Introduction
Splinting, taping, and structural adaptations are common modalities in rehabilitating the injured or atypical hand. There are many options available for the pediatric therapist to adapt adult modalities for children ; however, the materials, approach, and education may be very different in pediatrics. This chapter will highlight the uniqueness of pediatric splinting, taping, and adaptations, as well as techniques for successful design, fabrication, and carryover.
Splinting: Materials and Tools
Material Selection
Splinting is a modality that appears to have been used to support a body part as far back as 460 BC. Historically, materials were very rustic, using different wood shapes, sheet metals, belts, and eventually higher temperature plastics and foams. To this day, materials continue to evolve with a common goal of providing a splint that is lightweight, yet strong and functional enough to achieve the desired goal. Splinting materials have many different properties that are designed to meet the very unique needs of varying diagnoses and clinical presentations.
Properties of Materials
Stretch and pliability of material
Splint sheets are flat and can bend very easily. The material only gains strength by molding contours into the splint. When the sheets are heated, resistance to stretch can range from minimal to highly resistant to stretch. Splint material that is minimally resistant to stretch uses gravity to mold and conform easily on a still and cooperative body part, requiring gentle handling to obtain the desired shape. In the adult hand clinic, Polyflex and Orfit varieties are used widely to achieve these parameters; however, children tend to have very busy hands that are constantly moving, pulling away with fear, or tightening with spasticity, not to mention hands of varying shapes and sizes. Therefore, materials that are more resistant to stretch are optimal. This allows the therapist to work at molding a busy and uncooperative hand without compromising the integrity of the splint. Materials such as Aquaplast and Prism are moderately resistive to stretch and have the ability to be wrapped and tacked along the arm when splinting without assistance (see Fig. 5.1 ). EZ Form and Omega are more resistant to stretch that allows for more forgiveness when molding splints on busy little hands. Materials with higher resistance to stretch, such as Orthoplast and Synergy, tend to hold heat longer. More resilient materials also tend to hold heat longer and require the application of stockinette on a child’s sensitive skin before the material is applied.
A small percentage of children with very cooperative hands may need a splint following a tendon repair or a fracture. This group may permit the therapist to use a lower resistant-to-stretch material such as Tailor Splint or Preferred, which will give a more intimate fit when molded; however, this case-by-case basis relies on the therapist’s comfort with handling a material with minimal resistance to stretch.
Thickness and perforation
Splint material thicknesses range from 1/6″ to 3/16″. Thicker material will feel heavier on the arm, which can impact comfort on a child. The most versatile sheet thicknesses for pediatrics are usually 1/16″ and 1/8″. Most clinics will stock 1/8″ material, as it is the most universal; however, 1/16″ and even 3/32″ materials are very useful for tiny hands, skinny body parts, and fractured fingers. Perforation in material provide aeration to the skin and will lighten the splint overall; however, cutting along the perforations may sometimes create a bumpy edge that is more challenging in creating a smooth finish (see Fig. 5.2 ).
Colors
A variety of colors for splint material can be attractive to a child’s eye. The most child friendly colors are found in Aquaplast and Prism materials. Although a child’s preference is very valid for aesthetics of the splint, it is more important that the therapist is comfortable handling the material. Splints can be made more child friendly by adding colorful straps, decorations, glitter paint, or even splint scrap enhancements. See Figs. 5.3–5.5 .
Other Materials
In lieu of prefabricated splints, making soft splints with materials, such as Neoprene and Fabrifoam, is advantageous as these materials are thinner, lighter, and able to be issued at the appointment versus ordering. These stretchy materials are great for simple thumb and supinator straps, as well as strapping on hard splints (see Fig. 5.6 ).
Orficast combines a soft webbing like material with imbedded Orfit splint material, to make an intimate semirigid splint (see Fig. 5.7 ). The therapist can also use Orficast to strengthen a soft splint, or even use it as an adhesive to attach Velcro onto a soft strap versus sewing Velcro (see Fig. 5.8 ). Delta Cast Conformable has also gained popularity for very lightweight circumferential splinting that can be cleaned in a washing machine (see Fig. 5.9 ).
Tools
In addition to a heat pan that can maintain a temperature of 160 °F, good tools are also essential for a well-made splint. A large, sharp, clean pair of sewing scissors should be designated solely for cutting splint material. This will allow for speed in cutting the hot material and promote smoother splint edges. The therapist also needs a pair of office scissors for cutting stockinette, Velcro, and foam. A spatula is needed to remove the heated material from the pan, and a sharp exacto knife is used to score and split the large splint sheets. Other tools that may be very helpful in pediatric splinting include small curved Mayo scissors for cutting thumb holes and curves of the splint and large curved scissors for cutting angles on the ends of the splints and elbow joints. A turkey baster allows application of controlled heat onto a very small part of the splint, so the integrity is maintained with edge finishing (see Fig. 5.10 ). Although a heat gun’s primary purpose is for edge finishing, the heat is very intense and can easily melt a very small splint. It is best to use the heat gun for heating Velcro to bond to the splint; as well as securing pieces on a splint, such as outriggers and universal cuff designs.
Patterns
Basic principles for making splint patterns are universal for adults and children. Paper towels make great templates for patterns, as they are more moldable than paper to test on the child before tracing it onto expensive splint material. Pattern making can be a challenge for the wiggly, fearful, or spastic hand, so the therapist needs to be as quick as possible without upsetting the child. When possible, patterns can be traced on an unaffected opposite extremity, and then flipped for use on the affected side. Siblings or peers of similar size and age may also be called upon to have their hand traced. Adult patterns can be adapted for pediatrics by shrinking the patterns on a copy machine with card stock paper. The copies can then be laminated and wiped clean between patients.
Splinting: Psychological Readiness and Environmental Preparation
The pediatric patient requires special considerations when preparing for a splint fabrication visit. Certain amounts of compliance and participation are required of the patient and caregivers to create a custom splint that fits well and meets the criteria for the purpose of the splint. Efficient use of time is crucial for a successful session. Children generally lack the patience level of adults to sit and wait while material is heated or supplies are gathered; therefore, prepping the environment and the patient properly is essential. Creating a splint that is functional and extremely comfortable for the pediatric client takes 90% skillful preparation and 10% proper application.
Psychological Readiness
Psychological patient readiness is essential to the success of the splint fabrication visit. According to Meuthing et al., 2007, “The commonly accepted view of patients as passive recipients of health care is changing … The Accreditation Council for Graduate Medical Education has declared that residents must be able to provide family-centered patient care that is culturally effective, developmentally and age appropriate, compassionate, and effective as part of their core competencies.” Translating this ideology into everyday patient care takes a conscious effort. Although progress is being made in adult settings, these considerations are frequently undervalued and overlooked with regards to the pediatric client. Time constraints and lack of preparation time during busy days can lead a clinician to dismiss facilitating the child’s mental acceptance of splint wear and readiness for the procedure ahead. In addition, it is common to observe dialogue being pursued with the caregiver versus the child in the medical setting. It is important to include the child when explaining the process. Carefully consider their level of cognition, sensory perception, and state of mind in the moment. A calm demeanor and kind and thoughtful eye contact can reduce anxieties in both the child and parent. Explain the process with language and terms the patient will understand. A statement such as “we are making a special glove to help your arm” is a helpful, child friendly, verbal approach. Taking the necessary time to prepare the child and caregiver’s psychological readiness is instrumental to creating a product that best meet the patient’s needs.
The therapist should try to consider the patient’s entire day within context when approaching the patient. Did the child just spend 3 hours waiting to see the orthopedic surgeon before arriving for the occupational therapy visit? Is this the first time the child is seeing his or her stitches, wounds, or hardware upon cast removal? Was the commute long and stressful? Is the family anxious to get home to other siblings? Did the patient arrive late thus leaving limited time for the splint fabrication? Are there questions regarding the physician order that need to be clarified before splinting can begin? All of these factors and more can be part of a typical visit and could impact the outcome of the splint.
The patient’s receptive and expressive language skills can widely vary. For the nonverbal patient, keen assessment skills are required to assess pain signs or notice discomfort. Although it is easy to dismiss the need to provide explanation to the nonverbal child, it should still be integrated into the visit with language at the child and caregiver’s level of understanding. For the child with neuromotor impairments and tone, consider using a quiet voice to reduce jerky movements and startle reflexes that may alter the molding process. Provide demonstrations on how to remain still using child friendly language, such as “still as a statue” and “quiet as a mouse.” Even a sudden elevated pitch within a sentence or song from the caregiver during the molding process can startle the child and produce excessive muscle tone.
The medical setting and particularly the splinting process can be very intimidating. The sight of material being dropped in hot, steamy water can be enough to cause alarm. There are a number of good ways to allay the child’s fears including allowing the child to play with a scrap material to make objects or jewelry, introducing the feeling and temperature to the unaffected side first, having the child along with a sibling to assist with making matching splints, fabricating a splint for a doll or stuffed animal, or even presenting premade samples of dolls or superheroes with splints (see Fig. 5.11 ). Child life therapists can be utilized to help prepare the patient and provide distraction if necessary.
A child who is seen bedside in the hospital can have additional fears and anxiety. Good communication with the medical team can allow the therapist to find the best day or time for the patient, determine if the patient is medically stable enough for the splint, and communicate any other diagnostic tests that could impact patient comfort or timing. Nursing staff can also assist in making sure the patient has taken any prescribed pain medication at least 30 minutes before the splint is made.
Lastly, after all careful consideration of patient psychological readiness is complete, the ability to rapidly adapt to changing scenarios is a needed therapeutic skill set. The therapist may begin with a very relaxed child, but loud noises, other children crying, or the need to go to the bathroom, may change the child’s state quickly. The ability to remain flexible and make quick adjustments will lead to a more positive outcome.
Preparing the Environment
An organized and well-kept splint room leads to efficient and safe splint fabrication. Prepare the room with needed materials and have them ready before the client is brought into the treatment area. A binder stored in the splint room that includes a variety of splint patterns, along with a description of their use, is an extremely helpful resource. Safe and easy access to the tools and the patient are essential. Establish an organized work area before placing the splint material in the heat pan. Although in use, place tools in an area that are accessible to the therapist, yet out of reach of impulsive and curious children present. Sharp or potentially dangerous tools not in use should be stored in a locked drawer.
A child who is hospitalized, requiring bedside splint fabrication, poses unique challenges when obtaining environmental readiness. The team can work with therapists to make ready the environment by dimming lights or temporarily halting alarms. There are many obstacles at a patient’s bedside such as tables, monitors, bed rails, and supply carts. All obstacles should be moved ahead of fabrication to allow for a clear path from the splint pan to the patient for molding. The patient should only be a few unobstructed steps from the splint pan and work station.
Proper positioning of the child can definitely help ease fabrication. Choose the patient’s most desired and comfortable position that still allows good access to the arm. Placing the child supine on a mat or bed is often a preferred position as it fully supports the child and usually requires less handling from the therapist. In addition, it is easier to see the hand and arm surface being splinted, as the child’s shoulder can be rotated safely for a better view (see Fig. 5.12 ). However, the best position can vary depending on your client. For example, if an infant arrives asleep in a car seat, take advantage of this supine positioning for splinting. A child may arrive in a tilt in space wheelchair with full head and trunk support. Sometimes simply tilting the chair back may be all that is necessary to reduce tone and achieve a semisupine position for better handling of the material. If a child has severe reflux, use of a beanbag chair or wedge can provide a fully supportive but upright position that can reduce reflux episodes and increase comfort.
Finally, there should be one last mental check before removing material from the splint pan to make sure that:
- •
The patient is positioned comfortably
- •
There is good access to the arm being splinted
- •
The arm is free of any items of clothing, jewelry, or identification bands
- •
Stockinette was applied to the arm
- •
Available helpers in the room have good direction and understanding of their role.
- •
The child is as mentally ready as possible
Splinting: Fabrication Pearls
Therapists with expert knowledge of splinting the pediatric patient often have a number of helpful hints or tricks they utilize to accomplish the task of creating a well-made splint. The following are highlights of some of the anecdotal methods frequently used when splinting the child.
- •
For the busy child, have a quick cooling method with paper towels dipped in cold water ready to apply to a warm splint material for faster set time once proper positioning is obtained.
- •
Use the thenar eminence as a control point when splinting the hand by firmly supporting the child’s thenar with the therapist’s thenar when molding (see Fig. 5.13 ).
Fig. 5.13
To gain control with molding a splint on a busy hand, the therapist matches his thenar eminence to the teen’s thenar to support the thumb, normalize tone, and prevent subluxation of the thumb metacarpophalangeal (MP) joint.
- •
Placement of 50/50 Elastomer putty in the hand pan can be very useful to prevent windswept fingers, digits from crossing, and other deformities such as swan neck.
- •
Consider comfort and function jointly. Monitor for signs of facial grimacing, white fingertips, or limb withdraw, which may indicate too much stretch has been elicited. A splint that provides maximal stretch to the elbow, wrist, thumb, and fingers is only effective if it can be worn comfortably by the patient. At times, allowing for slightly more finger flexion to obtain better wrist alignment is the best clinical decision.
- •
A 1-inch block may be useful for the child to pinch while making a thumb splint to optimize thumb position.
- •
If fabricating a splint with gloves donned for infection control purposes, applying lotion on the gloves will help prevent the gloves from sticking to the material.
Creative Splint Designs
As previously mentioned, pediatric splints can be adapted from adult patterns. There are many possibilities for creative splint design that can be used by the pediatric therapist.
The weight-bearing splint, typically used for patients with high tone, is used to properly achieve an upper extremity weight-bearing position. Use of a small dome, such as a smaller ball, is appropriate when molding the splint (see Fig. 5.14 ). A cone splint can be a great option for serial wrist and finger splinting or as a secondary plan when molding the thumb becomes problematic (see Fig. 5.15 ). A long arm extension splint that controls motion at three joints may be easier for a caregiver to manage than applying a separate elbow splint and forearm-based splint (see Fig. 5.16 ).
