Words of wisdom imparted from decades of orthotic experience.
Vol. 31 • Issue 10 • Page 14
Occupational therapy has a long history of making splints with low-temperature thermoplastic material. When I was a student a long time ago, I asked my clinical supervisor why occupational therapists were making splints. She responded, “Because we have super glue for crafts, a sewing machine, and a metal workshop in our department.”
Part of the application process for therapy school at the time was an aptitude test to assess my ability to create a 3-D model from a 2-D pattern. From this origin, my humble experience in splinting began.
I have learned a lot about splints over the years, both from classes and from practicing in the clinic. It’s been a journey of art and science in creating these devices, which I would like to share with educators and new practitioners. The following are 10 helpful tips for the novice splint fabricator.
Test the pattern first. After creating a paper pattern of the splint you’re fabricating, test the pattern on the patient to adjust the tracing before cutting the material.
I’ve learned that when students skip this step when making simple proximal interphalangeal (PIP) gutter splints, which are indicated for PIP sprain injury, they end up spending more time cutting. They may even need to remake the splint because the finger trough is not the width of the finger pattern, with adding approximately one-third inch on each side and two-thirds of the length of the finger from the web space to the distal interphalangeal (DIP) joint. An inaccurate pattern will result in more cutting and smoothing of the edges later.
The clinician must also find out the characteristics of the material. The elasticity, drapability, memory, and conformity of the material can sometimes add a whole inch of surface to the pattern. The dimension of the pattern must be adjusted an additional one-quarter to one-half inch to the size of the digit.
Be flexible. Practice being more flexible in splint construction using partial sheets or scrap pieces. I can’t remember how many times the splint cart did not have a large enough piece of material for the splint I planned to make.
I’ve been lucky in having a backup material source in the outpatient department, but I can’t always rely on them stocking what I need. The typical time for delivery of equipment and materials, unless paying for overnight delivery, is at least a week. I have to be flexible in drawing my patterns to suit the available materials.
My adjustments must maintain the length of the forearm trough. Sacrifices can be made at the length of the MCP bar; longer straps can be made to secure the MCP joints.
Clean scissors with an alcohol swab. One major complaint is that the scissors in the clinic are never sharp enough. Unless you want to bring in your own scissors, I recommend always cleaning sharp tools with alcohol swabs between uses. The alcohol removes the residual glue from the self-adhesive Velcro, and can also sterilize the tools and keep them clean between patients.
I also recommend that students and clinicians don’t throw away scrap materials. Collect them in a box for practice cutting, especially if you use different types of materials.
Know your diagnosis. A good place to build skills is to practice molding the C-bar in a thumb spica splint with the thumb in palmar abduction rather than midway in opposition.
To choose between the positions of the thumb, the clinician must know the diagnosis. You need to put the thumb in palmar adduction for de Quervain’s disease, whereas the middle opposition between radial and palmar abduction is a safe position for most other diagnoses.
I choose the palmar adduction for my students because it requires more handling skills to contour the C-bar to the more irregular shape from the skin fold inside the web space. I believe if you can contour the more difficult position, you can do the easier one later.
Use gravity to assist your splint construction. If the patient will allow you, use gravity positioning by placing material on top of the patient’s body and letting it “sink” into the contour. The advantage of this approach is that the material will have fewer fingerprints and pressure points due to uneven handling. You can always use a towel, pillow or the edge of a table to prop the body part in the desired position. Gravity is free — use it!
Insist on a clean working area. Keep the heat pan clean at a temperature between 160-1800F, and maintain the water level to at least three inches. I always bring in a trash can next to the working area to collect scrap pieces of material.
Students will sometimes cut above the heat pan, allowing scraps to drop back into the pan. I have seen large pieces of material stick together and ruin the main splint because of a different color or density of materials. If you maintain cleanliness, correct temperature, and water level in the heat pan, you will prevent disasters.
Good padding is your best friend when you have rough edges and limited time. Some patients may live a few hours from us, and need to go home immediately. They may not even have a nearby occupational therapist to follow up with. I find that high-density padding can save a lot of time even after cutting the edges smoothly. Moleskin can trap dirt over time, and low-density padding typically flattens out rapidly.
Try wearing the splint yourself for at least 20 minutes. Trying the design yourself will help you locate pressure areas. Every splint we make in the classroom must be tried on by the students.
In the clinic, I always provide clear written instruction, and if possible, a photo of the splint being donned and doffed for the caregiver to follow. Included in the instructions are the purpose of the splint, wearing schedules, how to clean it, and how to cover it if it must be worn while bathing.
Prepare ahead for the worst situation. A long time ago, I worked in an outpatient department next to a hand clinic. Often, patients would arrive a few minutes before closing time, needing a new splint immediately because the doctor had just removed their post-operative cast.
I always kept some extra materials available, including pre-cut shapes, off-the-shelf splints, straps, and hinges. Being prepared in advance will help make these situations work.
If you have junior therapists in your department who are not comfortable making splints, take a lesson from nursing departments. Some departments require nurses to attempt setting up an IV at least once before calling for help.
My rule of thumb is to have the clinician try to make the splint once before seeking help. We all need to practice splinting to maintain the skills we were taught.
Practice, practice, practice. Some students may ask how many times they need to practice making splints. We’ve all learned motor control theory and know how important it is to practice.
I have practiced for more than two decades. I estimate that I’ve made or adjusted splints more than 10,000 times. I’m not saying you can’t buy a commercial prefabricated splint, but the time you spend handling patients and setting up a rapport with clients and caregivers is priceless.
- Bracciano A. Physical agent modalities: Theory and application for the occupational therapist. Thorofare, NJ: Slack Inc.; 2008.
- Coppard BM, Lohman H. Introduction to splinting: A clinical reasoning and problem-solving approach. 4th ed. Maryland Heights, MO: Mosby; 2008.