Description of Intervention
Fractures of the hand, wrist, and forearm are among the most common orthopedic injuries, with distal radius fractures alone accounting for about one-sixth of all fractures treated in U.S. emergency departments.1 A fracture occurs when a force is exerted against a bone that is greater than the bone can withstand, with falls on an outstretched hand, collisions, car accidents, and other traumatic events that involve sudden loading being the most common mechanism of injury. Less commonly, long-term repetitive stress and pathological causes (eg, osteoporosis, cancer) may instead contribute to an upper extremity fracture.2
Treatment of upper extremity fractures varies widely depending on the location, type, pattern, and severity of the fracture. Although surgery is technically an option for most of these injuries, it is often unnecessary, as nonsurgical treatment is recommended for the majority of upper extremity fractures.3 For example, about 90% of all hand fractures are indicated for nonsurgical treatment, and successful outcomes have been identified in 90–95% of patients with scaphoid fractures who are treated conservatively. Conservative treatment is generally indicated for fractures that are closed, nondisplaced or minimally displaced, and stable with minimal angulation or malrotation.4,5
The standard approach for injuries fitting these criteria is closed reduction followed by immobilization. Although a plaster cast is the preferred method of immobilization in most cases, a fracture splint or brace may be selected instead for patients with stable and nondisplaced fractures that have a reducible deformity.3,4 Splints and braces are frequently prescribed by hand therapists and physical therapists as a fundamental step to immobilize the hand, wrist, or forearm and prevent further injury to the bone while allowing adequate time for healing.
Indications for Intervention
A splint or brace may be indicated for stable and nondisplaced fractures of the hand, wrist, or forearm that have a reducible deformity.
- Ask the patient to describe their medical history, with a focus on any recent trauma to the hand, wrist, or forearm. Be sure the patient describes their symptoms and the duration of these symptoms in detail.
- Ask if the patient has any comorbidities, including diabetes, osteopenia, cardiovascular issues, or history of smoking.
- Perform a physical examination of the hand, wrist, and forearm. Measure the active and passive range of motion (ROM) of any involved joint(s) and compare these values to the contralateral side.
- Ask the patient to rate their pain on the visual analogue scale (VAS) or a similar outcome measure.
- Consider using the DASH (Disabilities of the Arm, Shoulder, and Hand) questionnaire to evaluate the patient’s subjective impairment of the upper extremity.
- Other parameters that may be evaluated include task performance with a hand function test, power grip with a hand dynamometer, pinch grip with a hydraulic pinch gauge, and dexterity with a pegboard.6
- Assess the length, alignment, and rotation of the fracture and determine if the position can appropriately be reduced or maintained with closed methods.
- Order an X-ray of the hand, wrist, or forearm if a fracture is suspected.
- Based on the patient’s symptomatology and examination findings, consider prescribing a brace or splint if the fracture is stable and nondisplaced with a reducible deformity.
Orthoses Guidelines3,4,6-10
If the patient is a good candidate for a brace or splint, the three main levels of customization available are as follows:
- Prefabricated: this type of splint or brace is made by a manufacturer and can be purchased over the counter or with a prescription from orthopedic supply stores; therefore, prefabricated splints and braces are not individualized for the patient and do not require any special fitting services, but can be adjusted minimally to ensure it fits properly
- Custom-fitted: this is a type of prefabricated splint or brace that requires adjustments by bending, cutting, or molding the device to fit the patient’s hand, wrist, or forearm properly; heat may also need to be applied to manipulate a custom-fitted orthotic
- Custom-fabricated: this type of splint or brace allows for the most individualized fit; castings, measurements, tracings, and images are taken of the injured area and then used create a specialized splint or brace; you will then fabricate the orthotic by molding, drilling, sewing, or bending its material before fitting it to the patient
Custom-fitted and custom-fabricated splints and braces are strongly recommended, but a prefabricated unit may be adequate in some cases. These devices can be constructed with a variety of materials, including plaster, fiberglass, padding, ace wraps, metal, cloth, or plastic. If fitting or fabricating the device, ensure the device fits the patient comfortably. Before applying the brace or splint, decide which joint(s) need to be immobilized by only targeting the joint above and below the deformity, then cut fabricate the device accordingly. Splints should be placed on the side of initial deformity to prevent redisplacement.
If outfitting a splint for a hand fracture, some of the most commonly used options include the following:
- Volar splint: this has many options dependent on the location of the injury. (A) a piece of alumofoam which can be bent to immobilize the interphalangeal (IP) and metacarpophalangeal (MP) joints of fingers and thumb tip injures. For bigger injuries involving the wrist, there are canvas/fabric splints with metal inserts which can be bent slightly to allow for different wrist and thumb positions. while providing volar support; it is suitable for extra-articular phalangeal fractures. Custom fabricated finger based, hand based, or forearm based are the preference for many of these injuries, especially when if wound care and/or hygiene issues/concerns present.
- Dorsal splint: similar to the volar splint, this splint can used to immobilize the IP and MP joints while providing dorsal support; it is also suitable for extra-articular phalangeal fractures. Custom fabricated finger based, hand based, or forearm based are the preference for many of these injuries, especially when if wound care and/or hygiene issues/concerns present.
- Extension block splint: another type of dorsal splint that allows motion within a restricted range; it can be bent at the level of the proximal interphalangeal (PIP) or distal interphalangeal (DIP) joints with the phalanx distal to the bend unsecured to the splint; it is suitable for stable IP joint fracture-subluxations that are reduced in flexion
- Bedford splint: this splint uses the adjacent finger to provide stabilization of the fractured digit while also encouraging ROM; it suitable for stable, extra-articular phalangeal or metacarpal neck or shaft fractures with an acceptable level of deformity
After the splint is fitted, provide the patient with wear and care instructions, including cleaning directions, which vary between devices. The frequency and duration of use depend on the type and severity of the fracture, but most patients should wear the splint or brace 24 hours a day, for about 3–4 weeks, but can increase to 6-8 weeks. Wearing a brace for longer could increase the risk for stiffness. If the splint/brace is allowed to be taken off, encourage patients to continue moving their affected joints normally to keep muscles flexible and strong during this time. The use of splints and braces should be supplemented with other interventions during and after their use, particularly stretching and strengthening exercises, manual therapy, therapeutic modalities, and functional training.
