On-line CEUs

August/September 2004
The Protective Orthosis: FRC Technique Used in Protecting Finger External Fixator
David Gallant, RN, OTC

Available credit for this article: 1 CEU

A fourteen year-old baseball player caught a fastball barehanded and sustained a comminuted dorsal fracture-dislocation of the left little finger PIP.  Following the emergent manual fracture reduction, continued stabilization was achieved with the use of the Richards Mini External Fixator.  This device was chosen for the dynamic flexion/extension arc with maintenance of the reduction.

Post reduction, preoperative x-rays		Postoperative x-rays

Due to the relative size, shape, and placement of the fixator and because of the expected high activity level of our patient, it was deemed prudent to provide a protective shield.  The plan was to protect the device from accidental external trauma without limiting access to the device for pin care and ROM adjustment.  The fixator superstructure was approximately 2 cm dorsal to the little finger and because of its required lateral placement; construction of a “low profile” orthosis might prove difficult.  To achieve that protection, but also allow for easy access to the device, a lateral opening hand-based orthosis was fabricated using the Focused Rigidity Casting technique. 

Material Used:

Two rolls 1” Delta Cast Conformable (DCC); Adhesive fleece padding; 3” wide Delta Terry Stockinet; 1” stockinet; Adhesive fleece liner; and Adhesive Velcro hook and elastic loop; and STS Sock Removal scissor.

Procedure:

Step 1.  As with all casting or splinting that surrounds the phalanges, it is important to place spacer padding between the digits.  This assures that if the cast is left in place; the fingers will not be cramped against each other resulting in pain, maceration, and skin breakdown.  If the cast is made into an immediate removable orthosis (as in this case), the above padding may be discarded following orthosis fabrication and usually does not have to be replaced.  Access to the fingers for daily hygiene is facilitated by this removable orthosis.

Step 2.  The 1”stockinet was drawn over the index finger.  This temporary covering is used to protect the exposed skin from the DCC resin.  Once the cast is firm, this finger cover is discarded.  Two small holes for the thumb and index finger are then cut into the 3” stockinet and then pulled gently over the fixator.  The length of the stockinet used is relative.  As the finished orthosis was going to be hand based, two or three inches of excess stockinet beyond the finger tips and proximal to the wrist is advised.  The excess can always be trimmed after cast removal.

Step 3.  Adhesive fleece padding was then applied with single layers on the volar and lateral sides, a double layer immediately superior to the device, and a sloping wedge on the dorsum from the device toward the middle finger.  This padding acts as a buffer preventing the internal section of the cast from pressing on the fixator while clamping onto the fingers to prevent excessive unwarranted motion.

Step 4.  Two ply splints of 1” DCC were centered on the dorsal and volar aspects of the ring finger and were secured in place by a 2-3 layer circumferential wrap of DCC.  Molding was done around the thumb, palm, and a simultaneous molding of the lateral side of the cast using three-sided pressure (volar, dorsal, and lateral).  The DCC was allowed to set for about two minutes prior to cutting the material with scissors along the volar lateral border.  The cast was removed, trimmed to allow for wrist, thumb, and index finger ROM.  Velcro strips followed by fleece liner were the last to be applied in the transformation of cast into orthosis.

The strong but flexible nature of the DCC assures fracture stabilization while allowing access for hygiene and adjustments of ROM.

Author’s notes.   The casting materials used for this orthosis are products of BSN/Depuy Casting.   The sock removal scissors may be obtained from: STS Company, 655 Redwood Highway, Suite 203, Mill Valley, CA 94941, (800)-787-9097.

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