do that with the resources I have without making something that is this big configured thing when those work really well.
Miranda Materi: service Yeah, I, I agree with you. Sometimes the jazz or the Dynasplint option is really nice. I think the problem I always have is I'm like, well, by the time we get the rep out here, get measured, get approval during the splint, we might be like four months, you know, not four months, but four weeks out.
josh MacDonald: Yeah, yeah.
Miranda Materi: At least what I see, I'm like, that's just like, in the meantime, I could make you something. Maybe, you know, you don't love how it looks or something, but yeah,
josh MacDonald: Sure, yeah.
Miranda Materi: you know, going to get.
josh MacDonald: and And so for those patients, you're right, the lag in receiving it is so significant. I try to identify those patients who are stuck, stuck very early.
Miranda Materi: Mm hmm.
josh MacDonald: Like I've gotten a feel for like, okay, this patient's stiff, but you know with some heat and some range, their weak score is not bad. they're They're moving okay. We can get through this a little bit.
josh MacDonald: But if they are like stuck in cement, then I may initiate that maybe their second visit in just to get that ball rolling sooner. um But yeah, it's it's it's a case by case sometimes.
josh MacDonald: Unfortunately, it's not always something we can apply general rules to.
Miranda Materi: Right, that's true.
josh MacDonald: Yeah, yeah. um Do you use anything specific for supination pronation tightness?
Miranda Materi: Oh my gosh. I've made supination pronation splints. I don't really love them. A lot of times I'll have the patient do like an active assist, you know, with, you know, them doing it manually or holding something in their hand and helping with, depending upon where the tightness is at, is it at the proximal radial inner joint or the the distal one? So those are factors and play as well. I don't think the ones I make are good enough for the patient. I've never been happy and thought this is a great splint for them. So I would oftentimes order the Jazz or the Dynasfoot ones.
josh MacDonald: Yeah.
Miranda Materi: How about you?
josh MacDonald: I'm kind of the same way. I don't feel like anything I have has the stability to provide the torque needed. Like it's, it's sliding on their forearm or it doesn't grip. I don't know. I've, I've tried two or three times and I thought, you know what, that is a fantastic tool. So I've had, like, I have a patient right now who had um, only shortening osteotomy and the doctor said zero rotation for six weeks.
josh MacDonald: And I'm just anticipating she's going to be stuck in concrete. And so my inclination is, you know, wait to like three weeks out and then send an order to the doctor. And I've done this before with some success is to send to the doctor and say and give a note that says this is an anticipation of them needing this in the future. Are you good to...
josh MacDonald: sign off on this order now knowing we won't apply it heck we won't even have it for four weeks until they're cleared and you run the risk of that patient being cleared and then like oh look they're moving great but those rentals then they're usually device rentals at this point um then they just turn it right back in again and it was one month for the insurance instead of waiting a while for the patient to get even more stiff
Miranda Materi: Yeah, that's a good idea. I've never done that before, but I like it.
josh MacDonald: Elbows, are you making your own elbows with a turnbuckle or or a theraband or what are you doing for those?
Miranda Materi: For like a hinged elbow, is that what you...
josh MacDonald: Yeah.
Miranda Materi: um i I really like making my own hinged elbows. I think they're way more comfortable for the patient. And you know the the turn the turnbuckle on the side isn't at night as nice.
Miranda Materi: You know you have to like put the little screws in to set the parameters, but I kind of like that because then I know I can do it in therapy with them and progress them with the Allen wrench as opposed to them like clicking it and moving it around.
Miranda Materi: And I've just found that off the shelf elbow ones don't fit the patient's well. I rarely see one that fits well, but that's, guess those are my biases and my experiences. How about you?
josh MacDonald: Um, so are you talking about a basic hinge double or are you talking like a static progressive?
Miranda Materi: Just a hinged elbow, a basic one.
josh MacDonald: Yeah, yeah, yeah.
Miranda Materi: Yeah.
josh MacDonald: I agree. I like the off the, excuse me. I like the custom made with the, with the hinge that we add on. And I feel like it's, it doesn't take super long to make.
Miranda Materi: Uh-huh.
josh MacDonald: And with the perforated material that we're using, it's usually not too big a deal to find holes that line up well. So I, I, I prefer that too. Um, I was thinking about like static progressive, serial progressive to increase elbow flexion.
josh MacDonald: I'll use a a serial progressive for extension gains, but are you using things to improve flexion like that?
Miranda Materi: yes
Miranda Materi: rarely rarely but I think it's just because I don't see it enough to yeah what about you are using I think I have probably in the past on like a TheraBand one or so you know something but
josh MacDonald: Okay.
josh MacDonald: Okay.
josh MacDonald: Yeah, yeah. um I feel like it so depends, and I haven't done a boatload of them for sure, but I feel like it so depends on the patient's available range and their size. If it's a bigger patient, the turnbuckle from Home Depot may be just great, but it's only going to go so small.
Miranda Materi: Yeah. Good.
josh MacDonald: But if I TheraBand, I can go behind the elbow and hook it around a little extra tab I make on the back of Thermoplast, go behind the triceps, and it pulls on another guide wire line thing on the owner's side of the wrist. And so you're kind of guesstimating on these things. and I feel like I could go with a jazz or dinosplint, or I could go with a custom. And it's kind of a case by case basis when I decide, but and I have to know that they can't be like only 30 degrees of flexion. And one of mine work, the line of pull is so bad in that situation. You're doing this ginormous angled thing and it's just not worth it.
Miranda Materi: ah doesn't work that well yeah i probably did default default to the jazz one and you know sometimes the jazz one's nice too because it can do both flexion extension forearm rotation if you need it or is that the guy i love one i don't know
josh MacDonald: Yeah.
josh MacDonald: Yeah. Yeah. Um, Yeah.
Miranda Materi: let me
josh MacDonald: Yeah. Yeah. Okay. So that's a bunch of information on what we use and don't use and kind of our general overview of perspectives on dynamic splinting. If you have any questions on any of that, or if you have any thoughts or suggestions, feel free to reach out to us at info at hand therapy, academy.com.
