Orthosis Q&A

How do I select the correct PIPro size? The best technique is to fit a PIPro on the contralateral digit and find a comfortable size then go up one or two sizes for the injured/contracted digit based on degree of edema and contracture. With the patient in your clinic, have them wear the PIPro for 5-10 minutes to confirm that the size you have chosen is comfortable, doesn’t cause tingling or coolness in the digit, nor undo discomfort.

Do you have a PIPro sizing chart with finger circumferences to go off of? We have found that circumference is only one of several elements that determines the best fit. Degree of joint contracture and tenderness of the joint play an important role as well. The Therapist Sizing Kit includes one of each of the 7 sizes (XXSmall through XXLarge) and is the best way to fit this orthosis.

What’s the difference between the standard PIPro and the new PIPro Soft-Fit? The PIPro Soft-Fit is constructed from neoprene with greater elasticity and reduced overlying reinforcement so that compression on the PIP joint is less and the rotational force is reduced. For tender digits that are uncomfortable with the standard PIPro or digits where increasing wear-time is slow, the Soft-Fit version is a great option to increase patient wear-time and compliance. Some patients do well with the intermittent standard PIPro use during the day but then use a Soft-Fit version for night time. As the PIP joint becomes less tender over time, the standard PIPro is a good option for increased rotational torque if the contracture persists. If you love science like we do, take a look at the rotational torque data on our ‘Science’ page where you can see the force of each version as a function of joint angle.

Can I use the PIPro as is, or does it need trimming? Although some digits will fit a PIPro right out of the box, most require a bit of trimming for best use. Typically the PIPro is trimmed in the webspace area to reduce rubbing webspace skin and to position the splint when donning to have its angular inflection at the level of the PIP joint. The small finger and shorter digits especially require trimming. See the instructional video on the Videos for Therapists webpage for a great tutorial!

Who should I use a PIPro on? The PIPro is designed for patients with contractures less than 40 degrees. Additionally, it is important to have intact/stable skin with good circulation and sensation. Very commonly, the PIPro is used for patients who have low angle residual contractures after trigger release or Dupuytren’s surgery. It is also a great orthosis to use after serial casting for higher angle contractures.

Are there patients who are poor candidates for the PIPro? Patients with open wounds, skin conditions, poor sensation/circulation are not good candidates for the PIPro. Additionally, patients with recent fractures or tendon repairs for whom extension force is not indicated would not be candidates. Patients with hypermobility where the PIP joint can be brought into hyperextension such as Ehlers Danlos should not be fitted with a PIPro.

How long should the PIPro be worn? Initially, the patient should be instructed to wear it 10-15 minutes, 3x/day. If comfortable, and with good skin integrity, instruct them to gradually increase over the coming days/weeks to 45 min, 3x/day. At this point, many patients can then convert to overnight wearing, however, a re-examination of the digit to confirm good fit and skin integrity before night wear is a good idea. Some patients quickly progress to night use whereas tender, swollen joints can take weeks to months. The PIPro Soft-Fit is a great option which has lower compressive force and may be more comfortable for night wearing in some individuals.

When should I wean from using a PIPro? When the patient has full extension or has plateaued at an acceptable angle, have the patient slowly reduce their daytime wear time (or number of nights a week). Like all PIP contractures, some patients will require months of maintenance extension splinting.

Can my patients purchase PIPros directly? Yes, the PIPro, the PIPro Soft-Fit, and the optional night straps are all available for direct purchase. If your clinic does not maintain orthosis inventory, the best option is to purchase the Therapist Sizing Kit which includes Patient Ordering Cards. On the cards, you can mark the size and version for the patient to purchase directly and there is a QR code on each card for your patient’s convenience to get them to the Angular Ortho Shop website page. We do not recommend using a PIPro if you are not under the care of a therapist or physician who will direct proper sizing, check for skin integrity, and determine suitability of the PIPro for the problem with the digit.

Can I return/exchange a PIPro? If a PIPro arrives damaged or defective, simply email us at contactus@angularortho.com. We will work with you to send you a new one right away and email you a shipping label to return the defective orthosis so that we can inspect it and continue to improve quality. We will credit you the cost of the replacement upon return of the damaged/defective item. As a soft-good that absorbs skin oils, lotions, etc. we do not offer size exchanges so that every PIPro delivered is brand new and unworn.

How long should I expect the PIPro to last? We treat patient who bring us a well-loved PIPro that has been used for 4-6 months. Some patients, however, seem to lose/rip/soil a PIPro within several weeks especially if the patient wears the orthosis during the day and contacts liquids, oils, or lotions. Patients who sweat heavily will see breakdown quicker as well. When donning the PIPro, we recommend to gently pull the orthosis proximally using the volar and dorsal tabs alternately. We instruct the patient to not pull “up” (orthogonal to the hand) on the dorsal tab since this can cause a tear over time where the orthosis is trimmed for the webspace.

Why does the PIPro sometimes seem to get looser fitting over time? There are two principle reasons, the first of which is reduced edema and contracture of the digit. A success! In such patients, we trial a smaller size in the clinic if a contracture remains in order to progress the patient’s treatment. If the smaller size is comfortable, we have the patient gradually convert to the smaller size during the day and eventually at night. The second reason is that the PIPro will develop creases during its break-in period. Like a leather shoe becomes more comfortable to wear over a period of days to weeks, the PIPro will do the same. We have tested patients with ‘broken in’ PIPros that have been worn for months and find that they retain 75% or more of their rotational torque. If, however, the patient’s improvement plateaus, it is reasonable to size down or fit a new splint. Also, if the patient has been using the PIPro Soft-Fit, it may be worthwhile to transition to a standard PIPro.

Can a PIPro also straighten an MCP or DIP contracture? The PIPro does not provide any corrective torque to the MCP joint. At the level of the DIP joint, the orthosis is purposely designed with a straight segment to prevent unintentional DIP hyperextension force. DIP hyperextension is a problem with the ‘banana’ splint designs where the orthosis curves upward distally. The straight distal segment, however, will provide a modest extension force to a contracted DIP joint.

How is the PIPro different than ‘spring’ style splints? Both wire spring splints and the PIPro provide rotational torque to the PIP joint. The PIPro, however, provides several advantages including its ability to trap body heat to warm the tissue and also provides circumferential compression to reduce edema. Unlike spring splints, the PIPro is soft and amenable for night time wearing. There is also an optional night strap. Spring splints have a small contact area which increases local pressure, whereas the PIPro has a broad area of contract.

Does my patient need a night strap for their PIPro? When instructing your patient in night time wearing, we recommend discussing the night strap if the PIPro falls off during sleep. This is most common with the small finger because of the shorter digit length, occasional with the index finger (as a border digit), and uncommon with the long and ring fingers.

How do I select my KnuckleUp/ThumbUp size? The KnuckleUp/ThumbUp sizer set is the best way to select your patient’s orthosis size.  The set includes neoprene tubes from XX-Small to XX-Large that match the size and feel of the actual orthosis.  When placed on a digit it should fit like a glove: comfortable and slightly warming.  If it feels too snug, the finger begins to feel cool, or turn colors, select a larger size. The KnuckleUp has two neoprene tubes to help extend two digits. If you are fitting both tubes on the patient, choose the size orthosis that fits the larger digit.

What about a sizing chart for the KnuckleUp/ThumbUp? Yes, there is a sizing chart on our website on the ‘For Therapists’  page.  This should be reserved, however, to get a general idea of orthosis sizes to consider rather than final sizing for a specific patient.  This sizing chart uses the circumference of the PIP joint, however, we find that digits with the same circumference vary as to what orthosis feels best based on digit length and shape.  As a soft, neoprene-based medical orthosis that contacts skin and can absorb perspiration and skin oils, the KnuckleUp/ThumbUp are not exchangeable for larger/smaller sizes so best to use the sizer set.

What are common KnuckleUp/ThumbUp uses? Our most common uses are attritional tendon ruptures (such as EPL following radius fracture, or ring/small ruptures in RA), and radial nerve palsy.  Therapists treating patients with brachial plexus injuries with loss of finger extension also will also find this a useful dynamic solution. They are perfect for anything that results in an MCP lag or low force contracture.  Static orthoses and other techniques are best with tight and contracted MCP joints.

What about trimming or modifying the KnuckleUp/ThumbUp? We will modify the orthosis if the patient feels that it rubs the webspace by trimming it a few millimeters on the proximal edge of the neoprene tube where it contacts the webspace skin.  If we are treating a single finger with a lag such as in a single attritional rupture, we will cut and remove the unneeded finger tube from the orthosis.  There are no sewn seams in the orthosis therefore it is trimmable on all edges. 

How do I combine the KnuckleUp and ThumbUp for 5 digit assistance? Great question.  The Radial Nerve Set includes 2-KnuckleUps and 1-ThumbUp for 5 digit assistance.  We typically fit the ring/small finger KnuckleUp first then cut the long strap of the next KnuckleUp short and attach it to the wrist wrapped portion of the first one.  Same with the ThumbUp.  We have a great demonstration of this on our ‘For Therapists’ page.

Are the KnuckleUp/ThumbUp washable? Yes, these orthoses are soap and water hand-washable. Rinse well in clear water and press on a dry towel to remove excess water.  Dry in a warm, dry place.  Do not place in a washing machine or dryer. Increase the lifespan of the product by washing your hands before donning and not applying hand lotion to the skin before donning.

Are there individuals who should not wear the KnuckleUp/ThumbUp? Yes, individuals with skin numbness (including diabetics, peripheral or central neuropathies ,or nerve injuries) should avoid these orthoses since fitting is based on feel. A digit with less sensation that does not feel skin irritation and pressure areas may develop a skin blister or open sore. Discontinue use and consult with your physician or therapists.  Patients with skin that is very thin from prednisone or medical conditions should similarly use any orthosis with caution to avoid skin breakdown.  Latex allergic patients should not use these orthoses.  Although the neoprene, fabric layers, hook/loop elements, and seam tape that is used in construction is all latex free, the glue at the seam is latex containing and a narrow ridge of this contacts the skin.

Mine is too small or large.  Can I exchange a KnuckleUp/ThumbUp? Every orthosis is new and unworn from the manufacturer.  As a soft, neoprene-based medical orthosis that contacts skin and can absorb perspiration and skin oils, the KnuckleUp/ThumbUp are not exchangeable for larger/smaller sizes.  Whether you are a large therapy clinic or a single individual wishing to use this orthosis, we price the KnuckleUp/ThumbUp Sizer Set inexpensively to encourage patients and therapists to use the Sizer Set for best fit.