Orthotic Intervention For The Hand and Upper Extremity Splinting Principles

Orthotic Intervention for the Hand and
Upper Extremity: Splinting Principles

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PREFACE vii
appreciate that the diagnoses appropriate for an orthosis and the recommended positioning
can be varied and depend on many factors. The pattern designs illustrated are suggestions of
the ones we have found simple to visualize and use. The Pattern Pearls give alternative pat-
tern designs that we have used in our clinical practice. The therapist is encouraged to modify
the pattern according to specific patient needs. Section II is meant as a guideline for orthosis
construction—use your creativity to individualize each device. The Clinical Pearls are not al-
ways unique to a particular orthosis, and many apply to a variety of orthoses. A complete list
of Clinical Pearls is provided at the front of the book to help the student locate specific points
of interest.
Section III describes alternative interventions for immobilization, mobilization, or restric-
tion of a body part. Because of time constraints, monetary issues, or perhaps lack of product
availability, it is not always practical or appropriate to make an orthosis from thermoplastic
materials. The chapters included in this section provide information on alternative means of
orthotic fabrication. Chapter 11 outlines the considerations and options related to the use of
prefabricated orthoses, including information on how to become an educated consumer on the
availability, application, and modification of these devices. Chapter 11 also reviews some of the
commonly used and currently available orthoses on the market. Chapter 12 describes cast-
ing as a treatment technique that has the ability to provide outcomes that no other orthotic
intervention approach can offer. It familiarizes the clinician with the characteristics of casting
products so he or she can choose the material that best meets the patient’s needs. Chapter 13
provides a brief overview of three popular taping methods: traditional athletic taping, McCon-
nell taping, and elastic therapeutic taping. Each technique is described with specific instruc-
tions and multiple clinical examples. Chapter 14 is a noteworthy chapter because neoprene
is becoming increasingly popular. It reviews the basic information regarding the benefits of
neoprene, qualities of neoprene materials, and a variety of thought provoking options and
alternatives for orthotic management.
Each chapter in Section IV goes into depth regarding a specific diagnosis or patient popu-
lation including stiffness, fractures, arthritis, tendon injuries, peripheral nerves injuries, the
athlete, adult neurologic dysfunction, the pediatric patient, burns, the musician, and, lastly,
the newly added chapter, the transplanted upper extremity. This chapter highlights emerging
concepts on the postoperative management of this unique population.
After an overview of the topic, the chapters include common orthotic interventions and
specific considerations. Many chapters include tables that clarify information and decrease
redundancy within the text. Case Studies accompany each chapter and are meant to stimulate
clinical reasoning and synthesize information reviewed in the text.
Appendix A, located on thePoint companion Web site, is a list of orthotic vendors/
resources that offer equipment, materials, and prefabricated orthoses. Appendices B and C,
on thePoint companion Web site, provides examples of forms used in a clinical setting. The
Index allows the reader to access information about orthoses by their common names as well
as by the ASHT terminology.
Features
• Chapter Objectives: At the beginning of each chapter, these guide both students and
instructors to the material in the chapter and help prepare for the information provided.
• Key Terms: Appearing at the beginning of each chapter, these are defined in the glossary
to emphasize basic terminology associated with orthotic fabrication.
• Case Studies: Located in the chapters and online, these foster critical thinking to apply
concepts to clinical practice.
• Clinical Pearls: Appearing in Section II, these illustrate tips on ways to modify the
design or alter the fabrication process to improve efficiency or maximize patient
specificity.
• Pattern Pearls: Presented in Section II, these provide alternative pattern designs
or other orthotic options.
• ASHT Orthotics Nomenclature: Nomenclature is described in detail for better
understanding.
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viii PREFACE
• Chapter Review Questions: Located at the end of each chapter, these help students
review and retain the information they have encountered in each chapter.
• Discussion Points: At the end of Section II chapters, these questions challenge students
to use critical thinking to recall concepts and theories learned in these chapters.
• Orthotic fabrication for a spectrum of diagnoses and special populations
• Multiple Views of Orthoses: These provide an overall full view of specific orthoses.
• Glossary: This provides a list of terms and definitions.
This book reviews numerous pattern designs and other options for orthotic management for
the upper extremity. Although this endeavor documents a spectrum of orthotic management,
the possibilities for different options extend far beyond a single text. New challenges face the
clinician daily; and it is with each patient that we learn something new, building on our previ-
ous knowledge. This book is meant to stimulate clinical skills and clinician creativity, encourag-
ing the integration of principles and process from which a clinician can create new orthoses.
ADDITIONAL RESOURCES
Orthotic Intervention for the Hand and Upper Extremity: Splinting Principles and Process includes
additional resources for both instructors and students that are available on the book’s compan-
ion Web site at http://thePoint.lww.com.
Instructor Resources
Approved adopting instructors will be given access to the following additional resources:
• Image bank
• PowerPoint Presentation as “Clinic in the Classroom”
• Sample Syllabi
• Lab Exercises
• Answers to Chapter Review Questions
• Answers to Discussion Points
Student Resources
Students who have purchased Orthotic Intervention for the Hand and Upper Extremity:
Splinting Principles and Process have access to the following additional resources:
• Videos called Video Pearls showing the most common injuries and splints
• Interactive Quiz Bank
• Online Case Studies
• Checklist
• Anatomy Reference Tables
• Appendix A: Distributors of Orthotic Fabrication Products
• Appendix B: Occupational/Physical Therapy Examination
• Appendix C: Care and Use of Your Custom Orthosis
• References
In addition, purchasers of the book can access the searchable full text online by going to the
Orthotic Intervention for the Hand and Upper Extremity: Splinting Principles and Process Web
site at http://thePoint.lww.com. See the inside front cover of this book for more details, includ-
ing the passcode you will need to gain access to the Web site.
Jacobs_FM.indd viii 6/26/13 1:34 AM

24 Adult Neurological
ContributorsDysfunction
Gary P. Austin, PT, PhD Richard A. Bernstein, MD

Associate Professor of Physical Therapy Partner, The Orthopaedic Group
Director, Orthopaedic Physical Therapy New Haven, CT
Residency Program
Director, Certificate Program in Advanced Assistant Clinical Professor, Department of
Orthopaedic Physical Therapy Orthopaedics and Rehabilitation
Sacred Heart University Yale University School of Medicine
Fairfield, CT New Haven, CT
Board Certified Orthopaedic Clinical Salvador Bondoc, OTD, OTR/L, BCPR,

Specialist CHT, FAOTA
Fellow, American Academy of Orthopaedic Associate Professor of Occupational Therapy
Manual Physical Therapists Quinnipiac University
Fellow, Applied Functional Science Hamden, CT
American Academy of Orthopaedic Manual
Physical Therapists Occupational Therapist
Baton Rouge, LA Griffin Hospital
Derby, CT
Physical Therapist
Sacred Heart University Sports Medicine Sabrina Cassella, MEd, OTR/L, CHT
and Rehabilitation Center Senior Hand Therapist
Fairfield, CT Attain® Therapy ⫹ Fitness
Springfield, Belchertown & Wilbraham, MA
Noelle M. Austin, MS, PT, CHT
Owner/Instructor Guest Lecturer
CJ Education and Consulting, LLC Springfield College
Woodbridge, CT Springfield Technical Community College
Springfield, MA
Hand Therapist
The Orthopaedic Group Nancy Chee, OTR/L, CHT
Hamden, CT Hand Therapist
California Pacific Medical Center
Guest Lecturer San Francisco, CA
Physical Therapy Program
Sacred Heart University Adjunct Assistant Professor
Fairfield, CT MOT Program/Department of
Occupational Therapy
Samuel Merritt University
Oakland, CA
ix
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x CONTRIBUTORS
Shrikant Chinchalkar, M.Th.O, B.Sc.OT, Rebecca Harris, MS, OTR/L, CHT

OTR, CHT, OT. Reg. (ONT) Hand Therapist
Hand Therapist 2 Thumbs Up Hand Therapy, LLC
Hand Therapy Division, Hand and Upper Plymouth and Norwell, MA
Limb Centre
St. Joseph’s Hospital Hand Therapist
London, Ontario, Canada Quincy Medical Center
Quincy, MA
Instructor
Rehab Education, LLC MaryLynn Jacobs, MS, OTR/L, CHT
Tallman, NY Partner/Owner/Hand Therapist
Attain® Therapy ⫹ Fitness
Jennifer Stephens Chisar, MS, PT, CHT Corporate Office
Supervisor of Hand Therapy East Longmeadow, MA
Rehabilitation Services
John Muir Health Guest Lecturer
Walnut Creek, CA Physical & Occupational therapy
Springfield College
Evan D. Collins, MD American International College
Chief, The Methodist Hand and Upper Springfield, MA
Extremity Center
The Methodist Hospital Colleen Lowe, MPH, OTR/L, CHT
Houston, TX Senior Therapist
Hand Therapy Outpatient Service,
Faculty Occupational Therapy Department
Weill Cornell Medical College Massachusetts General Hospital
New York, NY Boston, MA
Ruth Coopee, OTR/L, CHT, CLT, LMT Alexandra MacKenzie, OTR/L, CHT
Owner, Therapist Section Manager, Department of
Body Holistics Hand Therapy
Pinellas Park, FL Hospital for Special Surgery
New York, NY
Hand Therapist
Largo Medical Center Jonathan Niszczak, MS, OTR/L
Largo, FL Clinical Specialist
Bio Med Sciences, Inc.
Instructor Allentown, PA
Klose Training & Consulting, LLC
Lafayette, CO Senior Burn Therapist
Temple University, Physical Medicine and
Jerry Coverdale, OTR/L, CHT Rehabilitation
American Society of Hand Therapists Philadelphia, PA
(ASHT) Past President
Marie Pace, OTR/L, CHT
Director, Hand Therapist Senior Occupational Therapist
Broward Orthopedic Specialists Centers for Rehab Services
Fort Lauderdale, FL University of Pittsburgh Medical Center
Pittsburgh, PA
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CONTRIBUTORS xi
Jill Peck-Murray, MOT, OTR/L, CHT Karen Schultz, MS, OTR/L, FAOTA, CHT
Occupational Therapist/Hand Therapist Director, Hand Therapist
Rady Children’s Hospital Rocky Mountain Hand Therapy
San Diego, CA Edwards, CO
Instructor Adjunct Faculty

Rehab Education, LLC Rocky Mountain University of Health
Tallman, NY Professions
Provo, UT
Joey Pipicelli, M.Sc.OT, CHT, OT Reg.
(ONT) Kimberly Goldie Staines, OTR, CHT
Sessional Instructor Hand Therapist
Faculty of Health Sciences, School of Michael E. DeBakey Veterans Affairs
Occupational Therapy Medical Center
Western University Houston, TX
London, Ontario, Canada
Adjunct Faculty
Hand Therapist Baylor College of Medicine
Division of Hand Therapy, Hand and Upper Plastic Hand Surgery Fellowship, Orthopedic
Limb Centre Residency, Physical Medicine and
St. Joseph’s Health Care Rehabilitation Residency
London, Ontario, Canada Houston, TX
Director of Hand Therapy Kimberly Zeske-Maguire, MS, OTR/L,

Talbot Trails Physiotherapy and CHT
Musculoskeletal Centre Senior Occupational Therapist,
St. Thomas, Ontario, Canada Facility Director
Hand and Upper Extremity Rehab Clinic,
Reg Richard, MS, PT Centers for Rehab Services
Clinical Research Coordinator Burn University of Pittsburgh Medical Center
Rehabilitation Pittsburgh, PA
U.S. Army Institute of Surgical Research
Burn Center Guest Lecturer
Fort Sam Houston, TX Occupational Therapy Program
University of Pittsburgh
Jessica Griffin Scheff, MS, OTR/L Pittsburgh, PA
Hand Therapist
Attain® Therapy ⫹ Fitness
Springfield, MA
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Reviewers
Michael Borst, BA, MS, OTD Consuelo Kreider, MSH, OTR/L

Assistant Professor Occupational Therapy Department of Occupational Therapy
Concordia University Wisconsin University of Florida
Mequon, WI Gainesville, FL
Marianne McKittrick Crary, OTR/L, CHT Linda M. Martin, PhD, OTR/L, FAOTA
Occupational Therapy Assistant Chair/Professor
Bismarck, ND Florida Gulf Coast University
Fort Myers, FL
Connie Danko, BA, BS, OT
Registered Occupational Therapist Victoria Priganc, PhD, OTR, CHT, CLT
Niskayuna, NY Occupational Therapist
Hand Therapist
Emily Eckel, MS, OTR/L, CHT Richmond, VT
Assistant Professor
Master of Occupational Therapy Program Katherine Schofield, DHS, OTR, CHT
Chatham University Assistant Professor
Pittsburgh, PA School of Occupational Therapy
University of Indianapolis
Chris Eidson Glendale, AZ
Assistant Professor
Occupational Therapy Department Deborah Schwartz, BS, OTR/L, CHT
University of Alabama at Birmingham Physical Rehabilitation
Birmingham, AL Marlton, NJ
Wendy J. Holt, OTR, CHT Elizabeth Spencer Steffa, BS, OTR/L,

Occupational Therapy Department CHT
University of Florida Occupational Therapist
Gainesville, FL Tallman, NY
Pamela Kasyan-Itzkowitz, MS, OTR/L,

CHT
Nova Southeastern University
Fort Lauderdale, FL
xii
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Acknowledgments
The undertaking of this second edition would not be possible if it were not for the patient and
gentle approach Paula Williams, our product manager, provided for us. Sincere thanks to Doug
Smock and Terry Mallon, our design coordinators, for assisting with updating the design and
Jennifer Clements, our art director, for the overwhelming task of organizing the hundreds of ad-
ditional photographs and illustrations we added to this updated book. We truly appreciate the
hard work and patience provided by Harold Medina, Project Manager at Absolute Service, Inc.,
during this revision. He successfully conquered the daunting task of creating a user-friendly
format to present the images and information.
No book is solely the work of its authors. We would like to thank all the patients who were
so generous in allowing us to photograph their upper extremities and provide such a plethora
of examples for our book. We would like to express our gratitude to the many therapists and
physicians we have worked with over the years who contributed to our knowledge base, profes-
sional growth, and clinical skills. So many of you have urged and supported us to always dig
deeper and be as creative as possible! Your trust in our expertise and appreciation for what we
do has fueled the underlying passion for the writing of this book.
Many thanks to the following individuals, who have contributed their time and expertise in
reviewing various chapters or giving us valuable information and/or feedback: Gary P. Austin,
PT, PhD; Richard A. Bernstein, MD; Sabrina Cassella, MEd, OTR/L, CHT; Judy C. Colditz,
OTR/L, CHT, FAOTA; Gail Garfield Dadio, MHSc, OTR/L, CHT, CLT; Dominic L. DeMello, MD;
Barry R. Jacobs, MD; Julianne Lessard, OTR/L, CHT; Pat McKee, M.Sc.OT Reg. (Ont), OT(C);
Pranay Parikh, MD; Erik Rosenthal, MD; Caryn Salwen, MEd, OTR/L; Jessica Griffin Scheff, MS,
OTR/L; Joan Simmons, MS, OTR/L, PhD; and Steven Wenner, MD.
We would like to especially thank Patterson Medical, especially Paul England, Director of
Marketing, Orthopedics for the generous support in supplying the majority of thermoplastic
materials and components used in Section II for the photography. We have thoroughly enjoyed
working with all your materials, especially TailorSplint. Thanks so much!
Finally, we would like to express our sincere thanks to our families who have been so patient
and understanding during the first edition and didn’t commit us when we undertook the proj-
ect of this revision! Without their love, support, and ongoing patience, we would not have been
able to tackle such a huge, detail-oriented task successfully.
xiii
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Contents
Foreword. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .iv
Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .vi
Contributors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ix
Reviewers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .xii
Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xiii
Clinical Pearls . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xvii
SECTION I Fundamentals of Orthotic Fabrication

CHAPTER 1
Concepts of Orthotic Fundamentals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
by MaryLynn Jacobs, MS, OTR/L, CHT, and Jerry Coverdale, OTR/L, CHT
CHAPTER 2
Anatomical Principles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
by Noelle M. Austin, MS, PT, CHT
CHAPTER 3
Tissue Healing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
by Richard A. Bernstein, MD
CHAPTER 4
Mechanical Principles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66
by Gary P. Austin, PT, PhD, and MaryLynn Jacobs, MS, OTR/L, CHT
CHAPTER 5
Equipment and Materials. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84
CHAPTER 6
Fabrication Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107
xiv
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CONTENTS xv
SECTION II Orthotic Fabrication

by MaryLynn Jacobs, MS, OTR/L, CHT, and Noelle M. Austin, MS, PT, CHT
CHAPTER 7
Immobilization Orthoses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 128
PART 1: Digit- and Thumb-Based Orthoses 138
PART 2: Hand-Based Orthoses 150
PART 3: Forearm-Based Orthoses 174
PART 4: Arm-Based Orthoses 208
CHAPTER 8
Mobilization Orthoses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 218
CHAPTER 9
Restriction Orthoses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 268
CHAPTER 10
Nonarticular Orthoses. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 286
SECTION III Optional Methods

CHAPTER 11
Prefabricated Orthoses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 308
by Rebecca Harris, MS, OTR/L, CHT
CHAPTER 12
Casting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 326
by Karen Schultz, MS, OTR/L, FAOTA, CHT
Updated by MaryLynn Jacobs, MS, OTR/L, CHT
CHAPTER 13
Taping Techniques . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 352
by Ruth Coopee, OTR/L, CHT, CLT, LMT
CHAPTER 14
Neoprene Orthoses. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 373
by Sabrina Cassella, MEd, OTR/L, CHT, and Jessica Griffin Scheff, MS, OTR/L
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xvi CONTENTS
SECTION IV Orthotic Intervention for Specific Diagnoses

and Populations
CHAPTER 15
Stiffness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 391
by Karen Schultz, MS, OTR/L, FAOTA, CHT
Updated by MaryLynn Jacobs, MS, OTR/L, CHT
CHAPTER 16
Fractures ........................................................................... 423
by Jennifer Stephens Chisar, MS, PT, CHT, and Nancy Chee, OTR/L, CHT
CHAPTER 17
Arthritis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 444
by MaryLynn Jacobs, MS, OTR/L, CHT,
Shrikant Chinchalkar, M.Th.O, B.Sc.OT, OTR, CHT, OT Reg. (ONT),
and Joey Pipicelli, M.Sc.OT, CHT, OT Reg. (ONT)
CHAPTER 18
Tendon Injuries. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 480
by Alexandra MacKenzie, OTR/L, CHT
CHAPTER 19
Peripheral Nerves Injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 508
by MaryLynn Jacobs, MS, OTR/L, CHT
CHAPTER 20
The Athlete . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 544
by Kimberly Goldie Staines, OTR, CHT, and Evan D. Collins, MD
CHAPTER 21
Adult Neurologic Dysfunction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 565
by Salvador Bondoc, OTD, OTR/L, BCPR, CHT, FAOTA
CHAPTER 22
The Pediatric Patient . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 585
by Jill Peck-Murray, MOT, OTR/L, CHT
CHAPTER 23
Burns . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 604
by Reg Richard, MS, PT, and Jonathan Niszczak, MS, OTR/L
CHAPTER 24
The Musician. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 618
by Colleen Lowe, MPH, OTR/L, CHT
CHAPTER 25
Hand and Upper Extremity Transplantation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 631
by Marie Pace, OTR/L, CHT, and Kimberly Zeske-Maguire, MS, OTR/L, CHT
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 641
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Clinical Pearls
CLINICAL PEARLS
7-1. Management of Mallet Finger, 140 7-29. First Web Space “Handshake Hold” Molding
Technique, 173
7-2. Protective Fingertip Caps, 141
7-30. Prepadding of the Ulnar Styloid, 176
7-3. Securing Circumferential DIP Orthoses, 141
7-31. Proximal Forearm Strap Applied on an Oblique
7-4. Digit Exercise Orthoses, 145 Angle, 176
7-5. Small Finger PIP Orthoses, 145 7-32. Alternative Methods for Securing Straps, 180
7-6. Spiral Design with “Cling Wrap” for Edema, 145 7-33. Clearance of Radial and Ulnar Styloid Processes, 180
7-7. Strapping Alternatives for PIP Orthoses, 145 7-34. Thumbhole Preparation Prior to Application, 180
7-8. TheraBand®-Assisted Molding, 148 7-35. Light Tip Pinch to Incorporate Palmar Arches, 181
7-9. Strapping through Web Spaces, 153 7-36. Preventing Buckling of Material about the Thumb, 181
7-10. Flaring for Dorsal MCP Joint, 153 7-37. Reinforcing Volar Portion of the Orthosis, 181
7-11. Strap Alternative for Dorsal Hand Immobilization, 153 7-38. Ulnar Wrist Immobilization Orthosis for External
7-12. Dorsal Weave for Strap Application, 153 Fixator, 182
7-13. Thermoplastic Strap through Web Space, 157 7-39. Gravity-Assisted Molding with Ulnar-Based
Orthoses, 184
7-14. Strapping around Wrist to Prevent Migration, 157
7-40. Rivet Setting Techniques, 184
7-15. Rolling Material through Web Spaces, 157
7-41. Circumferential Orthosis as a Base for Mobilization
7-16. Contouring around Thumb to Increase IF Stability, 157 Components, 185
7-17. Accommodation for Dorsal Pins, 160 7-42. Zippered Circumferential Wrist Orthosis, 187
7-18. Pinch and Trim to Seal Distal Border, 163 7-43. Material with Memory: Using Stretch, Pinch, and Cut
Technique, 187
7-19. Clearing Thenar Region for Unrestricted Mobility, 163
7-44. Contouring about Wrist, 188
7-20. MCP Flexion (Antideformity) Positioning, 163
7-45. Estimating Material Required to Obtaining Two-Thirds
7-21. Easing Circumferential Thumb Orthosis Removal, 166
Forearm Circumference, 190
7-22. Thumb Exercise Orthoses, 166
7-46. Accommodating Sensitive Areas with Gel and Foam
7-23. Trap Door for Circumferential Thumb Orthoses, 167 Padding, 190
7-24. IF MCP Joint Border, 169 7-47. Neoprene Strap for Sensitive Thumb MP Joint, 193
7-25. Thumb Positioning, 169 7-48. Gentle Traction on Thumb during Molding
Process, 193
7-26. Thumb Post Orthosis, 172
7-49. Use of Hand Rest for Joint Positioning, 194
7-27. Incorrect Pressure Application to Address First Web
Tightness, 172 7-50. Techniques for Accommodating MCP Flexion
Angle, 196
7-28. Improving Pressure Distribution beneath First Web
Immobilization Orthosis, 173 7-51. Strapping Techniques to Prevent Distal Migration, 196
xvii
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xviii CLINICAL PEARLS
CLINICAL PEARLS
7-52. Dacron Batting to Absorb Perspiration, 200 8-20. Simultaneous Wrist/Thumb/MCP/IP Extension
Mobilization Orthosis, 243
7-53. Finger Separators, 200
8-21. Custom Hinges, 243
7-54. Strap Placement to Facilitate Digit Joint
Alignment, 200 8-22. Thumb CMC Radial Abduction, MP/IP Extension
7-55. Hints for Molding First Web Space, 200
8-23. Clearance of Distal Palmar Crease, 250
7-56. Therapy Cone to Aid Fabrication of Antispasticity
Orthoses, 204 8-24. Forearm-Based Dorsal Design PIP/DIP Flexion
7-57. Padding over Bony Prominences, 210
8-25. Simple Strapping to Address Composite Stiffness, 253
7-58. Techniques to Accommodate Elbow Flexion Angle, 211
8-26. Use of Neoprene for Composite Flexion Stretch, 253
7-59. Stretch, Pinch, and Pop Technique for Elbow Orthoses,
212 8-27. Serial Static Approach for MP and IP Extension, 254
7-60. Gravity-Assisted Positioning for Elbow Orthoses, 214 8-28. PIP/DIP Extension Orthoses/Cast with MCP Extension
8-1. Including MCP Joint to Increase Effectiveness of DIP
Stretch, 224 8-29. Modification of Small Finger Sling, 259
8-2. Creating 90° Angle of Application on a Digit 8-30. IF Radial Outrigger to Prevent Pronation and Ulnar
Orthosis, 224 Deviation, 259
8-3. Serial Static Casting to Mobilize Stiff DIP Joint, 225 8-31. Adjusting Tension of Intra-articular Dynamic Traction
Orthosis, 260
8-4. Thermoplastic Distal Phalanx Caps, 225
8-32. Measuring Tension of Intra-articular Dynamic Traction
8-5. Sewing Technique for Increasing Strap Orthosis, 261
Effectiveness, 226
8-33. Combination Neoprene and Thermoplastic Forearm
8-6. PIP/DIP Strap for Increasing EDC Glide, 226 Rotation Orthosis, 264
8-7. PIP/DIP Mobilization Straps, 227 8-34. Clearance of Elbow Flexion Crease, 265
8-8. PIP Extension Mobilization Used as Exercise 8-35. Neoprene for Creative Wrist and Elbow
Orthosis, 228 Mobilization, 267
8-9. Serial Static Casting to Mobilize Stiff PIP Joint, 230 8-36. Proper Hinge Placement, 267
8-10. Forearm-Based PIP Extension Mobilization 9-1. Buttonhole PIP Extension Restriction Orthosis, 270
Orthosis, 231
9-2. Thumb MP Extension Restriction Orthosis, 270
8-11. Multipurpose Orthosis: Alternating PIP Flexion/
Extension Mobilization, 231 9-3. Thumb MP and IP Extension Restriction Orthosis, 271
8-12. Convert Dynamic Orthosis to Static Progressive Using 9-4. Thumb MP Flexion Restriction Orthosis, 271
MERiT™ Component, 232
9-5. Dorsal PIP Extension Restriction Orthosis, 271
8-13. Forearm-Based PIP Flexion Mobilization Orthosis, 234
9-6. Volar PIP Flexion Restriction Orthosis, 271
8-14. PIP Flexion Mobilization Straps, 234
9-7. Spiral Design for Digit Extension/Flexion Restriction
8-15. Thumb MP/IP Flexion Mobilization Orthosis, 235 Orthosis, 271
8-16. Adding Thumb to Hand-Based MCP Extension 9-8. MCP Extension Restriction Orthosis with Thumb
Mobilization Orthosis, 238 Included, 275
8-17. Rolyan® Incremental Wrist Hinge, 242 9-9. Dorsal MCP Extension Restriction Orthosis, 275
8-18. Combined Wrist Flexion/Extension Mobilization 9-10. Hand-Based Digit Extension Restriction Orthosis, 275
Orthosis, 242
9-11. Digit Extension Restriction Strap, 280
8-19. Wrist Flexion Mobilization Orthosis, 243
Jacobs_FM.indd xviii 6/26/13 1:35 AM

CLINICAL PEARLS xix
CLINICAL PEARLS
9-12. Elbow Flexion Mobilization, Extension Restriction 10-6. Orthosis to Facilitate Active PIP Joint Motion, 293
Orthosis, 284
10-7. Use of Elasticized Sleeve to Help Molding Process, 300
10-1. Alternative Options for Pulley Protection, 287
10-8. Protective Playing Orthosis, 301
10-2. Additional Buddy Strapping Techniques, 289
10-9. Circumferential Designs and Material Adherence, 301
10-3. Techniques for Buddy Strapping Small Finger (SF), 290
10-10. Proximal Forearm Orthosis to Address Combined
10-4. Use of Microfoam™ Tape to Prevent Migration, 290 Medial and Lateral Epicondylitis, 302
10-5. Circumferential Phalanx Orthosis, 293 10-11. Preventing Skin Irritation from Overlapped
Segments, 306
ADDITIONAL CLINICAL PEARLS
7-X1. Transferring Pattern to Material, 128 7-X24. Various Stockinette/Liner Choices, 134
7-X2. Pattern Considerations for Border Digits, 128 7-X25. Edging Thermoplastic Material, 135
7-X3. Pin Care Window, 128 7-X26. Casting Tapes as Reinforcement Strips, 135
7-X4. Orthoses for Use during Therapy Session, 128 7-X27. Elastomer Scar Molds Integrated into Orthosis, 135
7-X5. Elastic-Based Materials Allow for Remolding, 129 7-X28. Forearm Trough Height, 136
7-X6. Using Scrap Thermoplastic Material, 129 7-X29. Color Stain Test, 136
7-X7. Reusing Old Orthoses, 129 7-X30. Final Strap Check, 136
7-X8. Cutting a Slit into Thermoplastic, 129 7-X31. Keeping Orthosis Dry, 137
7-X9. Use of a Dremel, 130 7-X32. Cleaning of an Orthosis, 137
7-X10. Quality Scissors, 130 7-X33. Removing Odors from an Orthosis, 137
7-X11. Caring for Scissors, 130 8-X1. Fingernail Attachments, 218
7-X12. Tips for Heating Thermoplastic Materials, 131 8-X2. Commercially Available Digit Slings, 218
7-X13. Heating Large Piece of Material Evenly, 131 8-X3. Finger Sling Combined with Thermoplastic
Material, 218
7-X14. Handling Warm Thermoplastic Material, 131
8-X4. Line Guides, 219
7-X15. Using a Wrap or Stockinette Sleeve to Aid
Fabrication, 132 8-X5. Line Stops, 220
7-X16. Fabricating an Orthosis over Edema Management 8-X6. Preparing Coated Materials for Bonding, 220
Products and Wound Dressings, 132
8-X7. Forming Holes in Thermoplastic Material, 220
7-X17. Techniques for Adding Clamshell Piece, 132
8-X8. Using Goniometer to Determine 90° Line of Force
7-X18. Flaring versus Rolling of Edges, 133 Application, 220
7-X19. Overstretching of Material, 133 8-X9. Mobilization Forces, 221
7-X20. Strapping Material Choices, 133 8-X10. Proximal Attachment Devices, 222
7-X21. Cutting Straps to Avoid Pressure on “At-Risk” Sites, 8-X11. Homemade D-ring, 222
133
8-X12. Elbow and Shoulder Harnesses to Secure Arm
7-X22. Foam beneath Strapping, 134 Orthoses, 223
7-X23. Rotating Rivet for Flexibility in Strap Orientation, 134 8-X13. Orthoses and Modalities, 223
Jacobs_FM.indd xix 6/26/13 1:35 AM

Jacobs_FM.indd xx 6/26/13 1:35 AM
SEC T IO N I
Fundamentals of
Orthotic Fabrication
Jacobs_CH01.indd 1 6/20/13 1:34 AM

Concepts of Orthotic
1 Fundamentals
MaryLynn Jacobs, MS, OTR/L, CHT
Jerry Coverdale, OTR/L, CHT
Chapter Objectives
After study of this chapter, the reader should be able to: • Explain the specific differences and uses for the terms
• Detect the proper nomenclature used to describe static, dynamic, serial static, and static progressive
orthoses for communication to peers, payers, and orthoses.
referral sources. • List the objectives for intervention for immobilization,
• Understand the clinical reasoning process for select- mobilization, and restrictive orthoses and be able to
ing the most appropriate orthosis for a patient. describe an example of each.
Key Terms
American Society of Hand Therapists Immobilization Prefabricated orthosis
Articular Immobilization orthosis Provider Enrollment, Chain and
Centers for Medicare & Medicaid Services L-Code Ownership System
Current Procedural Terminology Medicare Administrative Contractors Restriction
Custom fabricated Mobilization Restriction orthoses
Durable Medical Equipment, Mobilization orthoses Serial static orthoses
Prosthetics, Orthotics, and Supplies Modified Orthosis Classification System Splint Classification System
Dynamic orthoses Modifier Static progressive orthoses
Healthcare Common Procedure Coding National Supplier Clearinghouse Static Orthoses
System Level II Nonarticular orthosis
Introduction
Fabrication of upper extremity orthoses requires a unique combination of the
therapist’s creative abilities and a sound knowledge of anatomical, biomechanical,
physiologic, and healing principles as they relate to injury, surgery, and disease.
Orthosis fabrication can be one of the most challenging and most enjoyable aspects
of being a therapist. Before delving into the fabrication of orthoses, one must not
only understand proper nomenclature for universal communication but also
develop a solid understanding of the clinical reasoning process for selecting the
most appropriate orthosis for the patient. Owing to the growing recognition of spe-
cialists who treat the upper extremity and the increasing use of custom-fabricated
orthoses, it has been necessary to develop a standard language that clearly and
uniformly describes an orthosis to those who refer, fabricate, and/or pay for the
devices. The American Society of Hand Therapists (ASHT) recognized the need
to standardize, organize, and simplify terms and in 1992 developed the Splint
Classification System (SCS) that grouped orthoses into progressively more

CHAPTER 1 • Concepts of Orthotic Fundamentals 3
CHAPTER 1
refined categories (American Society of Hand Therapists [ASHT], 1992). The first
edition of this book was based on a modified version of this classification. This
second edition continues to support and integrate our historical nomenclature;
however, the authors recognize that the current climate of hand therapists dispens-
ing and fabricating orthoses has drastically changed. Occupational therapists (OTs)
and physical therapists (PTs) who practice in this arena have found their rights and
qualifications questioned. It has become imperative that adapting the language
put forth by the Centers for Medicare & Medicaid Services (CMS) along with
clinician documentation be very descriptive and streamlined. It is to this end that
the authors of this chapter have taken the ASHT SCS and the current CMS L-Codes
(a specific description of a custom or prefabricated orthosis) and developed a
modified and simplified version to be used for the purpose of teaching in this book
and is referred to as the Modified Orthosis Classification System (MOCS). A
comprehensive and detailed description of the expanded ASHT SCS can be found
in the book Rehabilitation of the Hand, Sixth Edition (Fess, 2011).
The authors of this chapter and the editors of this book have combined these
two systems for several reasons. The first reason is to simply link clinical documen-
tation to orthosis billing. For example, in a clinical note, a therapist may describe
an orthosis by using more traditional terminology; however, that clinician will be
responsible for choosing the correct L-Code to bill for that orthosis (which is in CMS
language). Second, the classification systems were combined to provide clear, con-
sistent, and accurate communication with all payers, physicians, and peers regard-
ing exactly what orthosis is being dispensed or fabricated. The CMS L-Code system
is just not detailed enough to meet the second requirement; therefore, the historical
nomenclature has been woven into this MOCS (Table 1–1 and Fig. 1–1).
book (ASHT, 2009; Centers for Medicare & Medicaid Services

Nomenclature: [CMS], 2008; Healthcare Common Procedure Coding System
[HCPCS], 2011; McKee & Rivard, 2011).
Orthosis versus Splint Because OT and PT qualifications to dispense and
The qualifications of licensed/registered OTs and PTs dis- fabricate orthoses have been questioned by policymak-
pensing and fabricating orthotic devices have been ques- ers and payers, it is extremely important that clinicians
tioned by CMS and state legislatures over the years. In 2000, use the proper language that has been adopted by CMS.
Congress passed legislation that required CMS to develop This is especially important because many payers follow
a regulation, through a negotiated rulemaking process, to CMS guidelines. The term splint has been used in thera-
restrict payment for custom-fabricated orthoses and all py professions for decades; however, CMS does not rec-
prosthetics to only those that are provided by qualified prac- ognize these devices by that name. Th ey designate the
titioners and suppliers. OTs and PTs are included as qualified term orthotic devices (orthoses), as defined in the 2008
practitioners in the law through state licensure and certifi- Durable Medical Equipment, Prosthetics, Orthotics,
cation examinations completed after receiving an entry- and Supplies (DMEPOS Quality Standards) manual as
level degree at an accredited institution. OTs and PTs have the reimbursable language (CMS, 2008). Therefore, it is
the educational background, clinical exposure, and clinical imperative that clinicians make a shift in terminology in
assessment/reasoning skills to design, fabricate, fit, and edu- all of the following areas:
cate a client safely and effectively with an orthotic device. • Documentation
This education includes, but is not limited to, orthosis train- • Patient education
ing, knowledge of anatomy, biomechanics, kinesiology, dis- • Academic/student education
ease/injury processes (including surgical procedures and • Continuing education courses
wound healing physiology), and the psychosocial aspects • Publications/presentations
of injury/disease. The CMS-negotiated rulemaking failed • Literature/research
to reach consensus, and CMS has not issued a regulation to • Communication with physicians, insurance carriers,
implement this legislation at the time of the printing of this and colleagues

4 SECTION I • Fundamentals of Orthotic Fabrication
TABLE 1–1
Relevant Terminology Definitions
CMS Centers for Medicare & Medicaid Services is a federal agency within the U.S. Department of Health and Human
Services that administers the Medicare program and works in partnership with state governments to administer
Medicaid and other such programs.
CPT Current Procedural Terminology
This refers to a number/code assigned to the majority of tasks and services a medical practitioner may provide
to a patient. It is then linked to a determined amount of reimbursement by the insurer. Level II of the HCPCS is a
standardized coding system that is used primarily to identify products, supplies, and other services not included in
these CPT codes (such as orthoses). CPT codes are developed and published by the American Medical Association
(AMA, 2011) and revised yearly.
DME Durable Medical Equipment
This is a term used to describe any medical equipment used in the home to aid in an improved quality of life.
Examples are walkers, wheelchairs, power scooters, hospital beds, and home oxygen equipment. Clinicians often
refer to orthoses as DME equipment; however, the proper terminology is DMEPOS.
DMEPOS Durable Medical Equipment, Prosthetics, Orthotics, and Supplies
Durable medical equipment is often referred to as DMEPOS because Medicare also covers prosthetics, orthotics,
and certain supplies (POS). Prosthetics are devices that can replace a missing body part, such as a hand or leg.
Orthotics are devices that help to immobilize, mobilize, or restrict a body part.
HCPCS Healthcare Common Procedure Coding System
HCPCS is a comprehensive, standardized system that classifies similar products that are medical in nature into
categories for the purpose of efficient claim processing and ensures uniformity. It is used primarily to identify
products, supplies, and services not included in the CPT codes, such as durable medical equipment, prosthetics,
orthotics, and supplies (DMEPOS) when used outside a physician’s office. Because Medicare and other insurers
cover a variety of services, supplies, and equipment that are not identified by CPT codes, the level II HCPCS codes
were established for submitting claims for these items.
L-Code L-Codes describe orthoses by identifying which body parts they are used for (S, shoulder; E, elbow; W, wrist;
H, hand; and F, finger), followed by the letter O for orthosis. They are also described as static (without joint)
or dynamic (nontorsion joint and elastic bands and turnbuckles) and specify whether an orthosis is custom or
prefabricated. The L-Code is the number linked to the specific description of a custom or prefabricated orthosis for
proper communication to the insurance carrier.
MAC Medicare Administrative Contractors
L-Codes are not billed to CMS directly but rather through regional/jurisdiction MAC. There are currently four
jurisdictions based on which region of the United States you are billing from.
Modifiers A code added to the end of a CPT code to clarify the services and increase accuracy regarding what is being billed.
Modifiers offer a way in which the service can be altered without changing the procedure code.
NPI National Provider Identification number
This is a unique 10-digit identification number issued to health care providers in the United States by CMS. This
number is a required identifier for Medicare services and is used by other payers, including commercial healthcare
insurers. All healthcare providers and facilities must obtain an NPI number to use in all standard transactions.
Therefore, a clinician and/or facility must have this number in order to bill for orthotic services.
NSC National Supplier Clearinghouse
This organization processes the enrollment applications submitted by DMEPOS suppliers for their NSC (DMEPOS)
number. This process is done online via PECOS enrollment.
PECOS Provider Enrollment Chain Ownership System
Allows DME suppliers to initially enroll for an NSC (DMEPOS) number, make changes to an existing number,
update information (such as adding a new provider), check on the status of an application or reenroll online.
Anyone wishing to become a Medicare provider must apply through PECOS. In addition, as the supplier of the
DMEPOS, you will be denied payment if your referral source is not enrolled in PECOS.

Articular Nonarticular
CHAPTER 1
Location Location
SO, SEO, SEWO, SEWHO, SEWHFO, Humerus, Forearm,
EO, EWO, EWHO, EWHFO, WHO, Metacarpal, Phalanx
WHFO, HFO, FO
Joint Position(s) Joint(s) Involved/Torque Application

Flexion, Extension, Supination, Pronation, Shoulder, Elbow, Forearm, Wrist, MCP,
Radial Deviation, Ulnar Deviation, MP, PIP, DIP, IP
P/R Abduction, Adduction, Internal Rotation,
External Rotation
Direction(s) of Torque Application

Flexion, Extension, Supination, Pronation,
Radial Deviation, Ulnar Deviation,
P/R Abduction, Adduction, Internal Rotation,
External Rotation
Immobilization Restriction Mobilization
Design Options
Dorsal, Volar, Radial, Ulnar,
Circumferential, Anterior,
Posterior, High Profile, Low Profile
FIGURE 11 The authors recommended Modified Orthosis Classification System (MOCS). Note that
the Centers for Medicare & Medicaid Services (CMS) does not recognize the thumb as a separate body part.
The thumb is classified as F, the same distinction used for the index, middle, ring, and small digits.
• Orthotic is an adjective and is used to describe a

Definition noun associated with the science of orthotics, such
as orthotic device, orthotic treatment plan, orthotic
Orthosis intervention, orthotic fabrication, or orthotic coding.
An orthosis is a rigid and/or semirigid device used for the The second edition of this book has adopted much of
purpose of support, alignment, prevention or correction the terminology put forth by CMS while continuing to gen-
of deformity, or to improve function or restrict motion of tly blend the historical nomenclature that so many physi-
a movable body part (CMS, 2008). Orthotic devices are cians and therapists are accustomed to. The editors and
described by the CMS using L-Codes that are found in the authors of this publication strongly believe that unified ter-
Healthcare Common Procedure Coding System (HCPCS) minology is paramount when referring to orthoses in every
Level II manual. aspect of our professions. Threaded throughout this chapter,
What is the proper terminology to use? the reader will find occasional examples of CMS language
• Orthosis is a noun and should be used in place of the (WHO, SO . . . ) and in Figures 1–2 through 1–5 correspond-
word splint. ing L-Codes for the orthosis described. The reader must note
• Orthoses is a plural noun and should be used to that the L-Codes described in this chapter are only discussed
replace the term for multiple splints. in this chapter as examples and are reflective of the time of
• Fabricating an orthosis should be used in place of this publication. L-Codes can be changed or altered by CMS
the verb splinting. at any time. It is important to keep current with individual

insurance carrier changes (including CMS) and the associ- structure (joints) that the orthosis supports and/or crosses.
ated reimbursements. It is the authors’ intent to continually Each joint is recognized with the first letter of that joint.
reinforce the important relationship between documenta- For example, “SO” would represent shoulder orthosis; “EO,”
tion and billing. elbow orthosis; “WHO,” wrist and hand orthosis; and so on.
The combination of each letter will determine the structures
that the orthosis crosses. The following coding examples
include the anatomical headings and the CMS descriptions
Overview of Orthosis of the corresponding L-Code (Table 1–2). In the coding
Classification examples (Figs. 1–2 to 1–5), the actual numerical number
associated with that L-Code description (e.g., L3908) has
It would be erroneous to have a book dedicated to ortho- been recommended. Each provider (clinician/organization)
ses and not discuss coding choices for reimbursement. This is encouraged to communicate with their local insurance
section is dedicated to assisting in proper L-Code selection companies to determine acceptable L-Codes that they cover.
and to promote unification of selection across our profession. This should be done yearly as well as staying informed on any
The codes used for reimbursement for orthoses are the bulletin a payer may put forth regarding this issue.
L-Codes found in the HCPCS manual. Although it is CMS Coding examples:
that uses the HCPCS coding system, many payers tend to
follow CMS guidelines. However, not all insurance carriers
may recognize all the L-Codes that CMS recognizes. Other
carriers may cover all or just a few. In addition, they may not
reimburse at the same rate that CMS does for the exact same
product. Each clinic/organization must abide by the contract
they have with the individual insurance carriers and accept
the negotiated rates mutually agreed upon through the con-
tract period. The reimbursement for orthoses will depend on
how each clinic/organizations individual insurance contract
is written, what is included within it, what L-Codes are cov-
ered, and what exactly is the rate for each. This may greatly
differ from clinic to clinic, state to state, private practice to
hospital setting, and so forth.
Easily identifying the reimbursement L-Codes is simple
and rendered timeless by being based on the anatomical
TABLE 1–2 FIGURE 12 Immobilization prefabricated orthosis: (EO). L3762

Elbow orthosis, rigid, without joints, includes soft interface material,
Key to Anatomical Headings prefabricated, and includes fitting and adjustment. Photo courtesy of
SEWHFO shoulder, elbow, wrist, hand, finger/thumb Corflex Inc. The Ventral Cubital Tunnel Splint.
orthosis
SEWHO shoulder, elbow, wrist, hand orthosis
SEO shoulder, elbow orthosis
EWHFO elbow, wrist, hand, finger/thumb orthosis
EWHO elbow, wrist, hand orthosis
WHFO wrist, hand, finger/thumb orthosis
WHO wrist, hand orthosis
HFO hand, finger/thumb orthosis
SO shoulder orthosis
EO elbow orthosis
HO hand orthosis FIGURE 13 Mobilization prefabricated orthosis: (EO). L3760
FO finger/thumb orthosis Elbow orthosis, with adjustable position locking joint(s), prefabri-
cated, includes fitting and adjustments, any type. Photo courtesy of
Patterson Medical; The Rolyan® Pre-Formed Elbow Hinge Splint.

The L-Code is generally inclusive of the evaluation, cost
CHAPTER 1
of base materials, fabrication, fitting, and adjustments to
the orthosis. The Current Procedural Terminology (CPT)
code 97760 (a time-dependent code) may be used in conjunc-
tion with the L-Code only if training goes above and beyond
what is considered customary. The CPT code should not
be used for basic and routine training for use and care. It is
imperative that documentation must justify why the training
time was lengthened and what that training entailed. An eval-
uation CPT code (97003 OT or 97001 PT) can only be charged
at the time of orthotic fabrication/dispensing if the orthosis
is part of a treatment plan and the patient will be seen for
ongoing treatment. If bilateral orthoses are dispensed or fab-
ricated, then a modifier is required on the billing form: “Rt”
for right upper extremity and “Lt” for the left upper extremity.
FIGURE 14 Immobilization custom-fabricated orthosis: (WHO). L3906 For example, a therapist receives a referral for a patient
Wrist hand orthosis, without joints, may include soft interface, straps, with the diagnosis of bilateral distal radius fractures and the
custom fabricated, includes fitting and adjustment.
prescription is for bilateral wrist orthoses, evaluation, and
treatment. At the time of this publication, the clinician can bill
an evaluation CPT code as well as treatment CPT codes, which
are billed directly to CMS. The L-Codes (L3906 in this exam-
ple) are billed using modifiers Rt and Lt to denote that two
orthoses were fabricated for the right and left upper extremi-
ties. The L-Codes are billed to the National Supplier Clear-
inghouse (NSC) via Medicare Administrative Contractors
(MACs) instead of directly to CMS and require that the pro-
vider have an NSC number, also known as a DMEPOS number.
Therapists apply for this DMEPOS number via the Internet
through Provider Enrollment, Chain and Ownership Sys-
tem (PECOS). Refer to Table 1–1 for greater detail. If the refer-
ral is only for bilateral wrist orthoses, then the therapist would
not bill the evaluation CPT code but only the WHO (L3906)
FIGURE 15 Mobilization custom-fabricated orthosis: (WHFO). L3806 code using the right and left modifiers to the NSC.
Wrist-hand-finger orthosis, includes one of more nontorsion joint(s),
turnbuckles, elastic bands/springs, may include soft interface mate-
rial, straps, custom fabricated, includes fitting and adjustment.
Challenges in the Use of L-Codes

Every L-Code has a detailed description. Each descrip- The clinician may be challenged to find the proper code
tion explains whether or not that L-Code is prefabricated to describe what has been fabricated. Because of the vast
or custom fabricated and if it is an orthosis that is used possibilities of designs, it is near impossible to have a code
to mobilize (dynamic, serial static, or static progressive) or description for everything. If a code cannot be found to
immobilize (static) the anatomical structures. If the L-Code match up with the orthosis fabricated, then the code that
is for an immobilization orthosis, then the description will best describes the orthosis should be chosen. Clear, proper,
contain the words without joint to indicate no joints are and meticulous documentation must justify this choice.
mobilized. If the L-Code is for a mobilization orthosis, then For example, there is no code that accounts for using an
the description will contain words such as “nontorsion joints, immobilization orthosis to function as a static progressive
elastic bands, and turnbuckles,” indicating there is at least (mobilization) device that can be sequentially adjusted over
one joint that the orthosis crosses which a torque is being several treatment sessions. The CPT code 97762 may be used
applied via elastic bands, springs, or turnbuckles but may when it is necessary to serially modify the immobilization
also include at least one joint which torque is not applied. orthosis in order to provide a mobilizing force. Remember
This language primarily applies to the custom-fabricated that this code is considered a timed code based on 15-minute
orthoses. The prefabricated orthoses descriptors have not increments; therefore, this code should not be used for basic
been altered by CMS and use words such as “rigid” to denote or quick modifications.
an immobilizing or restricting orthosis and “adjustable or An additional challenge is the limited options for codes
locking joints” for a mobilizing orthosis (HCPCS, 2011). describing nonarticular orthoses, with the exception of hand

FIGURE 17 Nonarticular hand orthosis: (HO). A hand immobiliza-

tion orthosis for treatment of a midshaft fifth metacarpal fracture;
the pressure applied through the volar–dorsal nature of this device
during fabrication minimizes the tendency for the bone fragments
to shift.
included in the design. By adding the word nonarticular,

the description becomes far more specific. In Section II,
FIGURE 16 Nonarticular humerus orthosis: (SO). A humeral frac- the articular orthoses are separated from the nonarticular
ture brace used to stabilize and protect a healing midshaft humerus to aid in pattern location; the term articular does not need
fracture. Although labeled as nonarticular, the orthosis partially crosses to appear in the description because the name of the orthosis
the shoulder joint. The most appropriate L-Code is L3671. (e.g., wrist immobilization orthosis or WHO) indicates
whether a joint is included. However, the term nonarticular
does need to appear in the descriptions (e.g., nonarticular
orthosis (HO) that can be used for midshaft metacarpal humerus orthosis or SO L3671 and nonarticular metacar-
fractures. Therefore, if a therapist fabricates a custom humeral pal orthosis or HO L3919), so there is no ambiguity as in
orthosis to protect a midshaft humeral fracture, then the code Figures 1–6 and 1–7. Note: for billing purposes, the CMS
chosen for billing would have to closely describe this orthosis. codes chosen here are the best choice (to this publication
A choice could be a custom-fabricated immobilization ortho- date) available to describe these devices for reimbursement.
sis or L3671 shoulder orthosis (SO); “shoulder joint design,
without joints, may include soft interface, straps, custom fab- Location
ricated, and includes fitting and adjustments” (HCPCS, 2011).
Location, the next level in the MOCS, refers to the joint, set of
Even though the description actually states it immobilizes the
joints, or body part on which the orthosis acts according to its
shoulder joint, it is the closest description offered (Fig. 1–6).
main intent. Therefore, in order to simplify naming, if there are
several joints involved, as commonly seen after a severe crush-
ing injury to the hand, MOCS groups the joints together. For
Summary of the Modified Orthosis example, if a crush injury involves all the metacarpophalangeal
Classification System (MCP), proximal interphalangeal (PIP), and distal interphalan-
geal (DIP) joints, the proper name would be a hand and digit
Articular and Nonarticular Orthoses immobilization orthosis or HFO. If the crush injury involves
the three joints of only the middle finger (MF), then the ortho-
Orthoses are divided into one of two broad groups: articular
sis is described as a digit immobilization orthosis or FO.
and nonarticular. Articular orthoses are those that cross
Nonarticular orthoses are described in much the same
one or more joints. Nonarticular orthoses provide support
way. For example, an orthosis used to immobilize a fifth
and protection to a healing bone (e.g., humerus, metacarpal,
metacarpal fracture is described as a nonarticular fifth meta-
or phalanx) or to a soft tissue structure (e.g., annular pul-
carpal orthosis or HO (Fig. 1–7). Similarly, an orthosis used to
ley or musculotendinous junction of the medial or lateral
protect a recently reconstructed annular pulley is described
epicondyle). There are far fewer nonarticular orthoses than
as a nonarticular proximal phalanx orthosis or FO (Fig. 1–8).
articular orthoses (Fig. 1–7).
When interpreting a referral, it is advantageous to dis-
tinguish between articular and nonarticular orthoses so Joint(s) Involved/Torque Application
that a joint is not unnecessarily immobilized. For example, if A mobilization orthosis may require immobilization support
the word nonarticular does not precede the words proximal of adjacent joints or, occasionally, mobilization in more than
forearm immobilization orthosis on the referral, then the one direction within the same orthosis. When noting the ana-
therapist may assume that the elbow or wrist needs to be tomical locations that the orthosis crosses, it is imperative to

gain PIP extension (mobilize), to rest (immobilize) the PIP in
CHAPTER 1
extension, or to block a portion of PIP extension (restriction)?
Intent: Immobilization, Mobilization, and

Restriction
Intent, the next level of the MOCS, refers to the overall func-
tion or primary purpose of the orthosis, which is generally
immobilization, mobilization, or restriction. Adding the
orthosis’ purpose to the description provides the fabricator
with a clearer understanding of what is being requested. For
example, a prescription for an RF PIP extension mobilization
orthosis tells the fabricator that an extension force needs to
FIGURE 18 Nonarticular proximal phalanx orthosis: (FO). This cir- be exerted on the PIP joint of the RF. The purpose of an RF
cumferential designed orthosis provides protection to a recently re- PIP extension immobilization orthosis, on the other hand, is
constructed A2 annular pulley. to immobilize the PIP joint in extension. Finally, an RF PIP
extension restriction orthosis restricts full extension of the
note which joint(s) are immobilized and which joint(s) have PIP joint but allows active flexion (as often requested for
torque applied to them. An example may be managing meta- management of a finger with a swan-neck deformity).
carpal phalangeal (MP) joint extension contractures after a In Section II, the orthoses are organized according to their
distal radius fracture. The wrist may require continued immo- most common purpose, although additional functions are
bilization, whereas the MCPs would benefit from flexion also defined. For example, the RF PIP immobilization ortho-
mobilization, as shown in Figure 1–24. This orthosis would be sis is discussed in Chapter 7. However, because it is essentially
noted for billing as a WHFO (L3806), and the written docu- the same pattern used for an RF PIP extension mobilization
mentation would reflect a statement such as “wrist extension orthosis (serial static design), this use is referenced under the
immobilization, MCP flexion mobilization orthosis.” A mobi- heading “Additional Functions.” The cross-reference list pro-
lization orthosis may also require torque application to more vided in this book will also help in quick pattern location.
than one joint and in different directions. An example may be
managing a claw hand from a long-standing ulnar nerve inju- Design Descriptors
ry where the patient exhibits MCP extension and interpha- The design descriptor improves understanding of the type
langeal (IP) flexion contractures. The joint torque in this case of orthosis that is requested. In this text, the descriptors
would be applied to the MPs in the direction of flexion and are used as an aid whenever necessary. Design descriptors
simultaneously to the IPs in the direction of extension. This include non-MOCS nomenclature that is still widely used by
orthosis would be noted for billing as an HFO (L3921) and for hand surgery and hand therapy specialists throughout the
documentation as a small finger and ring finger (SF/RF) MCP world; some examples are gutter, spica, static, dynamic, static
flexion/IP extension mobilization orthosis. progressive, and serial static. These terms are discussed sepa-
rately later in this chapter.
Direction In the MOCS, design descriptors, which are selectively
The direction descriptor, the next level in the MOCS, refers included, appear in parentheses after the name of the ortho-
to the position of the primary joint in an immobilization sis. In this book, however, the descriptors are most often
orthosis, the joint boundary of a restrictive orthosis, and found at the beginning of the name to help readers with criti-
the direction of torque in a mobilizing orthosis. The direc- cal thinking and decision-making processes. The descriptive
tion descriptor provides critical information necessary for terms include the following:
accurately fabricating the orthosis. Prior to fabrication, the • Digit-based: Originating from the digit, allowing MCP
specific purpose of the orthosis must be known before the joint motion, and possibly extending to the distal phalanx
therapist can add the direction descriptor. Direction defines • Hand-based: Originating from the hand, allowing wrist
the position of the involved joints (immobilization orthosis), motion, and possibly extending to the distal phalanx
the desired direction of the mobilizing force (mobilization • Thumb-based: Originating from the thenar eminence or
orthosis), or the direction in which motion is to be blocked thumb and incorporating one or more joints of the thumb
(restriction orthosis). For example, by adding a direction • Forearm-based: Originating from the forearm, allow-
term (e.g., RF PIP extension orthosis), the orthosis’ intent is ing full elbow motion, and possibly extending to the
further clarified, in this case by indicating that the joint is distal phalanx
to be extended. As noted in the next section—by then fol- • Arm-based: Originating from the upper arm and pos-
lowing “direction” by the use of the words immobilization, sibly including the wrist, elbow, and/or shoulder joints
mobilization, or restriction—there will be even more clear • Circumferential: Encompassing the entire perimeter
information about what that direction really means. Is it to of a body part

• Gutter: Including only the radial or ulnar portion of a the orthosis continues as long as the elastic component can
body part contract, even when the shortened tissue reaches the end of its
• Radial: Incorporating the radial aspect of a body part elastic limit (Schultz-Johnson, 1992, 2003b). As soon as appro-
• Ulnar: Incorporating the ulnar aspect of a body part priate, dynamic forces should be applied to the targeted tissue
• Dorsal: Traversing the dorsal aspect of the hand or because this provides better opportunity for contracture reso-
forearm lution and/or tissue elongation. The less mature the scar tis-
• Volar: Traversing the volar aspect of the hand or forearm sue, the better the tissue will respond to the intermittent force
• Anterior: Traversing the anterior aspect of a body part application of a dynamic orthosis (Colditz, 2011b; Glascow
• Posterior: Traversing the posterior aspect of a body part et al., 2011). Mature, dense scar tends to respond more favor-
ably to a prolonged static progressive force (Colditz, 2011b).
Non–Modified Orthosis Classification System A dynamic orthosis can also be used as an active-resistive exer-
Nomenclature cise modality against its line of pull.
The widely used terms static, serial static, dynamic, and static Static Progressive Orthoses
progressive are not included in the MOCS. These terms des- Static progressive orthoses achieve mobilization by apply-
ignate choices of designs that a therapist can incorporate to ing unidirectional, low-load force to the tissue’s maximum end
achieve immobilization, mobilization, or restriction of the ROM until the tissue accommodates. Construction is similar
intended structure(s). These choices are noted under “Common to dynamic orthoses, except these use nonelastic components
Names” in Section II and are listed in the book’s index. to deliver the mobilizing force, including, but not limited to,
nylon cord, strapping materials, screws, hinges, turnbuck-
Static Orthoses
les, and nonelastic tape (Sueoka & DeTemple, 2011). Once
Static orthoses have a firm base and immobilize the joint(s) the joint position and tension are set, the orthosis does not
they cross. They can be used to facilitate dynamic functions, continue to stress the tissue beyond its elastic limit (Schultz-
for example, by blocking one joint to encourage movement of Johnson, 1992, 2003a, 2003b). The force can be modified only
another. In some cases, a static orthosis is considered to be through progressive adjustments. Some patients may tolerate
nonarticular—having no direct influence on joint mobility— static progressive application better than dynamic applica-
while providing stabilization, protection, and support to a tion, perhaps because the joint position is constant while the
body segment, such as the humerus or metacarpal. Static tissue readily accommodates to the tension and is less sub-
orthoses may be the most common orthosis that therapists ject to the influences of gravity and motion (Colditz, 2011b;
are called on to make. They can be used as an alternative to Schultz-Johnson, 1992, 1996, 2002, 2003b).
mobilization devices when ease of application and compli-
ance are potential issues (Riggs, Lyden, & Chung, 2011).
Serial Static Orthoses
Serial static orthoses or casts are applied with the tissue Function of Orthoses and
at its near maximum length; they are worn for long periods
to accommodate elongation of soft tissue in the desired
Objectives for Intervention
direction of correction. They are remolded or new devices This section reviews the objectives for orthotic intervention
are made by the therapist to maintain the joint(s), soft tis- and provides appropriate clinical examples for immobilization,
sue, and/or muscle–tendon units they cross in a lengthened mobilization, and restriction. Remember that not all orthoses
position. Serial static orthoses are constructed to be cir- can be simply classified, and the primary objective may not
cumferential and nonremovable. This option provides for always be clear-cut. There may be multiple objectives for orthot-
greater patient compliance and assures the therapist and ic intervention. For example, a wrist/hand immobilization
physician that the tissue is being continually stressed with- orthosis (WHFO) for a patient with rheumatoid arthritis may be
out the risk of the tissue rebounding, which could happen designed to immobilize inflamed arthritic joints while placing
if the orthoses were removed (Brand & Thompson, 1993; the MCP joints in near extension and a gentle radially deviated
Colditz, 2011a; Schultz-Johnson, 2003a). position to minimize ulnar drift and periarticular deformity.
Dynamic Orthoses The discussion that follows covers general and common
examples to emphasize how critical thinking is necessary
Dynamic orthoses generate a mobilizing or supportive force on
when fabricating orthoses. Experienced therapists recognize
a targeted tissue that results in passive gains or passive-assisted
that managing complex injuries requires much overlap and
range of motion (ROM) (Fess & Phillips, 1987; Glascow, Tooth,
problem solving in order to determine the best approach.
Fleming, & Peters, 2011). Dynamic orthoses have a static base
that provides the foundation for some type of outrigger attach-
ment. Controlled mobilizing forces are applied via a dynamic Immobilization Orthoses
(elastic) assist, which may be rubber bands, springs, neoprene, Although the immobilization orthosis is the most common
or wrapped elastic cord. The dynamic force applied through and simplest form of orthotic intervention, it can be used for

the most complex of injuries. Static orthoses are considered
CHAPTER 1
immobilization orthoses because they do not allow motion
of the joints to which they are applied. Immobilization
orthoses can be considered either articular or nonarticular,
immobilizing the joints they cross (articular), or stabilizing
the structure to which they are applied (nonarticular), as in
the case of a humerus orthosis (Fig. 1–6).
The common objectives for immobilization are as follows:
• Provide symptom relief after injury or overuse
• Protect and properly position edematous structure(s)
• Aid in maximizing functional use of the hand
• Maintain tissue length to prevent soft tissue contracture
FIGURE 110 Wrist/thumb immobilization orthosis: (WHFO).
• Protect healing structures and surgical procedures
Immobilization of the thumb and wrist can provide relief for a patient
• Maintain and protect reduction of a fracture with acute deQuervain’s tenosynovitis.
• Protect and improve joint alignment
• Block or transfer power of movement to enhance exercise
• Reduce tone and contracture of a spastic muscle
These objectives and examples of orthotic intervention A radial wrist/thumb immobilization orthosis (WHFO)
are discussed in the following sections. can assist in decreasing inflammation and pain within the
first dorsal compartment (deQuervain’s tenosynovitis) by
• Provide Symptom Relief preventing simultaneous wrist ulnar deviation and thumb
An immobilization orthosis can provide significant pain relief flexion. The wrist is positioned in neutral to 20° exten-
when applied as soon as possible after injury. The injured sion with 0 to 5° of ulnar deviation. This position keeps
structures should be placed in a resting, nonstressed position, the extensor pollicis brevis (EPB) and the abductor pol-
minimizing movement that can influence pain. This orthosis is licis longus (APL) tendons in alignment with the radius
initially worn day and night and may be removed for only short as they exit the pulley about the radial styloid (Eaton,
periods of exercise and hygiene. After the initial symptoms 1992). The thumb carpometacarpal (CMC) joint is posi-
have subsided, orthosis use is decreased; eventually, the ortho- tioned in slight abduction, and the MP joint is included
sis may be used only for preventing the risk of reinjury. For in a slightly flexed, comfortable position (Fig. 1–10). The
example, a person who has sustained a wrist sprain may pres- orthosis is generally worn full time for 3 to 4 weeks, and
ent with exquisite pain when wrist motion is attempted. The then use is gradually reduced to nights only once the day
use of a wrist immobilization orthosis (WHO custom or prefab- symptoms have resolved. The orthosis is discontinued
ricated) is appropriate for approximately 1 month or until pain when the patient is asymptomatic to provocative (painful)
subsides. After the period of immobilization, the orthosis may positioning.
be used for only sleeping and/or at-risk activities (Fig. 1–9).
EXAMPLE: WRIST/THUMB IMMOBILIZATION
EXAMPLE: WRIST/HAND IMMOBILIZATION ORTHOSIS (WHFO) (Fig. 1–10)
ORTHOSIS (WHO) (Fig. 1–9)
• Protect and Position Edematous Structures
Edema is often the first observable reaction to injury yet
not always the first addressed. Its immediate reduction is
critical to facilitate proper healing with minimal compli-
cations (such as tight joint capsules and ligaments, which
could lead to joint and soft tissue contracture). An edem-
atous hand may be a painful hand that has associated
injuries that must be considered before orthosis applica-
tion. For example, consider fabricating an orthosis that
places the digital joints in a safe position (MCP flexion, IP
extension) and can be donned and doffed easily to allow
access for wound and pin care. Attention to joint posi-
tioning in the orthosis, elevation, massage, compression
wraps, and gentle active ROM of adjacent structures (if
FIGURE 19 Wrist/hand immobilization orthosis: (WHO). A simple appropriate) all contribute to reducing edema and pre-
prefabricated wrist orthosis can be used to stabilize a painful wrist venting deformity (e.g., MCP extension and PIP flexion
when a custom design is not warranted or feasible. contractures).

Compression bandages or gloves (e.g., Coban™ and • Aid in Maximizing Functional Use
Isotoner® gloves) can be worn under the orthosis for
edema reduction and can complement the device’s effec- An orthosis can enhance function by correctly positioning
tiveness. However, caution is necessary when donning and supporting structures that are injured or unstable. Dur-
and doffing these compression devices to avoid injury or ing the day, these supportive, lightweight, functional orthoses
reinjury of the healing bones, tendons, and/or ligaments. can often help patients use their hands to engage in voca-
Furthermore, the therapist must carefully consider tional, academic, or recreational activities. Without support,
the type and placement of the straps. A narrow strap function is diminished and deforming forces may dominate.
placed across an edematous area may cause pooling of Figures 1–12A–D shows a patient with advanced scleroder-
edema proximal and distal to the strap and may irritate ma and how a small, light orthosis can allow the simple act
superficial sensory nerves. Circumferentially wrapping of turning a key. These orthoses can be fabricated to position
or encompassing the orthosis, distal to proximal, with and support with minimal bulk (Fig. 1–12C,D). The bulkier the
an elasticized wrap or compressive garment (e.g., Ace™ orthosis, the more likely it will interfere with functional use.
wrap, elasticized stockinette, or Coban™) may help dis- EXAMPLE: INDEX FINGER RADIAL DEVIATION
tribute pressure evenly along the extremity and aid in ORTHOSIS (HFO) (Fig. 1–12)
minimizing edema.
A thumb CMC joint that becomes subluxed and pain-
In addition, patient education regarding the impor-
ful when a pinch is attempted may benefit from the use of
tance of the use of an orthosis, in conjunction with other
a well-molded first CMC immobilization orthosis (Colditz,
edema management methods, facilitates early reduc-
1995a; Sillem, Backman, Miller, & Li, 2011). Function and
tion of edema. Crush injuries are often complex and may
comfort are gained by careful attention to molding and pres-
involve one or more structures, including bone, ligament,
sure distribution about the base of the first metacarpal bone
tendon, and nerve. Patients often do well during the ini-
and the CMC joint. These types of orthoses (rigid or soft)
tial stages of healing with a simple wrist/hand/thumb
offer a degree of stabilization to a thumb CMC joint and
immobilization orthosis to keep the involved structures
places the first metacarpal bone in a better anatomical posi-
positioned, supported, and protected. Therapists working
tion of abduction. Small devices such as the one shown in
with these patients should strive to achieve optimal joint
Figure 1–13B can significantly relieve pain during active use
positioning. One of the most important goals is to main-
of the thumb and enable the patient to grasp and pinch more
tain the antideformity position of the hand (also referred
effectively (Fig. 1–13A,B).
to as the intrinsic plus or safe position): MCP flexion, IP
extension, and thumb palmar abduction. If this is not EXAMPLE: THUMB CMC IMMOBILIZATION ORTHOSIS
accomplished early after injury, MCP joint collateral liga- (HFO) (Fig. 1–13)
ment shortening and PIP joint volar plate contracture may • Maintain Tissue Length
occur, which can result in MCP extension and PIP flexion
contractures. Optimal joint positions may be difficult to Orthoses can preserve tissue length when applied care-
achieve initially owing to stiffness, pain, and significant fully and accurately and within the appropriate time frame.
edema. Be persistent, fabricate the orthosis within a com- Contractures of soft tissue can occur from many sources.
fortable ROM, monitor, and serially adjust the orthosis as One such cause is nerve injury, resulting in muscle–tendon
pain allows (Fig. 1–11). imbalances in the hand. Left untreated, these imbalances
often result in tendon–ligament shortening, which in turn
EXAMPLE: WRIST/HAND/THUMB IMMOBILIZATION may create some degree of joint contracture.
ORTHOSIS (WHFO) (Fig. 1–11) During the initial stages of injury, the goal for orthotic
intervention should be to place the joints in a position that
inhibits tissue shortening and enables functional use. During
the end stages of scar maturation (3 to 6 months or longer),
the goal may be to keep the tissue at its achieved maximum
length to prevent regression of tissue tightness (Genova,
Lester, & Walsh, 2010; McFarlane, 1997). At this stage, the
orthosis is not influencing the tissue length but is maintain-
ing the desired and previously achieved ROM. Gains attained
in therapy sessions and at home can be maintained with a
balanced program of proper immobilization and exercise.
Adduction contractures of the thumb can occur after
FIGURE 111 Wrist/hand/thumb immobilization orthosis: (WHFO). injury to or repair of the median nerve. To prevent this, an
A simple wrist/hand/thumb immobilization orthosis (traditionally orthosis should be applied as soon as possible after nerve
named a resting hand splint) can provide the support, proper posi- repair. The orthosis can be forearm-based, with the wrist
tioning (MCP flexion, IP extension, thumb palmar abduction), and slightly flexed, intimately molded into the first web space, and
healing environment that crush injuries require. extending distally to the thumb IP joint crease. Care should

CHAPTER 1
A B
C D
FIGURE 112 Digit immobilization orthosis: (HFO). A, Severe MCP/PIP instability and ulnar deformity of
the index finger makes it nearly impossible for this patient with scleroderma to (B) turn a key. C, A small
orthosis holding the index finger in neutral deviation allows for a stable post for the thumb to hold the
key against. D, Note how the material wraps along the ulnar border, keeping the volar–radial border free
for tactile input.
A B
FIGURE 113 Thumb immobilization orthosis: (HFO). A, A thumb CMC immobilization orthosis is
being used for stabilization of this joint while writing is attempted. This small device is only one of
many design options available that can help prevent subluxation of the first CMC joint during func-
tional use. B, Note the thumb posture before application of the orthosis.
be taken to avoid undue stress on the ulnar collateral liga- night to maintain tissue length of the first web space. This
ment of the thumb MP joint during fabrication. This ortho- may be an option for patients who want to attempt func-
sis position maintains the thumb in maximum abduction, tional use of the hand during the day (Fig. 1–14B). Whatever
preventing a possible adduction contracture while placing option is chosen, the goal is to prevent an adduction con-
the nerve repair in a shortened position to allow for healing tracture of the first web space.
(Fig. 1–14A). As the nerve heals and greater extension of the
wrist is allowed, a small hand-based device can be made to EXAMPLE: WRIST/THUMB CMC PALMAR ABDUCTION
fit over a wrist immobilization orthosis. This can be worn at IMMOBILIZATION ORTHOSIS (WHFO) (Fig. 1–14)

• Protect Healing Structures and Surgical Procedures

A therapist may be called on to fabricate an immobiliza-
tion orthosis to rest and protect an extremity that has
undergone an operative procedure. This may involve a
simple orthosis or an intricate one that must immobilize
several structures in specific positions because of a com-
plex injury or surgical repair. For postoperative orthotic
fabrication, close communication with the surgeon is
critical to guide proper selection of orthosis. Consid-
eration needs to be given to fabricating the orthosis
around or over drains, wounds, external pins, or skin
grafts. These issues, as well as the pain level and psy-
chological trauma of injury and surgery, make fabrica-
tion of the orthosis in the postoperative extremity quite
a challenge.
Support, comfort, and protection of a patient’s status
after a Dupuytren’s contracture release can be achieved
A B by using a hand immobilization orthosis. This orthosis
is applied after the bulky dressing is removed, new hand
FIGURE 114 Wrist/thumb CMC palmar abduction immobilization
orthosis: (WHFO). A, A wrist/thumb CMC palmar abduction immo-
and digit dressings are reapplied, and the orthosis is then
bilization orthosis used to prevent adduction contractures of the first fabricated over these dressings. The patient is able to take
web space after median nerve injury or repair. It can be fabricated to the device off and perform the exercise regime dictated by
incorporate the wrist and first web space as shown here. B, As the nerve the therapist/surgeon (Fig. 1–15A–C).
heals and wrist extension is allowed, a removable spacer can be made
directly over a simple wrist orthosis and applied at night or when the EXAMPLE: HAND/DIGIT IMMOBILIZATION
hand is not being used. ORTHOSIS (HFO) (Fig. 1–15)
B
FIGURE 115 Hand/digit immobilization orthosis: (HFO). A hand and digit immobilization orthosis
is applied after a Dupuytren’s contracture release. The orthosis supports the MCP and IP joints of the
involved digits in a comfortable extension postoperatively. A, Dressings are removed. B, New dressings
are applied. C, The material is applied over the dressings and molded to the patient’s tolerable digit
extension end range.

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DANCE ON STILTS AT THE GIRLS’ UNYAGO, NIUCHI
Newala, too, suffers from the distance of its water-supply—at least

the Newala of to-day does; there was once another Newala in a lovely
valley at the foot of the plateau. I visited it and found scarcely a trace
of houses, only a Christian cemetery, with the graves of several
missionaries and their converts, remaining as a monument of its
former glories. But the surroundings are wonderfully beautiful. A
thick grove of splendid mango-trees closes in the weather-worn
crosses and headstones; behind them, combining the useful and the
agreeable, is a whole plantation of lemon-trees covered with ripe
fruit; not the small African kind, but a much larger and also juicier
imported variety, which drops into the hands of the passing traveller,
without calling for any exertion on his part. Old Newala is now under
the jurisdiction of the native pastor, Daudi, at Chingulungulu, who,
as I am on very friendly terms with him, allows me, as a matter of
course, the use of this lemon-grove during my stay at Newala.
FEET MUTILATED BY THE RAVAGES OF THE “JIGGER”
(Sarcopsylla penetrans)
The water-supply of New Newala is in the bottom of the valley,

some 1,600 feet lower down. The way is not only long and fatiguing,
but the water, when we get it, is thoroughly bad. We are suffering not
only from this, but from the fact that the arrangements at Newala are
nothing short of luxurious. We have a separate kitchen—a hut built
against the boma palisade on the right of the baraza, the interior of
which is not visible from our usual position. Our two cooks were not
long in finding this out, and they consequently do—or rather neglect
to do—what they please. In any case they do not seem to be very
particular about the boiling of our drinking-water—at least I can
attribute to no other cause certain attacks of a dysenteric nature,
from which both Knudsen and I have suffered for some time. If a
man like Omari has to be left unwatched for a moment, he is capable
of anything. Besides this complaint, we are inconvenienced by the
state of our nails, which have become as hard as glass, and crack on
the slightest provocation, and I have the additional infliction of
pimples all over me. As if all this were not enough, we have also, for
the last week been waging war against the jigger, who has found his
Eldorado in the hot sand of the Makonde plateau. Our men are seen
all day long—whenever their chronic colds and the dysentery likewise
raging among them permit—occupied in removing this scourge of
Africa from their feet and trying to prevent the disastrous
consequences of its presence. It is quite common to see natives of
this place with one or two toes missing; many have lost all their toes,
or even the whole front part of the foot, so that a well-formed leg
ends in a shapeless stump. These ravages are caused by the female of
Sarcopsylla penetrans, which bores its way under the skin and there
develops an egg-sac the size of a pea. In all books on the subject, it is
stated that one’s attention is called to the presence of this parasite by
an intolerable itching. This agrees very well with my experience, so
far as the softer parts of the sole, the spaces between and under the
toes, and the side of the foot are concerned, but if the creature
penetrates through the harder parts of the heel or ball of the foot, it
may escape even the most careful search till it has reached maturity.
Then there is no time to be lost, if the horrible ulceration, of which
we see cases by the dozen every day, is to be prevented. It is much
easier, by the way, to discover the insect on the white skin of a
European than on that of a native, on which the dark speck scarcely
shows. The four or five jiggers which, in spite of the fact that I
constantly wore high laced boots, chose my feet to settle in, were
taken out for me by the all-accomplished Knudsen, after which I
thought it advisable to wash out the cavities with corrosive
sublimate. The natives have a different sort of disinfectant—they fill
the hole with scraped roots. In a tiny Makua village on the slope of
the plateau south of Newala, we saw an old woman who had filled all
the spaces under her toe-nails with powdered roots by way of
prophylactic treatment. What will be the result, if any, who can say?
The rest of the many trifling ills which trouble our existence are
really more comic than serious. In the absence of anything else to
smoke, Knudsen and I at last opened a box of cigars procured from
the Indian store-keeper at Lindi, and tried them, with the most
distressing results. Whether they contain opium or some other
narcotic, neither of us can say, but after the tenth puff we were both
“off,” three-quarters stupefied and unspeakably wretched. Slowly we
recovered—and what happened next? Half-an-hour later we were
once more smoking these poisonous concoctions—so insatiable is the
craving for tobacco in the tropics.
Even my present attacks of fever scarcely deserve to be taken
seriously. I have had no less than three here at Newala, all of which
have run their course in an incredibly short time. In the early
afternoon, I am busy with my old natives, asking questions and
making notes. The strong midday coffee has stimulated my spirits to
an extraordinary degree, the brain is active and vigorous, and work
progresses rapidly, while a pleasant warmth pervades the whole
body. Suddenly this gives place to a violent chill, forcing me to put on
my overcoat, though it is only half-past three and the afternoon sun
is at its hottest. Now the brain no longer works with such acuteness
and logical precision; more especially does it fail me in trying to
establish the syntax of the difficult Makua language on which I have
ventured, as if I had not enough to do without it. Under the
circumstances it seems advisable to take my temperature, and I do
so, to save trouble, without leaving my seat, and while going on with
my work. On examination, I find it to be 101·48°. My tutors are
abruptly dismissed and my bed set up in the baraza; a few minutes
later I am in it and treating myself internally with hot water and
lemon-juice.
Three hours later, the thermometer marks nearly 104°, and I make
them carry me back into the tent, bed and all, as I am now perspiring
heavily, and exposure to the cold wind just beginning to blow might
mean a fatal chill. I lie still for a little while, and then find, to my
great relief, that the temperature is not rising, but rather falling. This
is about 7.30 p.m. At 8 p.m. I find, to my unbounded astonishment,
that it has fallen below 98·6°, and I feel perfectly well. I read for an
hour or two, and could very well enjoy a smoke, if I had the
wherewithal—Indian cigars being out of the question.
Having no medical training, I am at a loss to account for this state
of things. It is impossible that these transitory attacks of high fever
should be malarial; it seems more probable that they are due to a
kind of sunstroke. On consulting my note-book, I become more and
more inclined to think this is the case, for these attacks regularly
follow extreme fatigue and long exposure to strong sunshine. They at
least have the advantage of being only short interruptions to my
work, as on the following morning I am always quite fresh and fit.
My treasure of a cook is suffering from an enormous hydrocele which
makes it difficult for him to get up, and Moritz is obliged to keep in
the dark on account of his inflamed eyes. Knudsen’s cook, a raw boy
from somewhere in the bush, knows still less of cooking than Omari;
consequently Nils Knudsen himself has been promoted to the vacant
post. Finding that we had come to the end of our supplies, he began
by sending to Chingulungulu for the four sucking-pigs which we had
bought from Matola and temporarily left in his charge; and when
they came up, neatly packed in a large crate, he callously slaughtered
the biggest of them. The first joint we were thoughtless enough to
entrust for roasting to Knudsen’s mshenzi cook, and it was
consequently uneatable; but we made the rest of the animal into a
jelly which we ate with great relish after weeks of underfeeding,
consuming incredible helpings of it at both midday and evening
meals. The only drawback is a certain want of variety in the tinned
vegetables. Dr. Jäger, to whom the Geographical Commission
entrusted the provisioning of the expeditions—mine as well as his
own—because he had more time on his hands than the rest of us,
seems to have laid in a huge stock of Teltow turnips,[46] an article of
food which is all very well for occasional use, but which quickly palls
when set before one every day; and we seem to have no other tins
left. There is no help for it—we must put up with the turnips; but I
am certain that, once I am home again, I shall not touch them for ten
years to come.
Amid all these minor evils, which, after all, go to make up the
genuine flavour of Africa, there is at least one cheering touch:
Knudsen has, with the dexterity of a skilled mechanic, repaired my 9
× 12 cm. camera, at least so far that I can use it with a little care.
How, in the absence of finger-nails, he was able to accomplish such a
ticklish piece of work, having no tool but a clumsy screw-driver for
taking to pieces and putting together again the complicated
mechanism of the instantaneous shutter, is still a mystery to me; but
he did it successfully. The loss of his finger-nails shows him in a light
contrasting curiously enough with the intelligence evinced by the
above operation; though, after all, it is scarcely surprising after his
ten years’ residence in the bush. One day, at Lindi, he had occasion
to wash a dog, which must have been in need of very thorough
cleansing, for the bottle handed to our friend for the purpose had an
extremely strong smell. Having performed his task in the most
conscientious manner, he perceived with some surprise that the dog
did not appear much the better for it, and was further surprised by
finding his own nails ulcerating away in the course of the next few
days. “How was I to know that carbolic acid has to be diluted?” he
mutters indignantly, from time to time, with a troubled gaze at his
mutilated finger-tips.
Since we came to Newala we have been making excursions in all
directions through the surrounding country, in accordance with old
habit, and also because the akida Sefu did not get together the tribal
elders from whom I wanted information so speedily as he had
promised. There is, however, no harm done, as, even if seen only
from the outside, the country and people are interesting enough.
The Makonde plateau is like a large rectangular table rounded off
at the corners. Measured from the Indian Ocean to Newala, it is
about seventy-five miles long, and between the Rovuma and the
Lukuledi it averages fifty miles in breadth, so that its superficial area
is about two-thirds of that of the kingdom of Saxony. The surface,
however, is not level, but uniformly inclined from its south-western
edge to the ocean. From the upper edge, on which Newala lies, the
eye ranges for many miles east and north-east, without encountering
any obstacle, over the Makonde bush. It is a green sea, from which
here and there thick clouds of smoke rise, to show that it, too, is
inhabited by men who carry on their tillage like so many other
primitive peoples, by cutting down and burning the bush, and
manuring with the ashes. Even in the radiant light of a tropical day
such a fire is a grand sight.
Much less effective is the impression produced just now by the
great western plain as seen from the edge of the plateau. As often as
time permits, I stroll along this edge, sometimes in one direction,
sometimes in another, in the hope of finding the air clear enough to
let me enjoy the view; but I have always been disappointed.
Wherever one looks, clouds of smoke rise from the burning bush,
and the air is full of smoke and vapour. It is a pity, for under more
favourable circumstances the panorama of the whole country up to
the distant Majeje hills must be truly magnificent. It is of little use
taking photographs now, and an outline sketch gives a very poor idea
of the scenery. In one of these excursions I went out of my way to
make a personal attempt on the Makonde bush. The present edge of
the plateau is the result of a far-reaching process of destruction
through erosion and denudation. The Makonde strata are
everywhere cut into by ravines, which, though short, are hundreds of
yards in depth. In consequence of the loose stratification of these
beds, not only are the walls of these ravines nearly vertical, but their
upper end is closed by an equally steep escarpment, so that the
western edge of the Makonde plateau is hemmed in by a series of
deep, basin-like valleys. In order to get from one side of such a ravine
to the other, I cut my way through the bush with a dozen of my men.
It was a very open part, with more grass than scrub, but even so the
short stretch of less than two hundred yards was very hard work; at
the end of it the men’s calicoes were in rags and they themselves
bleeding from hundreds of scratches, while even our strong khaki
suits had not escaped scatheless.
NATIVE PATH THROUGH THE MAKONDE BUSH, NEAR

MAHUTA
I see increasing reason to believe that the view formed some time
back as to the origin of the Makonde bush is the correct one. I have
no doubt that it is not a natural product, but the result of human
occupation. Those parts of the high country where man—as a very
slight amount of practice enables the eye to perceive at once—has not
yet penetrated with axe and hoe, are still occupied by a splendid
timber forest quite able to sustain a comparison with our mixed
forests in Germany. But wherever man has once built his hut or tilled
his field, this horrible bush springs up. Every phase of this process
may be seen in the course of a couple of hours’ walk along the main
road. From the bush to right or left, one hears the sound of the axe—
not from one spot only, but from several directions at once. A few
steps further on, we can see what is taking place. The brush has been
cut down and piled up in heaps to the height of a yard or more,
between which the trunks of the large trees stand up like the last
pillars of a magnificent ruined building. These, too, present a
melancholy spectacle: the destructive Makonde have ringed them—
cut a broad strip of bark all round to ensure their dying off—and also
piled up pyramids of brush round them. Father and son, mother and
son-in-law, are chopping away perseveringly in the background—too
busy, almost, to look round at the white stranger, who usually excites
so much interest. If you pass by the same place a week later, the piles
of brushwood have disappeared and a thick layer of ashes has taken
the place of the green forest. The large trees stretch their
smouldering trunks and branches in dumb accusation to heaven—if
they have not already fallen and been more or less reduced to ashes,
perhaps only showing as a white stripe on the dark ground.
This work of destruction is carried out by the Makonde alike on the
virgin forest and on the bush which has sprung up on sites already
cultivated and deserted. In the second case they are saved the trouble
of burning the large trees, these being entirely absent in the
secondary bush.
After burning this piece of forest ground and loosening it with the
hoe, the native sows his corn and plants his vegetables. All over the
country, he goes in for bed-culture, which requires, and, in fact,
receives, the most careful attention. Weeds are nowhere tolerated in
the south of German East Africa. The crops may fail on the plains,
where droughts are frequent, but never on the plateau with its
abundant rains and heavy dews. Its fortunate inhabitants even have
the satisfaction of seeing the proud Wayao and Wamakua working
for them as labourers, driven by hunger to serve where they were
accustomed to rule.
But the light, sandy soil is soon exhausted, and would yield no
harvest the second year if cultivated twice running. This fact has
been familiar to the native for ages; consequently he provides in
time, and, while his crop is growing, prepares the next plot with axe
and firebrand. Next year he plants this with his various crops and
lets the first piece lie fallow. For a short time it remains waste and
desolate; then nature steps in to repair the destruction wrought by
man; a thousand new growths spring out of the exhausted soil, and
even the old stumps put forth fresh shoots. Next year the new growth
is up to one’s knees, and in a few years more it is that terrible,
impenetrable bush, which maintains its position till the black
occupier of the land has made the round of all the available sites and
come back to his starting point.
The Makonde are, body and soul, so to speak, one with this bush.
According to my Yao informants, indeed, their name means nothing
else but “bush people.” Their own tradition says that they have been
settled up here for a very long time, but to my surprise they laid great
stress on an original immigration. Their old homes were in the
south-east, near Mikindani and the mouth of the Rovuma, whence
their peaceful forefathers were driven by the continual raids of the
Sakalavas from Madagascar and the warlike Shirazis[47] of the coast,
to take refuge on the almost inaccessible plateau. I have studied
African ethnology for twenty years, but the fact that changes of
population in this apparently quiet and peaceable corner of the earth
could have been occasioned by outside enterprises taking place on
the high seas, was completely new to me. It is, no doubt, however,
correct.
The charming tribal legend of the Makonde—besides informing us
of other interesting matters—explains why they have to live in the
thickest of the bush and a long way from the edge of the plateau,
instead of making their permanent homes beside the purling brooks
and springs of the low country.
“The place where the tribe originated is Mahuta, on the southern
side of the plateau towards the Rovuma, where of old time there was
nothing but thick bush. Out of this bush came a man who never
washed himself or shaved his head, and who ate and drank but little.
He went out and made a human figure from the wood of a tree
growing in the open country, which he took home to his abode in the
bush and there set it upright. In the night this image came to life and
was a woman. The man and woman went down together to the
Rovuma to wash themselves. Here the woman gave birth to a still-
born child. They left that place and passed over the high land into the
valley of the Mbemkuru, where the woman had another child, which
was also born dead. Then they returned to the high bush country of
Mahuta, where the third child was born, which lived and grew up. In
course of time, the couple had many more children, and called
themselves Wamatanda. These were the ancestral stock of the
Makonde, also called Wamakonde,[48] i.e., aborigines. Their
forefather, the man from the bush, gave his children the command to
bury their dead upright, in memory of the mother of their race who
was cut out of wood and awoke to life when standing upright. He also
warned them against settling in the valleys and near large streams,
for sickness and death dwelt there. They were to make it a rule to
have their huts at least an hour’s walk from the nearest watering-
place; then their children would thrive and escape illness.”
The explanation of the name Makonde given by my informants is
somewhat different from that contained in the above legend, which I
extract from a little book (small, but packed with information), by
Pater Adams, entitled Lindi und sein Hinterland. Otherwise, my
results agree exactly with the statements of the legend. Washing?
Hapana—there is no such thing. Why should they do so? As it is, the
supply of water scarcely suffices for cooking and drinking; other
people do not wash, so why should the Makonde distinguish himself
by such needless eccentricity? As for shaving the head, the short,
woolly crop scarcely needs it,[49] so the second ancestral precept is
likewise easy enough to follow. Beyond this, however, there is
nothing ridiculous in the ancestor’s advice. I have obtained from
various local artists a fairly large number of figures carved in wood,
ranging from fifteen to twenty-three inches in height, and
representing women belonging to the great group of the Mavia,
Makonde, and Matambwe tribes. The carving is remarkably well
done and renders the female type with great accuracy, especially the
keloid ornamentation, to be described later on. As to the object and
meaning of their works the sculptors either could or (more probably)
would tell me nothing, and I was forced to content myself with the
scanty information vouchsafed by one man, who said that the figures
were merely intended to represent the nembo—the artificial
deformations of pelele, ear-discs, and keloids. The legend recorded
by Pater Adams places these figures in a new light. They must surely
be more than mere dolls; and we may even venture to assume that
they are—though the majority of present-day Makonde are probably
unaware of the fact—representations of the tribal ancestress.
The references in the legend to the descent from Mahuta to the
Rovuma, and to a journey across the highlands into the Mbekuru
valley, undoubtedly indicate the previous history of the tribe, the
travels of the ancestral pair typifying the migrations of their
descendants. The descent to the neighbouring Rovuma valley, with
its extraordinary fertility and great abundance of game, is intelligible
at a glance—but the crossing of the Lukuledi depression, the ascent
to the Rondo Plateau and the descent to the Mbemkuru, also lie
within the bounds of probability, for all these districts have exactly
the same character as the extreme south. Now, however, comes a
point of especial interest for our bacteriological age. The primitive
Makonde did not enjoy their lives in the marshy river-valleys.
Disease raged among them, and many died. It was only after they
had returned to their original home near Mahuta, that the health
conditions of these people improved. We are very apt to think of the
African as a stupid person whose ignorance of nature is only equalled
by his fear of it, and who looks on all mishaps as caused by evil
spirits and malignant natural powers. It is much more correct to
assume in this case that the people very early learnt to distinguish
districts infested with malaria from those where it is absent.
This knowledge is crystallized in the
ancestral warning against settling in the
valleys and near the great waters, the
dwelling-places of disease and death. At the
same time, for security against the hostile
Mavia south of the Rovuma, it was enacted
that every settlement must be not less than a
certain distance from the southern edge of the
plateau. Such in fact is their mode of life at the
present day. It is not such a bad one, and
certainly they are both safer and more
comfortable than the Makua, the recent
intruders from the south, who have made USUAL METHOD OF
good their footing on the western edge of the CLOSING HUT-DOOR
plateau, extending over a fairly wide belt of
country. Neither Makua nor Makonde show in their dwellings
anything of the size and comeliness of the Yao houses in the plain,
especially at Masasi, Chingulungulu and Zuza’s. Jumbe Chauro, a
Makonde hamlet not far from Newala, on the road to Mahuta, is the
most important settlement of the tribe I have yet seen, and has fairly
spacious huts. But how slovenly is their construction compared with
the palatial residences of the elephant-hunters living in the plain.
The roofs are still more untidy than in the general run of huts during
the dry season, the walls show here and there the scanty beginnings
or the lamentable remains of the mud plastering, and the interior is a
veritable dog-kennel; dirt, dust and disorder everywhere. A few huts
only show any attempt at division into rooms, and this consists
merely of very roughly-made bamboo partitions. In one point alone
have I noticed any indication of progress—in the method of fastening
the door. Houses all over the south are secured in a simple but
ingenious manner. The door consists of a set of stout pieces of wood
or bamboo, tied with bark-string to two cross-pieces, and moving in
two grooves round one of the door-posts, so as to open inwards. If
the owner wishes to leave home, he takes two logs as thick as a man’s
upper arm and about a yard long. One of these is placed obliquely
against the middle of the door from the inside, so as to form an angle
of from 60° to 75° with the ground. He then places the second piece
horizontally across the first, pressing it downward with all his might.
It is kept in place by two strong posts planted in the ground a few
inches inside the door. This fastening is absolutely safe, but of course
cannot be applied to both doors at once, otherwise how could the
owner leave or enter his house? I have not yet succeeded in finding
out how the back door is fastened.
MAKONDE LOCK AND KEY AT JUMBE CHAURO

This is the general way of closing a house. The Makonde at Jumbe
Chauro, however, have a much more complicated, solid and original
one. Here, too, the door is as already described, except that there is
only one post on the inside, standing by itself about six inches from
one side of the doorway. Opposite this post is a hole in the wall just
large enough to admit a man’s arm. The door is closed inside by a
large wooden bolt passing through a hole in this post and pressing
with its free end against the door. The other end has three holes into
which fit three pegs running in vertical grooves inside the post. The
door is opened with a wooden key about a foot long, somewhat
curved and sloped off at the butt; the other end has three pegs
corresponding to the holes, in the bolt, so that, when it is thrust
through the hole in the wall and inserted into the rectangular
opening in the post, the pegs can be lifted and the bolt drawn out.[50]
MODE OF INSERTING THE KEY
With no small pride first one householder and then a second

showed me on the spot the action of this greatest invention of the
Makonde Highlands. To both with an admiring exclamation of
“Vizuri sana!” (“Very fine!”). I expressed the wish to take back these
marvels with me to Ulaya, to show the Wazungu what clever fellows
the Makonde are. Scarcely five minutes after my return to camp at
Newala, the two men came up sweating under the weight of two
heavy logs which they laid down at my feet, handing over at the same
time the keys of the fallen fortress. Arguing, logically enough, that if
the key was wanted, the lock would be wanted with it, they had taken
their axes and chopped down the posts—as it never occurred to them
to dig them out of the ground and so bring them intact. Thus I have
two badly damaged specimens, and the owners, instead of praise,
come in for a blowing-up.
The Makua huts in the environs of Newala are especially
miserable; their more than slovenly construction reminds one of the
temporary erections of the Makua at Hatia’s, though the people here
have not been concerned in a war. It must therefore be due to
congenital idleness, or else to the absence of a powerful chief. Even
the baraza at Mlipa’s, a short hour’s walk south-east of Newala,
shares in this general neglect. While public buildings in this country
are usually looked after more or less carefully, this is in evident
danger of being blown over by the first strong easterly gale. The only
attractive object in this whole district is the grave of the late chief
Mlipa. I visited it in the morning, while the sun was still trying with
partial success to break through the rolling mists, and the circular
grove of tall euphorbias, which, with a broken pot, is all that marks
the old king’s resting-place, impressed one with a touch of pathos.
Even my very materially-minded carriers seemed to feel something
of the sort, for instead of their usual ribald songs, they chanted
solemnly, as we marched on through the dense green of the Makonde
bush:—
“We shall arrive with the great master; we stand in a row and have
no fear about getting our food and our money from the Serkali (the
Government). We are not afraid; we are going along with the great
master, the lion; we are going down to the coast and back.”
With regard to the characteristic features of the various tribes here
on the western edge of the plateau, I can arrive at no other
conclusion than the one already come to in the plain, viz., that it is
impossible for anyone but a trained anthropologist to assign any
given individual at once to his proper tribe. In fact, I think that even
an anthropological specialist, after the most careful examination,
might find it a difficult task to decide. The whole congeries of peoples
collected in the region bounded on the west by the great Central
African rift, Tanganyika and Nyasa, and on the east by the Indian
Ocean, are closely related to each other—some of their languages are
only distinguished from one another as dialects of the same speech,
and no doubt all the tribes present the same shape of skull and
structure of skeleton. Thus, surely, there can be no very striking
differences in outward appearance.
Even did such exist, I should have no time
to concern myself with them, for day after day,
I have to see or hear, as the case may be—in
any case to grasp and record—an
extraordinary number of ethnographic
phenomena. I am almost disposed to think it
fortunate that some departments of inquiry, at
least, are barred by external circumstances.
Chief among these is the subject of iron-
working. We are apt to think of Africa as a
country where iron ore is everywhere, so to
speak, to be picked up by the roadside, and
where it would be quite surprising if the
inhabitants had not learnt to smelt the
material ready to their hand. In fact, the
knowledge of this art ranges all over the
continent, from the Kabyles in the north to the
Kafirs in the south. Here between the Rovuma
and the Lukuledi the conditions are not so
favourable. According to the statements of the
Makonde, neither ironstone nor any other
form of iron ore is known to them. They have
not therefore advanced to the art of smelting
the metal, but have hitherto bought all their
THE ANCESTRESS OF
THE MAKONDE
iron implements from neighbouring tribes.
Even in the plain the inhabitants are not much
better off. Only one man now living is said to
understand the art of smelting iron. This old fundi lives close to
Huwe, that isolated, steep-sided block of granite which rises out of
the green solitude between Masasi and Chingulungulu, and whose
jagged and splintered top meets the traveller’s eye everywhere. While
still at Masasi I wished to see this man at work, but was told that,
frightened by the rising, he had retired across the Rovuma, though
he would soon return. All subsequent inquiries as to whether the
fundi had come back met with the genuine African answer, “Bado”
(“Not yet”).
BRAZIER
Some consolation was afforded me by a brassfounder, whom I

came across in the bush near Akundonde’s. This man is the favourite
of women, and therefore no doubt of the gods; he welds the glittering
brass rods purchased at the coast into those massive, heavy rings
which, on the wrists and ankles of the local fair ones, continually give
me fresh food for admiration. Like every decent master-craftsman he
had all his tools with him, consisting of a pair of bellows, three
crucibles and a hammer—nothing more, apparently. He was quite
willing to show his skill, and in a twinkling had fixed his bellows on
the ground. They are simply two goat-skins, taken off whole, the four
legs being closed by knots, while the upper opening, intended to
admit the air, is kept stretched by two pieces of wood. At the lower
end of the skin a smaller opening is left into which a wooden tube is
stuck. The fundi has quickly borrowed a heap of wood-embers from
the nearest hut; he then fixes the free ends of the two tubes into an
earthen pipe, and clamps them to the ground by means of a bent
piece of wood. Now he fills one of his small clay crucibles, the dross
on which shows that they have been long in use, with the yellow
material, places it in the midst of the embers, which, at present are
only faintly glimmering, and begins his work. In quick alternation
the smith’s two hands move up and down with the open ends of the
bellows; as he raises his hand he holds the slit wide open, so as to let
the air enter the skin bag unhindered. In pressing it down he closes
the bag, and the air puffs through the bamboo tube and clay pipe into
the fire, which quickly burns up. The smith, however, does not keep
on with this work, but beckons to another man, who relieves him at
the bellows, while he takes some more tools out of a large skin pouch
carried on his back. I look on in wonder as, with a smooth round
stick about the thickness of a finger, he bores a few vertical holes into
the clean sand of the soil. This should not be difficult, yet the man
seems to be taking great pains over it. Then he fastens down to the
ground, with a couple of wooden clamps, a neat little trough made by
splitting a joint of bamboo in half, so that the ends are closed by the
two knots. At last the yellow metal has attained the right consistency,
and the fundi lifts the crucible from the fire by means of two sticks
split at the end to serve as tongs. A short swift turn to the left—a
tilting of the crucible—and the molten brass, hissing and giving forth
clouds of smoke, flows first into the bamboo mould and then into the
holes in the ground.
The technique of this backwoods craftsman may not be very far
advanced, but it cannot be denied that he knows how to obtain an
adequate result by the simplest means. The ladies of highest rank in
this country—that is to say, those who can afford it, wear two kinds
of these massive brass rings, one cylindrical, the other semicircular
in section. The latter are cast in the most ingenious way in the
bamboo mould, the former in the circular hole in the sand. It is quite
a simple matter for the fundi to fit these bars to the limbs of his fair
customers; with a few light strokes of his hammer he bends the
pliable brass round arm or ankle without further inconvenience to
the wearer.
SHAPING THE POT
SMOOTHING WITH MAIZE-COB
CUTTING THE EDGE

FINISHING THE BOTTOM
LAST SMOOTHING BEFORE

BURNING
FIRING THE BRUSH-PILE

LIGHTING THE FARTHER SIDE OF
THE PILE
TURNING THE RED-HOT VESSEL
NYASA WOMAN MAKING POTS AT MASASI

Pottery is an art which must always and everywhere excite the
interest of the student, just because it is so intimately connected with
the development of human culture, and because its relics are one of
the principal factors in the reconstruction of our own condition in
prehistoric times. I shall always remember with pleasure the two or
three afternoons at Masasi when Salim Matola’s mother, a slightly-
built, graceful, pleasant-looking woman, explained to me with
touching patience, by means of concrete illustrations, the ceramic art
of her people. The only implements for this primitive process were a
lump of clay in her left hand, and in the right a calabash containing
the following valuables: the fragment of a maize-cob stripped of all
its grains, a smooth, oval pebble, about the size of a pigeon’s egg, a
few chips of gourd-shell, a bamboo splinter about the length of one’s
hand, a small shell, and a bunch of some herb resembling spinach.
Nothing more. The woman scraped with the
shell a round, shallow hole in the soft, fine
sand of the soil, and, when an active young
girl had filled the calabash with water for her,
she began to knead the clay. As if by magic it
gradually assumed the shape of a rough but
already well-shaped vessel, which only wanted
a little touching up with the instruments
before mentioned. I looked out with the
MAKUA WOMAN closest attention for any indication of the use
MAKING A POT. of the potter’s wheel, in however rudimentary
SHOWS THE a form, but no—hapana (there is none). The
BEGINNINGS OF THE embryo pot stood firmly in its little
POTTER’S WHEEL
depression, and the woman walked round it in
a stooping posture, whether she was removing
small stones or similar foreign bodies with the maize-cob, smoothing
the inner or outer surface with the splinter of bamboo, or later, after
letting it dry for a day, pricking in the ornamentation with a pointed
bit of gourd-shell, or working out the bottom, or cutting the edge
with a sharp bamboo knife, or giving the last touches to the finished
vessel. This occupation of the women is infinitely toilsome, but it is
without doubt an accurate reproduction of the process in use among
our ancestors of the Neolithic and Bronze ages.
There is no doubt that the invention of pottery, an item in human
progress whose importance cannot be over-estimated, is due to
women. Rough, coarse and unfeeling, the men of the horde range
over the countryside. When the united cunning of the hunters has
succeeded in killing the game; not one of them thinks of carrying
home the spoil. A bright fire, kindled by a vigorous wielding of the
drill, is crackling beside them; the animal has been cleaned and cut
up secundum artem, and, after a slight singeing, will soon disappear
under their sharp teeth; no one all this time giving a single thought
to wife or child.
To what shifts, on the other hand, the primitive wife, and still more
the primitive mother, was put! Not even prehistoric stomachs could
endure an unvarying diet of raw food. Something or other suggested
the beneficial effect of hot water on the majority of approved but
indigestible dishes. Perhaps a neighbour had tried holding the hard
roots or tubers over the fire in a calabash filled with water—or maybe
an ostrich-egg-shell, or a hastily improvised vessel of bark. They
became much softer and more palatable than they had previously
been; but, unfortunately, the vessel could not stand the fire and got
charred on the outside. That can be remedied, thought our
ancestress, and plastered a layer of wet clay round a similar vessel.
This is an improvement; the cooking utensil remains uninjured, but
the heat of the fire has shrunk it, so that it is loose in its shell. The
next step is to detach it, so, with a firm grip and a jerk, shell and
kernel are separated, and pottery is invented. Perhaps, however, the
discovery which led to an intelligent use of the burnt-clay shell, was
made in a slightly different way. Ostrich-eggs and calabashes are not
to be found in every part of the world, but everywhere mankind has
arrived at the art of making baskets out of pliant materials, such as
bark, bast, strips of palm-leaf, supple twigs, etc. Our inventor has no
water-tight vessel provided by nature. “Never mind, let us line the
basket with clay.” This answers the purpose, but alas! the basket gets
burnt over the blazing fire, the woman watches the process of
cooking with increasing uneasiness, fearing a leak, but no leak
appears. The food, done to a turn, is eaten with peculiar relish; and
the cooking-vessel is examined, half in curiosity, half in satisfaction
at the result. The plastic clay is now hard as stone, and at the same
time looks exceedingly well, for the neat plaiting of the burnt basket
is traced all over it in a pretty pattern. Thus, simultaneously with
pottery, its ornamentation was invented.
Primitive woman has another claim to respect. It was the man,
roving abroad, who invented the art of producing fire at will, but the
woman, unable to imitate him in this, has been a Vestal from the
earliest times. Nothing gives so much trouble as the keeping alight of
the smouldering brand, and, above all, when all the men are absent
from the camp. Heavy rain-clouds gather, already the first large
drops are falling, the first gusts of the storm rage over the plain. The
little flame, a greater anxiety to the woman than her own children,
flickers unsteadily in the blast. What is to be done? A sudden thought
occurs to her, and in an instant she has constructed a primitive hut
out of strips of bark, to protect the flame against rain and wind.
This, or something very like it, was the way in which the principle
of the house was discovered; and even the most hardened misogynist
cannot fairly refuse a woman the credit of it. The protection of the
hearth-fire from the weather is the germ from which the human
dwelling was evolved. Men had little, if any share, in this forward
step, and that only at a late stage. Even at the present day, the
plastering of the housewall with clay and the manufacture of pottery
are exclusively the women’s business. These are two very significant
survivals. Our European kitchen-garden, too, is originally a woman’s
invention, and the hoe, the primitive instrument of agriculture, is,
characteristically enough, still used in this department. But the
noblest achievement which we owe to the other sex is unquestionably
the art of cookery. Roasting alone—the oldest process—is one for
which men took the hint (a very obvious one) from nature. It must
have been suggested by the scorched carcase of some animal
overtaken by the destructive forest-fires. But boiling—the process of
improving organic substances by the help of water heated to boiling-
point—is a much later discovery. It is so recent that it has not even
yet penetrated to all parts of the world. The Polynesians understand
how to steam food, that is, to cook it, neatly wrapped in leaves, in a
hole in the earth between hot stones, the air being excluded, and
(sometimes) a few drops of water sprinkled on the stones; but they
do not understand boiling.
To come back from this digression, we find that the slender Nyasa
woman has, after once more carefully examining the finished pot,
put it aside in the shade to dry. On the following day she sends me
word by her son, Salim Matola, who is always on hand, that she is
going to do the burning, and, on coming out of my house, I find her
already hard at work. She has spread on the ground a layer of very
dry sticks, about as thick as one’s thumb, has laid the pot (now of a
yellowish-grey colour) on them, and is piling brushwood round it.
My faithful Pesa mbili, the mnyampara, who has been standing by,
most obligingly, with a lighted stick, now hands it to her. Both of
them, blowing steadily, light the pile on the lee side, and, when the
flame begins to catch, on the weather side also. Soon the whole is in a
blaze, but the dry fuel is quickly consumed and the fire dies down, so
that we see the red-hot vessel rising from the ashes. The woman
turns it continually with a long stick, sometimes one way and
sometimes another, so that it may be evenly heated all over. In
twenty minutes she rolls it out of the ash-heap, takes up the bundle
of spinach, which has been lying for two days in a jar of water, and
sprinkles the red-hot clay with it. The places where the drops fall are
marked by black spots on the uniform reddish-brown surface. With a
sigh of relief, and with visible satisfaction, the woman rises to an
erect position; she is standing just in a line between me and the fire,
from which a cloud of smoke is just rising: I press the ball of my
camera, the shutter clicks—the apotheosis is achieved! Like a
priestess, representative of her inventive sex, the graceful woman
stands: at her feet the hearth-fire she has given us beside her the
invention she has devised for us, in the background the home she has
built for us.
At Newala, also, I have had the manufacture of pottery carried on
in my presence. Technically the process is better than that already
described, for here we find the beginnings of the potter’s wheel,
which does not seem to exist in the plains; at least I have seen
nothing of the sort. The artist, a frightfully stupid Makua woman, did
not make a depression in the ground to receive the pot she was about
to shape, but used instead a large potsherd. Otherwise, she went to
work in much the same way as Salim’s mother, except that she saved
herself the trouble of walking round and round her work by squatting
at her ease and letting the pot and potsherd rotate round her; this is
surely the first step towards a machine. But it does not follow that
the pot was improved by the process. It is true that it was beautifully
rounded and presented a very creditable appearance when finished,
but the numerous large and small vessels which I have seen, and, in
part, collected, in the “less advanced” districts, are no less so. We
moderns imagine that instruments of precision are necessary to
produce excellent results. Go to the prehistoric collections of our
museums and look at the pots, urns and bowls of our ancestors in the
dim ages of the past, and you will at once perceive your error.
MAKING LONGITUDINAL CUT IN
BARK
DRAWING THE BARK OFF THE LOG
REMOVING THE OUTER BARK

BEATING THE BARK
WORKING THE BARK-CLOTH AFTER BEATING, TO MAKE IT

SOFT
MANUFACTURE OF BARK-CLOTH AT NEWALA

To-day, nearly the whole population of German East Africa is
clothed in imported calico. This was not always the case; even now in
some parts of the north dressed skins are still the prevailing wear,
and in the north-western districts—east and north of Lake
Tanganyika—lies a zone where bark-cloth has not yet been
superseded. Probably not many generations have passed since such
bark fabrics and kilts of skins were the only clothing even in the
south. Even to-day, large quantities of this bright-red or drab
material are still to be found; but if we wish to see it, we must look in
the granaries and on the drying stages inside the native huts, where
it serves less ambitious uses as wrappings for those seeds and fruits
which require to be packed with special care. The salt produced at
Masasi, too, is packed for transport to a distance in large sheets of
bark-cloth. Wherever I found it in any degree possible, I studied the
process of making this cloth. The native requisitioned for the
purpose arrived, carrying a log between two and three yards long and
as thick as his thigh, and nothing else except a curiously-shaped
mallet and the usual long, sharp and pointed knife which all men and
boys wear in a belt at their backs without a sheath—horribile dictu!
[51]
Silently he squats down before me, and with two rapid cuts has
drawn a couple of circles round the log some two yards apart, and
slits the bark lengthwise between them with the point of his knife.
With evident care, he then scrapes off the outer rind all round the
log, so that in a quarter of an hour the inner red layer of the bark
shows up brightly-coloured between the two untouched ends. With
some trouble and much caution, he now loosens the bark at one end,
and opens the cylinder. He then stands up, takes hold of the free
edge with both hands, and turning it inside out, slowly but steadily
pulls it off in one piece. Now comes the troublesome work of
scraping all superfluous particles of outer bark from the outside of
the long, narrow piece of material, while the inner side is carefully
scrutinised for defective spots. At last it is ready for beating. Having
signalled to a friend, who immediately places a bowl of water beside
him, the artificer damps his sheet of bark all over, seizes his mallet,
lays one end of the stuff on the smoothest spot of the log, and
hammers away slowly but continuously. “Very simple!” I think to
myself. “Why, I could do that, too!”—but I am forced to change my
opinions a little later on; for the beating is quite an art, if the fabric is
not to be beaten to pieces. To prevent the breaking of the fibres, the
stuff is several times folded across, so as to interpose several
thicknesses between the mallet and the block. At last the required
state is reached, and the fundi seizes the sheet, still folded, by both
ends, and wrings it out, or calls an assistant to take one end while he
holds the other. The cloth produced in this way is not nearly so fine
and uniform in texture as the famous Uganda bark-cloth, but it is
quite soft, and, above all, cheap.
Now, too, I examine the mallet. My craftsman has been using the
simpler but better form of this implement, a conical block of some
hard wood, its base—the striking surface—being scored across and
across with more or less deeply-cut grooves, and the handle stuck
into a hole in the middle. The other and earlier form of mallet is
shaped in the same way, but the head is fastened by an ingenious
network of bark strips into the split bamboo serving as a handle. The
observation so often made, that ancient customs persist longest in
connection with religious ceremonies and in the life of children, here
finds confirmation. As we shall soon see, bark-cloth is still worn
during the unyago,[52] having been prepared with special solemn
ceremonies; and many a mother, if she has no other garment handy,
will still put her little one into a kilt of bark-cloth, which, after all,
looks better, besides being more in keeping with its African
surroundings, than the ridiculous bit of print from Ulaya.
MAKUA WOMEN

Orthotic Intervention For The Hand and Upper Extremity Splinting Principles

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Orthotic Intervention for the Hand and

Upper Extremity: Splinting Principles

Jacobs_FM.indd vii 6/26/13 1:34 AM

Jacobs_FM.indd viii 6/26/13 1:34 AM

Gary P. Austin, PT, PhD Richard A. Bernstein, MD

Board Certified Orthopaedic Clinical Salvador Bondoc, OTD, OTR/L, BCPR,

Jacobs_FM.indd ix 6/26/13 1:34 AM

Shrikant Chinchalkar, M.Th.O, B.Sc.OT, Rebecca Harris, MS, OTR/L, CHT

Jacobs_FM.indd x 6/26/13 1:35 AM

Instructor Adjunct Faculty

Director of Hand Therapy Kimberly Zeske-Maguire, MS, OTR/L,

Jacobs_FM.indd xi 6/26/13 1:35 AM

Michael Borst, BA, MS, OTD Consuelo Kreider, MSH, OTR/L

Wendy J. Holt, OTR, CHT Elizabeth Spencer Steffa, BS, OTR/L,

Pamela Kasyan-Itzkowitz, MS, OTR/L,

Jacobs_FM.indd xii 6/26/13 1:35 AM

Jacobs_FM.indd xiii 6/26/13 1:35 AM

SECTION I Fundamentals of Orthotic Fabrication

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SECTION II Orthotic Fabrication

SECTION III Optional Methods

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SECTION IV Orthotic Intervention for Speciﬁc Diagnoses

Jacobs_FM.indd xvi 6/26/13 1:35 AM

Jacobs_FM.indd xvii 6/26/13 1:35 AM

Jacobs_FM.indd xviii 6/26/13 1:35 AM

ADDITIONAL CLINICAL PEARLS

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book (ASHT, 2009; Centers for Medicare & Medicaid Services

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Joint Position(s) Joint(s) Involved/Torque Application

Direction(s) of Torque Application

Immobilization Restriction Mobilization

• Orthotic is an adjective and is used to describe a

Jacobs_CH01.indd 5 6/20/13 1:34 AM

TABLE 1–2 FIGURE 12 Immobilization prefabricated orthosis: (EO). L3762

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The L-Code is generally inclusive of the evaluation, cost

Challenges in the Use of L-Codes

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FIGURE 17 Nonarticular hand orthosis: (HO). A hand immobiliza-

included in the design. By adding the word nonarticular,

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gain PIP extension (mobilize), to rest (immobilize) the PIP in

Intent: Immobilization, Mobilization, and

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the most complex of injuries. Static orthoses are considered

Jacobs_CH01.indd 11 6/20/13 1:34 AM

Jacobs_CH01.indd 12 6/20/13 1:34 AM

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• Protect Healing Structures and Surgical Procedures

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Newala, too, suffers from the distance of its water-supply—at least

The water-supply of New Newala is in the bottom of the valley,

NATIVE PATH THROUGH THE MAKONDE BUSH, NEAR

MAKONDE LOCK AND KEY AT JUMBE CHAURO

MODE OF INSERTING THE KEY

With no small pride first one householder and then a second