Forms
FORM 2-1 Occupation-based Splinting Checklist (OBS)
1. ______ Splint meets requirements of protocol for specific pathology; ensuring attention to bodily functions and structures.
2. ______ If indicated, splint design is approved with referring physician.
3. ______ Splint allows client to engage in all desired occupation-based tasks through support of activity demands.
4. ______ Splint supports client habits, roles, and routines.
5. ______ Splint design fits client’s cultural needs.
6. ______ Splint design fits with temporal needs, including season, age of client, and duration of use.
7. ______ Splint design takes into consideration the client’s physical environment.
8. ______ Splint design supports the client’s social pursuits.
9. ______ Client’s personal needs are addressed through splint design.
10. ______ Client is able to engage in the virtual world (e.g., cellular phone, PDA, computer use).
11. ______ Splint is comfortable.
12. ______ Client verbalizes understanding of splint use, care, precautions, and rationale for use.
13. ______ Client demonstrates the ability to don and doff splint.
14. ______ Adaptations to the physical environment are made to ensure function in desired occupations.
15. ______ Client indicates satisfaction with splint design and functionality within splint.
FORM 3-1 Hints for Drawing and Fitting a Splint Pattern
Explain the pattern-making process to the person.
Ask or assist the person to remove any jewelry from the area to be splinted.
Wash the area to be splinted if it is dirty.
If splinting over bandages or foam, cover the extremity with stockinette or a moist paper towel to prevent the plastic from sticking to the bandages.
Position the affected extremity on a paper towel in a flat, natural resting position. The wrist should be in a neutral position with a slight ulnar deviation. The fingers should be extended and slightly abducted.
To trace the outline of the person’s extremity, keep the pencil at a 90-degree angle to the paper.
Mark the landmarks needed to draw the pattern before the person removes the extremity from the paper.
For a more accurate pattern, the paper towel can be wet and placed on the area for evaluation of the pattern, or aluminum foil can be used.
Folding the paper towel to mark adjustments in the pattern can help with evaluation of the pattern.
When evaluating the pattern fit of a forearm-based splint on the person, look for the following:
• Half the circumference of body parts for the width of troughs
• Two-thirds the length of the forearm
• The length and width of metacarpal or palmar bars
• The correct use of hand creases for landmarks
• The amount of support to the wrist, fingers, and thenar and hypothenar eminencies
When tracing the pattern onto the thermoplastic material, do not use an ink pen because the ink may smear when the material is placed in the hot water to soften. Rather, use a pencil, grease pencil, or awl to mark the pattern outline on the material.
FORM 5-1 Hand Evaluation Check-off Sheet
FORM 5-2 Splint Precaution Check-off Sheet
Account for bony prominences such as the following:
• Metacarpophalangeal (MCP), proximal interphalangeal (PIP), and distal interphalangeal (DIP) joints
Identify fragile skin and select the splinting material carefully. Monitor the temperature of the thermoplastic closely before applying the material to the fragile skin.
Identify skin areas having impaired sensation. The splint design should not impinge on these sites.
If fluctuating edema is a problem, consider pressure garment wear in conjunction with a splint.
Do not compress the superficial branch of the radial nerve. If the radial edge of a forearm splint impinges beyond the middle of the forearm near the dorsal side of the thumb, the branch of the radial nerve may be compressed.
FORM 5-3 Hints for Splint Provision
Give the person oral and written instructions regarding the following:
• Responsibility in therapy program
• Phone number of contact person if problems arise
• Actions to take if skin reactions such as the following occur: rashes, numbness, reddened areas, pain increase because of splint application
Evaluate the splint after the person wears it at least 20 to 30 minutes and make necessary adjustments.
Position all joints incorporated into the splint at the correct therapeutic angle(s).
Design the splint to account for bony prominences such as the following:
If fluctuating edema is a problem, make certain the splint design can accommodate the problem by using a wider design. Consider pressure garment to wear under splint.
Make certain the splint design does not mobilize or immobilize unnecessary joint(s).
Make certain the splint does not impede or restrict motions of joints adjacent to the splint.
Make certain the splint supports the arches of the hand.
Take into consideration the creases of the hand for allowing immobilization or mobilization, depending on the purpose of the splint.
Make certain the splint does not restrict circulation.
Make certain application and removal of the splint are easy.
Secure the splint to the person’s extremity using a well-designed strapping mechanism.
Make certain the appropriate edges of the splint are flared or rolled.
