The Position of Safe Immobilisation (POSI)

Juliet SchneemannOccupational Therapist

Bachelor of Science (Psychology) Masters of Occupational Therapy

julietchapman@hotmail.com

Overview of Presentation What is the POSI? Why is it important? When should it be used? How to splint a POSI? Key points Questions References

What is the POSI? A position to rest the hand during periods of immobilisation James (1962, 1970) - Joint position can influence risk of

contractures MCP joints are safe when immobilised in flexion & most unsafe in

extension PIP joints are safe when immobilised in extension & most unsafe

in flexion Also known as:

The intrinsic plus position Table top position The James position Edinburgh position Clam digger

“The MCPJs are safe from contracture in flexion & most unsafe in extension; the PIPJs, conversely, are safe in extension & exceedingly unsafe if immobilised in flexion” (James, 1970)

MCP flexion 60-90°PIP in full extension

DIP in full extensionWrist extension 10-45°

What is the POSI?

Why is it an Important Position? Excessive immobilisation, incorrect positioning, trauma,

inflammation, infection, tumor, CNS disease, joint destruction can all lead to joint stiffness & intrinsic contractures

Joint stiffness & contractures can lead to deformities & functional disability

Immobilising the hand in the POSI can minimise/prevent joint stiffness & intrinsic contractures

Basic Anatomy of the Finger (excluding tendons) Bones: Metacarpal, Proximal Phalanx, Middle Phalanx,

Distal Phalanx Joints: Metacarpal Phalangeal (MCP), Proximal

Interphalangeal (PIP), Distal Interphalangeal (DIP)

Support Structures of the Fingers Joint capsule, Volar plate, Collateral ligaments, Palmar

ligaments, Extensor hood Collateral ligaments provide lateral joint stability whilst

the hand is being used for functional activities The length of the collateral ligaments are critical in

allowing normal joint motion

Why is it an Important Position?

Anatomy of the Metacarpal Joint MCP joint is a condyloid/ellipsoid joint

MCP Flexion Collateral ligaments are stretched & tight Greater bone surface area contact causing more joint stability

MCP Extension Collateral ligaments are lax & loose Less bone surface contact causing less joint stability

Why is it an Important Position?

“It is well known that the MCP develop an extensor contracture if they are held in extension for as little as 3 weeks” (James, 1970)

Anatomy of the IP Joints IP joints are hinge joints

IP Flexion: Collateral ligaments are lax & loose Fibers between the collateral ligament & palmar plate contract

IP Extension Collateral ligaments are stretched & tight Volar plate is maximally stretched

Why is it an Important Position?

“It is easier to regain flexion than extension at the PIPJ after a period of immobilisation” (Hardy,2004)

When should it be used? Fractures

Metacarpals (neck, head, shaft) Phalanges (proximal, excluding volar plate injuries)

Tendon Injuries Flexor tendon (wrist in flexion not extension) Extensor tendon (depending on zone, surgery & surgeon’s advice)

Nerve injuries (depending on level & type of injury)

Burns (all hand burns unless indicated otherwise)

Preventing scar contractures (following soft tissue injury & surgery)

Hand replants (position depends on structures involved & surgeon’s advice)

Corrective Splinting

“MP joint stiffness with loss of flexion is the most common post operative soft tissue complication of P1 fractures.

Therefore, protective splinting must rest the MCPJ in flexion.” (Hardy, 2004)

When should it be used?

How to splint in the POSI? Apply back slab or cast in usual manner then place one

hand on the volar aspect of forearm and the other hand on the dorsum of the hand

The splint should usually be applied to the volar surface (exception may be if a patient has a burn on the volar surface)

Aim to achieve an ideal POSI as soon as possible, as changes to soft tissue can begin after just 3 days

“Simple errors in the plaster for a Colles’ fracture which block flexion at the MCP joints, and similar minor errors give imperfect results in these patient. It cannot be stressed too much

how rapidly these joints stiffen in the dangerous position even in young people, how irreversible the situation is even with activephysiotherapy, and how simple are the mistakes

that lead to these difficulties” (James, 1970)

How to splint in the POSI?

Key Principles for Effective SplintingREDUCE

Reduction of the fracture is maintained Eliminate contractures through positioning Don’t immobilise fractures more than 3 weeks Uninvolved joints should not be splinted in stable

fractures Creases of the should should not be obstructed by the

splint Early active tendon gliding is encouraged

Unpublished work by Greer, 1998. Splinting for closed metacarpal fractures. 4th International Congress of IFSHT. Vancouver, BC: International Federation of Societies for Hand Therapy. As cited in Hardy, 2004)

Key Points to Take Home Incorrect positioning during periods of immobilisation can

lead to shortening of the collateral ligaments, which results in hand stiffness & contractures

Hand stiffness & contractures can lead to significant loss of hand function

The POSI allows the collateral ligaments to be in a position of stretch, which limits shortening

The POSI can be used for a wide range of hand related injuries & conditions

The hand should be placed in the POSI as soon as possible to prevent stiffness & contractures

Early referral for hand therapy is vital in preventing unnecessary hand stiffness & contractures

Any Questions?“Any hand injury is incomplete without appropriate rehabilitation in the post

repair/reconstruction period”(Karunadasa, 2015)

References Boscheinen-Morrin, J., & Conolly, B. (2003). The Hand: Fundamentals of Therapy (3rd

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Guidelines for Common Diagnoses of the Upper Extremity. Mosby Elsevier, Missouri, USA.

Dean, B., & Little, C. (2010). Fractures of the metacarpals & phalanges. Orthopaedics & Trauma. 25(1), 43-56.

Hardy, M. (2004). Principles of metacarpal & phalangeal fracture management: A review of rehabilitation concepts. Journal of Orthopaedic & Sports Physical Therapy. 34(12), 781-799.

James, J. (1970). Common, simple errors in the management of hand injuries. Proceedings of the Royal Society of Medicine Journal. 63, 69-71.

Karunadasa, K. (2015). Management of the injured hand- basic principles in rehabilitation. The Sri Lanka Journal of Surgery. 33(2), 25-28.

Kucynski, K. (1968). The proximal interphalangeal joint: Anatomy & causes of stiffness in the fingers.The Journal of Bone & Joint Surgery. 50B(3), 656-663.

References Markiewitz, A. (2013). Complications of hand fractures & their prevention. Hand Clinic.

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Plastic Surgery. 44(2), 178-185. Schreuders, T., & Prosser, R. (No Date). Fractures, luxation & ligament teasr of the

hand & wrist. Erasmus University Rotterdam the Netherlands & Sydney Hand Therapy & Rehabilitation Centre Australia. Retreievd from www.handweb.nl/uploads/files/docus/fractures_and_luxation.pdf on 31st August, 2015.

Schreuders, T., Brandsma, J., & Stam, H. (2006). The intrinsic muscles of the hand: Function, assessment & principles for therapeutic intervention. Physikalische Medizin Rehabilitationsmedizin Kurortmedizin . 16, 1-9.

Sprague, M. (1975). Proximal interphalangeal joint injuries & their initial treatment. The Journal of Trauma. 15(5), 380-385.

Taams, K., Ash, G., & Johannes, S. (1996). Maintaining the safe position in a palmar splint. Journal of Hand Surgery, British & European Volume. 21B(3), 396-399.

Tavassoli, J., Ruland. R., Hogan, C., & Cannon, D. (2005). Three cast techniques for the treatment of extra-articular metacarpal fractures: Comparison of short-term outcomes & final fracture alignments. Journal of Bone & Joint Surgery, American Volume. 87, 2196-201.

1- Main Collateral Ligament; 2- Accessorry Collateral Ligament; 3- Volar Plate