4.position of safe immobilisation

Bất động an toàn

1. The Position of Safe
Immobilisation (POSI)
Juliet Schneemann
Occupational Therapist
Bachelor of Science (Psychology)
Masters of Occupational Therapy
[email protected]

2. 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

3. 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)

4. MCP flexion 60-90°
PIP in full extension
DIP in full extension
Wrist extension 10-45°
What is the POSI?

5. 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

6. 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?

7. 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)

8. 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)

9. 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)

10. When should it be used?

11. 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)

12. How to splint in the POSI?

13. Key Principles for Effective Splinting
REDUCE
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. 4
th
International Congress of IFSHT. Vancouver, BC:
International Federation of Societies for Hand Therapy. As cited in
Hardy, 2004)

14. 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

15. Any Questions?
“Any hand injury is incomplete without
appropriate rehabilitation in the post
repair/reconstruction period”
(Karunadasa, 2015)

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

ed.) Elsevier Science Limited, Avon, Great Britain.
Bueno, E., Benjamin, M., Sisk, G., Sampson, C., Carty, M., Pribaz, J., Pomahac, B.,
& Talbot, S. (2014). Rehabilitation following hand transplantation. Hand. 9, 9-15.
Bruner, J. (1963). Problems of postoperative position & motion in surgery of the hand.
Journal of Bone & Joint Surgery. 35A(2), 355-366.
Cooper, C. (2007). Fundamentals of Hand Therapy: Clinical Reasoning & Treatment
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.

17. References
Markiewitz, A. (2013). Complications of hand fractures & their prevention. Hand
Clinic. 29, 601-620.
Moran, C. (1989). Anatomy of the hand. Journal of the American Physical Therapy
Association. 69, 1007-1013.
Rath, S. (2011). Hand kinematics: Application in clinical practice. Indian Journal of
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.

18. 1- Main Collateral Ligament; 2- Accessorry Collateral Ligament; 3- Volar Plate