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Posterior Night Splint

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61. Clubfoot (Follow-up)

in the corrected position. Apply an above-the-knee plaster-of-Paris cast, which is changed at 3 weeks and maintained to 6 weeks. The foot is initially held in slight equinus if there is tension on the skin closure, which is corrected at the time of cast change. Splintage is continued for at least 4 months after surgery, and night splints are used for several years. The Ilizarov correction is used for recurrent clubfeet, especially in conditions such as arthrogryposis. [ , , , ] (See the image below (...) the deformity early and fully and to maintain the correction until growth stops. Traditionally, two categories of clubfeet are identified, as follows: Easy or correctable clubfeet - These are readily corrected with manipulation, casting, and splintage alone Resistant clubfeet - These respond poorly to splinting and relapse quickly after seemingly successful manipulative treatment; they require early operative management and are said to be associated with a thin calf and a small high heel. The Pirani scoring

2014 eMedicine Surgery

62. Ulnar Nerve Entrapment (Diagnosis)

Author: Charles F Guardia, III, MD; Chief Editor: Nicholas Lorenzo, MD, MHA, CPE Share Email Print Feedback Close Sections Sections Ulnar Neuropathy Overview Background The ulnar nerve is an extension of the medial cord of the brachial plexus. It is a mixed nerve that supplies innervation to muscles in the forearm and hand and provides sensation over the medial half of the fourth digit and the entire fifth digit (the ulnar aspect of the palm) and the ulnar portion of the posterior aspect of the hand (...) to be satisfactory. Next: Anatomy Course of ulnar nerve The ulnar nerve is the terminal branch of the medial cord of the brachial plexus and contains fibers from C8, T1, and, occasionally, C7. [ , ] It enters the arm with the axillary artery and passes posterior and medial to the brachial artery, traveling between the brachial artery and the brachial vein. At the level of the insertion of the coracobrachialis in the middle third of the arm, the ulnar nerve pierces the medial intermuscular septum to enter

2014 eMedicine Surgery

63. Tendon Transfers (Diagnosis)

is performed in an end-to-side manner so that if reinnervation occurs, the continuity of the reinnervated ECRB is not lost. Low-profile dynamic splints can be worn during the day, with night splints maintaining the digits and wrist in extension. [ ] All joints must maintain full passive range of motion, including the first web space. During World War I, Sir Robert Jones developed a set of tendon transfers for radial nerve paralysis, which formed the basis for reconstructive tendon transfer surgery (...) , tenodesis, capsulodesis, and pulley release Protect the tendon transfer postoperatively, with no tension on the transfer; for example, if a tendon passes volarly, the wrist is splinted in palmar flexion The first three steps in the above list are also referred to as the three-column theory or principle for tendon transfers. Drawing out these steps in three columns facilitates the decision-making process. Previous Next: Radial Nerve Paralysis Tendon transfers for radial nerve paralysis have the best

2014 eMedicine Surgery

64. Swan-Neck Deformity (Diagnosis)

after the procedure, the patient is fitted for a dynamic outrigger splint that maintains extension in an appropriate anatomic position of the fingers while the patient undergoes active flexion exercises. Night splints are manufactured to maintain the fingers in extension. Splinting is required for the next 4-8 weeks. Follow-up radiographs are obtained to confirm the appropriate positioning of the implants. Crossed intrinsic transfer of the extensor tendons from the ulnar side to the radial side (...) this problem should be considered. First, MP joint dislocation produces a fixed deformity with a flexed and ulnarly deviated finger. Second, volar and ulnar subluxation of the extensor tendons into the gutters between the phalanges limits extensor function as the extensors essentially become flexors in this position. In this condition, the patient can sometimes maintain MP extension actively after the finger is passively extended. Finally, paralysis due to posterior interosseous nerve compression can also

2014 eMedicine Surgery

65. Ulnar Neuropathy (Follow-up)

symptoms. The ulnar nerve should be protected from prolonged elbow flexion during sleep and protected during the day through avoidance of direct pressure or trauma. For initial conservative treatment of cubital tunnel syndrome, use of an elbow pad or night splinting for a 3-month trial period is recommended. [ , ] If symptoms do not improve with splinting, daytime immobilization for 3 weeks should be considered. Surgical release may be warranted if the symptoms do not improve with conservative (...) option is to apply a commercial soft elbow splint, with a thermoplastic insert, for persistent symptoms. For constant pain and paresthesia, one should consider using a rigid thermoplastic splint positioned in 45° of flexion to decrease pressure on the ulnar nerve. Initially, patients should wear this splint at all times; as symptoms subside, they can wear it only at night. Patient education and insight are important. Resting on elbows at work, using elbows to lift the body from bed, and resting

2014 eMedicine.com

66. Middle Cerebral Artery Stroke (Diagnosis)

by cerebrovascular accident. The MCA supplies most of the outer convex brain surface, nearly all the basal ganglia, and the posterior and anterior internal capsules. Infarcts that occur within the vast distribution of this vessel lead to diverse neurologic sequelae. Understanding these neurologic deficits and their correlation to specific MCA territories has long been researched. Research has also focused on the correlation between specific neurologic deficits after and differing outcomes and prognoses (...) spasticity. Bracing, especially at night, allows continuous passive range to tight, spastic muscle. This includes serial casting, which allows gradual increase in range over weeks. [ ] Oral medications also are often used for spasticity management, including tizanidine, baclofen, dantrolene, and benzodiazepines. . The functional benefit of these drugs is not well demonstrated despite their common use. These medications often have at least some sedating effect on patients, which should be weighed

2014 eMedicine.com

67. Geriatric Rehabilitation (Diagnosis)

, dot hemorrhages), which can be managed with glycemic control or laser surgery. The result of these various changes is a loss of visual acuity, decrease in peripheral vision, and a decline in dark adaptation ability. These visual impairments are related to a higher incidence of falls in the geriatric population, especially at night. Correction and management of visual impairment In the majority of the geriatric population, eyeglasses are sufficient to correct the visual impairments described above (...) unstable furniture, and installing good lighting. A well-lit pathway to the bathroom that is clear of clutter must be emphasized. Large touch-lights or automatic sensory lights, which do not require dexterity, can be placed at the patient's bedside or in other areas to help decrease the risk of falls, especially at night. Motion-detector lights are helpful in providing illumination (eg, to the bathroom) at night. Falls in the shower and bathtub are the third leading cause of accidental death, and more

2014 eMedicine.com

69. Assistive Devices to Improve Independence (Diagnosis)

; and diabetic retinopathy (eg, microaneurysms, dot hemorrhages), which can be managed with glycemic control or laser surgery. The result of these various changes is a loss of visual acuity, decrease in peripheral vision, and a decline in dark adaptation ability. These visual impairments are related to a higher incidence of falls in the geriatric population, especially at night. Correction and management of visual impairment In the majority of the geriatric population, eyeglasses are sufficient to correct (...) thick carpet, repairing unstable furniture, and installing good lighting. A well-lit pathway to the bathroom that is clear of clutter must be emphasized. Large touch-lights or automatic sensory lights, which do not require dexterity, can be placed at the patient's bedside or in other areas to help decrease the risk of falls, especially at night. Motion-detector lights are helpful in providing illumination (eg, to the bathroom) at night. Falls in the shower and bathtub are the third leading cause

2014 eMedicine.com

70. Stress Fracture (Treatment)

were considered normal. This scintigraphic pattern is consistent with medial tibial stress syndrome (shin splints), but not with stress fracture. Courtesy of Michael Spieth, MD, and Nandita Bhattacharjee, MD, MHA; Marshfield Clinic Department of Radiology. This image is of an 18-year-old female soccer player with a 3-week history of left leg pain, which was worse at night and with activity. Upon examination, she reported tenderness in response to palpation over the midtibia. Bilateral pes planus (...) Bhattacharjee, MD, MHA; Marshfield Clinic Department of Radiology. A 17-year-old female dancer with a 2-week history of left shin pain. Plain film imaging was unremarkable. Three-phase bone scanning demonstrated an area of linear uptake in the posterior medial aspect of the left tibia on blood pool images, but delayed images were considered normal. This scintigraphic pattern is consistent with medial tibial stress syndrome (shin splints), but not with stress fracture. Courtesy of Michael Spieth, MD

2014 eMedicine.com

71. The Approach to the Painful Joint (Treatment)

of the provocative occupational or athletic activity, shoe modification, a heel lift to reduce tendon stretching during walking, and NSAID therapy. Physical therapy includes local heat application, gentle stretching exercises, and a temporary splint with slight plantar flexion. Retrocalcaneal bursitis (see ) is inflammation of the retrocalcaneal bursa, resulting in pain and tenderness at the back of the heel. The area anterior to the Achilles tendon and posterior to the calcaneus is tender; passive dorsiflexion (...) , spine, or knees may also have pain at rest and at night. Pain that arises from small peripheral joints tends to be more accurately localized than pain arising from larger proximal joints. For example, pain arising from the hip joint may be felt in the groin or buttocks, in the anterior portion of the thigh, or in the knee. Stiffness is a perceived sensation of tightness when attempts are made to move joints after a period of inactivity. It typically subsides over time. Its duration may serve

2014 eMedicine.com

72. Obstructive Sleep Apnea (Treatment)

. The first image in each series depicts the baseline upper airway narrowing present in this patient. Effectively, CPAP acts as a pneumatic splint to maintain UA patency during sleep, preventing the soft tissues from collapsing. By this mechanism, it effectively eliminates the apneas and/or hypopneas, decreases the arousals, and normalizes the oxygen saturation (see the image below). Effect of nasal continuous positive airway pressure (CPAP) on oxygen saturation in sleep apnea. The upper portion (...) of this figure shows the raw oxygen saturation trace from 1 night of a sleep study. Below the raw trace are vertical lines that indicate the presence of either an apnea or hypopnea. Before CPAP, frequent respiratory events with significant desaturations occurred. During the night, CPAP was applied, resulting in the elimination of the apnea and hypopneas and normalization of the oxygen trace. Guidelines for use Patients with severe SDB (respiratory disturbance index [RDI] >20-30) should be treated

2014 eMedicine.com

74. Neuropathy of Leprosy (Treatment)

around the neck of the fibula Superficial peroneal nerves in front of the ankles Posterior tibial nerves immediately below the internal malleoli Sural nerves In TT disease, thickening is usually confined to 1 nerve. In lepromatous (LL) disease, the increase in nerve size is symmetrical; however, the degree of nerve thickening may differ between the 2 sides. The enlargement often may be segmental rather than diffuse and uniform. Disparity may be noted between specific areas of thickened nerves (...) after clinical cure and release from treatment. Local treatment measures include the following: Appropriate splints (eg, for wrist drop or foot drop) Exercises Prevention of corneal exposure when the facial nerve is involved Prevention of injuries to anesthetic areas Prevention and protection of plantar ulcers through the wearing of special controlled-rigidity footwear for redistributing pressure Rest, splints, and physiotherapeutic measures may be appropriate. Thalidomide is not useful for reversal

2014 eMedicine.com

75. Obstructive Sleep Apnea-Hypopnea Syndrome (Treatment)

. The first image in each series depicts the baseline upper airway narrowing present in this patient. Effectively, CPAP acts as a pneumatic splint to maintain UA patency during sleep, preventing the soft tissues from collapsing. By this mechanism, it effectively eliminates the apneas and/or hypopneas, decreases the arousals, and normalizes the oxygen saturation (see the image below). Effect of nasal continuous positive airway pressure (CPAP) on oxygen saturation in sleep apnea. The upper portion (...) of this figure shows the raw oxygen saturation trace from 1 night of a sleep study. Below the raw trace are vertical lines that indicate the presence of either an apnea or hypopnea. Before CPAP, frequent respiratory events with significant desaturations occurred. During the night, CPAP was applied, resulting in the elimination of the apnea and hypopneas and normalization of the oxygen trace. Guidelines for use Patients with severe SDB (respiratory disturbance index [RDI] >20-30) should be treated

2014 eMedicine.com

76. Rehabilitation Management of Neuromuscular Disease (Treatment)

is hypoventilation, which leads to hypercapnia (elevated carbon dioxide levels in the blood). End-tidal carbon dioxide levels or arterial blood gases should be periodically measured, depending on the clinical circumstances. Pulse oximetry, which measures only oxygen saturation levels, may be inadequate. Performing a thorough review of systems is important. Patients who are hypoventilating become hypercapnic at night and experience a morning headache as a result. They may also have nocturnal restlessness (...) , mainly at night, may initially avoid the need for tracheostomy and maintain a reasonable quality of life (QOL). However, bulbar palsy may occur in ALS and in some rare forms of SMA. In such cases, if better airway access becomes necessary and an informed patient wishes more aggressive care, a tracheostomy may be performed. However, an alternative procedure, laryngeal diversion (or laryngotracheal separation), has several distinct advantages over tracheostomy. In laryngeal diversion, the trachea

2014 eMedicine.com

77. Ulnar Neuropathy (Treatment)

symptoms. The ulnar nerve should be protected from prolonged elbow flexion during sleep and protected during the day through avoidance of direct pressure or trauma. For initial conservative treatment of cubital tunnel syndrome, use of an elbow pad or night splinting for a 3-month trial period is recommended. [ , ] If symptoms do not improve with splinting, daytime immobilization for 3 weeks should be considered. Surgical release may be warranted if the symptoms do not improve with conservative (...) option is to apply a commercial soft elbow splint, with a thermoplastic insert, for persistent symptoms. For constant pain and paresthesia, one should consider using a rigid thermoplastic splint positioned in 45° of flexion to decrease pressure on the ulnar nerve. Initially, patients should wear this splint at all times; as symptoms subside, they can wear it only at night. Patient education and insight are important. Resting on elbows at work, using elbows to lift the body from bed, and resting

2014 eMedicine.com

78. Plantar Fasciitis (Treatment)

. [ ] Commonly prescribed silicone inserts are effective in reducing pain and increasing functions in the short term. Both affordable and readily available, popular recommendation includes first-line treatment with silicone orthotics for patients with plantar fasciitis. [ ] Combined use of foot orthoses and night splits may provide better outcomes than either modality alone. [ ] Dorsiflexing both the ankle and metatarsophalangeal joints can reduce the tension of the posterior calf along with the plantar (...) fascia, thereby reducing pain. These modalities can be applied both during the day, while being active, and at night, increasing the chance of pain reduction. [ ] While evidence has been somewhat inconsistent regarding the effectiveness of night splints and orthoses used separately for reducing pain caused by plantar fasciitis, recent studies suggest that the treatment protocol combining the 2 modalities is more effective than orthotics alone in relieving foot pain in patients with plantar fasciitis

2014 eMedicine.com

79. Plantar Fasciitis (Treatment)

, NSAID therapy, strapping and taping, and over-the-counter (OTC) orthoses. Counseling as to activity modification, as well as choice of shoe gear, is important. After 6 weeks, recalcitrant cases should be treated additionally with a night splint and, possibly, an injection, along with the initial regimen for another 6 weeks. If pain persists, referral to a foot and ankle specialist should be considered. Injection therapy, immobilization in a cast or walker boot, physical therapy, and custom orthotics (...) in patients with chronic plantar fasciitis that does not respond to conservative management. IPST may be considered before surgery when ESWT devices are not available. A randomized, double-blind, prospective clinical pilot study showed that IPST is safe and effective; however, the exact mechanism is unknown and thus warrants further research. [ ] Previous Next: Splints and Orthoses Night splints Most people naturally sleep with their feet in a plantar-flexed position, which causes the plantar fascia

2014 eMedicine.com

80. Phalangeal Fractures (Treatment)

to allow the terminal tendon to heal in a shorter position. Maintenance phase Full activity is allowed during the 8-week interval of continuous splinting for a mallet finger. However, additional finger protection and supervision by an athletic trainer or physician is required during contact sports. The splint may be removed during the day after 8 weeks. Tendon stability is maximized if the splint is used at night and during athletic activity for another 8 weeks. Patients with an undiagnosed (...) splint, bone healing and movement recovery can be achieved simultaneously. [ ] Previous Next: PIP fracture dislocations Posterior PIP fracture-dislocations occur with volar lip fractures and volar dislocations with dorsal avulsion fractures. Posterior fracture-dislocations usually involve some degree of axial compression, comminution, and involvement of the volar articular surface. Treatment methods are grouped into the following 5 categories: static immobilization, dorsal extension block splinting

2014 eMedicine.com

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