Night Pain, Fixed Right;

Chapters

• 0:00 Why Night Wrist Position Matters;
• 1:18 Dangers Of Over-The-Counter Braces;
• 3:35 Ideal Splint Alignment Explained;
• 4:58 Choosing Palmar Or Dorsal Build;
• 7:02 Patterning And Thermoplastic Basics;
• 10:25 Cutting, Heating, And Shaping;
• 13:45 Molding On The Patient;
• 16:20 Edge Flaring And Fine Trims;
• 18:40 Strategic Padding For Comfort;

Transcript

SPEAKER_00: 0:03

Welcome back to the Hand to Shoulder Solution, Giving Pain the Middle Finger. I'm Carl Petito. I'm an occupational therapist and a board certified hand therapist. I specialize in the rehabilitation of orthopedic conditions that affect the fingertips through the shoulder. Now, in previous episodes of this channel, we talked quite a bit about carpal tunnel syndrome. And it's very important at night when patients are sleeping that the wrist be in a certain position to maintain the maximum diameter of the tunnel. What that does is it decreases pressure on that very wide, thick nerve that travels through there and branches off and innervates or plugs into the thumb, index finger, long finger, and half of the ring finger. So that thumb side where you're having the numbness and tingling, aching pain in the palm or surface of the wrist, aching pain throughout the thumb side of the hand. When a person is sleeping, and if the wrist bends like this and puts pressure on the nerve, or the wrist bends like that and over tensions the nerve, that increases the symptoms of carpal tunnel syndrome and makes it much worse. Now, another thing is we can't have any external pressure on this. So a lot of people will start having wrist pain. They'll go to the store, they'll get a wrist brace, and in the over-the-counter braces, there's a stiffener bar in there. So when that brace is around and either velcroed or laced, that bar puts pressure on the tunnel, and the carpal tunnel is right on the heel of the palm. So that's the carpal tunnel right here. Now, if a person is in that brace and they try to extend back like that, it puts pressure even more so into the stiffener bar. Now, on these braces, you can remove the stiffener bar. So if that's all you have at home, while you're waiting to get into your hand therapist for a nice optimal custom molded split, you can just take a needle nose plier or something, pull this out of the brace so that is not jamming you any longer, and don't wear the brace so very, very tight, just wear it snug so it doesn't slide around too much, and that will at least block you from flexing and extending the wrist while you're sleeping, and that'll take pressure off the nerve. What's most effective is the splint that I'm going to demonstrate now, which studies have shown most recently that little slight flexion and only deviation to follow the angles of the bones of the forearm maintains a maximum diameter of the carpal tunnel. Now I always ask the patient, do you sleep with your hand under the pillow between the pillow and the mattress or under your head? If it's under the head, the splint will remind the person not to do that to put pressure directly on there. I can fabricate the splint on the back side of the forearm or the palmer surface of the forearm to position that wrist how I want it. When I do it over the palmer surface, this is bubbled up a little bit, so nothing is touching that carpal tunnel. But I really like to put it back here, which I'll demonstrate today, to optimally position that. But if the patient is the type of person to always have the hand between the pillow and the mattress, I will make it on the palmer surface with this bubbled up a little bit over the carpal tunnel, and that'll bridge that area so it isn't so it isn't a problem. So for today's episode, I'm going to demonstrate fabricating a splint on the back side of the form. I'll show you the material we use and how we do it. Usually takes about 15 to 20 minutes to make one of these splints. I like to put pads, really make it super comfortable for the patient. So here we have our hand model, and I'm going to trace out a uh a template or a pattern. I'm just gonna mark some landmarks here. And then make this pattern that I'm gonna trace out onto flat stock. And the the flat stock, once I trace this out and cut it out, I'll heat it up again and then mold it onto the patient, add some pads and some velcro straps. This group of muscles right here is called the thanar eminence, so I want to go around that. And then I want a bar that's gonna go around the hand to position the wrist. So now I'm gonna cut this out. This is my template, and then I'll trace it out on the flat stock. So the flat stock is called thermoplastic material. So when I heat it up, it gets soft and pliable, easily moldable. As it cools, it hardens. And this part, you know, should be accurate, it doesn't have to be too exact, because what really matters is when I'm cutting it out of the flat stock material. And you can watch in coming months, I'm going to be demonstrating this in greater detail so that therapists who want to enter this specialty area can learn some easy tips and tricks for making uh quick, accurate, very effective custom splints. So I'm just gonna trace this out. I don't have to trace out the whole exact thing, I can just cut dot to dot as I'm cutting it out out of the heated material. Now you can always make it smaller, but you can't make it larger. So if anything, I'm gonna err on the side of making it a little too big anytime the opportunity pres uh presents itself, like this bar, sometimes it'll be a little too long, but I can always make it shorter. The old joke when I was you know fabricating parts for aircraft in the Navy was you know, I cut it five times and it's still too short. Now, what we're gonna do is score the material so I can fold it, then break it along this line. You really have to pay attention to where your other hand is. Then I'm just gonna fold this to weaken it. Then I can just tear that right off. Fold this. And sometimes it's handy to get just give it a little start, rip that right out of there, get it in into the hot water. Now this is just big enough it fits. In the clinic, we have a nice big pan. And while that's heating up, usually just clean up a little. I always like to keep an electric frying pan handy for situations where maybe in the morning I forgot to plug in my nice splint pan at the clinic, or have a patient first thing in the morning, and the splint pan isn't really that hot yet. But I'm just gonna test it, see if it's getting pliable. Yeah, and that's perfect. So I'm gonna take that out. Now you can see how pliable that is. Now let's just cut that out. I take the scrap piece and I'm pulling the whole thing into my scissor as I'm going around here. Alright. And then as I'm working it, it's important to, you know, get right in here and move your body. Any therapists are watching, you know, just move, move around. And don't be afraid of the splint. Get right in there and make it do what you want it to do. I I this is the scrap piece, I'm pulling that way. I'm keeping it, helps me keep better control, making a nice round corner. I don't want any areas that are gonna dig into the patient. There we go. So now I have this, I'm gonna heat it up again. Then when I this time when I take it out, I'm gonna dry it off because when I roll some edges, them to stick to each other. I think my hand model left and went and got a cup of coffee, but she'll be back. I need my hand model, I need my hand model. Alright, so I just heated this up. Now I'm gonna get it ready to go on the patient. So I just want to roll a couple little edges. So I heated it up, now I dried it off. I want it to stick to itself, and then this piece is gonna go through the thumb web space, and I don't want any sharp edges digging into the patient, of course. Alright, so you're gonna come up here like this, and then just keep your hand up. You're gonna have your hand bend down just a little bit. That's good. And you're gonna rest right there on the table. That's perfect. This is gonna go right through here. And I'm gonna hold that. Let's bring your hand down a little bit. And that looks like a good position right there. We'll add some pads and some velcro straps in a few minutes and let this cool down. That crease right there is called the distal pommer crease. That's where your fingers bend. This crease right here, that's just that just takes up takes up space. So there's this hinge, and then there's this hinge right here. So the distal pommer crease should be free. So let's turn it like let's turn it thumb side up. So I have this, so her hand bends right there, it's below that area. So let's turn it palm down. Okay, good. Now that's hard enough, and it comes off just like that. Okay. Now what I'm gonna do is put go back to the water and I'm gonna roll this edge so it's not gonna dig into the back of her forearm when she's sleeping. It's nice to have a sink right by it, so I usually have the cold water on, so I can take this out, then I could just I could flare this edge, and I put it right under the cold water and freeze it right there in place. So that's a nice, nicely flared, so it's not I don't have an edge that's gonna be digging into her. Now, what I'll do here, I noticed that this was extending beyond her hand a little bit. I just want to trim that. I I buy these great scissors right at the hardware store, and I have other big tint snips and other things, so I just trim that, make that a perfect size. Then I have some nice handy padding where I can cut some strips to go in the forearm. I want to make note of any therapists who are watching this bone right here. So you can see a lot on me, that bone that pops up, that's on their head. So I want to I I like to make the a pad right here, and then a pad here on the end of the metacarpals so that this nothing is touching this on their head. Sometimes I'll just make a mark right there where that is on the splint, heat up the splint with the heat gun and bubble that up. But I I like to make pads anyway, so I'll show you what I'm talking about here. Make a nice wide pad, and then a couple of thin strips, and maybe one a little bit wider. Alright, so then I'll take this and just one here, and then one here. So then let's just lay that right in here at the part that's closest up the forearm, and then let's put this one just proximal or just behind that on their head, which should be about right there. Good, and then I want to put a pad right over here because I don't want anything really jamming into the these this bony area right there, so let's put that right there. Make that a little more narrow. And again, these splints they take about 15 to 20 minutes to make. I've seen that a lot of therapists don't bother putting the pads, but I really like the pads because it makes it super comfortable, and then you get more compliance from your patient, and then this area right here. I want that nice and padded right inside the thumb, and I'll go right on this this edge closest to me. I'm gonna follow that edge closest to me, so now I have room for my scissors to go around it. So I'm just gonna go peel right around right there. Bing, that's done. Alright, now this is super easy. You're over here. I'm just gonna measure the length of that with my thumb, snip that off. Then I'm just gonna follow the top edge of that splint. Then let's snip that off. Let's snip this off. Now, what happens is the glue from this from these um adhesive pads starts to build up on the scissors. I started to get D.Vainstenovitis, which we talked about on a on a previous episode on this channel, very severe tendinitis right here, and radiostyloiditis on this area. I said, Why am I getting this? What was happening was the adhesive was building up on my scissors, so it was forcing me to have to open these scissors real hard, and it was causing terrible pain right there. Now, barbers and other people usually anybody using scissors, if this is too tight and that's working your extensor tendon on your thumb too hard, you're gonna get that terrible condition of Dick Ravane's Tino Cinovitis. Now, this I'm just gonna trim these a little bit in here. I just like to open that scissor. Another reason I have a good pair of sharp scissors is you can just slice that right off nice and just modify this a little bit. Let's get that out of the way. You know, it's fun to I I have fun making things, especially making something that it's gonna help a patient. We make splints that protect surgeries. You know, we very rarely do we use a cast, even for fractures, we'll we'll use a well-molded, closely molded splint, so that way we can start range of motion. So now we have some nice pads in there, and that is going to really be comfortable for the patient. Now, if this is too tight like this, you can just spring it out a little bit. Now I'm gonna put some velcro straps, and this is a really handy technique. We just have the velcro that comes in on rolls, and you really have to have a good workplace setup, and um in the clinic is just a perfect, perfect setup. So I know I need four for the forearm and then two narrow ones for the strap that goes around the hand. So I'm gonna go here and they cut that in half. That's the piece that goes around the hand. This is the hook velcro and self-adhesive. If I'm done with that one, we'll get that out of the way. It's like a cooking show, isn't it? Most people come in hungry anyway. I'm always hungry. You know what I like my jokes. Maybe others don't think they're funny. I have fun. My patients do too. You know, we're not all stuffy in the clinic. We like to we like to have fun and keep up keep it light. Dear hand model, you are gonna love this splint. So let's put this on. That just hooks over the back, over the palm of your hand, and then this is gonna position you just like that. There you go. That now that, if I may say so myself, is a really nice splint. So when you put it on, just have that, have your hand mold directly to the splint. Now hold that right there. Let's put some straps on there. When you wear this at night when you're sleeping, just wear it tight enough so it doesn't slide all over the place. Don't cinch it right down hard. Just uh, and it might slide a little bit, that's okay. Just wear it snug. And when you put it on, just secure the forearm first and then and then put it around your hand. So just snug. Now don't forget to call your friendly hand therapist, yours truly. If this becomes uncomfortable, if it gets a little sore because maybe it's rubbing on a spot, that looks that looks really good. That's gonna position you perfectly. Let's turn it palm up a little bit. And now there's there's nothing but air on your carpal tunnel, so that position is gonna be that is gonna be protected, is taking the pressure off the nerve that goes through there, and I'm pleased with that. So let's take that off. So when you take it off, just take off one side. Nothing to cause a problem, molded directly to you. Every hand is different. Very important that therapists can fabricate a custom split that's molded directly to the patient. The patient's sure to appreciate it, and it's absolutely crucial in order for the patient to get better. Fractures, stiff joints, carpal tunnel syndrome, dicker veins tendinitis, we talked about earlier, radial styloiditis, the list goes on and on, ECU tendinitis, um, it uh intercarpal problems, uh ligament repairs, tendon repairs. This one we made in the previous episode, the relative motion orthosis, those are being used now, along with one of these, to protect a healing extensor tendon so that the fingertips can still be used, but the tendon that has been repaired is on slack and allowed to heal so it doesn't rip apart because if it bends, then it the the repair tendon can rupture. But we used to have an outrigger with cables and finger finger loops that hold all the fingers up. Now it's much more simple. We use the relative motion orthosis along with the wrist hand orthosis, and that allows the fingers to move much easier and it's easier on the patient. Thank you for watching. Uh, this is an introduction to splint making. Look to the future. For some educational videos for therapists who want to get into making custom splints because it is an absolutely crucial tool. Thank you for watching and check out the website carlpatito.com.