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Relative Motion Splinting
502 Plays6 months ago
Miranda and Josh talk about all of the uses for a relative motion orthosis.
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Transcript
Introduction and Trending Orthosis Topics
00:00:06
Speaker
Hi, I'm Josh McDonald. And I'm Miranda Materi, and we are Hand Therapy Academy. Let's talk today a little bit about a relative motion orthosis or a yoke orthosis. It's kind of a big hot topic now. Lots of journal articles coming out about when to use it and its applications.
Common Uses and Functional Advantages of Yoke Orthosis
00:00:21
Speaker
So let's talk about some of the common ones that we see and maybe some of the quirky ones that we see that may be a good application for it. So Miranda, what are some common ones that you see that are kind of the standard one? We would go to that as a first choice.
00:00:33
Speaker
Yeah, I think the most common one I probably see is for an extensor tendon injury or a sagittal band injury. I think those are some go-to ones that we have. And I think the beauty of the relative motion splint is it really doesn't limit the patient's function that much, right? So they're able to do a lot more than what maybe they would not be able to do if they were in a traditional extensor tendon splint or whatever the type of splint might be.
00:00:58
Speaker
And they seem to be very effective for many different
Effective Patient Cases of Yoke Orthosis
00:01:02
Speaker
things. So not only extensor tendon, but PIP joint stiffness in either the flexion or extension plane. Anything that you can kind of load the joint a little bit more. How about you? What are you using it for?
00:01:16
Speaker
I had a couple of patients recently come in where the doctor specifically requested eochrotosis, which is interesting because it's, I think, becoming much more commonplace for the doctors. We were educating surgeons on it maybe six, seven years ago, saying, hey, can we use this for Accenture tenant? And that doctors are asking for it, which is great. I had one patient who had a vulgar plate rupture after a dorsal dislocation of the PIP joint.
00:01:40
Speaker
and the doctor wanted a yoke orthosis in relative extension so that that PIP didn't come to full extension so that we were protecting that boulder plate and like at the ASHC conference they talked about you know we really need to go into that you know full dorsal block maybe a rings like an oval eight but I think that was an interesting option because of lots of function there was no like soft tissue injury so that yoke riding across the
00:02:07
Speaker
crease of that joint wasn't a problem, but a really good application of it for that. Yeah, that's one.
Limitations and Protocols of Yoke Orthosis
00:02:14
Speaker
I think that's a really good one as well that I don't often think of, right? I'm always thinking about putting them in a dorsal blocking finger splint. Yeah. Yeah. And with the dorsal blocking, I feel like there's so much soft tissue squish on P1 that a lot of times they can kind of plow out of it and still go into full extension. Full extensions
00:02:33
Speaker
okay, we're finding out, but it doesn't really hold them in that 30, but I think that's a decent option too. Yeah, definitely. And then I know we're talking about extensor tendons. You can't do it for every single extensor tendon though, right? So I think that's one thing we need to mention with our audience. There's definitely still a place for a longer splint than the relative motion splint. And when are you not using it for an extensor tendon injury?
00:02:58
Speaker
Yes, so our ICAM protocol, the immediate controlled active motion protocol is for zones four through seven. If it is the right combination of digits, so it can be any single digit you can use it for, you can use it if there's two digits, if they're either both central or both lateral, but you can't use it for neighboring digits like index and long or ring and small. You also can't use it if it's three or more because you can't maintain that balance where
00:03:26
Speaker
the injured digits kept up, things start to tip and tilt. So that's when you would need a longer one. And you mentioned sagittal band earlier too. What would be our angle of relative extension for an extensor tendon RMO versus a sagittal band RMO?
00:03:43
Speaker
Yeah, so for the extensor tendon, I'll do 15 to 20 degrees usually around that. And then for a sagittal band, I'm doing at least 25 degrees.
Challenges in Crafting Comfortable Orthoses
00:03:52
Speaker
So it has to be a bit more than what it would be for just an extensor tendon because you want a little bit more slack on those structures for it to heal.
00:04:02
Speaker
Yeah, and we just want to avoid the peaks and valleys that happen at the MCP and then in that interjoint space when you make a full fist. So trying to keep that from being that dramatic peak that the saddle bands end up with tension on them.
00:04:15
Speaker
Yeah, and I think these are hard to make right, right? Like I feel like the extensive tendon or the relative motion splints are a little bit tricky. And I think you and I have talked about this before. Like one time I had a patient that came from Josh's office and he had made the splint for this patient and she wanted me to like make it just like Josh made it.
00:04:36
Speaker
And she's still been a patient. This has been going on for like six years and she comes into me like two times a year for a new yolk splint, but it's just kind of funny because she's like that original one was the best one. Which is funny because I feel like I could make the same yolk splint on the same patient twice and have two completely different fits. The difference between the PIP and P1
00:04:58
Speaker
Can be dramatic and the ends like flopping around and just to get over the pip joint i'll have patients i have one now that the doctor wanted to uh relative motion to get some extensions another use for it if they have a pip flexing contracture you put them in a relative flexion of that digit and it encourages more extension edc pull through stretch the folder surfaces.
00:05:17
Speaker
but we're chasing all the skin integrity issues. She comes in with constantly dry, ashy skin and she gets breakdowns. I mean, she's got rashes all over it. She's like, I just can't wear this thing.
3D Printing in Orthosis Production
00:05:28
Speaker
It splints as awful. I'm like, I don't think it's the splint, but yes, I'll pad the bejeebers out of it. And I'm putting soft surfaces and I'm rounding everything. So sometimes you just chase your tail on those because it's in delicate web spaces and folder creases and yeah,
00:05:42
Speaker
Yeah. And I think they're really a challenging splint to make actually, despite how easy it probably looks. Um, I just had a patient that was really into 3d printing. So he, um, told me, you know, whenever you want to make one of those, just send me your ring sizes and the differential you want to degrees and he'll print one for me. Interesting. Yeah. I'll be interested to try. He printed one for me and I was like, Oh, this is actually pretty cool. So I might be interested in seeing if it works or not.
00:06:08
Speaker
Do you have the ability to make those, I'll say the edges, soft and graded or rounded? Yeah. He's doing some type of, I forget the type of like resin or whatever. It's a softer one. So I don't know. We'll test and see. That might be an interesting concept, especially for the person that comes in twice a year for the exact same splint. If I had her measurements, I could just print off
00:06:31
Speaker
know, however many she needed. Yeah, yeah. And she could get the same thing. Yeah. I typically will make mine out of the Orphacast material, unless it's a larger hand. And then I'll maybe use something like the Aqua Plast non perforated. The perforated edges, you just end up with all these jaggedness and the scallops at the cut of the perforation. So I'll use a non, like an eighth inch
00:06:55
Speaker
I don't have to double it over. I can smooth the edges beforehand when it comes out of the hot water soil, but a lot of times I'm making out of the Orphacast. I just feel like that's softer on the patient and I can shape it pretty well.
00:07:06
Speaker
Yeah, I like a solid material. It's not easy form. It's more like the prism, but oh, it's encore. It's encore. OK. And that's what I've been doing mine out of. But I change. You know, sometimes we just try something new and you're like, oh, I'll try that again. Yeah. Yeah. Just out of desperation. Let's
Innovative Applications and Materials in Orthoses
00:07:24
Speaker
give this a try. Yeah. Yeah. Another diagnosis possibility for it that we're seeing a couple of journal articles out on is using it for a flexor tendon injury.
00:07:34
Speaker
So if you've got one, possibly two digits with the flexor tendon injury, you can put them into that relative flexion and then they can't get that full extension because they're held down and so there's still slack on there. It's almost like the hand-based, wrist-free protocol from St. John's. It just limits that terminal extension of the flexor tendon. Interesting concept. I think it's a little early to be adopting that for a lot of patients just yet, but interesting.
00:08:03
Speaker
Yeah, I think as sutra materials improve and tech surgeon techniques and the different types of anchors they're using and things like that now that maybe that will definitely have a place in the future.
00:08:15
Speaker
Yeah. And you definitely want to make sure it's, uh, the wound bed is clean and clear. You know, I wouldn't do it if it was, you know, zone two right over that P one and you're putting a yoke orthosis right there. Or if there's other neighboring wounds, you know, if that you've got to make sure that skin integrity is there and wound, uh, and there's probably lots of going to be changes in the DMA for those that will be interesting to see where, how that develops in the next five to 10 years. Yeah. Yeah. So when you do a relative motion orthosis, how do you,
00:08:44
Speaker
get the patient to understand when they walk out how to put the thing on later, because it can go on like five or six different directions. Do you put some marking on it so that they understand how to put it on? Yeah, I usually put like an arrow or something like saying, hey, put this arrow towards your, um, the finger or the nail, whichever one. I think they'll, I usually tell them to let me know how they want it. So they'll remember it that way, but it doesn't feel right. It's probably on wrong.
00:09:13
Speaker
I would hope so. Sometimes it's on right and still doesn't feel quite right if I did a funky job on it. Yeah. Yeah. Yeah. We're taking picture, you know.
00:09:21
Speaker
I love that using their own phone to take a picture. We'll do videos of how to put it on. I usually like to just to make it standard for myself. So I always remember, cause I've taken it off the patient, walked over to my heat gun to shape it and thought, Oh shoot, which one? Cause if it's index, middle and ring and they're all relatively same in size, there's no big step down for, I have a hard time. So as I'm sliding it partway off, when it's cooled and I'm going to go like adjust it, I'll take a Sharpie and draw an arrow, the points to the nail and I'll usually put the arrow
00:09:51
Speaker
at the injured finger so they know it's either the injured finger hides the arrow or the injured finger is where the arrow goes. Just some point of reference when I come back over from the heat gun, I don't look like I'm fumbling around not remembering which way it goes. Yeah, that's a good pointer. Good pro tip.
00:10:11
Speaker
Yeah, so we've got all kinds of different options for. There's tons of other options
Yoke Orthosis for Athletic Support
00:10:16
Speaker
out there. One we didn't even get to yet was Miranda mentioned that I haven't heard of it is using it for tennis elbow. That's a new one for me too.
00:10:22
Speaker
Yeah. So I will do this sometimes, especially if patients can't wear the wrist support, um, you know, like now pickleball such a big thing. And I feel like we're seeing more and more, um, more like tennis elbow, I guess we call it pickleball elbow. And so in the game, those people will stop playing is really not an option. So I've tried where we just do like a relative motion splint and put their long finger and extension relative to the other digits.
00:10:45
Speaker
And it unloads the forces just a little bit. So when they're grabbing the racket, it's not as painful. So I don't think it's like the silver bullet, but I think it's a good option to provide some support to that or some protection to it. And how much of a differential extension will you use?
00:11:05
Speaker
I typically do 20, 25, whatever, you know, it's going to be comfortable for them, but usually around 20, 25, I try to get them to 20, 25. You know, sometimes that's a little hard to do. Yeah. Yeah. Yeah. Sometimes finding that big angle change is hard. You know, you're putting a popsicle stick or a pen or trying to hold them and modify the splint. And then when you're done, you're like, uh, that's only 10 degrees. So it can be challenging. And then like the thing too, then you don't want to do too much where their fingers sticking out and it's going to get hit with a ball, you know, and they have another injury. So yeah. Yeah.
00:11:35
Speaker
All right. That's awesome. We covered tons of different options for when to use it, maybe some tips and tricks. If you have other ways that you use those splints, let us know. Maybe put them in the comments below, but we'd love to hear some ways that you use a relative motion or splint in your practice.