The splinting of extremities rendered dysfunction-al by injury or disease is not a new concept, and yetclinicians often are not aware of splinting historybeyond their own experiences. Delving into the paststrengthens the foundation of clinical practice byidentifying themes that have persisted over time andby expanding crucial knowledge of the field. It alsoimparts a heightened appreciation for current meth-ods by providing new insights into the pivotal eventsthat contributed to the development of modernsplinting theory and technique.

Those who ignore the past inevitably recreate it.*Both novice and experienced clinicians alike haveinvented revolutionary new splint designs, only todiscover later that their highly touted creations havebeen in use for years! Knowledge of history promotesperspective, wisdom, and humility. Historical infor-mation also diminishes the odds of recurring mis-takes being made by each new generation of clini-cians. With experience comes the realization thatlittle is truly new in the world. Ideas beget ideas,

eventually creating a wall of knowledge to whichmany have contributed. Splinting concepts and prac-tices have a rich and, for the most part, undocument-ed history. In an age abounding in historical treatis-es, the lack of historical analysis of splinting theoryand practice is both surprising and perplexing.

The purpose of this study, which is based on anintensive literature review, is to identify the primaryhistorical factors that shaped the evolution of currentsplinting technique and practice. With more than 900references specific to splint design, technique, andapplication available in the medical literature, indi-vidual mention and review of each article is not in thescope of this paper. Instead, published papers, man-uals, and books are grouped according to their con-tent and purpose, allowing identification of chrono-logical trends both internal and external to the field.

To more efficiently manage the sheer volume ofreferences, chapters in books are not included in thisstudy, unless omission of the work would create aserious deficit in the information base. Publicationdates determine the chronological order of events.While a material or technique may have been usedseveral years prior to, or after, its published report,the date of the report is the defining criterion in thisstudy, allowing uniform management of document-ed events and exclusion of unconfirmed accounts.Splints illustrated in this study are defined accordingto the ASHT Splint Classification System.1 This

Elaine Ewing Fess, MS, OTR, FAOTA, CHTHand ResearchZionsville, Indiana

ABSTRACT: The purpose of this study was to identify, using anintensive literature review, the primary historical factors andevents that shaped the evolution of current splinting techniqueand practice. Publication dates determine the chronological orderof events, and splints are defined according to the ASHT SplintClassification System. Purposes of splinting are analyzed and list-ed according to frequency of citation in splint manuals and books,and a historical review of splinting practice describes splints,events, and persons who influenced the evolution of splintingfrom the time of Hippocrates through the 20th century. Factorsinfluencing splint development include disease, political conflict,advancements in medicine and technology, agency and organiza-tional decision making, centers of practice, and availability ofinformation. Infection, polio, war, technology, plastics, surgicaladvances, soft tissue remodeling, anatomy, biomechanics, govern-ment agencies, hand centers, seminars, professional organiza-tions, publications, and a classification system have all playedimportant roles in 20th century splinting practice.J HAND THER. 2002;15:97132.

A History of Splinting:To Understand the Present, View the Past

AprilJune 2002 97

SCIENTIFIC/CLINICAL ARTICLES

This article will appear, with slight changes, as the first chapter ofthe 3rd edition of Hand Splinting: Principles and Methods, byE. Fess, K. Gettle, C. Philips, and R. Janson (St. Louis: Mosby,2003) and is published here with permission. Correspondence and reprint requests to Elaine Fess, MS, OTR,FAOTA, CHT, Hand Research, 635 Eagle Creek Court, Zionsville,IN 46077; e-mail: .*Cf. Those who cannot remember the past are condemned torepeat it.GEORGE SANTAYANA (18631952)

allows more accurate description, analysis, and com-parison of splints. For the sake of brevity and ease ofreading, and because many of the persons mentionedin this article are well known, only the surnames of20th century contributors to splinting practice areused in this text. Their full names and credentials arelisted in the Appendix.

DEFINITION AND PURPOSES OF SPLINTING

The definition of terms provides a foundation fromwhich to work. It also offers insight into past languageusage from which contemporary usage has evolved.

Splint, brace, and orthosis are often used inter-changeably, and support is a synonym for all threeterms. Websters Third International Dictionary definessplint as a rigid or flexible material (as wood, metal,plaster, fabric, or adhesive tape) used to protect,immobilize, or restrict motion in a part. Demonstrat-ing the close relationship between noun and verb, tosplint is to immobilize (as a broken bone) with asplint; to support or brace with or as if with a splint;to protect against pain by reducing motion.

Stemming from an archaic form meaning arm orarmor, brace refers to an appliance that gives sup-port to movable parts (as a joint or a fractured bone),to weak muscles (as in paralysis), or to strained liga-ments (as of the lower back). The verb form of bracemeans, to prop up or support with braces.

With origins from the Greek orthosis, meaningstraightening, an orthotic device is designed for thesupport of weak or ineffective joints or muscles, andorthotics is a branch of mechanical and medical sci-ence dealing with the support and bracing of weak orineffective joints or muscles.2

Despite subtle differences, it is apparent that con-siderable overlap exists in these definitions and thatthe definitional criterion focuses on immobilization,support, or restriction purposes. A weak case may bemade for the assertion that support includes mobi-lization splints for supple joints but, interestingly,none of these definitions addresses the importantconcept of splinting to mobilize stiff joints or con-tracted soft tissues.

Analysis of the reasons cited for splint application inpublished splinting manuals and books reveals a dif-ferent scenario, which is more comprehensive inscope. According to noted authors in the field, splintsimmobilize, mobilize, or restrict motion.1 Listedaccording to frequency of citation, the purposes ofsplints are to increase function,327 prevent deformity,*correct deformity, substitute for lost motion, protecthealing structures, maintain range of motion,# stabi-

lize joints,** restrict motion, allow tissuegrowth/remodeling, improve muscle balance, con-trol inflammation,## protect normal structures,***allow early motion, aid in fracture alignment, decrease pain, aid in wound healing,14-16,18,20 trans-mit muscular forces,18,32,37,38 rest joints,15,16,21,34

strengthen weak muscles,13,14,21 influence spastici-ty,6,18,23 resolve tendon tightness,34,35 decrease scar,33,35

keep paralyzed muscles relaxed,3,20 encourage prede-termined functional stiffness,3,32 treat infection,3,18

increase patient independence,39 and continuouslymove joints.23

From this comprehensive list, six of the cited rea-sons for splint application each have from 9 to 25 ref-erences spanning more than 50 years, indicating last-ing affirmation and verification over time. These sixrationales include 1) increase function, 2) preventdeformity, 3) correct deformity, 4) protect healingstructures, 5) restrict motion, and 6) allow tissuegrowth or remodeling. In contrast, three of the lastfive cited reasons for splintingkeep paralyzed mus-cles relaxed, encourage predetermined functionalstiffness, and treat infectionalthough still appropri-ate, are more reflective of earlier practice, when poliowas prevalent and before antibiotics were available.The final reason citedcontinuously move jointsisan obvious newcomer to the list.

GENERAL HISTORICAL OVERVIEW

Physical discomfort evokes an instinctive responseto immobilize the painful part, and use of extrinsicdevices to accomplish the immobilization process isinherently intuitive. In early antiquity, splints wereused primarily for treating fractures (Figure 1). Splintsof leaves, reeds, bamboo, and bark padded with linenhave been dated to ancient Egyptian times, and somemummified remains have been found wearing splintsfor fractures sustained either before or after death.40,41

Copper splints for treating burn injuries weredescribed in 1500 B.C.42 Hippocrates (460377 B.C.)used splints, compresses, and bandaging to immobi-lize fractures. These splints were gutter-shaped splitstalks of large plants, wrapped in wool or linen, thatwere put on separately.43 Hippocrates also devised adistraction splint for reducing tibial fractures, whichconsisted of proximal and distal leather cuffs separat-

98 JOURNAL OF HAND THERAPY

References 3, 5, 8, 10, 12, 17, 18, 2023, 3235.# References 5, 1016, 18, 30, 3234.** References 810, 1214, 17, 18, 2124, 32.References 3, 8, 10, 1214, 3436. References 3, 8, 12, 18, 21, 22, 35, 37, 38. References 5, 6, 9, 13, 14, 18, 25, 28, 35.##References 10, 17, 18, 23, 3235.

*** References 3, 5, 8, 1214, 35.References 8, 10, 12, 15, 16, 35.References 1416, 18, 19, 35.References 6, 10, 18, 20, 31, 34.

* References 3, 4, 68, 10, 1216, 18, 2023, 25, 26, 2833.References 36, 818, 20, 21, 23, 28, 30, 3235. References 5, 7, 8, 10, 12, 1518, 20, 21, 23, 24, 28, 32, 34, 35.

ed by multiple pairs of too-long, springy, narrowwooden slats. When in place on the lower leg, thissplint distracted the fracture and brought the bonesback into alignment.

In medieval times (1000 A.D.), use of palm-branchribs and cane halves for splinting continued. Plaster-like substances were made from flour dust and eggwhites, and vegetable concoctions were made of gum-mastic, clay, pulped fig, and poppy leaves. The Aztecs(1400 A.D.) made use of wooden splints and largeleaves held in place by leather straps or resin paste.40

Although most ancient splints were applied to immo-bilize, Hippocrates tibial distraction device is a clearexample of a mobilization splint.

Moving forward in time, with the introduction ofgunpowder in combat, European armor makers wereforced to seek other avenues for their armor fabricat-ing skills. Brace fabrication was a clear alternative forthese experts, with their knowledge of metalwork,exterior anatomy, and technicalities of joint alignment.By 1517, joint contractures were treated with turn-buckle and screw-driven metal splints appropriatelydubbed appliances for crooked arms (Figure 2).

The first one-page splint manual may have beenwritten in 1592, by Hieronymus Fabricius, a surgeon,who devised an illustrated compilation of armor-based splints to treat contractures of all parts of thebody (Figure 3). In France and England, from the

1750s to the 1850s, surgeons worked closely with theirfavorite appliance makers, or mechanics, to designand build custom braces and splints. A. M. Delacroix,a highly regarded French appliance maker, used thinmetal strips as mobilization assists in his braces.

Although plaster of Paris was used in 970 in Persia,it was not accepted until the mid-1800s in Europe orslightly later in America, where it was viewed withdisfavor by influential surgeons. Early disadvantagesincluded prolonged set-up time and lack of a suitablelatticing fabric.

By 1883, surgeons and appliance makers hadbecome fiercely competitive, with surgeons feelingthat appliance makers were only useful if kept intheir place. The surgeon/appliance-maker schismdeepened and the two parties diverged, becomingindependent factions for brace fabrication. Both dis-ciplines had talented devotees.

In 1888, F. Gustav Ernst, an appliance maker, pub-lished a book44 describing and illustrating sophisti-cated splints for treating upper extremity problems.These included a splint to support a paralyzed armusing a combination of gun-lock and centrifugalsprings; a supination splint with ball-and-socketshoulder movement, with a set screw to prevent rota-tion, rack-and-pinion elbow extension, and a two-piece forearm trough with rotation ratchet movementfor supination; a rack-and-pinion elbow and wristflexion contraction splint with ratchet movementwrist rotation; a spring-driven wrist splint for wristparalysis. It also included, for Dupuytrens disease, arack-and-pinion finger extension splint, a single fin-ger extension flat spring splint, a palmar retentionsplint, and a pistol-shaped splint for slight cases.

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FIGURE 1. Extension immobilization splint, type 0 (1).This ancient Egyptian splint for a fracture dates from27502625 B.C. (From British Medical Journal, March 1908.Reprinted from American Academy of Orthopaedic Surgeons:Orthopaedic Appliances Atlas, vol. 1. Ann Arbor, Mich.: J.W.Edwards, 1952.)

NOTE: The splint names shown in bold italics in the legends arethe official names assigned by the ASHT Splint ClassificationSystem1 and may include the following abbreviations: CMC,carpometacarpal joint; DIP, distal interphalangeal joint; IP, inter-phalangeal joint; MP, metacarpophalangeal joint; PIP, proximalinterphalangeal joint.

FIGURE 2. Elbow extension mobilization splint, type 0 (1).A turnbuckle provides incremental adjustments in this 1517splint. (Reprinted from LeVay D: The History of Orthopaedics.Park Ridge, NJ: Parthenon, 1990.)

At the same time, Hugh Owen Thomas, a Britishsurgeon, identified principles of treatment anddevised, among others, an inexpensive femoral splintand an ambulatory hip splint that allowed rest andoutpatient treatment. Sir Robert Jones wrote ofThomass splint workshop,

There was a blacksmith at work in a smithy, a sad-dler finishing off the various splints, and duties ofothers were the making of adhesive plasters andbandages and the preparation of dressings. Therewere splints of every size to suit any possible defor-mity that might appear or for any fracture that mighthave occurred.45

Thomass successful splinting endeavors spurredon the rapidly developing era of surgeon-fabricated splints and braces. In 1899, AlessandroCodivilla, an orthopedic surgeon in Italy, identifiedthe importance of eliminating contractures prior torebalancing with tendon transfers, foreshadowingthe important contemporary partnership betweensurgical procedures and splinting.

In America, surgical methods were expanding, andsurgeons were moving beyond being just bone set-ters, sprain rubbers, and bandagists. By the1880s, the importance of rehabilitation after treatmentwas beginning to be recognized and orthopedics, as a

specialty arena, was gradually assuming autonomyfrom general surgery. By the early 1900s, plaster ofParis had widespread acceptance as medium forimmobilizing fractures.

THE DEVELOPMENT OF SPLINTINGPRACTICE IN THE 20TH CENTURY

Many factors combined to shape evolving theoryand practice. These included, but are not limited to,disease, political conflict, advancements in medicineand technology, agency and organizational decisionmaking, centers of practice, and availability of infor-mation. Although these factors are discussed sepa-rately in the following review of 20th century events,many overlap and intertwine over time.

Disease and Epidemiology

Infection

Wound infection was a major problem during thefirst four decades of the 20th century. Seeminglyinconsequential trauma to a hand could lead to seriousinfection, and without the assistance of antibiotics,treatment results were unpredictable. In his 1916 book,Infections of the Hand, Kanavel46 grouped infections

100 JOURNAL OF HAND THERAPY

FIGURE 3. Fabricius 1592 illustration depicts front (left) and back (right) of armor-based splints for multiple parts of the body. (FromHieronymus Fabricius: Opera Chirurgica. Patavii, Italy: Bolzetti, 1641, in the collection of the Army Institute of Pathology. Reprintedfrom American Academy of Orthopaedic Surgeons: Orthopaedic Appliances Atlas, vol. 1. Ann Arbor, Mich.: J.W. Edwards, 1952.)

into two categories: simple, localized infections; andgrave infections, including tenosynovitis and deep fas-cial-space abscesses in one subgroup and acute lym-phangitis in another. This book of almost 500 pageswas important in that Kanavel defined the criticalassociations between synovial sheaths and fascialspaces. Case studies illustrated the dire consequencesof poorly treated hand injuries, including that of a manwho died from palmar scratches sustained from rub-bing meat; a man who bruised his thumb getting off astreetcar and died of staphylococcus/streptococcus-related pneumonia; and a woman with arthritis whodied from undiagnosed wrist infection of unknownetiology. Each of these patients presented with exten-sive local swelling, redness, and pain; septicemia ortoxemia developed; and death occurred within 4 to 5weeks. Kanavel noted that the age of patients whodied averaged 43.8 years.

Differentiating between non-lethal swellings, aswith thrombophlebitis or arthritis, was difficult, andfailure, by the patient or the physician, to compre-hend the potential seriousness of a problem couldlead to the patients untimely death. Although little ismentioned about splinting in his 1916 book, by 1924Kanavel strongly advocated splinting in the func-tional position as one of the most important factors insuccessful treatment of infected hands.47,48 Becausethe sequela of extensive infection was substantialrestrictive scar, he also employed elastic tractionsplints to correct soft tissue contractures after infec-tion was resolved.

Poliomyelitis

Identifying the underlying symptomatology and eti-ology of poliomyelitis spanned nearly two centuries ofstudy. Although they were described by MichaelUnderwood, a British physician, in 1774,49 it was notuntil 1840 that Jacob Heine, a German physician, iden-tified the inconsistent presenting symptoms of polio-myelitis as manifestations of a single disease process.Twenty years later, in 1860, Heine defined standardsof treatment management for spinal infantile paraly-sis victims, which were based on his experience. Headvocated splinting, baths, and tenotomies, if needed.He also differentiated polio from spastic paralysis.40

In 1890, Swedish pediatrician Oscar Medin con-firmed that polio was infectious and described ante-rior horn cell inflammation and tract degeneration asthe cause of the weakness and paralysis that accom-panied it.

Although the first outbreak of polio in the UnitedStates occurred in Louisiana, in 1841, the first epidem-ic happened in 1894, in Vermont. The first polio pan-demic began in Scandinavia in 1905, eventuallyspreading to New York City and Massachusetts in1907. In 1916, the first major epidemic in the UnitedStates occurred, with 8,900 new polio cases and 2,400

deaths reported in New York City alone.50 Epidemicswere reported in 1909 and then in 1912, 1916, 1921,1927, 1931, and 1935. By 1942, there were 170,000 poliovictims in the United States. In the majority of thesepatients, onset occurred between 1906 and 1939.49

Frighteningly, the magnitude of the epidemicsincreased as time passed. The 1933 epidemic resultedin 5,000 new polio cases. Ten years later, in the epi-demic of 1943, new cases rose to 10,000. By 1948,27,000 new cases were reported; and in the epidemicof 1950, the number of new cases was 33,000.50 By themid 1950s, with a peak of 57,879 new cases ofpoliomyelitis in the United States in 195251 and a 1955baseline annual morbidity of 16,316,52 polio hadbecome the major focus of national rehabilitation andresearch resources.

Development of the iron lung### in 1928 increasedpolio survival rates and amplified demand for rehabil-itative procedures. Large centers like those in WarmSprings, Georgia (1926), Gonzales, Texas, and RanchoLos Amigos, California (1949) became important hubsfor research and treatment of poliomyelitis, and theirdeveloping orthotic departments were recognized forthe splints and braces they created.24,49,50,53 Some cen-ters were so well known that splints made by thesecenters were identifiable solely by their configuralcharacteristics (Figure 4). Advancements were also

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###Websters Third International Dictionary defines the iron lung asa device for artificial respiration in which rhythmic alternationsin the air pressure in a chamber surrounding a patients chestforce air into and out of the lungs, especially when the nerves gov-erning the chest muscles fail to function.2

FIGURE 4. Thumb CMC palmar abduction, MP extensionimmobilization splint, type 1 (3). Top, Rancho Los Amigossplint; bottom, Bennett splint (Warm Springs). Although theyhave different configurations, these two splints have the sameSplint Classification System designation, because their functionsare identical. (Reprinted, with permission, from Fess EE, PhilipsCA: Hand Splinting Principles and Methods. 2nd ed. St.Louis, Mo.: Mosby, 1987.)

made in tendon transfer theory and technique forrebalancing involved joints and restoring function toparalyzed extremities.

Early on, splinting was a critical factor in the treat-ment of poliomyelitis. Therapists who worked withpatients with upper extremity polio needed in-depthknowledge of anatomy, kinesiology, and the deform-ing factors of pathology and substitution patterns,

since these patients had widely varied patterns ofmuscle involvement.

During the preparalytic and paralytic stages ofpolio, splints were used to put muscles in neutral bal-ance to prevent overstretching. Positions favoringmaximal return of function were prescribed. For theupper extremity, to protect the deltoid muscles, shoul-ders were positioned with bed sheets, pillows, andsandbags in the scarecrow attitude, with 90 humer-al abduction and external rotation and 90 elbow flex-ion. Splints were used to maintain forearms in 75%supination, wrists in dorsiflexion, fingers in slight flex-ion, and thumbs in opposition. Shoulder internal rota-tion and external rotation positions were alternated toprevent stiffness in either position. Metacarpophalan-geal joints were splinted in extension so that the fingerflexors would be used instead of the intrinsic muscles(Figure 5). If proximal interphalangeal (PIP) hyper-extension occurred, elastic traction was applied, withattachment to the fingertips by thimbles or wovenChinese finger-traps.49,54

Kendall advocated different shoulder, forearm,and finger metacarpophalangeal (MCP) joint posi-tions, with 75 shoulder abduction (Figure 6), fore-arm neutral, fingers slightly flexed, and thumb inpalmar abduction.55 Prevention of deformity was sostrongly emphasized that the extremities and torsosof some patients were encased in plaster to preventover- stretching of critical muscle groups.

Sister Kenny, a controversial figure in Australia,promoted use of hot packs instead of splints for poliopatients. Dismissing completely the traditionallyheld view that muscle imbalance was the cause ofdeformity in polio patients, she taught that deformi-

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FIGURE 5. Shoulder abduction and neutral rotation,elbow flexion, forearm supination, wrist and index-smallfinger MP extension, thumb CMC palmar abduction andMP extension immobilization splint, type 0 (10). This 1942splint for a patient with polio immobilizes all the joints of theupper extremity except the finger and thumb interphalangealjoints, to provide neutral muscle balance. (Reprinted, with per-mission, from Lewin P: Orthopedic Surgery for Nurses,Including Nursing Care. Philadelphia, Pa.: Saunders, 1942.)

FIGURE 6. Shoulder abduction andneutral rotation, elbow flexion, fore-arm neutral, wrist extension, index-small finger MP-IP flexion, thumbCMC palmar abduction, and MP ex-tension immobilization splint, type 0(19). These 1939 polio splints differslightly in that they maintain theshoulders in 75 abduction, the fore-arms in neutral, and the fingers in flex-ion. Inset, wire frame for splints.(Reprinted from Kendall H, Kendall F.Care During the Recovery Periodin Paralytic Poliomyelitis. Rev ed.Washington, DC: Public Health Ser-vice, 1939.)

ty arose from muscle spasm. In 1935, a royalAustralian commission found against Kennys meth-ods; so in 1940, she moved to the United States,where she found a more accepting climate. Although,it is now generally agreed that her methods had noeffect on residual paralysis,40 Sister Kenny was amajor influence in polio treatment in the UnitedStates. Many polio treatment centers eventuallyassumed a middle-of-the-road approach, using bothhot pack and splint interventions.

During the convalescent and chronic stages ofpolio, as weakness and loss of motion became appar-ent, splinting goals changed. Maintaining muscle bal-ance and encouraging predetermined joint stiffnessto enhance function became the primary focuses ofsplinting. Positioning was determined by individualpatient requirements. If the extrinsic finger extensorswere weak, the MP and interphalangeal (IP) jointswere splinted in extension. Splints were fabricatedfrom wire or plaster of Paris. Restricted passive rangeof motion slowed development of joint stiffness.Corrective splinting was used to increase range ofmotion of stiff joints in order to increase function andimprove range of motion for tendon transfers.Therapy often lasted 2 to 4 years.55

Jonas Salks inactivated-virus vaccine, in 1955, andAlbert Sabins oral vaccine, in 1961, resulted in theeventual eradication of poliomyelitis in the UnitedStates. By 1960, the incidence of polio had decreasedby 90%, and after 1961, the incidence was less than10%. The last case of polio in the United States fromwild virus, not stemming from vaccination, occurredin 1979.50,51

Upper extremity splinting continued to play animportant role in the treatment of the aftereffects ofpoliomyelitis:

Advances in [orthotics] leading to greater functionalcapacity of the paralyzed upper extremities cameafter the discovery of the polio vaccine. This came, inpart, from a lessening of the demands of acute andconvalescent care and the fact that by this time thephysician had learned to keep these very severelyinvolved patients alive.56

Splints that aided hand and wrist function were oftenpaired with overhead suspension slings, ball-bearingfeeders, or walking feeders for shoulder, elbow, andforearm positioning, allowing functional movementof extremities against gravity (Figure 7).39,50,57

Although leather hand-based splints were used forthumb or isolated finger positioning, most splintswere fabricated in metal and had narrow bar config-urations. Digital mobilization assists and wrist stopor spring mechanisms were incorporated as needed.Splints often served as bases for activities-of-daily-living (ADL) attachments, and as rehabilitationmeasures became more sophisticated, vocationalactivities were emphasized.57 The intent was to makepolio patients as independent as possible.39

Political Conflict and War

It has long been acknowledged that declared armedhostile conflict between political states or nations hasoften accelerated advances in medicine and develop-ment of technology. As medical and technologicchanges occur, splinting practice also changes.

Medical Advances Relating to Splinting

Despite the fact that one ninth of all wounds record-ed by the Union Army involved the hand and wrist,little attention was given to surgical or rehabilitationprocedures for the hand in the official medical andsurgical documentation of the Civil War (186165). Inthe official record of surgical procedures for handinjuries in World War I (191718), mention was alsonotably sparse.58 Gunpowder had forever changed theprofile of war injuries, producing wounds thatinvolved massive soft tissue loss and were contami-nated with bone fragments and foreign particles.During the Civil War, fear of infection lead to the prac-tice of amputating parts sustaining gunshot woundsthat resulted in comminuted fractures.

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FIGURE 7. Paralysis and weakness aftereffects of polio wereoften asymmetric, requiring different splints for upper extremityfunction. Left side, Wrist extension, thumb CMC palmarabduction and MP extension immobilization / index-smallfinger MP-PIP mobilization splint, type 0 (11). Right side,Index-small finger MP flexion restriction / thumb CMC pal-mar abduction and MP extension immobilization splint,type 0 (6). (From March of Dimes, archive no. G528; used withpermission.)

Joseph Listers concepts of antisepsis for surgicalprocedures did not gain universal acceptance until1877. Infection and the lack of understanding of theneed for thorough debridement also plagued woundtreatment in WWI. Primary vs. secondary closure ofwounds was just beginning to be understood by theend of the war, and penicillin would not become avail-able until 1941. Hand injuries were considered minorin comparison with the morbidity-producing prob-lems presented by rampant infection and gangrene.

During the period between WWI and WWII, gen-eral surgical practitioners who had no special knowl-edge of the hand were treating hand injuries. Flatsplinting of fractures was prevalent, traction wasoften incorrectly applied, and burns were treatedwithout asepsis despite groundbreaking contribu-tions in the treatment of hand infections,46 recon-structive surgery,45 tendon repair and grafting,59 andnerve repair.60,61

An important concept that would influence trans-fer of patients from battlefronts was reported byTrueta, in 1939namely, that the pressure andimmobilization provided by plaster casting promot-ed wound healing. He also observed that windows incasts caused swelling and edema that could lead totissue necrosis and infection.62

During the early involvement of the United Statesin World War II, in contrast to previous war experi-ence, the importance of treating hand and upperextremity trauma became apparent as casualties wereassessed. Resulting data showed that 25% of all treat-ed wounds involved the upper extremity, with 15%of these affecting the hand.

In 194344, at Letterman General Hospital (SanFrancisco, California), a major debarkation hospitalfrom multiple theaters of operations, delayed woundhealing and infection were associated with the longtime it took to transport the injured from the Pacificand the China-Burma-India theaters:

Many patients had been treated with the banjo splintor with flat, straight board splints applied to thehand and wrist in the position of nonfunction. Bothmethods are equally undesirable and were responsi-ble for many disabled hands.63

These difficulties were exacerbated by tropical dis-eases and metabolic problems.

Since hand and upper extremity injuries requiredcombined knowledge from the surgical fields oforthopedics, plastics, and neurosurgery, a plan wasdevised to treat patients with hand trauma as a dis-tinct group, to allow focused care. Specialized handcenters in the United States and Europe were estab-lished to treat hand and upper extremity trauma.

Appointed special civilian consultant to theSecretary of War in late 1944, Bunnell was given thetask of developing and coordinating the Armys handsurgery efforts. His already published book, Surgery ofthe Hand, became an official Army textbook.64

In an early report identifying problems of mal-union, joint stiffness, inferior splinting, poor posi-tioning, and ineffective wound coverage, Bunnelldescribed commonly observed, incorrect ways ofsplinting the hand. He also defined the position offunction as forearm neutral, wrist in 20 dorsiflexionand 10 ulnar deviation, fingers in slight flexion, withthe index finger flexed the least and the small fingerflexed the most, and the thumb in partial oppositionwith its joints partially flexed. Position of nonfunc-tion was the opposite. He recommended splints forspecific problems and emphasized the need foractive, as opposed to passive, therapy and active useof the hand as a mainstay of good hand rehabilita-tion. Splints were constructed of wood, metal, wire,leather, plaster of Paris, and occasionally, plastic.

In his report, Bunnell opposed rough manipulationof finger joints, stating that it was more harmful thangood.65 In addition to outlining surgical repair andreconstructive procedures, Bunnell discussed theimportance of good splinting and cautioned thatimproper splinting is harmful, and he dedicated mul-tiple pages to the characteristics of good splints, fittingsplints, splinting precautions, immobilizing and mobi-lizing splints, and splinting for specific problems.65

Bricker (March 1945), in the European theater ofoperations, outlined principles for managing combatinjuries of the hand, including:

Splint purposefully, maintaining the palmar archand flexion of the metacarpophalangeal joints; usetraction only when it is urgently indicated, and thenfor a minimum length of time; concentrate on main-tenance of function as remains; institute activemotion as early as possible and supplement by occu-pational therapy. . . .66

In July 1945, Hammond listed nine concepts toimprove hand care, with one of the nine being thatnormal fingers should never be immobilized andshould be moved for 10 minutes out of every hour,beginning immediately after the initial operation.66

In the United States, in the Zone of the Interior,Frackelton, at Beaumont General Hospital (El Paso,Texas), noted that segregation [of hand patients]permitted the proper supervision of corrective splint-ing and institution of physical and occupational ther-apy both before and after operation67; Hyroop, atCrile General Hospital (Cleveland, Ohio), reportedthat special types of splints were used in contrac-tures, nerve lesions, ankylosed joints, and as part ofpreoperative and postoperative therapy. He alsonoted that nerve repairs under tension were treatedpostoperatively with splints that allowed progressivemotion.68

Littler, at Cushing General Hospital (Framingham,Massachusetts), described MP hyperextension con-tractures and collateral ligament shortening due tosecondary joint and tendon fixation that severelyhampered reconstructive procedures. These contrac-

104 JOURNAL OF HAND THERAPY

tures required extensive surgical release followed byelastic spring splinting with the wrist in extension,and early active exercise. Noting that deformities ofinjured hands were common" and that "omission ofsplinting and improper splinting were very frequentcauses, Littler went on to say,

Corrective splinting was seldom necessary in handson which protective splinting had been employedand for which persistent active and passive exercisehad been undertaken. . . . Appropriate protectivesplinting lessened functional disability and avoidedthe necessity for weeks of corrective splinting.69

Pratt, at Dibble General Hospital (Menlo Park,California), reported that no difficulty was experi-enced in combining the two principles of immobi-lization of the injured part and mobilization of unin-volved joints. He continued with a review of splintsfrequently used at Dibble, ranging from simple webstraps for flexion to wrist immobilization with fingerMP flexion assists.70

Barsky, at Northington General Hospital (Tusca-loosa, Alabama), also noted the problem of immobi-lization with the MP joints in extension, whichallowed the collateral ligaments to contract. He notedthat, to avoid this, the splinting principles of Kochand Mason were followed with good results, and inthe future the universal Mason-Allen splint shouldbe standard equipment for all hand work. He alsostated, Where there was no demonstrable roent-genographic change, elastic splinting accomplished agreat deal.71

Phalen, at OReilly General Hospital (Springfield,Missouri), found Bunnells splints very satisfacto-ry, noting that the spring wrist cock-up splint wasparticularly effective in relieving flexion contracturesof the wrist. An MP flexion, thumb abduction splintdeveloped at OReilly was illustrated (Figure 8).72

Graham, at Valley Forge General Hospital (Phoenix-ville, Pennsylvania), reported that it was the generalrule to institute early motion and mobilization byactivity and steady traction. Elaborate mechanicalsplints and appliances were not used for this pur-pose. Instead, Bunnell knuckle benders, tractiongloves, flexion straps, and plaster casts with extensionor flexion outriggers were applied. He noted thattraction alone was not adequate in contractures asso-ciated with adherent tendons; in these cases surgerywas also necessary.73

Fowler, at Newton Baker General Hospital (Mar-tinsburg, West Virginia), reported that mobilizationof stiff metacarpophalangeal joints was good usingtraction applied by Bunnell knuckle benders or plas-ter casts with wire outriggers. If traction succeeded,it was almost always successful within 3 weeks.74

Howard, at Wakeman General Hospital (CampAtterbury, Indiana), stated that

. . . splinting was a very important procedure in thetreatment of hand injuries. . . . Splints had to be indi-

vidualized or they would fail to embody the properprinciples to obtain the desired correction. Tem-porary splints were often made by the ward surgeonwith plaster of Paris as a foundation, the attachmentsconsisting of embedded wires or other metallic appli-ances. The corrective type of splinting consisted ofslow, steady traction in the proper direction, withcare taken to avoid undue strain on joints not imme-diately involved.

Howard also cautioned that forceful manipulationof any small joint of the hand was contraindicated.Prolonged forceful elastic splinting could cause equaldamage to small joints.75

There is no question that Bunnell set the standardfor using hand splints in the treatment of hand trau-ma. His reports, bulletins, advice, and teaching, inconjunction with those of other dedicated early handsurgeons, forever changed how hand and upperextremity trauma was managed. Although thesplints he advocated may seem antiquated whencompared with contemporary ones, most of the prin-ciples Bunnell defined nearly 60 years ago continueto be applicable today.

In 1947, on the basis of their experiences in WWII,Allen and Mason described a universal splint thatthey had used with approximately 90% of the handinjuries they treated during the war.76 FollowingKanavels earlier proposal,47 this splint maintainedthe hand in the functional position and could be usedfor either extremity after initial surgery. They hadsubsequently employed this universal splint incivilian service, and advocated its use for all stages oftransport, under pressure dressings, and for a widerange of hand injuries including phalangeal andmetacarpal fractures, but excluding tendon andnerve injuries, which require different positioning.

AprilJune 2002 105

FIGURE 8. Index-small finger MP flexion, thumb CMCradial abduction and MP-IP extension mobilizationsplint, type 1 (8), with triceps strap. A triceps strap keeps theMP flexion and thumb abduction/extension directed mobiliza-tion forces from pulling the forearm trough distally on the arm.(Reprinted from Bunnell S [ed]: Surgery in World War II: HandSurgery. U.S. Medical Department. Washington DC: Office ofthe Surgeon General, 1955.)

The fabrication of this universal splint was simple.Using a special concrete die, an aluminum sheet washammered under blow torch heat into a molded cupconfiguration that supported the hand with a troughextension for the forearm. The dome shape wasdesigned to support the arch of the hand, conform tothe heel of the hand, and allow the thumb to rest in anatural grasping position. Following industrialstreamlining of fabrication processes, splints weremade in two sizes (or three at most). Allen andMasons universal splint became widely accepted asthe preferred method for immobilizing the hand whena position of function was required (Figure 9).

A few years later, during the Korean conflict(195053), the amputation rate had dropped to 13%(from 49% in WWII) because of improvements inarterial suture technique. Reconstruction . . . becamethe treatment of choice for arterial injuries, and theseceased to be a major indication for amputation.40

Although more upper extremities were saved,splinting practice did not mirror advances in vas-cular technique. Problems due to poor splintingmethods, similar to those encountered in WWII,arose. In 1952, Peacock wrote:

Unfortunately, the condition of some of the menfrom Korea with hand injuries arriving at this HandCenter has re-affirmed the lessons learned in WorldWar IInamely, that improper splinting results inserious deformities which often require months ofcorrective splinting and operative intervention.77

His article on plaster technique for mobilizationsplinting detailed methods for constructing effectivesplints that were independent of the services of abrace maker, providing busy community surgeonswith viable alternatives.

By the time the United States became involved in theVietnam conflict (196071), vascular repair was rou-tine. With better surgical skill, improvement in anti-biotics, more rapid evacuation of the injured, and bet-ter equipment, the amputation rate after vascularrepair dropped to 8.3%. Internal fixation came intogreater use, considerably changing the philosophy ofhow fractures were treated.40 Fewer amputations andbetter fixation of fractures meant that more combatinjuries were candidates for rehabilitation. Althoughsplinting concepts defined in WWII and reinforced inthe Korean War remained for the most partunchanged, patients arrived in therapy departmentsin better condition, with fewer contractures fromincorrect positioning.

The Brook Army Hospital Burn Unit contributedcritical information on the treatment of burn patients,influencing all hand rehabilitation endeavors withtheir sophisticated understanding of antideformityposition splinting and the importance of MP flexionand IP extension positioning. Progress in upper ex-tremity tendon and nerve repair technique improvedresults of surgical reconstruction.

Technologic Advances Relating to Splinting

Technology advances, for the most part, involveimprovements in materials used to fabricate splints.Military-generated, high-technology materials even-tually found their way into the civilian milieu,enhancing daily life in many arenas, including medi-cine.

As noted previously, gunpowder prompted thearmor makers precipitous change of vocation fromproducing suits of armor to creating specializedappliances, and metal splints came into commonusage, a definite improvement over previous fiber-based materials. Plaster of Paris changed how warwounds were treated in WWI, and by WWII and theKorean War, plaster had become an important foun-dation material for splint fabrication. The use of agiven material often overlapped in time that of oth-

106 JOURNAL OF HAND THERAPY

FIGURE 9. Index-small finger MP-IP flexion, index, ring-small finger MP abduction, thumb CMC palmar abduc-tion and MP-IP extension immobilization splint, type 1(16). Top, Cement molds; bottom, aluminum splints. Allenand Masons universal splint for immobilization of the handmaintained a functional position of the wrist, fingers, andthumb. The dome configuration of the finger pan held the fingerMP joints in 30 to 40 flexion, and the slight abduction of thefingers helped maintain some extra MP collateral length of theindex, ring, and small fingers but not of the centrally locatedlong finger, which was not abducted. (Reprinted, with permis-sion, from Allen HS, Mason M: A universal splint for immobi-lization of the hand in the position of function. Q BullNorthwest University Med School. 1947;21:220.)

ers. From the 1900s to today, there was no time frameduring which only one material was available forsplinting purposes (Figure 10).

Beginning with WWI, the aeronautic field has beena major source of technologic development, with itsever-evolving pursuit of materials that reduce struc-tural weight. The first all-metal, aluminum skin air-plane flew in WWI. A few years later, in 1924,Kanavel described several aluminum hand splints,47

introducing an innovative, durable, light-weightsplinting material that would reign supreme formore than forty years.

By 1934, aluminum alloy planes were prevalent andaluminum was commercially available. The relativeease of making aluminum splints facilitated accept-ance of the material. Koch and Mason described awide range of aluminum splints in 1939. Interestingly,because of Koch and Masons experiences with plas-ter and leather splints, their aluminum splint designsmore closely resembled contemporary splints, withtheir wide area of applications, than the eventual nar-row bar configurations with which aluminum is gen-erally associated.

Later, near European battlefronts during WWII, themilitary connection literally came full circle whenaluminum salvaged from downed planes provided aready source of splinting material for frontline med-ical units. Aluminum allowed individual fitting and

was easily sterilized78both important factors in awar environment.

Aluminum and aluminum alloys were the materialsof choice from the late 1940s through the1960s,3,2628,65,7984 playing a major role in the treatmentof polio patients.39,57 Although few therapists fabricatealuminum splints today, some commercially availablecomponents are made of aluminum alloys, and alu-minum continues to be a staple for many orthotists.

The plastics revolution began in the late 1800s andearly 1900s with the development of celluloid andBakelite. The 1930s produced acetylene and ethylenepolymers, and the 1950s brought urethanes and sili-cones.40 Early plastics were important in the rapidlydeveloping field of aeronautic technology, and a num-ber of aircraft with primitive plasticwood compositematerials were introduced in the late 1930s and1940s.85 During WWII, plastics played a role not onlyin the reduction of airplane and vehicle weight butalso in the creation of parachutes and body armor, inthe form of nylon and fiberglass, respectively.

The use of plastics for splinting hand injuries beganin the late 1930s and early 1940s. In 1941, Marbledescribed a new plastic material, Thermex, that couldbe heated and formed and reheated, noting that thesurgeon should select the material best suiting theneed.86 Celluloid, when heated, produced simpleone-plane-curve splints, but two curves required that

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FIGURE 10. Above, Splint-ing materials reported in usebetween 1900 and 2002, in 5-year increments. The graphshows overlaps in time, illustrat-ing the multiple material optionsavailable in each 5-year period.Right, Number of splintingmaterials reported in usebetween 1900 and 2002. Withthe introduction of plastics andthe continuing development ofmaterial science, the availabletypes of materials increasedmarkedly, beginning in 194045and peaking in 196065. Afterthis, a gradual decline of materi-al types occurred as low-temper-ature thermoplastics prevailed.

the celluloid be cut into strips, heated, and cementedwith acetone. Other plastic splint materials of the eraincluded acetobutyrate, cellulose acetate, andVinylite.

In industrial settings, pressure and heat forcedthese materials to flow conformingly into dies, butthe materials could also be shaped by hand usinghigh-temperature heat and molds.

Like later high-temperature plastics, these earlymaterials could not be fitted directly to patients.Bunnell reported that

A strip of Vinylite softened at one end by immersingin heavy lubricating oil heated over a hot plate to350F is quickly laid on a form and pressed about itwith a pad of cloth. It hardens at once and can thenbe trimmed on a bench grinder.3

Barsky, in 1945, designed a clear plastic splint toimmobilize a thumb 3 weeks after bone and skingrafting procedures (Figure 11). The splint, whichwas fabricated by the dental department ofNorthington General Hospital, was designed to pro-tect the thumb until sensation returned.71 Barskysplastic splint was unusual, given that most splintswere constructed of metal or plaster during WWII.

World War II ended, the Cold War began (1947),and within a few years the United States wasinvolved in the Korean War. Plastics technology con-tinued to evolve in the aeronautic and combat arenas,and new, more sophisticated plastic materials foundtheir way into the commercial market. Althoughnone of these materials were developed specificallyfor hand splinting endeavors, their considerableallure stemmed from their potential to improvewearability and decrease splint fabrication time incomparison with metal splints.

Celastic, an early plastic composite, was used as asplinting material for about 15 years, beginning in themid 1950s. It harkened back to celluloid in that it hadto be soaked in acetone to initiate curing. Celasticwas available in several thicknesses and could be

softened again after curing, so corrections andadjustments were feasible. If needed, metal reinforce-ments could be added as layers were applied. Itcould be fabricated on a mold or directly on a patientwhose skin was protected with several layers ofstockinette.6,27,28,36,79 Although it quickly becameobsolete with the introduction of high-temperaturethermoplastics, Celastic was important because itwas one of the earliest plastic splinting materialsreadily available to therapists.

Plastic foams of varying levels of rigidity werebriefly advocated as splinting materials. At first theywere fused to other materials, including elasticwraps87 and thermoplastic plastics. In 1954, a Britishphysician advocated fused polythene (polyethylene)and polyurethane for hand, foot, neck, and torsosplints.88,89 Beginning as separate sheet materials, thepolythene and polyurethane were heated together ina special oven to 120, at which time the polythenesoftened and fused to the polyurethane. The heatedfused materials were quickly fitted directly to thepatient with the heat-resistant polyurethane side nextto the skin, acting as a protective barrier. Thesesplints were lightweight, durable, and impervious tomoisture and secretions, but they lacked the closecontouring capacity of plaster-of-Paris splints, theirgreatest market rival.

A few years later, plastic foams were used as free-standing splint materials. Durafoam was a thermo-setting plastic substance that, when activated with itscatalyst in a special plastic bag, produced a plasticfoam that remained malleable for approximately 15minutes. To form it into a flat sheet, the foam, in itsplastic bag, was rolled smooth with a rolling pin andthen cut, following a predrawn pattern, while stillwarm from the catalytic reaction. The cut-out splintwas then applied directly to the patient and helduntil it cooled and became rigid.90

Eventually, in the early 1960s, Durafoam was soldin prefabricated sheets, but it quickly became evident

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FIGURE 11. Thumb CMC palmarabduction, MP-IP extension immobi-lization splint, type 1 (4). This thumbprotector splint, circa 1945, is made of ahigh-temperature thermosetting material.(Reprinted from Bunnell S [ed]: Surgery inWorld War II: Hand Surgery. U.S.Medical Department. Washington DC:Office of the Surgeon General, 1955.)

that this material was more appropriate for adaptingADL equipment than for splinting hands.91

Illustrating the level of creativity that exemplifiedthe times, Fuchs and Fuchs, in 1954, reported usingtoy Erector Set parts for splint construction!Providing almost endless adjustment possibilities,these metal pieces were assembled into an array offitted splint components, including outriggers, fore-arm bars, connector bars, and palmar bars. Theauthors noted that a wrist mobilization splint ofErector parts required about 45 minutes to construct.They also thoughtfully provided part numbers of themost frequently used pieces to facilitate orderingfrom the Erector set catalogue.92

Fiberglass, incorporated in military flak jackets inthe late 1940s, found increasing use in automotivecomponents, beginning with the 1953 Corvette withits first-ever plastic composite skin.85 Fiberglass, inthe form of Air-Cast, Orthoply, and Ortho-Bond, wasused as a thermosetting splinting material in the mid1950s to early 1960s.27,28 It did not gain wider accept-ance as a splinting material,4,6,36 however, until 1964,during the Vietnam conflict, when the U. S. ArmySurgical Research Unit, Brook Army Hospital, advo-cated the use of fiberglass splints for burn patientstreated with the open-air (exposure) technique,96

which was associated with the use of topical antibac-terial agents such as sulfamylon cream.9395

Fiberglass was lightweight, durable, nontoxic, andresistant to chemicals, and it could be autoclaved, animportant feature in decreasing sepsis in burnpatients. To make the required negative plasterbandage mold, a normal subject with a similar-sizehand first had to be found. Two key measurementswere matched between the patient and the normalsubjectthe breadth of the palm at the distal palmarcrease, and the distance between the distal wrist flex-ion crease and the distal palmar flexion crease overthe fifth metacarpal.93

A half-shell plaster cast that incorporated the fin-gers, thumb, wrist, and forearm in the antideformi-ty position was prepared on the normal subject. Thecured negative plaster cast was removed from thesubjects arm, dipped in paraffin, and cooled, provid-ing a separating layer for the fiberglass, which wasapplied next. After fiberglass mat was cut to the sizeof the plaster negative, it was laid on the mold andinfused with a thick liquid polyester resin by use of astiff brush, which pushed the resin into the mat andforced it to contour to the negative cast. When thefiberglass cured, in about an hour, the splint wasremoved from the plaster negative and hand-sandedto smooth its edges and surfaces. A set of splints wasmade for each burned extremity, providing a wear-autoclave rotation of sterilized splints.

The combination of open treatment with antibac-terial agents and fiberglass splints was adopted bymany burn centers throughout the United States dur-

ing the late 1960s and early 1970s. With the introduc-tion of low-temperature thermoplastics and changingphilosophies on burn treatment,30,97,98 use of fiber-glass as a splinting material declined rapidly.Fiberglass was recommended in an updated, band-age-roll form in 1990 as a casting material for spas-ticity management.99

During the mid to late 1950s, at about the sametime that Celastic, plastic foams, and fiberglass werefinding their way into therapy departments, Plexi-glas, Lucite, and Royalite, all-high temperaturethermoplastic materials, were well on their way tobecoming important additions to therapists splint-ing armamentaria.27,28 Because of the inherentstrength of these plastics, the narrow bar designsused with metal splints could also be used withsplints fabricated with the new plastics. Dealing withcommercial sources meant that sheets of plastic wereavailable only in large sizes, i.e., 52 x 88 inches. Bandsaws were required for cutting splints from thesheets; edges had to be filed and sanded; therapistshad to wear multiple pairs of cotton garden gloves tohandle the hot material25; and fitting was done on amold, not on the patient, because of the high temper-atures required to make the plastics pliable. Despiteall this, these high-temperature plastics were enthu-siastically welcomed because of their relative ease ofmalleability and efficiency of construction in compar-ison with metal.

Experience determined that Royalite was moreresilient than Plexiglas and Lucite, which tended toshatter with the cumulating forces accrued withwearing. At first, cut-out splints were heated part bypart as the fitting process progressed, but this causedsomewhat irregular contours as different splint com-ponents were heated and reheated.

Eventually it was discovered that an entire splintcould be heated at one time in an oven, greatly reduc-ing the heating time required using a heat gun.Therapists fabricating splints invaded ADL kitchens intherapy departments all over the United States, andthe phrase slaving over a hot stove took on newmeaning. Therapists also learned that the time -con-suming construction of negative and positive moldscould be eliminated entirely by fitting high- tempera-ture thermoplastic splints directly on patients whowere first protected with three or four layers of stock-inette. Once removed from a patients hand or arm, astill-warm splint needed only a few key adjustmentsto quickly obliterate the extra space caused by the mul-tiple layers of protective stockinette.

On the global front, the Cold War had intensifiedwith the successful launching of Sputnik 1 in 1957 andinitiation of the space race. In 1959, the Soviets Luna 1unleashed the race for the moon, further escalatingtensions between the United States and the SovietUnion. By the end of 1966, the United StatesSurveyor 1 had landed on the moon; and 3 years later,

AprilJune 2002 109

Neil Armstrong and Buzz Aldrin walked on the moon. Plastics were critical to aerospace research because

they lightened rocket payloads, and new develop-ments continued to expand uses for plastics and plas-tic compounds. Materials become more and moresophisticated as job-specific plastic composites werecreated.

Splinting materials continued to evolve. Alu-minum was relegated to splint reinforcement com-ponents, and solvent-requiring materials such asCelastic were abandoned in favor of the more practi-cable high-temperature thermoplastic materials.Therapists became adept at cutting out intricate barconfiguration splints on band saws and decreasededge-finishing time to 3 or 5 minutes with a few well-chosen files. New high-temperature thermoplasticmaterials were assessed for their splinting potentialas soon as they became commercially available,including Kydex, Lexan, Merlon, Boltaron, and high-impact rigid vinyl.4,6,36 Royalite and Kydex eventual-ly proved superior in their durability and relativeease of fabrication; they were used first as primarysplinting resources and later, in the 1980s, for spe-cialized narrow-splint components, such as outrig-gers, for which strength was essential.11,12

Although low-temperature thermoplastic materialswere enthusiastically welcomed in the mid to late1960s, they had a rocky beginning. Prenyl4,6 wasunattractive, was difficult to conform to small areasof the hand, and required 10 minutes to harden; andthe first Orthoplast, a beautiful plastic with a shinyslick surface, flattened with normal body tempera-ture!

Bioplastic,4,6,36 a thin, pinkish material with asmooth surface, was successful, and the era of low-temperature thermoplastic materials moved forwardwith smiles of relief. Bioplastic could be fitted direct-ly on patients, and although it had no stretch and lit-tle strength, its easy workability made it an instantfavorite. Orthoplast, first called Isoprene to differen-tiate it from the earlier failed material, was a tremen-dous success.**** It literally emancipated therapistsand patients from the protective gloves, stockinette,ADL kitchen ovens, and electric burners required tomold the high-temperature thermoplastic materialsefficiently. Therapists quickly discovered thatOrthoplast could be heated and held at a constanttemperature in a dry skillet throughout an entire clin-ic day. This unexpected bonus significantly increasedtreatment efficiency by providing a constant sourceof heated material for use whenever needed. SanSplint, a material similar to Orthoplast, was marketedin Canada.

To provide crucial strength, the low-temperaturethermoplastic materials mandated different splint con-figurations. Of necessity, splint designs changed from

narrow bar shapes to the contoured large contact areadesigns required for low- temperature materialstrength.

Still in the Cold War race for space, the 1970sbrought additional moon landings, and in 1976, twospace probes landed on Mars. In the 1980s, probes sentback photographs of Jupiter and Saturn, and thereusable space shuttles served as platforms for spaceresearch and deployment of satellites into orbit. Stealthtechnology, based on carbon-fiber composites andhigh-strength plastics, reduced radar signatures ofcombat aircraft.85 Plastics had become a part of every-day life, both military and civilian, in the United States.

A new type of splinting material based on poly-caprolactones was introduced in the mid to late1970s. Providing greater conformability and ease ofsplint fabrication, the first of these new materials,Polyform and Aquaplast, although different fromeach other in chemical composition and workingproperties, were instant successes. Spin-offs fromearlier plastics research, these and most of the splintmaterials that followed were created specifically forthe commercial splinting market. Kay Splint,Polyflex, and Orfit joined the ranks of available mate-rials in the mid 1980s. The era of designer splintingmaterials had arrived.

During the 20th century, major advancements insplinting material technology were accomplished.The rapidly escalating transition of materialsfromnatural-fiber-based materials such as wood and fab-ric, through metal and plaster, and eventually to along line of progressively more sophisticated plastic-based materialswas unprecedented. These ad-vancements were not the consequences of focusedsplinting-material-specific research but rather wereby-products of the rapid developments in combatand aerospace technology through five differentwars. It is interesting to notice that while materialschanged dramatically, underlying design conceptsremained surprisingly constant (Figure 12).

Commercial Products

The link between military and commercial evolu-tion is apparent throughout history. Nationalresearch resources are first directed at societies mostpressing needs, and few conditions have greater pri-ority than survival in war. Based on civilian need,commercial enterprise is an inexorable part of thenatural progression of research development.

As the Cold War came to a close in 1990, a strongcommercial contingent of multiple independent reha-bilitation product supply companies was already wellestablished, each with unique splinting material lines.Product research and development was, and contin-ues to be, based on therapist feedback. With the excep-tion of Orthoplast, which is an isoprene, or rubber-based material, most contemporary splinting

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**** References 4, 8, 11, 12, 31, 36, 97, 98, 100.

AprilJune 2002 111

C

E

G

D

F

AB

FIGURE 12. Splints from 1819 to 1987. Although they have different configurations, all these splints were designed for radial nerveproblems, and all have identical Splint Classification System names if the thumb is excluded. The splints use a pattern of reciprocal MPfinger flexion to achieve wrist extension, and wrist flexion to achieve MP finger extension. Splints A, B (1819), F (1978), and G (1987):Wrist flexion: index-small finger MP extension / index-small finger MP flexion: wrist extension mobilization splint, type 0(5). Splints F and G are identical except for the addition of a dorsal forearm trough component. Splints C (1916) and E (1919): Wristflexion: index-small finger MP extension / index-small finger MP flexion: wrist extension, thumb CMC radial abductionmobilization splint, type 0 (6). These two splints incorporate the thumb CMC joint, and splint C assists the thumb CMC and MPjoints. Splint D (1917): Wrist flexion: index-small finger MP extension / index-small finger MP flexion: wrist extension,thumb CMC radial abduction and MP extension mobilization splint, type 0 (7). ((Reprinted from LeVay D: The History ofOrthopaedics. Park Ridge, NJ: Parthenon, 1990.) Splints C, D, and E reprinted from American Academy of Orthopaedic Surgeons:Orthopaedic Appliances Atlas, vol. 1. Ann Arbor, Mich.: J.W. Edwards, 1952. Splint F reprinted, with permission, from Hollis LI:Innovative splinting ideas. In: Hunter JM, Schneider LH, Mackin EJ, and Bell JA [eds]: Rehabilitation of the Hand. St. Louis, Mo.:Mosby, 1978. Splint G reprinted, with permission, from Colditz JC: Splinting for radial nerve palsy. J Hand Ther. 1987;1:21; copyright Hanley & Belfus, Inc.)

materials are specialized blends of polycaprolactones,providing an almost endless array of potential splint-ing material properties.101,102 In addition, companiesoffer accessory products, such as strapping materialsand fasteners, heating units, die cuts of commonsplints, prefabricated splints, published resourcematerial, and knowledgeable resource personnel.Smaller companies market a wide range of splint com-ponents and prefabricated splints. Increasing accessi-bility of splinting materials is a key factor in the devel-opment and success of splinting endeavors.

Surgical Advances

Discussion of the progress in hand surgery over thelast 100 years is a book unto itself and is not withinthe confines of this study. However, several types ofsurgical procedures have significantly influenced thecourse of splinting history during the past 50 years.

Introduced in 1966, Swanson silicone implantsquickly became the hope of the future for manypatients suffering from arthritis and for some whohad sustained certain types of traumatic injuries tohand or wrist joints. Demand for the implants quick-ly escalated, as did need for the very specific post-operative hand splints that controlled the directionalforces affecting joint encapsulation.103109

The early passive motion program for zone II flexortendon repairs described by Kleinert110113 was intro-duced at about the same time; and, later, Duran114

published a different method for applying passivetension to repaired zone II flexor tendons. Each ofthese early passive motion programs had its ownunique postoperative splint and follow-up routine, asdid the two-stage flexor tendon repair described byHunter in 1971.115,116 The Kleinert and Duran conceptsof early motion for tendon repairs was based on workdone by Mason in the 1940s, in which a postoperativesplint had also been recommended.59

All these surgical procedures depended on sophis-ticated, well-fitted splints to control the developmentof scar during the postoperative phases of woundhealing. Inexperienced, inept, or unknowledgeablesplint fabricators could not be tolerated, since thesuccess of these surgeries relied heavily on correctapplication of the postoperative splints. Finding acapable and proficient splint maker suddenly becamea priority for many hand surgeons.

Advances in Basic Science

Soft Tissue Remodeling

Soft tissue remodeling is a fundamental concept tosplinting theory and technique that has been knownempirically since ancient times. Slow, gentle, pro-longed stress causes soft tissue to remodel or grow.In discussing treatment of contracted joints,Hippocrates wrote,

In a word, as in wax modeling, one should bring theparts into their true natural position, both those thatare twisted and those that are abnormally contracted,adjusting them in this way both with the hands andby bandaging in like manner; but draw them intoposition by gentle means, and not violently. . . . Thisthen is the treatment, and there is no need for inci-sion, cautery, or complicated methods; for such casesyield to treatment more rapidly than one wouldthink. Still, time is required for complete success, tillthe part has acquired growth in its proper position.43

In 1517, Hans Von Gersdorff advocated gradualcorrection of joint contractures using splints withturnbuckles for incremental adjustments; and in themid 1870s, Thomas noted that

Eccentric forms that cannot be altered in the deadbody without rupture of fracture can, during life, bealtered by mechanical influences as time and physio-logical action commode the part to the direction ofthe employed force.40

As marks of beauty, some native tribes insert pro-gressively larger wooden disks into ear lobes or lips,and other tribes gradually add rings to lengthennecks. Orthodontic dentistry is founded on soft tissueremodeling, and contemporary plastic surgeons rou-tinely use tissue expansion techniques to cover softtissue deficits. Bunnell wrote, The restraining tis-sues must not be merely stretched, as this only fur-ther stiffens the joints by provoking tissue reac-tion.117 Nearly all the surgeons who wrote splintingarticles between 1900 and 1960 emphasized the needfor slow, gentle traction to effect change in soft tissue.

For clinicians, use of soft tissue remodeling con-cepts seems to have an almost cyclic pattern of dis-missal and rediscovery over time, depending on themost alluring treatment du jour. Through experience,clinicians (surgeons and therapists) learn the devas-tating consequences of forceful manipulation; theyabandon these techniques in favor of slow gentleremodeling methods. Then time passes, and a newprocedure is advocated for more rapid results. Theprocedure is applied, experience shows that the pro-cedure either does not work or increases scar forma-tion, and the cycle begins anew.

Bunnell obviously had a dismal encounter withtherapy that was too aggressive. Throughout his dis-tinguished career, he extolled the advantages ofsplinting and active use of the hand and emphaticallycondemned forceful manipulation,3,65,79,117120 statingthat the best therapist was a bilateral upper extremityamputee!

Knowledge is an ever-evolving process, andremodeling concepts are not relegated to the upperextremity alone. In fact, much of our empiricalunderstanding of soft tissue remodeling is foundedhistorically on experiences dating back to antiquity inthe treatment of clubfoot deformity.43 Over the cen-turies, while there were those who favored bandag-ing and noninvasive treatment, forceful manipula-

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tive and surgical correction of clubfoot deformitybecame increasingly fashionable with surgeons, andfew questioned the results they obtained.

This, however, began to change in the late 1940s.Brand37,38 has been instrumental in bringing biome-chanical principles and soft tissue remodeling con-cepts and research to the arena of hand and upperextremity surgery and rehabilitation. It is insightfulto learn of the pivotal experiences that forever alteredhis approach for managing soft tissue problems.

In 1948, Brand changed from the technique of treat-ing clubfoot deformity practiced by Sir Denis Browne,a pediatric surgeon in England, to the total-contactplaster cast technique that Brand developed in India. Ina recent letter to the author, Brand has elegantlydescribed the early career experiences that provokedhis interest in soft tissue remodeling and deepened hisunderstanding of this process.

This perceptive transition began when Brand hadthe opportunity to compare untreated clubfeet inIndia with feet treated by the Denis Browne manip-ulation technique in England. Although the feet treat-ed by the English method were straight, they werecapable of little motion, and a noticeable inflammato-ry response persisted for years. This was in directcontrast to the untreated clubfeet in India, whichretained suppleness and showed no inflammation,despite their lack of correct alignment.

Brand developed a method of serially applyingtotal contact plaster casts that slowly and graduallybrought a deformed foot into correct alignment byallowing soft tissues to remodel or grow. BecauseBrands narration is fundamental to the tissueremodeling concepts on which splinting endeavorsare based, the full text of his important and astute let-ter appears immediately following this article.121

By 1949, Brand began applying the same contactcasting techniques to the insensitive feet of leprosypatients. Brands tissue remodeling work becamemore focused in the mid 1960s with his move to theU.S. Public Health Service Hansens Disease Center,in Carville, Louisiana, where he continued to treatpatients with Hansens disease and started the bio-mechanics laboratory that would eventually receiveworldwide acclaim.

Brands investigations into the biomechanical reac-tion of insensate living soft tissue to pressure openeda fountainhead of better understanding of soft tissueremodeling processes.

Others were also interested in soft tissue remodel-ing. In 1957, Neumann reported on expansion of skinusing progressive distention of a subcutaneous bal-loon.122 During the late 1960s and early to mid 1970s,Madden and Peacock described the dynamic metab-olism of scar collagen and remodeling; and Maddenand Arem noted that the response of noncalcified softtissue to stress is modification of matrix structure,i.e., soft tissue remodeling.123,124 In 1994, Flowers and

LaStayo demonstrated that for PIP joint flexion con-tractures, the length of time soft tissues are held attheir end range influences the remodeling process,with a 6-day time span resulting in statistically betterimprovement in passive range of motion than a 3-dayspan.125

While investigation continues into the histologicmechanism for remodeling of different soft tis-sues,126135 one area of agreement is apparent:Application of too much force results in microscopictearing of tissue, edema, inflammation, and tissuenecrosis. Prolonged gentle stress is the key factor inachieving remodeling, and splinting is the only cur-rently available treatment modality that has the abil-ity to apply consistent and constant gentle stress fora sufficient amount of time to achieve true soft tissuegrowth.132

Digital Joint Anatomy and Biomechanics

Digital joint anatomy and biomechanics are betterunderstood today than they were in the early 20thcentury. Kanavels 1924 recommendation of thefunctional position for splinting infected hands,with the wrist in 45 dorsiflexion, the MP and IPjoints in 45 flexion, and the thumb abducted fromthe palm and rotated so that the flexor surface of thethumb is opposite the flexor surface of the index fin-ger, was based on achieving rudimentary use of thehand following injury, even though only a mini-mum of motion of the fingers and thumb is retained.He noted that If such a splint were in universal use,much less would be heard of disability after handinfections.47,48

In the same year, Bunnell also advocated the use ofthe functional position.117 The position of functionsubsequently was recommended by leading handspecialists for the next 40 years. During this time,hand surgeons consistently reported problems withMP extension/hyperextension contractures and IPflexion contractures, blaming the deformities on poorsplinting technique while at the same time continu-ing to recommend the functional position for handinjuries excluding tendon and/or nerve damage,which mandated other splint positions.

In 1962, James, discussing fractures of the fingers,reported that

The metacarpophalangeal joints unless held in6090 flexion during treatment will develop withintwo to three weeks a permanent extensor contrac-ture, limiting flexion. The interphalangeal joints, par-ticularly the proximal, rapidly develop flexion con-tractures when held in flexion. . . .136

Based on empirical experience, Yeakel, in 1964,challenged the use of Allen and Masons universalsplint for functional position immobilization ofhand injuries, advocating instead the antideformityposition for the splinting of burn patients.9396,137,138

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The University of Michigan Burn Center andShriners Burn Center also reported that anti-deformity splinting with burns was preferable tothe functional position.96,139

Researchers were also contributing to the growingbody of knowledge.140142 In 1965, Landsmeer andLong published their decisive paper describing effectsof a system of two monoaxial joints controlled byeither a two-tendon or three-tendon unit, identifyingthe important interdependent roles of the extrinsic andintrinsic muscle systems.143 Hand specialists began toregard the intercalated digital joints as functional unitsin which action at one or two joints affects the remain-ing joints or joint within the ray. James coined thephrase safe position in 1970, noting,

The metacarpophalangeal joints are safe in flexionand most unsafe in extension; the PIP joints, con-versely, are safe in extension and exceedingly unsafeif immobilized in flexion.144

The importance of maintaining collateral ligamentlength by splinting the MP joints in 70 to 90 of flex-ion and the IP joints in extension98,139 had not beenfully understood by early specialists, hence the earli-er recurring problems with MP hyperextension andIP flexion contractures.

Variations of the antideformity splint usuallyinvolved minor changes in wrist or thumb position.Devised by deLeeuw, dress hooks glued to fingernailsand hooked with rubber bands or sutures to the distalend of splint finger pans were important for achievingand maintaining the antideformity position.94,145

Advantages of the antideformity/safe positionsplint quickly became apparent, and use of thefunctional position for patients with acute handinjuries was all but abandoned by the early 1970s.

Mechanical Systems of Splints

Mechanical systems of splints are alluded to orreviewed briefly by several early 20th centuryauthors, including Bunnell,3,117 Kanavel,47,48 andKoch.45 Early splint manuals also dealt with basicconcepts of leverage, pressure, and 90 angle of pull,but the information was inconsistently presented andsparse in comparison with the wealth of informationon splinting materials and fabrication instructions.Despite being a major element of successful splintdesign and application, the principles of mechanicswere addressed only superficially in related litera-ture published prior to 1980.

Beginning in 1974, Fess applied mechanical con-cepts to common hand splint designs, identifyingthrough trigonometry and simple scale drawings,basic forces generated by splints.1,8,12,146,147 Brandemphasized the importance of understanding splintbiomechanics as they relate to critical soft tissue via-

bility, responses to stress and force, inflammationand scar forming process, and tissue remodeling.37,38

Van Lede and van Veldhoven integrated mechanicalprinciples into a rational and systematic approach tocreating and designing splints.35 Boozer and othersidentified the important mechanical differencesbetween high- and low-profile splint designs.147149

Brand37,38 and Bell-Krotoski150 emphasize the impor-tance of understanding the transfer of forces inunsplinted joints when a splint is applied.

A thorough knowledge of mechanical concepts ofsplinting is requisite to treating hand and upperextremity dysfunction from injury or disease. Moremechanical principles will be identified as splintingpractice continues to evolve.

Agencies

The Office of Vocational Rehabilitation, theDepartment of Health, Education, and Welfare(DHEW), the U.S. Public Health Service, the NationalResearch Council, the National Academy of Sciences,and the National Academy of Engineering are agen-cies that have at one time or another influenced theadvancement of upper extremity splinting throughtheir support and funding of related grants. Theinfluence of these agencies has far-reaching ramifica-tions, yet few clinicians are aware of the importantcontributions made by these powerful groups.

It is important to view historical events in context.Beginning at the end of WWI, vocational rehabilitationprograms progressively expanded from aiding veter-ans to assisting civilians with disabilities (1920). By1940, those who benefited from vocational rehabilita-tion services included persons in sheltered workshops,the homebound, and workforce personnel. In 1950,Mary Switzer was named director of the Office ofVocational Rehabilitation. Switzer, an economist,career bureaucrat, and long-time advocate of rehabili-tation concepts, demonstrated to Congress the eco-nomic advantages of rehabilitating the disabled ratherthan supporting them in long-term care facilities, not-ing that rehabilitated adults with disabilities becomeproductive, tax-paying citizens.

During Switzers 20-year tenure, funding for voca-tional rehabilitation increased 40 fold. Her visionincluded education of medical and rehabilitation pro-fessionals, research and development in medicine andrehabilitation engineering (Figure 13), in-service train-ing programs, and the establishment of rehabilitationcenters and sheltered workshops.151 While Switzer isacknowledged as the grandmother of the independ-ent living movement, Brand notes that she is also themother and grandmother of much of the present con-cept of hand centers in the United States.152

In 1939, in the midst of the devastating poliomyelitisepidemics that were sweeping the United States withever-increasing virulence, the U.S. Public Health

114 JOURNAL OF HAND THERAPY

Also called the duckbill or the clam digger splint.

Service published bulletin no. 242, Care During theRecovery Period in Paralytic Poliomyelitis, by Kendall,Kendall, Bennett, and Johnson. This $0.29 monographexplained the line of treatment required during thevery long recovery period that follows an acute attackof infantile paralysis. In addition to treatment princi-ples and detailed manual muscle testing instructions,positioning and splinting rationales were clearlydefined, and practicable shoulder, elbow, hand, anddigital splints were described. Simple plaster splintsfor thumb palmar abduction, MP flexion, and wristextension were illustrated, and drawings of heavy-wire-based shoulder abduction splints were included.

In a hand-written note, Florence Kendall recalls,

Mr. Kendall and I made (to the best of our knowl-edge) the first lumbricals cuff. It was made for a poliopatient at Childrens Hospital School in Baltimore, in1933 (or 1934). In 1933, Dr. Jean McMamara fromAustralia showed us how she made an opponenscuff out of papier-mch.

A training grant from the Office of VocationalRehabilitation to Milwaukee-Downer College finan-cially underwrote one of the earliest splinting manu-als written by a therapist.28 This important splintingmanual, written in 1956 by Dorothy Bleyer, OTR,clearly validates that

... the occupational therapist has been called uponprofessionally to fabricate splints and assistivedevices as an aid to the patient for restoration ormaintenance of function, correction of dysfunction,or substitution for normal function.

She also warned that the therapist must be carefulnot to become known solely as a splint or gadget-maker. The 85-page manual reviewed normal func-tional upper extremity anatomy, purposes of splint-ing, and precautions and gave detailed instructionsfor fabricating splints from a wide range of materials.The U.S. government openly supported this candidaffirmation for therapists to actively embrace splint-ing endeavors.

In March and again in June 1967, the DHEWcosponsored, with Harmarville Rehabilitation Centerand the Western Pennsylvania Occupational TherapyAssociation, a 2-day Institute and Workshop onHand Splinting Construction4 for physicians, thera-pists, and orthotists. Faculty included Edwin Smith,MD, Eleanor Bradford, OTR, Helen Hopkins, OTR,Maude Malick, OTR, Helen Smith, OTR, Major MaryYeakel, AMSC, and Elizabeth Yerxa, OTR. Amongthose giving presentations, Yeakel, a research occu-pational therapist with the Army Medical Bio-mechanical Research Laboratory at Walter ReedArmy Medical Center (Washington, DC), introducedthe concept of materials science and discussedresearch in experimental media for splinting.

In 1967, the Committee on Prosthetic-OrthoticEducation, National Academy of SciencesNationalResearch Council published the Study of Orthotic and

Prosthetic Activities Appropriate for Physical Therapistsand Occupational Therapists.100 This study noted that

Inasmuch as the total number of certified orthetistsand prosthetists in this country (1,103) is relativelylow and their distribution inequitable, it is realistic toexpect that occupational therapists and physicaltherapists will frequently be called on to function inan area for which they may not be specifically pre-pared upon completion of their formal educationprogram.

The report defined criteria that graduates of therapyprograms should meet: Know the basic principles involved in prosthetics

and orthotics, including anatomy, physiology,pathology, biomechanics, and kinesiology.

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FIGURE 13. Mary E. Switzer, commissioner of the VocationalRehabilitation Administration, Department of Health, Education,and Welfare, visited the U.S. Public Health Service Hospital atCarville, Louisiana, on Mar 9, 1966, to talk to Dr. Paul Brand,Chief Rehabilitation Branch, about the combined research projectproposed by the Carville hospital and Louisiana State UniversitySchool of Electrical Engineering. The project involved three phas-es: 1) measure forces/pressures exerted to hands and feet by dailytasks; 2) identify a way of teaching patients with Hansens diseaseto sense when they are using too much force and are riskinginjury; 3) study the pathologic/histologic effects of bruising anddamage to soft tissues of the hands and feet. This research wasimportant not only for patients with Hansens disease but also forpatients with other diseases and injuries that resulted in dimin-ished sensibility of the extremities.

Switzer and Brand each received the renowned Lasker Awardin 1960. Switzer was cited for her great contributions to thetraining of rehabilitation personnel, rehabilitation research, andher success in bringing about greater cooperation between gov-ernment and voluntary rehabilitation efforts. She was describedas being the prime architect of workable rehabilitation services.(The Star [Carville, Louisiana]. 1966;25(4):1,7.)

Know basic terminology used in identification ofprosthetic and orthotic devices and the compo-nents thereof.

Know the mechanical principles on which opera-tion of a device is based as well as the uses andlimitations of various devices.

Know properties and characteristics of materialsused in fabrication of devices; know basis of selec-tion of materials for specific purposes.

Know the basic principles underlying the applica-tion of the following clinical activities regardingpatients and device useevaluation, training andpatient education, maintenance, adjustments, andcheckout performance.

Appreciate contributions of other disciplines inthese areas.

The study also noted that, where orthotic serviceis not available, simple orthotic devices may be fur-nished by occupational therapists and physical ther-apists. Closing the door to orthotist-controlledsplinting practice, this significant 1967 documentfreed therapists, as long as they were qualified, toprovide splinting services to patients.

Funded by the DHEW and the VeteransAdministration and compiled by the Committee onProsthetic-Orthotic Education, National Academy ofSciencesNational Research Council, Braces, Splintsand Assistive Devices: An Annotated Bibliography waspublished in July 1969. This extensive work classifiedand briefly described articles about splints andorthoses of the neck and face, upper extremity, andlower extremity that had been indexed in IndexMedicus from 1956 through 1968. Nearly 500 articleswere indexed according to subject matter and author,creating a user-friendly reference document for clini-cians interested in splinting.

In 1970, the First Workshop Panel on UpperExtremity Orthotics26 of the Subcommittee on Designand Development, National Academy of Sciences,National Academy of Engineering, met to review thecurrent status of upper extremity orthotic practiceand design and development work and to discussfuture design and development needs. The panel con-sisted of noted physicians, orthotists, therapists, andengineers in the field, including therapists LoisBarber, Kay Bradley (Carl), Clark Sabine, and FredSammons. Hand surgeon Mack Clayton was includedon this panel. With orthotists from Rancho LosAmigos, Texas Institute for Rehabilitation andResearch (TIRR), Rehabilitation Institute of Chicago(RIC), and New York UniversityInstitute ofRehabilitation Medicine (NYU-IRM), a majority of themajor orthotic facilities in the United States were rep-resented.

After reviewing upper extremity