Protecting A Repaired UCL With A Custom Hand-Based Thumb Spica

Chapters

• 0:01 Welcome And Episode Focus
• 0:19 What Gamekeeper’s Thumb Is
• 1:52 Why A Custom Thumb Spica Matters
• 2:26 Template Design And Landmarks
• 4:45 Cutting, Heating, And Molding Material
• 6:20 Static Progressive vs Elastic Tension
• 8:18 Finishing Edges And Comfort Flares
• 12:30 Straps, Padding, And Fit Tips
• 14:10 Final Advice And Where To Learn More

Transcript

SPEAKER_01: 0:01

Welcome back to the Hand to Shoulder Solution, Giving Pain the Middle Finger. I'm your host, Carl Petito. I'm an occupational therapist and a board certified hand therapist specializing in the rehabilitation of orthopedic conditions that affect the fingertips through the shoulder. Today I want to talk about how do we make custom splints? Custom molded, you know, we make a template, we cut out of flat stock material, then mold it onto the patient. In this situation, I have a pretend patient that had a ligament rupture right here, which is very common. The nickname for this is called gamekeeper's thumb. The gamekeeper's thumb occurs when this ligament ruptures either somebody's reaching for something real fast or they fall, or for whatever reason the thumb is cranked back. And this ligament, which keeps the joint stable, so this hinge right here, it keeps this joint stable laterally. So it's only obviously only supposed to bend down and up. But if it's bending back like this and it's very loose compared to the other one, and you're having a lot of pain and swelling right here, most likely you have a torn ulnar collateral ligament, UCL. That ulnar collateral ligament, when it's torn, has to be repaired. And what the surgeon does is makes an incision, goes in there, and puts in a bone anchor, depending on the severity of the condition, that gets repaired, and then it has to be protected because if you're going around with nothing on your hand, and then you bump it or you reach for something and you can easily rip out the repair. So what I'm going to demonstrate is fabrication of this kind of a splint. It's called a hand finger orthosis, a hand-based thumb spiker orthosis that positions the thumb in a functional position so that the thumb cannot be pulled this way. It protects the repaired ligament. Remember, the ligaments connect bone to bone. So let's get to it. I want to demonstrate how this is molded onto the patient. So now I'd like to demonstrate fabrication of a hand finger orthosis or a hand-based thumb spica that would protect that ligament so that the surgery that repaired that ligament is not going to fail. That has to be protected. Now we don't want to put the patient in a cast because there are some exercises that have to be done between now and full recovery. If we just fully immobilize it, it's going to get so stiff that the patient will not be able to bend their thumb. So this allows me to coach the patient through a home program so that things can be very controlled so we can restore motion while at the same time protecting the healed the healing ligament. Now I have my hand model here, and you won't be seeing her face, only her hand, because if we were to show more than her hand, she is gonna charge triple, and uh and I just can't have that. So let's look at this right here. So it starts out with fabricating a template, and it's important to use something that is very flexible so I can mold right over the patient, and I always take a look to see where the wrist is and the base of the thumb, so I'll just go along that location. Let's bring it up a little bit like this, and then I'm feeling the the big knuckles of the fingers. I'm going around my land my landmarks because of course it has to be comfortable and it has to be very effective, and I don't want to immobilize any joints that I don't have to, because why have any unnecessary stiffness? And one of the main things is the last knuckle of the thumb, the last hinge where the thumb bends, I want that to be free for function. Because while she's in the split and healing from the surgery, the thumb can still move and oppose or pinch to the fingertips of the other fingers that are not involved. So I'm planning ahead here. I have a piece that's gonna wrap around that middle bone of the thumb, and the tip of the thumb is gonna be free. So there's my template. Now I'm gonna cut that out, trace it onto the splinting material, and then warm it up in hot water, cut out the material, warm it up again and then mold onto the patient. After I mold it onto the patient, what I do is add nice comfortable pads and then velcro straps, and I'll demonstrate that. This goes pretty quickly. Custom splints, I mean some some days make five or six of these long arm splints, also splints that immobilize the elbow. For example, if somebody had trauma or if they have cubital tunnel syndrome with numbness and tingling on the little finger side of the hand, which we talked about in further in past episodes on this channel. So I'm getting my template or my pattern. I used to work fabricating parts for aircraft. I served on aircraft carriers in the US Navy. That was fun. I like fabricating. Uh, I used to spend a lot of time working as a a welder and a machinist. So I'm gonna trace out this pattern so that I have something accurate to mold onto the patient. Then I'll roll some edges, put the pads, the straps. We make some sponsor actually stretch joints, they have cables and um elastic. A note on the elastic. So, for it, for example, if you use a rubber band or something rubber to stretch a joint or to pull a finger, the rubber component never stops pulling. So, what's really nice to do is to use what's called static progressive. So it's a it's a stretch that you can progress, and the stretch can be pushed to the point of a pulling sensation and then stop. And that allows the soft tissues, in this case tendons and ligaments, um, to lengthen without going into what's called a stretch reflex because the the tendons of the soft tissue under the microscope will actually try to protect itself if you if it's never stops pushing, pushing, pushing, pushing, pushing. That's why a nice solid cable is most often the best thing to use. And in for in future episodes, we will fabricate what's called a dynamic splint that stretches joints, and that's quite interesting. Patients are always quite surprised at the efficiency of making these splints that are purely 100% custom for the patient, which is very important because if it's rubbing on a wrong area and causing pain and and not adequately adequately protecting the surgery site, bad things will certainly happen. If it's rubbing on an area and causing an additional wound, now you have another wound to worry about, you risk the chance of infection. And you see how pliable this material gets once it's warm. And I like the scrap piece, I like pulling. I like I pull it right into the scissor. I'm gonna do a terminal cut right here. Then I'm gonna bring just bring it around while I'm making it, I'm rounding out the edges. This is the piece that's gonna wrap around the thumb. It's a good recipe. You know, everybody has their own technique, and you come up with your own little time-saving methods, because in another short period of time, I'm gonna have another patient waiting in the waiting room. But you know, you gotta work way along if you're making five or six or seven of these a day, and let's bring your hand right back over here, and while I'm making the splint, I'm educating the patient how to take care of their wounds. And I usually start with people about four days post-operative. I tell them they can start washing normally with soap and water, allow it to dry really well. I test it on myself, make sure it's not too hot. Now, this is gonna feel warm, it's not hot enough to burn you. As it cools, it hardens. So let's bring this up a little bit. Good. You're gonna have your thumb right in line with the index finger. Just a way about right there, but in line with the finger. Good.

SPEAKER_00: 10:10

That's good right there.

SPEAKER_01: 10:21

And that's just gonna cool right there. That's gonna cool and harden. In the clinic, I have a sink right here, so while it's before it's fully hardened, I can just slide it off and then stick it under cold running water, then that really solidifies it. Okay. So when you take this off, you roll it off like that, and then it rolls back on. So I want to demonstrate what I usually do here is I'll put the tip of that splend in here, heat it up. The hot water is nice because it's heating up both sides at the same time, so it heats up uh quite quickly. This material, when it's warm, it sticks to itself. So I can roll this edge where the thumb is. The rest of it's still a little warm, so it's a little challenging to control. But once you get used to handling this stuff, it goes quite nicely. So I just roll that edge so that's nice and smooth and comfortable, and then this edge where the wrist is, I don't want it digging in here, and I do have it cut up high enough on the hand so that it's not going to dig in, but I like to just put a flare. So I flare this area, heat it up. So now I'm just gonna I'm just gonna flare this. That's gonna be nice and smooth and comfortable. Alright, so that's the basic design of a splint that is going to protect that healing ligament in there because remember the thumb cannot get yanked out this way, otherwise, that is gonna that surgery is gonna be ripped right out. So when you put this on, you always got lead with your thumb, so it's on your thumb first. Now you roll it around the back of your hand, and there it is. So I'll show you the one that I made on myself. Lead with the thumb, rolls around the back of the hand, and you can see the padding that I put in there, and that allows airflow, especially in the summer. You know, you know, this is this is plastic type material, and then the padding keeps the plastic off the hand and makes it all the more comfortable, and then once that's right in place, I have one strap that goes through the thumb web space and that secures right here on this velcro. The velcro is sticky, I it comes on a roll, I can cut it to any shape and size that I want it, and then this one just goes around the hand. So, what I used to do is put one strap that went around the wrist and you know was a little more complicated. Now I found that just going around the pinky side of the hand that secures it nicely, and then through the web space, and that feels very solid on me, and I feel well protected. If if my thumb gets bumped or something, then I'm not worried about that surgery site. Also, sometimes you might be wondering, well, is that plastic rubbing on the surgery site? So, what I'll do is I'll just heat this up a little bit and pull it away, just a hair. I'll make a little also put a little protector on this side that juts out because if the tip of the thumb is hit, I don't want any any stress there at all. So this stop, which will be connected to this, there'll be a little bar there, so the thumb would be would be supported a little extra while at the same time it can be used to pick up things and you know handle things, and most people can still you know work with this splint on. Well, thank you very much for watching. It's very important that if a ligament is torn and so sometimes it can just heal on its own if it's not too severe, it still needs this splint. Then if it's so severe that it needs surgical repair, of course, it still needs a splint. So every situation is different, every hand is different, and that's why we have to make custom splints. To be a hand therapist that doesn't make custom splints, it's like a dentist that who doesn't do fillings. You have to be able to make custom splints. Very, very crucial. Thank you for watching. Check out other videos, check out my website, carlpetito.com. Thank you.