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Restoration of strong grasp and lateral pinch in tetraplegia due to cervical spinal cord injury
Restoration of strong grasp and lateral pinch in tetraplegia due to cervical spinal cord injury Patients with tetraplegia who hal'e "strong" sixth cervical neurologic (C-6)fllnction often can be given active grasp and strong lateral pinch by tendon transfers and tenodeses. Wrist control can be retained by the extensor carpi radialis breI-is and flexor carpi radialis and can permit transfer of the extensor carpi radialis longlls to provide fin ger flexion. Either the brachioradialis or pronator teres then is availablefor transfer to restore addllction-opposition of the thumb with an in situ tendon graft of a paralyzed flexor super:/icialis rerouted to the thumb through a palmar fascial pulley. The other motor can provide thumb flexion f or strong lateral pinch . Extrinsic and intrinsic extension call be provided by tenodeses, With seventh cervical neurologic (C-7)junction retained. actil-e digital extension is present andfunctional expectations are better, Ten hands in seven patients with traumatic tetraplegia from injuries at C-6 or C-7level have been reconstructed. The average grasp and pinchforce after operation was 5.5 and 3 .0 Kg" respectively, All patients but one were pleased with the increased functi on and improved efficiency .
James H. House, M,D" M.S., Frank W. Gwathmey, M,D" and Douglas K. Lundsgaard, M.D. Minneapolis, Minn .
Injury to the cervical spinal cord , resulting in permanent tetraplegia, causes a radical change in the life style of a person . The disability is profound, and a broad· based rehabilitation program must be provided to achieve the maximum function consistent with the level of injury . The purpose of this paper is to describe the functional benefits of surgical restoration of grasp and key pinch in selected patients with tetraplegia and to discuss the procedures employed. Before considering surgical reconstruction, ample time should be allowed for the patient to learn to accept his handicap and to learn through the rehabilitation process exactly what goals may be realistic , This usually takes a minimum ofa year. Initially, a physical therapy program is designed to prevent contractures and to strengthen functional muscles that remain , Through occupational therapy the patient is taught to become as independent as possible in the activities of From the Department of Orthopedic Surgery . University of Min· nesota, Minneapolis. Minn. Supported in part by Kappa Delta Inc. of Minnesota. Recei ved for publication Jan . 21 , 1976. Presented in part at the annual meeting of the American Academy of Orthopaedic Surgeons, New Orleans, La., Jan. 28, 1976. Reprint requests: James H. House, M,D., Department of Orthopedic Surgery , University of Minnesota, 412 Union St., P. O. Box 190, Minneapolis. Minn . 55455 ,
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THE JOURNAL OF HAND SURGERY
daily living by the use of transfer techniques, adaptive utensils, and tenodesis splints . In addition, he may need the help of psychological and social counselling to adjust to the emotional and dependency aspects of this severe disability, When he has reached his maximal functional level and shows sufficient motivation, a decision is made as to whether or not surgery would offer any further functional improvement. Many patients who are unable to apply tenodesis splints without help may be freed of the splint and made more efficient functionally , The potential for surgical reconstruction is determined by the level of injury . Since the individual muscles spared may vary from patient to patient and from side to side, it is appropriate to think of functional levels remaining, as has been suggested by Zancolli and Moberg and reiterated by Freehafer. 1 Lesions of the upper cervical spinal cord , if not fatal, are as· sociated with such profound deficits that surgery is rarely indicated, Patients having elbow flexion but weak or absent wrist extension may benefit occasionally from brachioradialis transfer to augment wrist extension , This motion aids a flexor tenodesis or provides power for orthotic devices, The most common injury to the cord occurs at the level of the sixth cervical vertebra (C-6) spinal segment. At this level of injury, the brachioradialis, extensor carpi radialis longus , extensor
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Fig. 1. Adduction-opponensplasty. The brachioradialis has been transferred to the paralyzed flexor superficial is of the ring finger as an in situ tendon graft rerouted around a palmar fascial pulley to a split thumb insertion.
Fig. 2. Flexor phase. The extensor carpi radialis longus has been transferred to the flexor digitorum profundus and the pronator teres to the flexor pollicis longus. carpi radialis brevis, pronator teres, and flexor carpi radialis usually are spared. Zancolli2 • 3 defines this as a C-6 "strong wrist extension" functional group. In this group, surgery can improve function significantly. Selected tendons can be transferred from the forearm or wrist to provide more useful digital motion.
Concept of reconstruction of grasp and release Priority should be given to restoration of power of active digital flexion to provide strong grasp and pinch. The release phase can be provided by extensor and intrinsic tenodeses, as depicted in Figs. I and 2. The tenodesis is inserted into the central slip and lateral bands so it functions on the extensor side of interphalangeal joints and is passed through the lumbrical canals of the index and middle fingers with proximal fixation accomplished by looping the tendon graft around the neck of the second metacarpal dorsally. This in effect provides a linkage from the metacarpophalangeal (MP) to the proximal interphalangeal
(PIP) joint that acts much as the oblique retinacular ligament of Landsmeer does across the PIP and distal interphalangeal (DIP) joints. It prevents MP hyperextension and enhances interphalangeal extension as the MP joint is extended by the extrinsic tenodesis. During active flexion, as the interphalangeal joints are flexed by way of the flexor digitorum profundus, the extensor hood is pulled distally and tension on the intrinsic tenodesis facilitates early flexion at the MP joint, providing more balance to the flexion of the digit and avoiding the premature hyperfiexion of the interphalangeal joints commonly seen in the intrinsic minus hand. Active wrist extension is essential and is maintained by the extensor carpi radialis brevis which usually is strong and is located centrally . It is desirable to preserve the flexor carpi radialis if present, since this will increase power for wheelchair propUlsion, assist in transfers, and augment the function of any extensor tenodesis . Digital flexion is probably restored best by transfer-
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Fig. 3. Extensor phase (dorsal view). Tenodesis of the extensor digitorum communis, extensor pollicis longus, and rerouted abductor pollicis longus to the distal radius. Free tendon grafts routed through the lumbrical canals of the index and middle fingers, fixed proximally by a subperiostral loop dorsally around the second metacarpal and sutured distally to the extensor hood to produce an intrinsic tenodesis.
Fig. 4. Extensor phase (lateral view) . The extrinsic tenodesis produces finger and thumb extension and the intrinsic tenodesis prevents metacarpophalangeal hyperextension and facilitates interphalangeal extension when the wrist is Hexed . ring the extensor carpi radialis longus to the flexor digitorum profundus (Fig. 3). This wrist extensor has adequate amplitude and is synergistic with finger flexion . Its transfer also may remove a radial deviating force. In the strong C-6 functional group, the brachioradialis and the pronator teres are available for use as transfers to the thumb to restore pinch and grasp . In the seventh cervical vertebra (C-7) functional group with preserva-
tion of the extensor digitorum communis in addition to those muscles already mentioned, the extensor carpi ulnaris and occasionally the flexor carpi ulnaris are strong enough to use as motors for transfer.
Concept of reconstruction of lateral pinch An adduction-opponensplasty to provide strong lateral pinch is desirable because it provides a broad sur-
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Restoration of strong grasp and lateral pinch ill tetraplegia
face of contact between the thumb and index finger and is controlled more easily by a minimum of dynamic forces (Fig. 4). An improved position of the thumb to provide pinch on wrist extension can be achieved by tenodesis, but this type of pinch is very dependent upon wrist position, and the tenodesis may stretch, weakening the pinch. The classical opponensplasty, desirable in median palsy, is not useful in the tetraplegic hand because the thumb is abducted away from the palm and may miss the fingertips. After profundus replacement, digital flexion begins at the distal joint and the fingers curl into the palm because the fingers are without intrinsic function. Intrinsic tenodesis or transfers to the fingers may occasionally correct this to provide three point tip pinch. However, this is an action for fine manipulation not often used by the tetraplegic patient and it is not an appropriate goal of reconstruction. Pulley. An important point in the creation of this type of lateral pinch is the placement of the pulley to direct the thumb along the course of the flexor pollicis brevis, as is appropriate for a combined median and ulnar nerve palsy. A pulley around the palmar fascia just distal to the carpal tunnel, as described by Thompson,4 provides the proper vector for adduction-opposition. A force acting on the thumb from this location will cause the thumb to move across the palm in a plane parallel to that of the palm rather than away from it. This produces a lateral pinch of thu mb to the side of the index finger. Motors. In selecting the motor, either the pronator teres or the brachioradialis can be used, for both have sufficient strength and excursion to provide suitable function . The pronator teres has a rather broad attachment to the radius through a short tendon and is used more easily as a thumb flexor motor because of its anatomical relationship to the flexor pollicis longus . It is useful to elevate a strip of periosteum distally to elongate the tendon and to provide a suitable length for an interwoven junction with the recipient tendon. The brachioradialis is invested in fascia along its course in the forearm and must be mobilized from the distal radius and forearm fascia to provide adequate excursion. If the extensor carpi ulnaris and flexor carpi ulnaris are of suitable strength, either may be used for the adduction-opposition motor. Tendons. To transmit the force of the motor to the thumb, a middle or ring finger superficialis tendon is used as an in situ graft rather than as a free graft . It is divided tbrough a transverse incision in the finger, just proximal to the flexion crease of the proximal interphalangeal joint. After separating the two slips and splitting the decussation to free the tendon from the profundus, the tendon is withdrawn into the palm
ISS
through a short incision approximately two fifths of the distance between the wrist flexion crease and the proximal flexion crease of the little finger at a point just distal to the hook of the hamate. The tendon is left in its synovial bed proximally in the carpal tunnel and forearm and thereby retains much of its blood supply. A subcutaneous tunnel is created from the palmar incision to a curved incision over the radial side of the thumb. The tendon is directed around the ulnar border of the palmar fascia distal to the transverse carpal ligament . Then it is passed superficially to the fascia to the incision in the thumb at approximately the metacarpophalangeal joint level. Insertion. The tendon is split and one slip is woven through the abductor pollicis brevis tendon, passed through the extensor pollicis longus tendon distal to the metacarpophalangeal joint, and sutured in place. The other slip is passed dorsal to the extensor pollicis brevis and is inserted into the tendon of the extensor pollicis longus proximal to the metacarpophalangeal joint or into a bony insertion on the ulnar side of the base of the proximal phalanx . This insertion provides a rotatory motion to correct thumb supination and aids in interphalangeal joint extension and metacarpophalangeal joint stabilization during the pinch action. Proximal anastomosis of the motor. Through a radial mid lateral incision in the forearm, the motor selected for the adduction-opponensplasty is woven into the proximal superficialis tendon, usually leaving it attached to its paralyzed motor. Tension is adjusted to bring the thumb into a position of lateral pinch, with approximately 30° of wrist extension, and to still allow passive extension by tenodesis during wrist flexion. A remaining motor is transferred to the musculotendinous junction of the flexor pollicis longus to provide interphalangeal flexion and the power for pinch. The entire flexor phase of reconstruction, including transfer of the extensor carpi radialis longus to the flexor digitorum profundus, is done in one operation. This procedure is done before or after a long extensor tenodesis, which provides digital extension, and with intrinsic tenodesis of the index and middle fingers, which prevents acute interphalangeal flexion that would limit the area of index finger available for key pinch. After each procedure the hand and forearm are immobilized in a bulky dressing reinforced with plaster splints.
Case reports Seven patients have had an adduction-opponensplasty in ten hands, with follow-up ranging from 3 months to 6 years. There were six men, who were ages 16,19,19,22,27, and 54 years, respectively, and one girl, age 14 years of age, at the time of injury.
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Table I Case
Extensor phase* 19
2
3
4
5
54
21
22
14
R
Strong C-6
Extensor-intrinsic tenodesis
L
Strong C-7
Extensor-intrinsic tenodesis
R
Strong C-6
Extensor-intrinsic tenodesis
R
Strong C-6
L
Strong C-6
R
C-6
Extrinsic-intrinsic tenodesis
L
Strong C-6
Extrinsic- intrinsic tenodesis
R
Strong C-6
Extrinsic- intrinsic tenodesis
6
16
R
C-7
7
27
R
C-7
Grade III FCU- EDC Extensor-intrinsic tenodesis
Dynamic intrinsic tenodesis FDS-4 fingers Stiles- Bunnell None
Flexor phase* ECR PT BR
FDP FPL FDSH
ECRL BR FCU ECRL BR PT ECRL PT BR ECRL XR PT ECRL BR PT ECRL PT BR ECRL BR PT ECRL PT ECU
FDP FPL FDS R FDP FPL FDS R FDP FPL FDS R FDP FPL FDS R FDP FPL FDS R FDP FPL FDS R FDP FPL FDS R FDP FPL FDS R
Thumb
ECRL FDP PT FPL FCU FDS R
Thumb
Follow-up
Pinch
(yr.)
6
Thumb
(Kg.)
9.1
5.5
9.1
6.8
Thumb
2
o
o
Thumb
4
8.6
4.8
Thumb
2
6.4
2.3
Thumb
4.5
2.3
Thumb
4.5
2.0
3 mo.
2.7
1.8
Thumb
7 mo.
5.0
3.2
Thumb
4 mo.
6.8
3.2
*FCU = flexor carpi ulnaris; EDC = extensor digitorum communis; ECR = extensor carpi radialis; PT = pronator teres; BR = brachioradialis; FOP = flexor digitorum profundus; FPL = flexor polhcls longus; FOS R = flexor digitorum superficialis, ring finger; ECRL = extensor carpi radialis longus.
All patients sustained traumatic injuries to the cervical spine resulting in tetraplegia. Common to all patients was preservation of normal sensation in at least the thumb, index, and radial side of the long finger. The brachioradialis, extensor carpi radialis longus, extensor carpi radialis brevis, and pronator teres were graded four or better with the flexor carpi radialis graded three or better. Digital flexion was restored in all by the transfer of the extensor carpi radialis longus to the flexor digitorum profundus. At some point every hand except one had extensor and/or intrinsic reconstruction with tenodesis or transfer. Before operation no patient was able to produce a reading for grip on the Jamar dynamometer or pinch on the tensiometer. In seven hands with strong function retained at the C-6Ievel, the pronator teres was used as the adductionopponensplasty motor in four and the brachioradialis in
three. There were three hands with C-7 function and the flexor carpi ulnaris was used in two and the extensor carpi ulnaris in one (Table I). Case 1. J. D. was 19 years of age at the time of injury and retained strong C-6 function on the right and C-7 function on the left. A year later he was able to perform self-care activities such as morning care at a sink, transfers, putting on his shirt, and handling silverware with soft foods. He used tenodesis splint on the right hand for eating, writing, dressing, and hygiene. He performed these activities with some degree of difficulty but was nearly independent in his wheelchair and attended college. Three months following extensor and intrinsic tenodeses on the right hand, thumb function was restored with the pronator teres for thumb flexion and the brachioradialis as the motor for adduction-opposition. Between these two procedures, on the left hand which had adequate extensor function, the brachioradialis was transferred to the flexor pollicis
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Table II. Patient's reaction
Case I
2
3 4 5 6 7
Adaptive utensils Eliminated Not eliminated Eliminated Eliminated Eliminated Eliminated Eliminated
Transfers
Social self-image
Wheelchair propulsion
Activities of daily living
Would repeat
Improved Unchanged
Improved Unchanged
Improved Unchanged
Faster Unchanged
Yes Died
Unchanged Unchanged Improved Improved Improved
Improved Improved Improved Improved Improved
Improved Improved Improved Improved Improved
Faster Faster Faster Faster Faster
Yes Yes Yes Yes Yes
longus and the flexor carpi ulnaris was used as an adductionopposition motor. Six years after operation the left hand is more functional than is the right, but he has 9 . 1 Kg . of grasp in both and 5.5 Kg . of key pinch in the right and 6 .8 Kg. in the left. He is totally independent, including driving a specially equipped car, and is delighted with the results. He is working as a counselor in a rehabilitation institute . Case 2. M. H. was 54 years of age when he became tetraplegic . Two years later he was partially independent in dressing, personal hygiene, and bed-to-chair transfer. The right hand, being the worst of the two, had a flexor phase with pinch being restored by transferring the brachioradialis to the flexor pollicis longus and the pronator teres as a motor for the adduction-opponensplasty . This was followed by an extensor phase . His rehabilitation program after operation was interrupted by intermittent illnesses and psychological difficulties. Two years following operation he had no measurable grasp nor any functional key pinch and stated that his function was no better than before the operation. He had had preoperative joint contractures that had to be overcome before operation and his hand stiffened considerably following immobilization. His motivation was not as strong as in the other patients, and he had many depressive episodes after his wife's death. Failure was probably a result of poor patient selection. Case 3. D. T. was 19 years of age at the time of his accident. Nineteen months later he would not use tenodesis splints because he did not like them . He could not do bed-tochair transfers and relied upon a swivel bar. Activities of daily living were done poorly with adaptive utensils. It was felt that the majority of his problems were of an emotional basis and he was very dependent upon his mother. However, because of his desire for increased function without braces, it was elected to do reconstructive surgery on his right hand. Two months following a dynamic tenodesis of a Grade III flexor carpi ulnaris to the extensor digitorum communis, the pronator teres was transferred to the flexor pollicis longus and the brachioradialis was used as an adduction-opponensplasty motor. Two months later. because of radial migration of the pulley, the thumb was in too much abduction and the tip missed the index finger during attempted pinch. A tenodesis
of the extensor pollicis brevis to the second metacarpal was done to correct this. Four years later he had grasp of 8.6 Kg. and lateral pinch of 3.0 Kg. The dynamic tenodesis of the extensor mechanism had stretched considerably requiring wrist flexion of 40° to open the hand and to provide thumb extension . However. he was happy with the result and recently he has had a reconstructive procedure on the other hand . Case 4. J. M. survived a parachute failure when he was 22 years of age. Because of other systemic problems, it was 4 years before he was ready for hand surgery. During this time he had become relatively independent in activities of daily living. A tenodesis splint provided 1.4 Kg. of three point pinch. but he did not like the splint and used it only for writing and fine manipulations . Reconstruction began with the left hand. The pronator teres was used to power the adduction-opponensplasty and also the flexor pollicis longus . The brachioradialis was preserved for use as an extensor transfer later. Several weeks following cast removal. he feIt a tearing sensation in the forearm and noticed a decrease in pinch power. The adduction-opponensplasty was revised and the brachioradialis was transferred to the flexor pollicis longus. An extensor and intrinsic tenodesis was done 6 months later. The right hand was reconstructed 3 months later with the brachioradialis transferred to the flexor pollicis longus and the pronator teres used as the adductionopposition motor. One and a half years after reconstruction of the left hand. grip strength was 6.4 Kg . and key pinch strength was 2.3 Kg . Six months after reconstruction of the right hand. grip strength was 4.5 Kg. and key pinch was 2 .3 Kg . He was very happy with the outcome and said that his efficiency was greatly improved and that he had become essentially independent . Case 5. T. F. was 14 years of age when she became tetraplegic. Two years later she was able to transfer, to partially dress and feed herself. and to propel her wheelchair. She used a tenodesis splint for putting on her make-up and for other manipulative tasks. In order to make her free of splints and to increase her functional capacity, reconstruction of the left hand was done. The pronator teres was transferred to the flexor pollicis longus and the brachioradialis was used as the
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House, Gwathmey, and Lundsgaard
motor for adduction-opposition. This was followed by extensor tenodeses. Eighteen months later she had 4.5 Kg. of grasp and 2.0 Kg. of key pinch. The right hand was treated similarly, and at 3 months she had 2.7 Kg. of grip and 1.8 Kg. of key pinch. She was extremely happy with her outcome and became very adept in wheelchair sports-throwing both the javalin and the discus. Case 6. R. P. was 16 years of age when he was injured, but it was 31 /2 years before he was seen for evaluation for reconstruction. He was attending college and was nearly independent in his wheelchair and was able to perform most activities of daily living with adaptive utensils. His right hand had fair extensor function, but lacked grasp and pinch. The pronator teres was transferred to the flexor pollicis longus and the extensor carpi ulnaris was used as the motor for adduction-opposition. Seven months after operation he had grip strength of 5.0 Kg. and pinch strength of 3.2 Kg. He is now waiting for reconstruction of the other hand. Case 7. R. C. was 27 years of age when injured. He underwent extensive rehabilitation and became relatively independent in his wheelchair. He used a tenodesis splint for eating and writing. His functional level was slightly higher on the left, but since he was left handed and functionally more adept with it, his right hand was reconstructed first. The pronator teres was transferred to the flexor pollicis longus and the flexor carpi ulnaris was used as the adduction-opposition motor. He had sufficient active extension to provide release, but thumb extension augmentation has been contemplated. At 3 months his grip strength was 6.8 Kg. and pinch strength was 3.2 Kg. He was happy with the increased function and has just had the other hand operated upon. Discussion A good program of rehabilitation can restore a tetraplegic patient with retained wrist control to relative independence. Although he lacks active digital flexion, he can be taught to feed and dress himself, to transfer, and to perform most of the activities of daily living with adaptive techniques. He has to stabilize objects between both hands and occasionally has to use his mouth to grasp objects. Wrist-driven orthotic devices are useful but are cumbersome and often are rejected. Surgery does not necessarily enable the patient to perform activities that he could not do before, but, because of the restoration of active grasp and pinch, the efficiency is improved dramatically since he can use each hand independently. Prior to operation no patient in this series was able to register any grasp or pinch force without linking the fingers to wrist motion with an orthosis. After operation the average grasp strength was 5.7 Kg. and pinch strength was 3.0 Kg. If Case 2, who was an error in pa-
tient selection, is excluded, average grasp and pinch would have been 6.5 and 3.3 Kg., respectively. Freehafer, V onHaam, and AlienS recent! y reported their experience with tendon transfers in the hand of patients with tetraplegia, used a similar technique for adduction-opposition. Their patients with levels of injury comparable to those in our series averaged 4.0 Kg. of grasp and 1.9 Kg. of pinch force after operation. Two possible reasons for the greater strength obtained in our patients are the increased power produced by the addition of a motor to the flexor polIicis longus and the use of the extensor and intrinsic tenodesis. Thus the flexor transfers can be placed under greater tension and yet the hand can be opened adequately. The results of both series indicate that reconstruction is a very useful tool in the final rehabilitation of certain tetraplegic patients. Patient acceptance of reconstruction has been particularly encouraging. With the exception of Case 2, all patients have stated that they would again choose to have the operation. They feel that their self-image has improved and that they can accomplish tasks much more quickly. No patient reported loss of any preoperative function because of operation (Table II). When a tetrapelgic patient comes for evaluation, if he has not met and talked with a postoperative patient, a meeting is arranged. The patient must be welI motivated and understand the functional expectations of surgery as well as recognize that he will be more dependent during the recovery period after each phase. Problems exist in the convalescent period that require special attention. Since one hand is in a splint, transfers and pressure-relieving push-ups in a wheel chair are difficult or impossible; one patient developed a pressure sore because of this. An attendant will be required, and if the patient does not have help, it must be arranged. Later, in using his hands, many of the previously learned techniques will have to be changed. Frequently transfers are more difficult because of a new wrist and finger position. These obstacles can be overcome, however, and all of our patients have learned to modify their techniques to allow the same independence in transfer as before the operation. Summary Active digital flexion and key pinch are functions that can be restored to certain tetraplegic patients to facilitate activities of daily living. For successful results, all patients should have at least strong wrist extension and a pronator teres. In those hands with strong C-6 function in which there are at least five functioning muscles in the forearm, digital flexion can be provided
Vol. I No.2 September, 1976
Restoration of strong grasp and lateral pinch in tetraplegia
by transferring the extensor carpi radialis longus to the flexor digitorum profundus. By transferring a motor to the flexor digitorum superficialis of the ring finger which has been passed to the thumb around a pulley just distal to the hook of the hamate, adduction-opposition can be produced. Additional strength for grasp and pinch is provided by an active transfer to the flexor pollicis longus. Release is accomplished through extensor and intrinsic tenodesis. When digital extension is preserved, reconstruction is simplified and functional expectations are better. Ten hands in seven patients with traumatic tetraplegia have been reconstructed in this manner. The average grasp and pinch force after operation was 5.5 and 3.0 Kg., respectively. All patients but one were pleased with the increased function and efficiency derived from the procedure. We wish to thank Jean Magney, who assisted with the illustrations .
REFERENCES I. Freehafer, A. A.: Care of the hand in cervical spinal cord injuries, Paraplegia 7: 118, 1969. 2. Zancolli, E.: Structional and dynamic basis of hand surgery, Philadelphia, 1968, J. B. Lippincott Company, Chapter II. 3. Zancolli, E.: Surgery for the quadriplegic hand with active strong wrist extension preserved-a study of 97 cases, Clin . Orthop. 112: 101, 1975. 4. Thompson, T. c.: A modified operation for opponens paralysis, J. Bone Joint Surg . 24: 632. 1942. 5. Freehafer, A. A., VonHaam, E., and Allen V.: Tendon transfers to improve grasp after injuries to the cervical spinal cord, J. Bone Joint Surg. 56A: 951, 1974.
SUGGESTED READING Curtis, R. M.: Tendon transfers in the patient with spinal cord injury, Orthop. Clin . North Am. 5: 415, 1974. Engel, W. H., Kmiotek, M. A., Hoaf, J. P., et al.: A func-
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tional splint for grasp driven by wrist extension , Arch . Phys . Med. 48: 43, 1967. Freehafer, A. A., and Mast, W. A.: Transfer of the brachioradialis to improve wrist extension in high spinal cord injury, J. Bone Joint Surg . 49A: 648, 1967 . Garret, A. L., Perry, J ., and Nickel, V. L.: Traumatic quadriplegia, J. A. M. A. 187: 7,1964. Henderson, E. D.: Transfer of wrist extensors and brachioradialis to restore opposition of the thumb, J. Bone Joint Surg. 44A: 513, 1962. Kay, H. W.: Clinical evaluations of the engen plastic hand orthosis, Artif. Limbs 13: 13, 1969. Kiwerski, J. , and Pasniczek, R.: Early results of use of implanted stimulators for paralysis of the upper extremities following spinal cord injury, Neurol. Neurochir. Pol. 7: 811, 1973. Lamb, D. W., and Landry, R.: The hand in quadriplegia, Hand 3: 31, 197 I. Lamb, D. W., and Landry, R.: The hand in quadriplegia, Paraplegia 9: 204, 1972. Moberg, E.: Surgical treatment for absent single-hand grip and elbow extension in quadriplegia, J. Bone Joint Surg. 57A: 196 , 1975. Nickel, V. L., Perry, J ., and Garrett, A. L. : Development of useful functions in the severely paralyzed hand, J. Bone Joint Surg. 45A: 933, 1963. Riordan, D. C.: Surgery of the paralytic hand, instructional course lecture, Am . Acad . Orthop. Surg. 16: 1959. Royle, N. D.: An operation for paralysis of the intrinsic muscles of the thumb, J . A. M. A. 111: 612, 1938. Siebens, A., Engel, W. , Peyrot, A., et al.: An assistive device for forearm lift, Arch. Phys . Med. Rehabil. 52: 567, 1971. Spieker. J. L., and Lethcoe, B. J.: Upper extremity functional bracing-a follow-up study, Am. J. Occup. Ther. 25: 398, 1971. Staros, A., and Peizer, E.: Veterans administration prosthetic center report, Bull. Prosthet. Res. 10: 146, 1973. Stauffer, E. S.: Orthotics for spinal cord injuries, Paraplegia 7: 118, 1969 .
James H. House, M,D" M.S., Frank W. Gwathmey, M,D" and Douglas K. Lundsgaard, M.D. Minneapolis, Minn .
Injury to the cervical spinal cord , resulting in permanent tetraplegia, causes a radical change in the life style of a person . The disability is profound, and a broad· based rehabilitation program must be provided to achieve the maximum function consistent with the level of injury . The purpose of this paper is to describe the functional benefits of surgical restoration of grasp and key pinch in selected patients with tetraplegia and to discuss the procedures employed. Before considering surgical reconstruction, ample time should be allowed for the patient to learn to accept his handicap and to learn through the rehabilitation process exactly what goals may be realistic , This usually takes a minimum ofa year. Initially, a physical therapy program is designed to prevent contractures and to strengthen functional muscles that remain , Through occupational therapy the patient is taught to become as independent as possible in the activities of From the Department of Orthopedic Surgery . University of Min· nesota, Minneapolis. Minn. Supported in part by Kappa Delta Inc. of Minnesota. Recei ved for publication Jan . 21 , 1976. Presented in part at the annual meeting of the American Academy of Orthopaedic Surgeons, New Orleans, La., Jan. 28, 1976. Reprint requests: James H. House, M,D., Department of Orthopedic Surgery , University of Minnesota, 412 Union St., P. O. Box 190, Minneapolis. Minn . 55455 ,
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daily living by the use of transfer techniques, adaptive utensils, and tenodesis splints . In addition, he may need the help of psychological and social counselling to adjust to the emotional and dependency aspects of this severe disability, When he has reached his maximal functional level and shows sufficient motivation, a decision is made as to whether or not surgery would offer any further functional improvement. Many patients who are unable to apply tenodesis splints without help may be freed of the splint and made more efficient functionally , The potential for surgical reconstruction is determined by the level of injury . Since the individual muscles spared may vary from patient to patient and from side to side, it is appropriate to think of functional levels remaining, as has been suggested by Zancolli and Moberg and reiterated by Freehafer. 1 Lesions of the upper cervical spinal cord , if not fatal, are as· sociated with such profound deficits that surgery is rarely indicated, Patients having elbow flexion but weak or absent wrist extension may benefit occasionally from brachioradialis transfer to augment wrist extension , This motion aids a flexor tenodesis or provides power for orthotic devices, The most common injury to the cord occurs at the level of the sixth cervical vertebra (C-6) spinal segment. At this level of injury, the brachioradialis, extensor carpi radialis longus , extensor
September. 1976
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Fig. 1. Adduction-opponensplasty. The brachioradialis has been transferred to the paralyzed flexor superficial is of the ring finger as an in situ tendon graft rerouted around a palmar fascial pulley to a split thumb insertion.
Fig. 2. Flexor phase. The extensor carpi radialis longus has been transferred to the flexor digitorum profundus and the pronator teres to the flexor pollicis longus. carpi radialis brevis, pronator teres, and flexor carpi radialis usually are spared. Zancolli2 • 3 defines this as a C-6 "strong wrist extension" functional group. In this group, surgery can improve function significantly. Selected tendons can be transferred from the forearm or wrist to provide more useful digital motion.
Concept of reconstruction of grasp and release Priority should be given to restoration of power of active digital flexion to provide strong grasp and pinch. The release phase can be provided by extensor and intrinsic tenodeses, as depicted in Figs. I and 2. The tenodesis is inserted into the central slip and lateral bands so it functions on the extensor side of interphalangeal joints and is passed through the lumbrical canals of the index and middle fingers with proximal fixation accomplished by looping the tendon graft around the neck of the second metacarpal dorsally. This in effect provides a linkage from the metacarpophalangeal (MP) to the proximal interphalangeal
(PIP) joint that acts much as the oblique retinacular ligament of Landsmeer does across the PIP and distal interphalangeal (DIP) joints. It prevents MP hyperextension and enhances interphalangeal extension as the MP joint is extended by the extrinsic tenodesis. During active flexion, as the interphalangeal joints are flexed by way of the flexor digitorum profundus, the extensor hood is pulled distally and tension on the intrinsic tenodesis facilitates early flexion at the MP joint, providing more balance to the flexion of the digit and avoiding the premature hyperfiexion of the interphalangeal joints commonly seen in the intrinsic minus hand. Active wrist extension is essential and is maintained by the extensor carpi radialis brevis which usually is strong and is located centrally . It is desirable to preserve the flexor carpi radialis if present, since this will increase power for wheelchair propUlsion, assist in transfers, and augment the function of any extensor tenodesis . Digital flexion is probably restored best by transfer-
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The Journal of HAND SURGERY
Fig. 3. Extensor phase (dorsal view). Tenodesis of the extensor digitorum communis, extensor pollicis longus, and rerouted abductor pollicis longus to the distal radius. Free tendon grafts routed through the lumbrical canals of the index and middle fingers, fixed proximally by a subperiostral loop dorsally around the second metacarpal and sutured distally to the extensor hood to produce an intrinsic tenodesis.
Fig. 4. Extensor phase (lateral view) . The extrinsic tenodesis produces finger and thumb extension and the intrinsic tenodesis prevents metacarpophalangeal hyperextension and facilitates interphalangeal extension when the wrist is Hexed . ring the extensor carpi radialis longus to the flexor digitorum profundus (Fig. 3). This wrist extensor has adequate amplitude and is synergistic with finger flexion . Its transfer also may remove a radial deviating force. In the strong C-6 functional group, the brachioradialis and the pronator teres are available for use as transfers to the thumb to restore pinch and grasp . In the seventh cervical vertebra (C-7) functional group with preserva-
tion of the extensor digitorum communis in addition to those muscles already mentioned, the extensor carpi ulnaris and occasionally the flexor carpi ulnaris are strong enough to use as motors for transfer.
Concept of reconstruction of lateral pinch An adduction-opponensplasty to provide strong lateral pinch is desirable because it provides a broad sur-
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September, 1976
Restoration of strong grasp and lateral pinch ill tetraplegia
face of contact between the thumb and index finger and is controlled more easily by a minimum of dynamic forces (Fig. 4). An improved position of the thumb to provide pinch on wrist extension can be achieved by tenodesis, but this type of pinch is very dependent upon wrist position, and the tenodesis may stretch, weakening the pinch. The classical opponensplasty, desirable in median palsy, is not useful in the tetraplegic hand because the thumb is abducted away from the palm and may miss the fingertips. After profundus replacement, digital flexion begins at the distal joint and the fingers curl into the palm because the fingers are without intrinsic function. Intrinsic tenodesis or transfers to the fingers may occasionally correct this to provide three point tip pinch. However, this is an action for fine manipulation not often used by the tetraplegic patient and it is not an appropriate goal of reconstruction. Pulley. An important point in the creation of this type of lateral pinch is the placement of the pulley to direct the thumb along the course of the flexor pollicis brevis, as is appropriate for a combined median and ulnar nerve palsy. A pulley around the palmar fascia just distal to the carpal tunnel, as described by Thompson,4 provides the proper vector for adduction-opposition. A force acting on the thumb from this location will cause the thumb to move across the palm in a plane parallel to that of the palm rather than away from it. This produces a lateral pinch of thu mb to the side of the index finger. Motors. In selecting the motor, either the pronator teres or the brachioradialis can be used, for both have sufficient strength and excursion to provide suitable function . The pronator teres has a rather broad attachment to the radius through a short tendon and is used more easily as a thumb flexor motor because of its anatomical relationship to the flexor pollicis longus . It is useful to elevate a strip of periosteum distally to elongate the tendon and to provide a suitable length for an interwoven junction with the recipient tendon. The brachioradialis is invested in fascia along its course in the forearm and must be mobilized from the distal radius and forearm fascia to provide adequate excursion. If the extensor carpi ulnaris and flexor carpi ulnaris are of suitable strength, either may be used for the adduction-opposition motor. Tendons. To transmit the force of the motor to the thumb, a middle or ring finger superficialis tendon is used as an in situ graft rather than as a free graft . It is divided tbrough a transverse incision in the finger, just proximal to the flexion crease of the proximal interphalangeal joint. After separating the two slips and splitting the decussation to free the tendon from the profundus, the tendon is withdrawn into the palm
ISS
through a short incision approximately two fifths of the distance between the wrist flexion crease and the proximal flexion crease of the little finger at a point just distal to the hook of the hamate. The tendon is left in its synovial bed proximally in the carpal tunnel and forearm and thereby retains much of its blood supply. A subcutaneous tunnel is created from the palmar incision to a curved incision over the radial side of the thumb. The tendon is directed around the ulnar border of the palmar fascia distal to the transverse carpal ligament . Then it is passed superficially to the fascia to the incision in the thumb at approximately the metacarpophalangeal joint level. Insertion. The tendon is split and one slip is woven through the abductor pollicis brevis tendon, passed through the extensor pollicis longus tendon distal to the metacarpophalangeal joint, and sutured in place. The other slip is passed dorsal to the extensor pollicis brevis and is inserted into the tendon of the extensor pollicis longus proximal to the metacarpophalangeal joint or into a bony insertion on the ulnar side of the base of the proximal phalanx . This insertion provides a rotatory motion to correct thumb supination and aids in interphalangeal joint extension and metacarpophalangeal joint stabilization during the pinch action. Proximal anastomosis of the motor. Through a radial mid lateral incision in the forearm, the motor selected for the adduction-opponensplasty is woven into the proximal superficialis tendon, usually leaving it attached to its paralyzed motor. Tension is adjusted to bring the thumb into a position of lateral pinch, with approximately 30° of wrist extension, and to still allow passive extension by tenodesis during wrist flexion. A remaining motor is transferred to the musculotendinous junction of the flexor pollicis longus to provide interphalangeal flexion and the power for pinch. The entire flexor phase of reconstruction, including transfer of the extensor carpi radialis longus to the flexor digitorum profundus, is done in one operation. This procedure is done before or after a long extensor tenodesis, which provides digital extension, and with intrinsic tenodesis of the index and middle fingers, which prevents acute interphalangeal flexion that would limit the area of index finger available for key pinch. After each procedure the hand and forearm are immobilized in a bulky dressing reinforced with plaster splints.
Case reports Seven patients have had an adduction-opponensplasty in ten hands, with follow-up ranging from 3 months to 6 years. There were six men, who were ages 16,19,19,22,27, and 54 years, respectively, and one girl, age 14 years of age, at the time of injury.
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Table I Case
Extensor phase* 19
2
3
4
5
54
21
22
14
R
Strong C-6
Extensor-intrinsic tenodesis
L
Strong C-7
Extensor-intrinsic tenodesis
R
Strong C-6
Extensor-intrinsic tenodesis
R
Strong C-6
L
Strong C-6
R
C-6
Extrinsic-intrinsic tenodesis
L
Strong C-6
Extrinsic- intrinsic tenodesis
R
Strong C-6
Extrinsic- intrinsic tenodesis
6
16
R
C-7
7
27
R
C-7
Grade III FCU- EDC Extensor-intrinsic tenodesis
Dynamic intrinsic tenodesis FDS-4 fingers Stiles- Bunnell None
Flexor phase* ECR PT BR
FDP FPL FDSH
ECRL BR FCU ECRL BR PT ECRL PT BR ECRL XR PT ECRL BR PT ECRL PT BR ECRL BR PT ECRL PT ECU
FDP FPL FDS R FDP FPL FDS R FDP FPL FDS R FDP FPL FDS R FDP FPL FDS R FDP FPL FDS R FDP FPL FDS R FDP FPL FDS R
Thumb
ECRL FDP PT FPL FCU FDS R
Thumb
Follow-up
Pinch
(yr.)
6
Thumb
(Kg.)
9.1
5.5
9.1
6.8
Thumb
2
o
o
Thumb
4
8.6
4.8
Thumb
2
6.4
2.3
Thumb
4.5
2.3
Thumb
4.5
2.0
3 mo.
2.7
1.8
Thumb
7 mo.
5.0
3.2
Thumb
4 mo.
6.8
3.2
*FCU = flexor carpi ulnaris; EDC = extensor digitorum communis; ECR = extensor carpi radialis; PT = pronator teres; BR = brachioradialis; FOP = flexor digitorum profundus; FPL = flexor polhcls longus; FOS R = flexor digitorum superficialis, ring finger; ECRL = extensor carpi radialis longus.
All patients sustained traumatic injuries to the cervical spine resulting in tetraplegia. Common to all patients was preservation of normal sensation in at least the thumb, index, and radial side of the long finger. The brachioradialis, extensor carpi radialis longus, extensor carpi radialis brevis, and pronator teres were graded four or better with the flexor carpi radialis graded three or better. Digital flexion was restored in all by the transfer of the extensor carpi radialis longus to the flexor digitorum profundus. At some point every hand except one had extensor and/or intrinsic reconstruction with tenodesis or transfer. Before operation no patient was able to produce a reading for grip on the Jamar dynamometer or pinch on the tensiometer. In seven hands with strong function retained at the C-6Ievel, the pronator teres was used as the adductionopponensplasty motor in four and the brachioradialis in
three. There were three hands with C-7 function and the flexor carpi ulnaris was used in two and the extensor carpi ulnaris in one (Table I). Case 1. J. D. was 19 years of age at the time of injury and retained strong C-6 function on the right and C-7 function on the left. A year later he was able to perform self-care activities such as morning care at a sink, transfers, putting on his shirt, and handling silverware with soft foods. He used tenodesis splint on the right hand for eating, writing, dressing, and hygiene. He performed these activities with some degree of difficulty but was nearly independent in his wheelchair and attended college. Three months following extensor and intrinsic tenodeses on the right hand, thumb function was restored with the pronator teres for thumb flexion and the brachioradialis as the motor for adduction-opposition. Between these two procedures, on the left hand which had adequate extensor function, the brachioradialis was transferred to the flexor pollicis
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Table II. Patient's reaction
Case I
2
3 4 5 6 7
Adaptive utensils Eliminated Not eliminated Eliminated Eliminated Eliminated Eliminated Eliminated
Transfers
Social self-image
Wheelchair propulsion
Activities of daily living
Would repeat
Improved Unchanged
Improved Unchanged
Improved Unchanged
Faster Unchanged
Yes Died
Unchanged Unchanged Improved Improved Improved
Improved Improved Improved Improved Improved
Improved Improved Improved Improved Improved
Faster Faster Faster Faster Faster
Yes Yes Yes Yes Yes
longus and the flexor carpi ulnaris was used as an adductionopposition motor. Six years after operation the left hand is more functional than is the right, but he has 9 . 1 Kg . of grasp in both and 5.5 Kg . of key pinch in the right and 6 .8 Kg. in the left. He is totally independent, including driving a specially equipped car, and is delighted with the results. He is working as a counselor in a rehabilitation institute . Case 2. M. H. was 54 years of age when he became tetraplegic . Two years later he was partially independent in dressing, personal hygiene, and bed-to-chair transfer. The right hand, being the worst of the two, had a flexor phase with pinch being restored by transferring the brachioradialis to the flexor pollicis longus and the pronator teres as a motor for the adduction-opponensplasty . This was followed by an extensor phase . His rehabilitation program after operation was interrupted by intermittent illnesses and psychological difficulties. Two years following operation he had no measurable grasp nor any functional key pinch and stated that his function was no better than before the operation. He had had preoperative joint contractures that had to be overcome before operation and his hand stiffened considerably following immobilization. His motivation was not as strong as in the other patients, and he had many depressive episodes after his wife's death. Failure was probably a result of poor patient selection. Case 3. D. T. was 19 years of age at the time of his accident. Nineteen months later he would not use tenodesis splints because he did not like them . He could not do bed-tochair transfers and relied upon a swivel bar. Activities of daily living were done poorly with adaptive utensils. It was felt that the majority of his problems were of an emotional basis and he was very dependent upon his mother. However, because of his desire for increased function without braces, it was elected to do reconstructive surgery on his right hand. Two months following a dynamic tenodesis of a Grade III flexor carpi ulnaris to the extensor digitorum communis, the pronator teres was transferred to the flexor pollicis longus and the brachioradialis was used as an adduction-opponensplasty motor. Two months later. because of radial migration of the pulley, the thumb was in too much abduction and the tip missed the index finger during attempted pinch. A tenodesis
of the extensor pollicis brevis to the second metacarpal was done to correct this. Four years later he had grasp of 8.6 Kg. and lateral pinch of 3.0 Kg. The dynamic tenodesis of the extensor mechanism had stretched considerably requiring wrist flexion of 40° to open the hand and to provide thumb extension . However. he was happy with the result and recently he has had a reconstructive procedure on the other hand . Case 4. J. M. survived a parachute failure when he was 22 years of age. Because of other systemic problems, it was 4 years before he was ready for hand surgery. During this time he had become relatively independent in activities of daily living. A tenodesis splint provided 1.4 Kg. of three point pinch. but he did not like the splint and used it only for writing and fine manipulations . Reconstruction began with the left hand. The pronator teres was used to power the adduction-opponensplasty and also the flexor pollicis longus . The brachioradialis was preserved for use as an extensor transfer later. Several weeks following cast removal. he feIt a tearing sensation in the forearm and noticed a decrease in pinch power. The adduction-opponensplasty was revised and the brachioradialis was transferred to the flexor pollicis longus. An extensor and intrinsic tenodesis was done 6 months later. The right hand was reconstructed 3 months later with the brachioradialis transferred to the flexor pollicis longus and the pronator teres used as the adductionopposition motor. One and a half years after reconstruction of the left hand. grip strength was 6.4 Kg . and key pinch strength was 2.3 Kg . Six months after reconstruction of the right hand. grip strength was 4.5 Kg. and key pinch was 2 .3 Kg . He was very happy with the outcome and said that his efficiency was greatly improved and that he had become essentially independent . Case 5. T. F. was 14 years of age when she became tetraplegic. Two years later she was able to transfer, to partially dress and feed herself. and to propel her wheelchair. She used a tenodesis splint for putting on her make-up and for other manipulative tasks. In order to make her free of splints and to increase her functional capacity, reconstruction of the left hand was done. The pronator teres was transferred to the flexor pollicis longus and the brachioradialis was used as the
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motor for adduction-opposition. This was followed by extensor tenodeses. Eighteen months later she had 4.5 Kg. of grasp and 2.0 Kg. of key pinch. The right hand was treated similarly, and at 3 months she had 2.7 Kg. of grip and 1.8 Kg. of key pinch. She was extremely happy with her outcome and became very adept in wheelchair sports-throwing both the javalin and the discus. Case 6. R. P. was 16 years of age when he was injured, but it was 31 /2 years before he was seen for evaluation for reconstruction. He was attending college and was nearly independent in his wheelchair and was able to perform most activities of daily living with adaptive utensils. His right hand had fair extensor function, but lacked grasp and pinch. The pronator teres was transferred to the flexor pollicis longus and the extensor carpi ulnaris was used as the motor for adduction-opposition. Seven months after operation he had grip strength of 5.0 Kg. and pinch strength of 3.2 Kg. He is now waiting for reconstruction of the other hand. Case 7. R. C. was 27 years of age when injured. He underwent extensive rehabilitation and became relatively independent in his wheelchair. He used a tenodesis splint for eating and writing. His functional level was slightly higher on the left, but since he was left handed and functionally more adept with it, his right hand was reconstructed first. The pronator teres was transferred to the flexor pollicis longus and the flexor carpi ulnaris was used as the adduction-opposition motor. He had sufficient active extension to provide release, but thumb extension augmentation has been contemplated. At 3 months his grip strength was 6.8 Kg. and pinch strength was 3.2 Kg. He was happy with the increased function and has just had the other hand operated upon. Discussion A good program of rehabilitation can restore a tetraplegic patient with retained wrist control to relative independence. Although he lacks active digital flexion, he can be taught to feed and dress himself, to transfer, and to perform most of the activities of daily living with adaptive techniques. He has to stabilize objects between both hands and occasionally has to use his mouth to grasp objects. Wrist-driven orthotic devices are useful but are cumbersome and often are rejected. Surgery does not necessarily enable the patient to perform activities that he could not do before, but, because of the restoration of active grasp and pinch, the efficiency is improved dramatically since he can use each hand independently. Prior to operation no patient in this series was able to register any grasp or pinch force without linking the fingers to wrist motion with an orthosis. After operation the average grasp strength was 5.7 Kg. and pinch strength was 3.0 Kg. If Case 2, who was an error in pa-
tient selection, is excluded, average grasp and pinch would have been 6.5 and 3.3 Kg., respectively. Freehafer, V onHaam, and AlienS recent! y reported their experience with tendon transfers in the hand of patients with tetraplegia, used a similar technique for adduction-opposition. Their patients with levels of injury comparable to those in our series averaged 4.0 Kg. of grasp and 1.9 Kg. of pinch force after operation. Two possible reasons for the greater strength obtained in our patients are the increased power produced by the addition of a motor to the flexor polIicis longus and the use of the extensor and intrinsic tenodesis. Thus the flexor transfers can be placed under greater tension and yet the hand can be opened adequately. The results of both series indicate that reconstruction is a very useful tool in the final rehabilitation of certain tetraplegic patients. Patient acceptance of reconstruction has been particularly encouraging. With the exception of Case 2, all patients have stated that they would again choose to have the operation. They feel that their self-image has improved and that they can accomplish tasks much more quickly. No patient reported loss of any preoperative function because of operation (Table II). When a tetrapelgic patient comes for evaluation, if he has not met and talked with a postoperative patient, a meeting is arranged. The patient must be welI motivated and understand the functional expectations of surgery as well as recognize that he will be more dependent during the recovery period after each phase. Problems exist in the convalescent period that require special attention. Since one hand is in a splint, transfers and pressure-relieving push-ups in a wheel chair are difficult or impossible; one patient developed a pressure sore because of this. An attendant will be required, and if the patient does not have help, it must be arranged. Later, in using his hands, many of the previously learned techniques will have to be changed. Frequently transfers are more difficult because of a new wrist and finger position. These obstacles can be overcome, however, and all of our patients have learned to modify their techniques to allow the same independence in transfer as before the operation. Summary Active digital flexion and key pinch are functions that can be restored to certain tetraplegic patients to facilitate activities of daily living. For successful results, all patients should have at least strong wrist extension and a pronator teres. In those hands with strong C-6 function in which there are at least five functioning muscles in the forearm, digital flexion can be provided
Vol. I No.2 September, 1976
Restoration of strong grasp and lateral pinch in tetraplegia
by transferring the extensor carpi radialis longus to the flexor digitorum profundus. By transferring a motor to the flexor digitorum superficialis of the ring finger which has been passed to the thumb around a pulley just distal to the hook of the hamate, adduction-opposition can be produced. Additional strength for grasp and pinch is provided by an active transfer to the flexor pollicis longus. Release is accomplished through extensor and intrinsic tenodesis. When digital extension is preserved, reconstruction is simplified and functional expectations are better. Ten hands in seven patients with traumatic tetraplegia have been reconstructed in this manner. The average grasp and pinch force after operation was 5.5 and 3.0 Kg., respectively. All patients but one were pleased with the increased function and efficiency derived from the procedure. We wish to thank Jean Magney, who assisted with the illustrations .
REFERENCES I. Freehafer, A. A.: Care of the hand in cervical spinal cord injuries, Paraplegia 7: 118, 1969. 2. Zancolli, E.: Structional and dynamic basis of hand surgery, Philadelphia, 1968, J. B. Lippincott Company, Chapter II. 3. Zancolli, E.: Surgery for the quadriplegic hand with active strong wrist extension preserved-a study of 97 cases, Clin . Orthop. 112: 101, 1975. 4. Thompson, T. c.: A modified operation for opponens paralysis, J. Bone Joint Surg . 24: 632. 1942. 5. Freehafer, A. A., VonHaam, E., and Allen V.: Tendon transfers to improve grasp after injuries to the cervical spinal cord, J. Bone Joint Surg. 56A: 951, 1974.
SUGGESTED READING Curtis, R. M.: Tendon transfers in the patient with spinal cord injury, Orthop. Clin . North Am. 5: 415, 1974. Engel, W. H., Kmiotek, M. A., Hoaf, J. P., et al.: A func-
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tional splint for grasp driven by wrist extension , Arch . Phys . Med. 48: 43, 1967. Freehafer, A. A., and Mast, W. A.: Transfer of the brachioradialis to improve wrist extension in high spinal cord injury, J. Bone Joint Surg . 49A: 648, 1967 . Garret, A. L., Perry, J ., and Nickel, V. L.: Traumatic quadriplegia, J. A. M. A. 187: 7,1964. Henderson, E. D.: Transfer of wrist extensors and brachioradialis to restore opposition of the thumb, J. Bone Joint Surg. 44A: 513, 1962. Kay, H. W.: Clinical evaluations of the engen plastic hand orthosis, Artif. Limbs 13: 13, 1969. Kiwerski, J. , and Pasniczek, R.: Early results of use of implanted stimulators for paralysis of the upper extremities following spinal cord injury, Neurol. Neurochir. Pol. 7: 811, 1973. Lamb, D. W., and Landry, R.: The hand in quadriplegia, Hand 3: 31, 197 I. Lamb, D. W., and Landry, R.: The hand in quadriplegia, Paraplegia 9: 204, 1972. Moberg, E.: Surgical treatment for absent single-hand grip and elbow extension in quadriplegia, J. Bone Joint Surg. 57A: 196 , 1975. Nickel, V. L., Perry, J ., and Garrett, A. L. : Development of useful functions in the severely paralyzed hand, J. Bone Joint Surg. 45A: 933, 1963. Riordan, D. C.: Surgery of the paralytic hand, instructional course lecture, Am . Acad . Orthop. Surg. 16: 1959. Royle, N. D.: An operation for paralysis of the intrinsic muscles of the thumb, J . A. M. A. 111: 612, 1938. Siebens, A., Engel, W. , Peyrot, A., et al.: An assistive device for forearm lift, Arch. Phys . Med. Rehabil. 52: 567, 1971. Spieker. J. L., and Lethcoe, B. J.: Upper extremity functional bracing-a follow-up study, Am. J. Occup. Ther. 25: 398, 1971. Staros, A., and Peizer, E.: Veterans administration prosthetic center report, Bull. Prosthet. Res. 10: 146, 1973. Stauffer, E. S.: Orthotics for spinal cord injuries, Paraplegia 7: 118, 1969 .