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Surgery of the spastic hand in cerebral palsy: Report of the Committee on Spastic Hand Evaluation
The Journal of HAND SURGERY
Eversmann
44 . Hecht 0, Lipsher E: Median and ulnar nerve entrapment caused by ectopic calcification. J HAND SURG 5:30-1,1980 45. Broudy AS, Leffert RD, Smith RJ: Technical problems with ulnar nerve transposition at the elbow: Findings and results of reoperation. J HAND SURG 3:85-9, 1978 46. Learmonth JR: Technique for transplanting the ulnar nerve. Surg Gynecol Obstet 75:792-3, 1942 47. Craven PR, Green DP: Cubital tunnel syndrome. Treatment by medial epicondylectomy. J Bone Joint Surg [Am] 62:986-9, 1980 48 . King T, Morgan FP: The treatment of traumatic ulnar neuritis . Mobilization of the ulnar nerve at the elbow by removal of the medial epicondyle and adjacent bone . Aust NZ J Surg 20:33-42, 1950 49. Eversmann WW Jr, Green DP. editors: Operative hand surgery. New York, 1982, Churchill-Livingstone, pp 957-1009 50 . Shea JD, McClain EJ: Ulnar nerve compression syndromes at and below the wrist. J Bone Joint Surg [Am] 51: 10'5-103, 1969 51. Swanson AB. Biddulph SL, Baughman FA. deGroot G: Ulnar nerve compression due to an anomalous muscle in the canal of Guyon . Clin Orthop 83:64-9. 1972 52. Howard FM: Ulnar nerve palsy in wrist fractures. J Bone Joint Surg [Am] 43:1197-201,1961 53 . Bakke JL , Wolff HG: Occupational pressure neuritis of the deep palmar branch of the ulnar nerve. Arch Neurol Psychiatry 60:549-53 . 1948 54. Comtet J, Quicot I, Moyen B: Compression of the deep palmar branch of the ulnar nerve by the arch of the adductor pollicis. Hand 10:176-80, 1978 55. Gori DR: Carpometacarpal dislocation producing compression of the deep branch of the ulnar nerve. J Bone Joint Surg [Am] 53:1387-90,1971 56. Vance RM, Gelberman RH: Acute ulnar neuropathy with fractures at the wrist. J Bone Joint Surg [Am] 60:962-5, 1978 57 . Kaplan EB: Variation of the ulnar nerve at the wrist. Bull Hosp Joint Dis 24:85-8. 1963 58 . Engber WD , Cmeiner JG: Palmar cutaneous branch of the ulnar nerve . J HAND SURG 5:26-9 , 1980
59. Lotem M, Fried A, Levy M. Solzi P, Najenson T. Nathan H: Radial palsy following muscular effort. A nerve compression syndrome possibly related to a fibrous arch of the lateral head of the triceps. J Bone Joint Surg [Br] 53:500-6, 1971 60. Manske PR: Compression of the radial nerve by the triceps muscle. Case report. J Bone Joint Surg [Am] 59:835-6. 1977 61. Packer JW, Foster RR, Garcia A, Grantham SA: The humeral fracture with radial nerve palsy: Is exploration warranted? Clin Orthop 88:34-8, 1972 62. Lister GD, Belsole RB, Kleinert HE: The radial tunnel syndrome. J HAND SURG 4:52-9, 1979 63 . Roles NC. Maudsley RH: Radial tunnel syndrome. Resistant tennis elbow as a nerve entrapment. J Bone Joint Surg [Br] 54:499-508, 1972 64. Wartenberg R: Cheiralgia paresthetica (isolierte neuritis des ramus superficial is nervi radialis). Zeitung Neurol Psychiatry 141:145-55. 1932 65. Williams HT, Carpenter NH: Surgical treatment of the thoracic outlet compression syndrome. Arch Surg 113:850-2. 1978 66. Gilliatt RW, Willison RG, Dietz V, Williams IR: Peripheral nerve conduction in patients with a cervical rib and band. Ann NeuroI4:124-9,1978 67. Howard FM, Shafer SJ: Injuries to the clavicle with neurovascular complications. A study of fourteen cases. J Bone Joint Surg [Am] 47: 1335-46. 1965 68 . Lain TM: The military brace syndrome: A report of sixteen cases of Erb's palsy occurring in military cadets. J Bone Joint Surg [Am] 51:557-60,1969 69. Gilliat RW: Classical neurological syndrome associated with cervical rib and band. Ann NeuroI4:124-9, 1979 70. Glover JL. Werth RM, Bendick PJ , et al: Evoked responses in the diagnosis of thoracic outlet syndrome. Surgery 89:86-93, 1981 71 . Dale WA: Thoracic outlet compression syndrome. Arch Surg 117: 1437-45,1982
Surgery of the spastic hand in cerebral palsy: Report of the Committee on Spastic Hand Evaluation Eduardo A. Zancolli, M.D.,* Chairman, Leonard 1. Goldner, M.D.,** and Alfred B. Swanson, M.D.***
Reprint requests: Eduardo A. Zancolli, M.D ., Avenida Alvear 1535, Buenos Aires, 1014 Argentina . *Professor of Orthopedics . University of Buenos Aires; Chief of Surgery of the National Rehabilitation Center. Buenos Aires . '*Professor and Chairman of Orthopaedic Surgery. Duke University. Durham. N.C. ***Director of Orthopaedic and Hand Surgery Training Program. Blodgett and Butterworth Hospitals, Grand Rapids. Mich.; Professor of Surgery. Michigan State University. Lansing. Mich.
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Most patients with cerebral palsy involvement of the upper extremity are not candidates for surgical reconstructive procedures . However, selected deformities related to muscle imbalance secondary to spasticity may be corrected by appropriate surgical procedures . Although surgery cannot make a functionally poor limb perfect, it can greatly improve the initial condition. A reasonable degree of success can be obtained if the patients are selected carefully through precise and complete examination, testing, and clinical evaluation of impairment of daily life activities. I. 2 Most poor surgical re-
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suIts are due to poor indication, selection, or execution of the surgical techniques." Rehabilitation of the spastic hand in cerebral palsy is a complex problem in reconstructive surgery . The initial central nervous system lesion can produce abnormal hand function patterns secondary to spasticity, with variable degrees of flaccid paralysis and paresis. general neurologic disorders, and disturbances in hand sensibility. As a result, the spastic muscles cannot be used as tendon transfers with the same efficiency as in patients with exclusive flaccid paralysis .~ This article will discuss: (I) the clinical factors influencing the selection and results of surgical treatments; (2) the preoperative evaluation for selection of surgical candidates; a classification of patterns of hand deformity and function will be presented also; (3) the surgical goals and prognosis; (4) surgical indications; (5) most commonly used surgical procedures; and (6) a classification for assessment of results. Clinical factors influencing surgical treatment and results The principal clinical factors influencing surgical treatment are: (I) type of neuromuscular disorder. (2) general neurologic disorders. (3) topographic involvement. (4) hand sensibility impairment. (5) severity of hand's deformity. and (6) voluntary ability to grasp and release . Type of neuromuscular disorder. There are three main types of neuromuscular disorders produced by the lesion of the central nervous system: (I) spastic or pyramidal (50%), (2) dystonic or extrapyramidal (40%), and (3) mixed (10%) . Most cases have pyramidal and extrapyramidal involvement , but usually one type of disorder predominates. Typical findings of each type of disorder will be discussed. Spastic type. The characteristics of the spastic type of cerebral palsy include the following: I. Muscle spasticity: The most common posture of the spastic upper Ii mb is one of elbow , wrist, and finger flexion with forearm pronation and the thumb in adduction or flexion-adduction. These deformities depend on the spasticity of the extrinsic muscles of the forearm and hand and most often on that of the flexor-pronator mass. Occasionally, spasticity produces some internal rotation contracture of the shoulder. Very seldom are the intrinsic muscles of the hand the principal deforming forces (predominant intrinsic spasticity).:!. 4 Muscular tension produced by spasticity increases progressively as the muscle is gradually stretched. Spasticity is posturally and emotionally induced and is rather constant unless the child is asleep or under general anesthesia ." 2. Synchronous activity or cocontraction: This represents an abnormal reaction of the spastic muscles during rest or when the muscles are acting as antagonists.' Antagonist muscles remain electrically active on both flexion and extension of the involved part of the limb. A typical finding is the persistent activity of the flexor muscles of the wrist when complete finger and wrist extension is attempted, especially at the level of the flexor carpi ulnaris.:! Synchronous activity produces a defect of normal grasping and release patterns of the hand . 3. Overactive stretch reflex: Hyperactivity of the normal stretch reflex is produced by failure of the normal muscle lengthening reaction on elongation by sudden stretching .6 Owing to the hyperactive stretch reflex, the spastic muscle contracts at the same point in the arc of motion each time the
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passive elongation maneuver is produced . Stretch reflex can be investigated for each muscle or group of muscles by appropriate maneuvers. 3 Spasticity and overactive reflexes can be decreased by certain surgical procedures, such as lengthening of distal tendons or release of proximal muscle insertions. Selective neurotomies used in the past are now contraindicated in most cases because they produce too much associated muscle weakness .6 Muscles with cocontraction and overactive stretch reflex can be used as tendon transfers; a typical example is the transfer of a spastic flexor carpi ulnaris to extend the wrist. 4. Hyperreflexion or increased tendon jerks 5 . Positive Hoffmann reflex 6 . Diminished superficial reflexes 7 . Clonus 8. Slowness and weakness of voluntary contraction and loss of control of fine movements 9. Myostatic contractures: After long-standing flexion contracture , the spastic muscles have a tendency to secondary retraction owing to fibrosis . Secondary muscular fibrosis can be demonstrated under general anesthesia or peripheral nerve block . Myostatic contracture, as frequently seen in the flexor muscles of the fingers and wrist, can be treated either by physical methods of stretching with casts or braces or by surgical tendon lengthening or proximal muscular release . I. 6 10. Aaccid paresis or paralysis: In the typical flexionpronation deformity, the extensor and supinator muscles of the hand and forearm are usually affected by flaccid paresis or paralysis according to the severity of deformity. 2-4 Extrapyramidal type . This ty~' of neuromuscular disorder may be represented by athetosis, clfaxia , tremor, and rigidity . The most frequent extrapyramidal disorder is athetosis (25%) and it is characterized by: (I) abnormal, involuntary, and poorly coordinated movements with varying degrees of tension; the deformity decreases at rest and disappears during sleep, but it is accentuated by efforts to move or by any emotional or environmental stimulus; (2) delayed postural development; (3) hypotonus in infancy, which may change with growth to increased tonus in stress situations; (4) decreased reflexes in infancy , which may become hyperactive later; (5) no tendency to muscular contracture; (6) absence of Hoffmann reflex; and (7) frequently preserved sensibility of the hand . Trem or is represented by involuntary movements that folIowa regular rhythmic pattern in which flexor and extensor muscles contract alternatively . Ataxia is characterized by disturbed balance and equilibrium, muscle incoordination, and hypotonia . Rigidity is demonstrated by resistance to movement through the hand's entire range with no exaggerated stretch reflex: both contracting muscles and their antagonists are affected . There is a greater tendency for diminished motion rather than abnormal motions . Mixed form. This is a common form; most frequently, spasticity is present with athetosis as characterized by the association of hypertonus and abnormal movements. General neurologic disorders. The general neurologic disorders found in cerebral palsy include the following: speech impairments (delayed speech, aphasia , voice disorders); visual impairments (strabismus, optic atrophy, cataract, etc .); hearing impairments (perceptive, conductive and central deafness); convulsion disorder; behavior disorders re-
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suiting from brain injury; emotional instability; distractibility and defective concentration and cooperation; psychological problems; nutritional problems; perceptual and conceptual disturbances; mental deficiency (intelligence quotient); and defects in spatial judgment or spatial orientation. Topographic involvement. Cerebral palsy can involve all four extremities as follows: (I) tetraplegia-both arms and both legs; (2) hemiplegia-one side of the body, usually with greater involvement of the upper limb; (3) diplegia-all four limbs, with the lower limbs much more severely involved than the upper limbs; (4) triplegia-three extremities, usually with both legs and one arm being affected; and (5) monoplegia-single limb involvement. Hand sensibility impairment. Most patients with cerebral palsy have satisfactory epicritic sensation. The patient usually can recognize hot, cold, sharp, and dull sensations without difficulty, but often shows deficits in proprioception (conscious control of position, motion, and power) and in stereoception or tactile gnosis (ability to recognize objects by touch only) because of cortical involvement. 2 • :I. 7. H Almost two thirds of the cases of pyramidal involvement present impairment of sensibility.
Severity of deformity and voluntary grasp and release pattern. Surgical results are closely related with the degree of deformity of the hand, which depends on the severity ofimbalance between the spastic and paretic or paralytic muscles, and with its voluntary ability to grasp and release. These clinical characteristics must be examined with great precision during preoperative evaluation.
Preoperative evaluation for selection of surgical candidates A complete and precise preoperative evaluation of all factors influencing surgical treatment and results is a prerequisite to any procedure and includes both a general clinical evaluation and evaluation of the upper limb. General clinical evaluation. The general clinical evaluation should determine the following: (1) etiology of central nervous system lesion; (2) type of neuromuscular disorder; (3) presence of general neurologic disorders; (4) topographic involvement; and (5) evaluation of intellectual maturity by psychological testing (lQ); normal-more than 90, mildly retarded-between 70 and 90, and severely retarded-less than 70. Upper limb evaluation. A detailed examination of the upper limb includes (1) evaluation of the range of motion of all joints; (2) assessment of grasp and release pattern; (3) grasp and pinch strength; (4) performance of activities of daily living; (5) hand sensibility examination; (6) type of deformity; and (7) classification of voluntary grasp and release patterns. Active and passive range of motion of all the joints. Shoulder, elbow, forearm, wrist, fingers, and thumb are evaluated. The range of motion should be recorded on the principle that the neutral position equals 0° (American Academy of Orthopaedic Surgeons, 1965). The patient is asked to straighten his fingers and to make a fist, in order to obtain a general idea of motion of all digits and to note any limited motion or abnormal attitudes. Assessment of voluntary ability to grasp and release the hand. Different tests are used to evaluate the ability to open and close the hand, and the patterns of prehension are noted. 1. The ability to open the hand is evaluated by: (1) mea-
suring with disks of graduated sizes-6, 8, 10, 12, 14, 16, and 18 cm; (2) determining hand placement over the table; and (3) measuring the degrees of wrist flexion that will enable the patient to extend the fingers. 2. Grasp and pinch patterns are studied. The ability to grasp is evaluated through the use of spherical balls of graduated sizes (5, 8, 10, and 12 cm) and cylinders of graduated sizes (3, 5, 8, 10, and 12 cm). Pinch patterns, including tip, pulp, and lateral pinches, chuck or three-digit pinch, and pinch to separate fingers, are evaluated with the use of different objects. 3. Speed, skill, voluntary control, and coordination for prehension are functions that are evaluated by the pickup test and by manipulation of different objects. The use of manipulative toys in evaluating children can help the surgeon to make decisions on the indication of reconstructive procedures to improve both function and cosmetics. 2 Coordination between both hands is observed and recorded. Grasp and pinch strength. The grip strength is evaluated with a dynamometer. (A sphygmomanometer may be used to record grip strength in weak hands.) A pinch meter is used to evaluate pinch strength. Activities of daily living. Activities of daily living involving hygiene, dressing, writing, and feeding are evaluated. Hand sensibility. The principal tests used to evaluate hand sensibility include: (I) tactile gnosis (Tactile recognition is rated according to the patient's ability to recognize objects by their shape, size, consistence, and temperature. Testing is done in small children by differentiating cubes from marbles and in others by Seddon's coin test.); two-point discrimination (The modified Moberg's paper clip test is very useful.); and stereognosis. This is tested by moving the fingers vertically. Type of deformity. The most commonly noted deformities are outlined here: I. II. III. IV.
Shoulder-internal rotation contracture Elbow-flexion contracture Forearm-pronation contracture Hand A. Wrist and fingers-flexion and ulnar contracture of wrist, and flexion contracture of fingers, with occasional swan-neck deformities B. Thumb 1. Adducted thumb (adduction of the first metacarpal) 2. Flexion-adduction (thumb-in-palm deformity)
Classification of voluntary grasp and release patterns. The classification of patterns of hand deformity and of voluntary grasp and release patterns of the fingers can help the examiner to determine a program of treatment and its prognosis. 2-4 Three different patterns of hand function can be demonstrated in the spastic or spastic-athetoid patient. These patterns usually are associated with abnormal thumb posture in adduction of flexion-adduction contracture, elbow flexion contracture, and pronation contracture of the forearm of variable degrees of severity. The degree of sensory impairment may vary considerably from one pattern to another. Pattern I: The fingers can actively extend with the wrist in less than 20° of flexion. This represents a mild deficiency to open the fingers, and the appearance of the extremity is satisfactory. These patients can benefit from reconstructive surgery, particularly if the proprioceptive sensation is good. Pattern II: The wrist and fingers are maintained in flexion.
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Active finger extension is possible only with more than 20° of wrist flexion. These patients can be subdivided in two groups according to their ability to voluntarily extend the wrist when the fingers are flexed. Pattern II, A: The patients have positive voluntary extension of the wrist when the fingers are flexed; the extensors of the wrist are active and have good voluntary control. Pattern II, B: The subject is unable to extend the wrist when the fingers are flexed; the extensors of the wrist are very weak or paralyzed. Surgical treatments can provide reasonably good results in patients with patterns I and II, considering their limited motor power to close the hand and their decreased stereoception and proprioception. Functional result is better when sensibility is not affected. Pattern III: There is a severe flexion deformity of the hand. There is no active finger extension even with maximal wrist flexion, and there is no active wrist extension even with the fingers flexed. Passive extension of the fingers and thumb is possible when the wrist is flexed. Hand sensibility is usually poor. In these cases, it is very difficult to obtain a satisfactory hand function, and prognosis after surgery is poor. Surgical goals and prognosis The principal goals in surgical rehabilitation of the spastic hand are: (I) to improve grasp and release patterns; (2) to improve hand cosmesis; and (3) to improve the psychological status of the patient and his family. According to the classification just described, basic hand functions in grasp, release, and pinch functions can be significantly improved in patterns I and II. In these cases it is possible to obtain: (I) improved finger release with decreased flexion of the wrist; (2) decreased spasticity of the flexor muscles of the elbow, wrist, and fingers; (3) partial correction of forearm pronation contracture; (4) correction of thumb-inpalm deformity; (5) improved lateral pinch; and (6) improved grasp. Improvement in the existing pattern of function can be achieved by improving the balance between the spastic pronator-flexor muscles and the normal or paretic extensorsupinator muscles. Attempts to radically modify the existing patterns of activity usually will result in a functional disaster. Only in very mild cases of pattern I is it possible to obtain complete release of the digits with simultaneous and complete extension of the wrist. In patients with pattern III, surgery is indicated primarily to improve the appearance, hygiene and comfort. This can be achieved by reducing the spasticity of the flexor-pronator muscles without trying to obtain active hand release. Surgical indications The principal prerequisites to any surgical procedure in the spastic patient are listed here. Spastic or spastic-athetosis type of neuromuscular disorder. Patients with pure spasticity are good candidates for surgery provided there are no other contraindicating factors and that a reasonable degree of improvement can be predicted. The surgical procedures most often used in these cases include: tendon transfers, myotomies, tenotomies, capsuloplasties, arthrodesis, selected neurectomies, etc. Cases with spasticity and a minor degree of athetosis can be managed similarly.2. a. 8 Tendon transfers are contraindicated in the pure athetoid patient. 3 In these cases, tendon transfers or other
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soft tissue procedures may transfer the original distorted position to another group of muscles and produce a worse postoperative situation. Therefore, patients with pure or predominant athetosis are rarely candidates for surgery of the upper extremity. Spastic hemiplegia. Patients with spastic hemiplegia are good candidates for surgery. In general, these individuals offer the best local and general conditions to achieve improved hand function, muscular balance, and correction of deformity. Patients with spastic tetraplegia are rarely candidates for hand surgery because they frequently present associated severe, general neurologic defects. Young patients. Reconstructive procedures for the spastic hand in cerebral palsy usually can be carried out after the ages of 4 or 5 years. Some degree of maturation of the central nervous system is necessary to obtain adequate cooperation from the patient during the postoperative reeducation. Youngsters who have completed their growth may present with muscular fibrosis superimposed (myostatic contracture) on the spasticity. Adults with afflictions that began in childhood usually have accepted their cosmetic and functional defects and usually are not good candidates for surgery. Adequate sensibility. As previously mentioned, the great majority of patients who are candidates for reconstructive surgery have some loss of sensibility in proprioception and stereognosis (inability to recognize objects without sight); however, this is not a contraindication to surgical improvement of the function and cosmesis of the affected hand.2. :1 Children with stereognosis defects prefer to use the normal hand (spastic hemiplegia); they will use the affected hand only when necessary for bimanual activities and always as an assistive limb. When sensibility is not affected, better function can be obtained and independent function of the affected hand can be expected. 3 In those few patients presenting severe sensory defects, with loss of even touch and pain sensation, any attempts at functional restoration through surgery are ineffective. Sufficient IQ and emotional stability. Surgical prerequisites for upper limb reconstruction include adequate behavior patterns, ability to cooperate, and good motivation, psychological status, and IQ.I The patient must be sufficiently intelligent to understand the surgical goals and to be able to collaborate during postoperative reeducation. Mild alterations of the mental condition are not a surgical contraindication. Surgery is also contraindicated when other major neurologic defects are present, such as defects in speech, vision, and hearing. When spasticity is markedly increased by emotional stimuli, it is very difficult to obtain reasonably good results. 4 Usually, surgery is indicated if the IQ is greater than 70. Voluntary control of spastic muscles and ability to release the fingers by wrist flexion. Voluntary control of the spastic muscles and some ability to open the fingers by active wrist flexion are important to obtain a good postoperative functional result. I. 3 The most favorable candidates for surgery are found in patterns I and II of the classifications presented. Adults and older patients with hemiplegia of vascular origin do not adapt well to hand reconstruction because voluntary control of the wrist and fingers is usually absent. These patients generally cannot voluntarily flex the wristto open the fingers, and consequently, the hand is permanently closed.
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Surgical procedures The most common deformities that can usually be improved through reconstructive surgery are: thumb deformities and flexion contracture of the wrist and fingers. Other deformities that are occasionally corrected include swan-neck deformity, pronounced flexion contracture of the elbow, and pronation contracture of the forearm. Generally. all deformities are corrected at the same surgical stage. Thumb deformities, Surgery is indicated to hold the thumb out of the palm during grasp and to improve pinch. The surgical procedures indicated depend on the type of deformity presented: adduction contracture or adduction-flexion contracture (thumb-in-palm deformity). Adduction contracture. The adduction contracture basically depends on the spasticity of the adductor pollicis muscle. 2 . " There is adduction contracture of the first metacarpal, and the metacarpophalangeal and interphalangeal joints are in extension. Correction is obtained by the following methods: ( I ) Release of the proximal insertions of the adductor pollicis muscle at the level of the third metacarpal through a palmar incision, parallel to the proximal palmar crease ' : Usually it is not necessary to release the origin of the lateral thenar muscles in a pure or predominant spastic thumb deformity." (2) Tendon transfer to reinforce the abductor pollicis longus and extensor pollicis brevis. or tenodesis of the abductor pollicis longus: In the latter, the proximal end of the abductor pollicis longus is fixed to the radius" or to the distal tendon of the brachioradialis.:1. !I The abductor pollicis longus or extensor pollicis brevis can be shortened by tendinous plication. 111 Adduction-flexion contracture (tll11mh-in-palm def{mnity). The main deforming forces relate to the spasticity of the adductor pollicis and flexor pollicis longus muscles. The most frequently used and effective reconstructive procedures are: ( I ) release of the proximal insertions of the adductor pollicis muscles on the third metacarpal; (2) lengthening of the flexor pollicis longus at its musculotendinous junction in the forearm; (3) rerouting of the extensor pollicis longus and relocating it toward the radial aspect of the wrist; (4) reinforcement of the abductor pollicis longus and extensor pollicis longus by tendon transfers (motors: brachioradialis, flexor superficialis, palmaris longus, etc.); (5) shortening of the abductor pollicis longus by tendinous plication at the level of the distal end of the radius '''; (6) metacarpophalangeal arthrodesis can be indicated when the metacarpophalangeal joint is hypermobile in both extension and flexion (Arthrodesis alone, without proper release of contractures and dimunition of spasticity and without reinforcement of the abductor and extensor muscles, will not in itself eliminate the "thumb-in-palm" deformity. In performing metacarpophalangeal joint arthrodesis in children, damage to the epiphyseal line can be avoided by use of smooth fixation pins. Ill); and (7) metacarpophalangeal capsuloplasty. 1-:1. II This represents an excellent procedure to correct hyperextension deformity of this joint. The proximal end of the volar plate, 1. 11 or the radial sesamoid" is firmly fixed to the metacarpal neck in 10° to ISO of flexion. A Kirschner wire is placed obliquely across the joint to maintain the desired degree of flexion. Flexion contracture of the wrist and fingers. This deformity basically results from the spasticity and occasional myostatic contracture of the flexor muscles of the wrist and fingers and of the pronator teres muscles. The goal of surgery is to improve the opening of the hand without affecting voluntary closure of the digits and grasping functions. This is
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achieved by improving the muscular balance between the flexor and extensor muscles of the hand. Preoperatively, it is important to note the degree of wrist flexion needed to enable the patient to extend the fingers completely or partially. It is also important to note if the wrist can be extended with the fingers flexed. These tests demonstrate the degree of spasticity of the flexor muscles of the wrist and fin,gers, the functional condition of the wrist extensors. and the voluntary control I. " needed to correct the deformity. This evaluation allows classi fication (grouping) of grasp and release patterns and selection of the most appropriate surgical procedure for each patient. Arthrodesis of the wrist joint should be the exception rather than the rule in the spastic hand 2 . "; it is occasionally indicated in cases of predominant athetosis and only if the patient can voluntarily extend the fingers with the wrist held in neutral or mild flexion (5° to 10°). Wrist arthrodesis should never be done as an initial procedure in a spastic hand where the fingers completely close owing to spasticity when the wrist is passively held in extension. Therefore, wrist arthrodesis is contraindicated in a patient who requires wrist flexion in order to obtain finger extension. According to the patterns of pathologic hand function. previously presented. the most frequently encountered surgical indications to correct flexion contracture of the wrist and fingers are as follows: Pattern I. In this group, flexion spasticity is mild and mainly affects the flexor carpi ulnaris muscle and long muscles of the fingers. The procedures usually indicated are: (I) tenotomy of the distal tendon of the flexor carpi ulnaris" and (2) aponeurotic or musculoaponeurotic release of the medial epicondyle muscles."ln this procedure. 3 cm offascia and its septum are excised at the proximal part of the forearm. 6 cm distal to the medial epicondyle (aponeurotic release). Occasionally some muscle fibers need to be released because of myostatic contracture (musculoaponeurotic release). Pattern II. Surgical indications basically depend on the severity of the muscle spasticity and the functional condition of the wrist extensor muscles. The usual procedures follow: I. Tendon transfer of the flexor carpi ulnaris to the extensor carpi radialis brevis. This is indicated only when active wrist extensors are very weak or completely paralyzed (pattern group II. B). It is not indicated in group II. A. where active wrist extension is present. In the classic technique. '2 . '" the flexor carpi ulnaris tendon is passed around the ulnar border of the wrist and is fixed to the extensor carpi radialis brevis tendon since this muscle is the major dorsiflexor of the hand. The goal is to obtain wrist extension and supination of the forearm. The other wrist flexors. flexor carpi radialis and palmaris longus. must remain in place to avoid undesirable permanent wrist hyperextension postoperatively. If wrist extension is required without supination. the flexor carpi radialis can be passed through the interosseous membrane and sutured to the wrist extensor. 2. " 2. Aponeurotic or musculoaponeurotic release of the medial epicondyle muscles. In this procedure. the major part of the proximal end of the medial epicondyle muscles is left intact. It is indicated when finger extension is possible with less than 50° of wrist flexion.:! 3. Flexor muscle origin release procedure. '4 - IH This is indicated when extension of the fingers is possible but only with more than 50° of wrist flexion. This surgical technique allows the flexor muscles to reattach distally without inter-
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rupting their main neurovascular supply. This procedure decreases strength. spasticity. overactive stretch reflex. and myostatic contracture of the flexor-pronator muscle mass. Occasionally the lacertus fibrosus is sectioned. Additional release of the pronator teres at its distal end is most useful to improve the frequently associated pronation deformity. The proximal origin of the flexor carpi ulnaris muscle is left intact when this muscle is used for Green 's transfer. Pattern III. Patients with severe flexion of the fingers into the palm and total inability to extend the fingers even with full wrist flexion can be candidates for mulTiple Tendon releases in The forearm. As previously mentioned . these patients have a poor functional potential and inadequate sensibility and do not have voluntary grasp and release patterns. Multiple tendon lengthenings will allow the fingers to remain permanently out of the palm for cosmetic and hygienic reasons. In this procedure, the flexor superficialis tendons are divided distally. near the wrist, and the flexor digitorum profundus tendons are sectioned proximally at the mid forearm leve!l!'· 20; the fingers are then extended to a median flexed position. and while maintaining this position . the proximal end of the flexor superficialis tendons is sutured to the distal end of the flexor digitorum profundus tendons with laterolateral tenoraphies . The flexor tendons of the wrist are lengthened. Severe pronation contracture is improved by distal division of the pronator teres tendon. In severe contracture of the elbow, the biceps tendon is lengthened. Thumb deformities are corrected by the procedures previously discussed. Swan-neck deformity. Swan-neck deformities are commonly present in the cerebral palsied hand. In the classic spastic flexion-pronation deformity , the main deformity results from a muscle imbalance caused by permanent flexion of the wrist and metacarpophalangeal joints of the fingers and secondarily by intrinsic spasticity. I. :I . " Stretching of the volar plate of the proximal interphalangeal joint results in its hyperextension and in flexion of the distal interphalangeal joint. The fingers frequently lock in extension. and the ability and force of pinch and grasp are impaired. Once the finger develops severe swan-neck collapse deformities. surgical treatment is indicated. Mild swan-neck deformities can improve spontaneously with correction of flexion contracture of the wrist. because this decreases the traction of the digital extensor tendons over the middle phalanx . When the deformity is severe. it must be corrected . preferably by flexor tendon tenodesis" at the same surgical stage as correction of the flexor-pronation deformity. Tenodesis of the flexor sublimis tendon to the neck of the proximal phalanx" creates a checkrein to hyperextension; the tendon is fixed to bone and the tension should be adjusted to allow 20° to 40° of extension lag at the proximal interphalangeal joint. A small Kirschner wire is inserted across the joint to maintain the desired angle of flexion through the healing period. Flexion contracture of the elbow. Flexion contracture of the elbow is a common finding in the spastic upper limb and it is frequently influenced by emotional stimuli. Correction of marked flexion contracture of the elbow improves the appearance and function of the upper limb. A flexor muscle origin release or aponeurotic release of the medial epicondyle muscles produces a partial correction of the deformity. In severe flexion contracture of the elbow, a Z lengthening of the biceps tendon is indicated along with release of the origin of the long flexor muscles of the hand. Pronation contracture of the forearm. A pronated posi-
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Table I Excellent: I. Complete digital extension with less than 20° of wrist flexion 2. Complete thumb opening with good tip, lateral, and pulp pinch 3. Complete finger flexion 4. Active supination of more than 45° 5. Stable joints 6. Complete elbow extension 7. Good activities of daily living 8. Good voluntary control of muscles 9. Complete independence in the use of (he affected hand (usually with normal sensibility) Good: I. Complete digital extension with 20° to 50° of wrist flexion 2. Partial thumb opening with good lateral pinch 3. Complete or almost complete finger flexion 4. Active supination between 0° and 45° 5. Stable joints 6. Partial elbow extension; flexion contractures between 0° and 20° 7. Fair activities of daily living 8. Good voluntary control of muscles 9. Partial independence in the use of the affected hand (sensibility defects in proprioception and stereoception) Fair: I . Partial finger extension in spite of complete wrist flexion 2. Partial thumb opening and defective lateral pinch 3. Partial finger flexion with defective grasping 4. No active supination 5. Pronation contracture between 0° and 30° 6. Unstable joints 7. Flexion contracture of the elbow between 20° and 45° 8. Poor activities of daily living 9. Fair muscular control 10. Helping hand in bimanual activities (fair sensibility) Poor: I. Hand passive 2. Poor thumb function 3. No grasping 4. No active supination 5. Pronation contracture of more than 30° 6. Unstable joints 7. Flexion contracture of the elbow of more than 45° 8. No activities of daily living 9. Poor helping upper limb in bilateral activities (poor sensibility)
tion is more useful and desirable than a permanent supinated position. An origin release procedure of the flexor muscles and transfer of the flexor carpi ulnaris muscle around the ulnar border of the wrist (Green's procedure) improve mild pronation contractures. In severe cases , a tenotomy of the distal tendon of the pronator teres muscle can be coupled with the above procedures. Tenotomy of the pronator teres is indicated for fixed contractures that cannot be corrected by passive manipulation; it is also indicated if the patient desires improved supination and notices difficulties in carrying out activities of daily living. Classification of assessment of results The results of operative procedures for cerebral palsy in the upper extremity are difficult to predict and reproduce. Careful preoperative and postoperative evaluations are important in these patients. Results can be classified as excellent, good, fair, and poor, according to the function of the hand and correction of deformities and as suggested by Swanson' (Table I) .
The Journal of Zancolli et al.
HAND SURGERY
SPASTIC HAND EVALUATION COMMITTEE (CONGENITAL AND STROKE) Eduardo A. Zancolli, Chairman Sante Fe 954 4015 Buenos Aires, Argentina
Richard M. Braun, U.S.A. J. Leonard Goldner, U.S.A. Allan E. Inglis, U.S.A.
REFERENCES I. Swanson AB: Surgery of the hand in cerebral palsy .In Flynn JE, editor: Hand surgery, ed 3. Baltimore, 1982, The Williams &
Wilkins Co, pp 476-88 2. Goldner JL: The upper extremity in cerebral palsy. In Samilson RL, editor: Orthopaedic aspects of cerebral palsy. New York, 1975, Harper & Row, pp 221-57 3. Zancolli EA: Structural and dynamic bases of hand surgery, ed 2. Philadelphia, 1979,18 Lippincott Co 4. Zancolli EA, Zancolli ER: Surgical management of the hemiplegic spastic hand in cerebral palsy. Surg C1in North Am 61:395-406, 1981 5. Samilson RL, Morris JM: Surgical improvement of the cerebral-palsied upper limb. J Bone Joint Surg [Am] 46: 1203-16, 1964 6. Swanson AB: Surgery of the hand in cerebral palsy and the swan-neck deformity. J Bone Joint Surg [ Am] 42:951-64, 1960 7. Twitchell TE: Sensation and the motor deficit in cerebral palsy. Clin Orthop 46:55-62, 1966 8. Goldner JL: Reconstructive surgery of the hand in cerebral palsy and spastic paralysis resulting from injury to the spinal cord. J Bone Joint Surg [Am] 37:1141,1955 9. McCue FC, Honner R, Chapman we: Transfer of the brachioradialis for hands deformed by cerebral palsy. J Bone Joint Surg [Am] 52:1171-80, 1970 10. Matev I: Surgical treatment of the spastic "thumh-in-palm" deformity. J Bone Joint Surg [Br] 45:703-8, 1963
Rene Malek, France Alfred B. Swanson, U.S.A.
II. Filler BC, Stark HH, Boyes J: Capsulodesis of metacar-
12.
I3.
14. 15.
16.
17.
18. 19.
20.
pophalangeal joint of the thumb in children with cerebral palsy. J Bone Joint Surg [Am] 58:667-70, 1976 Green WT: Tendon transplantation of the flexor carpi ulnaris for pronation-flexion deformity of the wrist. Surg Gynecol Obstet 75:337-42, 1942 Green WT, Banks HH: Flexor carpi ulnaris transplant and its use in cerebral palsy. J Bone Joint Surg [Am] 44:148343-52, 1962 Page CM: An operation for the relief of flexion contracture in the forearm. J Bone Joint Surg [Am] 5:233-4, 1923 Inglis AE, Cooper W: Release of the flexor-pronator origin for flexion deformities of the hand and wrist in spastic paralysis. J Bone Joint Surg [Am] 48:847-57, 1966 Swanson AB: Surgery of the hand in cerebral palsy and muscle origin release procedures. Surg Clin North Am 48: 1129-38, 1968 Keats S: Surgical treatment of the hand in cerebral palsy: Correction of thumb-in-palm and other deformities. J Bone Joint Surg [Am] 47:274, 1964 White WF: Flexor muscle slide in the spastic hand. The Max Page operation. J Bone Joint Surg [Br] 54:453-9, 1972 Zancolli EA: Un nuevo metodo de correction de las contracturas congenitas de los musculos flexores digitales (alargamiento intertendinoso). Prensa Med Argentina 44:279-81,1957 Braun RM, Guy TV, Roper B: Preliminary experience with superficialis-to-profundus tendon transfer in the hemiplegic upper extremity. J Bone Joint Surg [Am] 52:466-72, 1974
Report of the Committee on Spinal Cord Injuries Erik A. Moberg, M.D.,* Chairman
This report will deal only with upper limb problems secondary to spinal cord injuries. Recent advances have clearly shown l - 15 that the continued prevailing negative attitude toward arm and hand surgery for improvement of function in tetraplegia secondary to spinal cord injury is no longer justified. This viewpoint was stressed by all the members of the International Group Conference in Edinburgh, 1978.10 However, this field of upper extremity surgery has to be approached with great care and knowledge. A new way to think, different from the concepts routinely used in everyday hand surgery, is required. Under such circumstances, the risk of
Correspondence: Erik Moberg, M.D., Terrassgatan 15, 411 33 Goteborg, Sweden. *Professor Emeritus of Orthopedic and Hand Surgery and Former Chief, Department of Orthopedic and Hand Surgery, Sahlgren's Hospital, University of Goteborg.
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further loss of function is almost nonexistent, especially if reversible procedures are used whenever possible. The old classification based on the so-called neurologic levels, for example, C5-C6, etc., is too crude for this field. Every arm must be classified separately.9-11 The classification must include and, according to most workers in the field, be built upon the presence or absence of afferent impulses, either from vision, or from cutaneous sensibility, or from both. The two-point discrimination test is to be used in this work, as ordinary sensory modalities are not a reliable base for classification of surgery. The classification is further completed by listing the available below-elbow muscles (including the brachioradialis) that have enough power to be used as transfers. The triceps muscle must also be evaluated and included. Generally, it is agreed that a classification should explain to the reader exactly what has been lost and what has been left. Important differences exist between various groups of patients according to geographic distribution: In the United
Eversmann
44 . Hecht 0, Lipsher E: Median and ulnar nerve entrapment caused by ectopic calcification. J HAND SURG 5:30-1,1980 45. Broudy AS, Leffert RD, Smith RJ: Technical problems with ulnar nerve transposition at the elbow: Findings and results of reoperation. J HAND SURG 3:85-9, 1978 46. Learmonth JR: Technique for transplanting the ulnar nerve. Surg Gynecol Obstet 75:792-3, 1942 47. Craven PR, Green DP: Cubital tunnel syndrome. Treatment by medial epicondylectomy. J Bone Joint Surg [Am] 62:986-9, 1980 48 . King T, Morgan FP: The treatment of traumatic ulnar neuritis . Mobilization of the ulnar nerve at the elbow by removal of the medial epicondyle and adjacent bone . Aust NZ J Surg 20:33-42, 1950 49. Eversmann WW Jr, Green DP. editors: Operative hand surgery. New York, 1982, Churchill-Livingstone, pp 957-1009 50 . Shea JD, McClain EJ: Ulnar nerve compression syndromes at and below the wrist. J Bone Joint Surg [Am] 51: 10'5-103, 1969 51. Swanson AB. Biddulph SL, Baughman FA. deGroot G: Ulnar nerve compression due to an anomalous muscle in the canal of Guyon . Clin Orthop 83:64-9. 1972 52. Howard FM: Ulnar nerve palsy in wrist fractures. J Bone Joint Surg [Am] 43:1197-201,1961 53 . Bakke JL , Wolff HG: Occupational pressure neuritis of the deep palmar branch of the ulnar nerve. Arch Neurol Psychiatry 60:549-53 . 1948 54. Comtet J, Quicot I, Moyen B: Compression of the deep palmar branch of the ulnar nerve by the arch of the adductor pollicis. Hand 10:176-80, 1978 55. Gori DR: Carpometacarpal dislocation producing compression of the deep branch of the ulnar nerve. J Bone Joint Surg [Am] 53:1387-90,1971 56. Vance RM, Gelberman RH: Acute ulnar neuropathy with fractures at the wrist. J Bone Joint Surg [Am] 60:962-5, 1978 57 . Kaplan EB: Variation of the ulnar nerve at the wrist. Bull Hosp Joint Dis 24:85-8. 1963 58 . Engber WD , Cmeiner JG: Palmar cutaneous branch of the ulnar nerve . J HAND SURG 5:26-9 , 1980
59. Lotem M, Fried A, Levy M. Solzi P, Najenson T. Nathan H: Radial palsy following muscular effort. A nerve compression syndrome possibly related to a fibrous arch of the lateral head of the triceps. J Bone Joint Surg [Br] 53:500-6, 1971 60. Manske PR: Compression of the radial nerve by the triceps muscle. Case report. J Bone Joint Surg [Am] 59:835-6. 1977 61. Packer JW, Foster RR, Garcia A, Grantham SA: The humeral fracture with radial nerve palsy: Is exploration warranted? Clin Orthop 88:34-8, 1972 62. Lister GD, Belsole RB, Kleinert HE: The radial tunnel syndrome. J HAND SURG 4:52-9, 1979 63 . Roles NC. Maudsley RH: Radial tunnel syndrome. Resistant tennis elbow as a nerve entrapment. J Bone Joint Surg [Br] 54:499-508, 1972 64. Wartenberg R: Cheiralgia paresthetica (isolierte neuritis des ramus superficial is nervi radialis). Zeitung Neurol Psychiatry 141:145-55. 1932 65. Williams HT, Carpenter NH: Surgical treatment of the thoracic outlet compression syndrome. Arch Surg 113:850-2. 1978 66. Gilliatt RW, Willison RG, Dietz V, Williams IR: Peripheral nerve conduction in patients with a cervical rib and band. Ann NeuroI4:124-9,1978 67. Howard FM, Shafer SJ: Injuries to the clavicle with neurovascular complications. A study of fourteen cases. J Bone Joint Surg [Am] 47: 1335-46. 1965 68 . Lain TM: The military brace syndrome: A report of sixteen cases of Erb's palsy occurring in military cadets. J Bone Joint Surg [Am] 51:557-60,1969 69. Gilliat RW: Classical neurological syndrome associated with cervical rib and band. Ann NeuroI4:124-9, 1979 70. Glover JL. Werth RM, Bendick PJ , et al: Evoked responses in the diagnosis of thoracic outlet syndrome. Surgery 89:86-93, 1981 71 . Dale WA: Thoracic outlet compression syndrome. Arch Surg 117: 1437-45,1982
Surgery of the spastic hand in cerebral palsy: Report of the Committee on Spastic Hand Evaluation Eduardo A. Zancolli, M.D.,* Chairman, Leonard 1. Goldner, M.D.,** and Alfred B. Swanson, M.D.***
Reprint requests: Eduardo A. Zancolli, M.D ., Avenida Alvear 1535, Buenos Aires, 1014 Argentina . *Professor of Orthopedics . University of Buenos Aires; Chief of Surgery of the National Rehabilitation Center. Buenos Aires . '*Professor and Chairman of Orthopaedic Surgery. Duke University. Durham. N.C. ***Director of Orthopaedic and Hand Surgery Training Program. Blodgett and Butterworth Hospitals, Grand Rapids. Mich.; Professor of Surgery. Michigan State University. Lansing. Mich.
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Most patients with cerebral palsy involvement of the upper extremity are not candidates for surgical reconstructive procedures . However, selected deformities related to muscle imbalance secondary to spasticity may be corrected by appropriate surgical procedures . Although surgery cannot make a functionally poor limb perfect, it can greatly improve the initial condition. A reasonable degree of success can be obtained if the patients are selected carefully through precise and complete examination, testing, and clinical evaluation of impairment of daily life activities. I. 2 Most poor surgical re-
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suIts are due to poor indication, selection, or execution of the surgical techniques." Rehabilitation of the spastic hand in cerebral palsy is a complex problem in reconstructive surgery . The initial central nervous system lesion can produce abnormal hand function patterns secondary to spasticity, with variable degrees of flaccid paralysis and paresis. general neurologic disorders, and disturbances in hand sensibility. As a result, the spastic muscles cannot be used as tendon transfers with the same efficiency as in patients with exclusive flaccid paralysis .~ This article will discuss: (I) the clinical factors influencing the selection and results of surgical treatments; (2) the preoperative evaluation for selection of surgical candidates; a classification of patterns of hand deformity and function will be presented also; (3) the surgical goals and prognosis; (4) surgical indications; (5) most commonly used surgical procedures; and (6) a classification for assessment of results. Clinical factors influencing surgical treatment and results The principal clinical factors influencing surgical treatment are: (I) type of neuromuscular disorder. (2) general neurologic disorders. (3) topographic involvement. (4) hand sensibility impairment. (5) severity of hand's deformity. and (6) voluntary ability to grasp and release . Type of neuromuscular disorder. There are three main types of neuromuscular disorders produced by the lesion of the central nervous system: (I) spastic or pyramidal (50%), (2) dystonic or extrapyramidal (40%), and (3) mixed (10%) . Most cases have pyramidal and extrapyramidal involvement , but usually one type of disorder predominates. Typical findings of each type of disorder will be discussed. Spastic type. The characteristics of the spastic type of cerebral palsy include the following: I. Muscle spasticity: The most common posture of the spastic upper Ii mb is one of elbow , wrist, and finger flexion with forearm pronation and the thumb in adduction or flexion-adduction. These deformities depend on the spasticity of the extrinsic muscles of the forearm and hand and most often on that of the flexor-pronator mass. Occasionally, spasticity produces some internal rotation contracture of the shoulder. Very seldom are the intrinsic muscles of the hand the principal deforming forces (predominant intrinsic spasticity).:!. 4 Muscular tension produced by spasticity increases progressively as the muscle is gradually stretched. Spasticity is posturally and emotionally induced and is rather constant unless the child is asleep or under general anesthesia ." 2. Synchronous activity or cocontraction: This represents an abnormal reaction of the spastic muscles during rest or when the muscles are acting as antagonists.' Antagonist muscles remain electrically active on both flexion and extension of the involved part of the limb. A typical finding is the persistent activity of the flexor muscles of the wrist when complete finger and wrist extension is attempted, especially at the level of the flexor carpi ulnaris.:! Synchronous activity produces a defect of normal grasping and release patterns of the hand . 3. Overactive stretch reflex: Hyperactivity of the normal stretch reflex is produced by failure of the normal muscle lengthening reaction on elongation by sudden stretching .6 Owing to the hyperactive stretch reflex, the spastic muscle contracts at the same point in the arc of motion each time the
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passive elongation maneuver is produced . Stretch reflex can be investigated for each muscle or group of muscles by appropriate maneuvers. 3 Spasticity and overactive reflexes can be decreased by certain surgical procedures, such as lengthening of distal tendons or release of proximal muscle insertions. Selective neurotomies used in the past are now contraindicated in most cases because they produce too much associated muscle weakness .6 Muscles with cocontraction and overactive stretch reflex can be used as tendon transfers; a typical example is the transfer of a spastic flexor carpi ulnaris to extend the wrist. 4. Hyperreflexion or increased tendon jerks 5 . Positive Hoffmann reflex 6 . Diminished superficial reflexes 7 . Clonus 8. Slowness and weakness of voluntary contraction and loss of control of fine movements 9. Myostatic contractures: After long-standing flexion contracture , the spastic muscles have a tendency to secondary retraction owing to fibrosis . Secondary muscular fibrosis can be demonstrated under general anesthesia or peripheral nerve block . Myostatic contracture, as frequently seen in the flexor muscles of the fingers and wrist, can be treated either by physical methods of stretching with casts or braces or by surgical tendon lengthening or proximal muscular release . I. 6 10. Aaccid paresis or paralysis: In the typical flexionpronation deformity, the extensor and supinator muscles of the hand and forearm are usually affected by flaccid paresis or paralysis according to the severity of deformity. 2-4 Extrapyramidal type . This ty~' of neuromuscular disorder may be represented by athetosis, clfaxia , tremor, and rigidity . The most frequent extrapyramidal disorder is athetosis (25%) and it is characterized by: (I) abnormal, involuntary, and poorly coordinated movements with varying degrees of tension; the deformity decreases at rest and disappears during sleep, but it is accentuated by efforts to move or by any emotional or environmental stimulus; (2) delayed postural development; (3) hypotonus in infancy, which may change with growth to increased tonus in stress situations; (4) decreased reflexes in infancy , which may become hyperactive later; (5) no tendency to muscular contracture; (6) absence of Hoffmann reflex; and (7) frequently preserved sensibility of the hand . Trem or is represented by involuntary movements that folIowa regular rhythmic pattern in which flexor and extensor muscles contract alternatively . Ataxia is characterized by disturbed balance and equilibrium, muscle incoordination, and hypotonia . Rigidity is demonstrated by resistance to movement through the hand's entire range with no exaggerated stretch reflex: both contracting muscles and their antagonists are affected . There is a greater tendency for diminished motion rather than abnormal motions . Mixed form. This is a common form; most frequently, spasticity is present with athetosis as characterized by the association of hypertonus and abnormal movements. General neurologic disorders. The general neurologic disorders found in cerebral palsy include the following: speech impairments (delayed speech, aphasia , voice disorders); visual impairments (strabismus, optic atrophy, cataract, etc .); hearing impairments (perceptive, conductive and central deafness); convulsion disorder; behavior disorders re-
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suiting from brain injury; emotional instability; distractibility and defective concentration and cooperation; psychological problems; nutritional problems; perceptual and conceptual disturbances; mental deficiency (intelligence quotient); and defects in spatial judgment or spatial orientation. Topographic involvement. Cerebral palsy can involve all four extremities as follows: (I) tetraplegia-both arms and both legs; (2) hemiplegia-one side of the body, usually with greater involvement of the upper limb; (3) diplegia-all four limbs, with the lower limbs much more severely involved than the upper limbs; (4) triplegia-three extremities, usually with both legs and one arm being affected; and (5) monoplegia-single limb involvement. Hand sensibility impairment. Most patients with cerebral palsy have satisfactory epicritic sensation. The patient usually can recognize hot, cold, sharp, and dull sensations without difficulty, but often shows deficits in proprioception (conscious control of position, motion, and power) and in stereoception or tactile gnosis (ability to recognize objects by touch only) because of cortical involvement. 2 • :I. 7. H Almost two thirds of the cases of pyramidal involvement present impairment of sensibility.
Severity of deformity and voluntary grasp and release pattern. Surgical results are closely related with the degree of deformity of the hand, which depends on the severity ofimbalance between the spastic and paretic or paralytic muscles, and with its voluntary ability to grasp and release. These clinical characteristics must be examined with great precision during preoperative evaluation.
Preoperative evaluation for selection of surgical candidates A complete and precise preoperative evaluation of all factors influencing surgical treatment and results is a prerequisite to any procedure and includes both a general clinical evaluation and evaluation of the upper limb. General clinical evaluation. The general clinical evaluation should determine the following: (1) etiology of central nervous system lesion; (2) type of neuromuscular disorder; (3) presence of general neurologic disorders; (4) topographic involvement; and (5) evaluation of intellectual maturity by psychological testing (lQ); normal-more than 90, mildly retarded-between 70 and 90, and severely retarded-less than 70. Upper limb evaluation. A detailed examination of the upper limb includes (1) evaluation of the range of motion of all joints; (2) assessment of grasp and release pattern; (3) grasp and pinch strength; (4) performance of activities of daily living; (5) hand sensibility examination; (6) type of deformity; and (7) classification of voluntary grasp and release patterns. Active and passive range of motion of all the joints. Shoulder, elbow, forearm, wrist, fingers, and thumb are evaluated. The range of motion should be recorded on the principle that the neutral position equals 0° (American Academy of Orthopaedic Surgeons, 1965). The patient is asked to straighten his fingers and to make a fist, in order to obtain a general idea of motion of all digits and to note any limited motion or abnormal attitudes. Assessment of voluntary ability to grasp and release the hand. Different tests are used to evaluate the ability to open and close the hand, and the patterns of prehension are noted. 1. The ability to open the hand is evaluated by: (1) mea-
suring with disks of graduated sizes-6, 8, 10, 12, 14, 16, and 18 cm; (2) determining hand placement over the table; and (3) measuring the degrees of wrist flexion that will enable the patient to extend the fingers. 2. Grasp and pinch patterns are studied. The ability to grasp is evaluated through the use of spherical balls of graduated sizes (5, 8, 10, and 12 cm) and cylinders of graduated sizes (3, 5, 8, 10, and 12 cm). Pinch patterns, including tip, pulp, and lateral pinches, chuck or three-digit pinch, and pinch to separate fingers, are evaluated with the use of different objects. 3. Speed, skill, voluntary control, and coordination for prehension are functions that are evaluated by the pickup test and by manipulation of different objects. The use of manipulative toys in evaluating children can help the surgeon to make decisions on the indication of reconstructive procedures to improve both function and cosmetics. 2 Coordination between both hands is observed and recorded. Grasp and pinch strength. The grip strength is evaluated with a dynamometer. (A sphygmomanometer may be used to record grip strength in weak hands.) A pinch meter is used to evaluate pinch strength. Activities of daily living. Activities of daily living involving hygiene, dressing, writing, and feeding are evaluated. Hand sensibility. The principal tests used to evaluate hand sensibility include: (I) tactile gnosis (Tactile recognition is rated according to the patient's ability to recognize objects by their shape, size, consistence, and temperature. Testing is done in small children by differentiating cubes from marbles and in others by Seddon's coin test.); two-point discrimination (The modified Moberg's paper clip test is very useful.); and stereognosis. This is tested by moving the fingers vertically. Type of deformity. The most commonly noted deformities are outlined here: I. II. III. IV.
Shoulder-internal rotation contracture Elbow-flexion contracture Forearm-pronation contracture Hand A. Wrist and fingers-flexion and ulnar contracture of wrist, and flexion contracture of fingers, with occasional swan-neck deformities B. Thumb 1. Adducted thumb (adduction of the first metacarpal) 2. Flexion-adduction (thumb-in-palm deformity)
Classification of voluntary grasp and release patterns. The classification of patterns of hand deformity and of voluntary grasp and release patterns of the fingers can help the examiner to determine a program of treatment and its prognosis. 2-4 Three different patterns of hand function can be demonstrated in the spastic or spastic-athetoid patient. These patterns usually are associated with abnormal thumb posture in adduction of flexion-adduction contracture, elbow flexion contracture, and pronation contracture of the forearm of variable degrees of severity. The degree of sensory impairment may vary considerably from one pattern to another. Pattern I: The fingers can actively extend with the wrist in less than 20° of flexion. This represents a mild deficiency to open the fingers, and the appearance of the extremity is satisfactory. These patients can benefit from reconstructive surgery, particularly if the proprioceptive sensation is good. Pattern II: The wrist and fingers are maintained in flexion.
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Active finger extension is possible only with more than 20° of wrist flexion. These patients can be subdivided in two groups according to their ability to voluntarily extend the wrist when the fingers are flexed. Pattern II, A: The patients have positive voluntary extension of the wrist when the fingers are flexed; the extensors of the wrist are active and have good voluntary control. Pattern II, B: The subject is unable to extend the wrist when the fingers are flexed; the extensors of the wrist are very weak or paralyzed. Surgical treatments can provide reasonably good results in patients with patterns I and II, considering their limited motor power to close the hand and their decreased stereoception and proprioception. Functional result is better when sensibility is not affected. Pattern III: There is a severe flexion deformity of the hand. There is no active finger extension even with maximal wrist flexion, and there is no active wrist extension even with the fingers flexed. Passive extension of the fingers and thumb is possible when the wrist is flexed. Hand sensibility is usually poor. In these cases, it is very difficult to obtain a satisfactory hand function, and prognosis after surgery is poor. Surgical goals and prognosis The principal goals in surgical rehabilitation of the spastic hand are: (I) to improve grasp and release patterns; (2) to improve hand cosmesis; and (3) to improve the psychological status of the patient and his family. According to the classification just described, basic hand functions in grasp, release, and pinch functions can be significantly improved in patterns I and II. In these cases it is possible to obtain: (I) improved finger release with decreased flexion of the wrist; (2) decreased spasticity of the flexor muscles of the elbow, wrist, and fingers; (3) partial correction of forearm pronation contracture; (4) correction of thumb-inpalm deformity; (5) improved lateral pinch; and (6) improved grasp. Improvement in the existing pattern of function can be achieved by improving the balance between the spastic pronator-flexor muscles and the normal or paretic extensorsupinator muscles. Attempts to radically modify the existing patterns of activity usually will result in a functional disaster. Only in very mild cases of pattern I is it possible to obtain complete release of the digits with simultaneous and complete extension of the wrist. In patients with pattern III, surgery is indicated primarily to improve the appearance, hygiene and comfort. This can be achieved by reducing the spasticity of the flexor-pronator muscles without trying to obtain active hand release. Surgical indications The principal prerequisites to any surgical procedure in the spastic patient are listed here. Spastic or spastic-athetosis type of neuromuscular disorder. Patients with pure spasticity are good candidates for surgery provided there are no other contraindicating factors and that a reasonable degree of improvement can be predicted. The surgical procedures most often used in these cases include: tendon transfers, myotomies, tenotomies, capsuloplasties, arthrodesis, selected neurectomies, etc. Cases with spasticity and a minor degree of athetosis can be managed similarly.2. a. 8 Tendon transfers are contraindicated in the pure athetoid patient. 3 In these cases, tendon transfers or other
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soft tissue procedures may transfer the original distorted position to another group of muscles and produce a worse postoperative situation. Therefore, patients with pure or predominant athetosis are rarely candidates for surgery of the upper extremity. Spastic hemiplegia. Patients with spastic hemiplegia are good candidates for surgery. In general, these individuals offer the best local and general conditions to achieve improved hand function, muscular balance, and correction of deformity. Patients with spastic tetraplegia are rarely candidates for hand surgery because they frequently present associated severe, general neurologic defects. Young patients. Reconstructive procedures for the spastic hand in cerebral palsy usually can be carried out after the ages of 4 or 5 years. Some degree of maturation of the central nervous system is necessary to obtain adequate cooperation from the patient during the postoperative reeducation. Youngsters who have completed their growth may present with muscular fibrosis superimposed (myostatic contracture) on the spasticity. Adults with afflictions that began in childhood usually have accepted their cosmetic and functional defects and usually are not good candidates for surgery. Adequate sensibility. As previously mentioned, the great majority of patients who are candidates for reconstructive surgery have some loss of sensibility in proprioception and stereognosis (inability to recognize objects without sight); however, this is not a contraindication to surgical improvement of the function and cosmesis of the affected hand.2. :1 Children with stereognosis defects prefer to use the normal hand (spastic hemiplegia); they will use the affected hand only when necessary for bimanual activities and always as an assistive limb. When sensibility is not affected, better function can be obtained and independent function of the affected hand can be expected. 3 In those few patients presenting severe sensory defects, with loss of even touch and pain sensation, any attempts at functional restoration through surgery are ineffective. Sufficient IQ and emotional stability. Surgical prerequisites for upper limb reconstruction include adequate behavior patterns, ability to cooperate, and good motivation, psychological status, and IQ.I The patient must be sufficiently intelligent to understand the surgical goals and to be able to collaborate during postoperative reeducation. Mild alterations of the mental condition are not a surgical contraindication. Surgery is also contraindicated when other major neurologic defects are present, such as defects in speech, vision, and hearing. When spasticity is markedly increased by emotional stimuli, it is very difficult to obtain reasonably good results. 4 Usually, surgery is indicated if the IQ is greater than 70. Voluntary control of spastic muscles and ability to release the fingers by wrist flexion. Voluntary control of the spastic muscles and some ability to open the fingers by active wrist flexion are important to obtain a good postoperative functional result. I. 3 The most favorable candidates for surgery are found in patterns I and II of the classifications presented. Adults and older patients with hemiplegia of vascular origin do not adapt well to hand reconstruction because voluntary control of the wrist and fingers is usually absent. These patients generally cannot voluntarily flex the wristto open the fingers, and consequently, the hand is permanently closed.
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Surgical procedures The most common deformities that can usually be improved through reconstructive surgery are: thumb deformities and flexion contracture of the wrist and fingers. Other deformities that are occasionally corrected include swan-neck deformity, pronounced flexion contracture of the elbow, and pronation contracture of the forearm. Generally. all deformities are corrected at the same surgical stage. Thumb deformities, Surgery is indicated to hold the thumb out of the palm during grasp and to improve pinch. The surgical procedures indicated depend on the type of deformity presented: adduction contracture or adduction-flexion contracture (thumb-in-palm deformity). Adduction contracture. The adduction contracture basically depends on the spasticity of the adductor pollicis muscle. 2 . " There is adduction contracture of the first metacarpal, and the metacarpophalangeal and interphalangeal joints are in extension. Correction is obtained by the following methods: ( I ) Release of the proximal insertions of the adductor pollicis muscle at the level of the third metacarpal through a palmar incision, parallel to the proximal palmar crease ' : Usually it is not necessary to release the origin of the lateral thenar muscles in a pure or predominant spastic thumb deformity." (2) Tendon transfer to reinforce the abductor pollicis longus and extensor pollicis brevis. or tenodesis of the abductor pollicis longus: In the latter, the proximal end of the abductor pollicis longus is fixed to the radius" or to the distal tendon of the brachioradialis.:1. !I The abductor pollicis longus or extensor pollicis brevis can be shortened by tendinous plication. 111 Adduction-flexion contracture (tll11mh-in-palm def{mnity). The main deforming forces relate to the spasticity of the adductor pollicis and flexor pollicis longus muscles. The most frequently used and effective reconstructive procedures are: ( I ) release of the proximal insertions of the adductor pollicis muscles on the third metacarpal; (2) lengthening of the flexor pollicis longus at its musculotendinous junction in the forearm; (3) rerouting of the extensor pollicis longus and relocating it toward the radial aspect of the wrist; (4) reinforcement of the abductor pollicis longus and extensor pollicis longus by tendon transfers (motors: brachioradialis, flexor superficialis, palmaris longus, etc.); (5) shortening of the abductor pollicis longus by tendinous plication at the level of the distal end of the radius '''; (6) metacarpophalangeal arthrodesis can be indicated when the metacarpophalangeal joint is hypermobile in both extension and flexion (Arthrodesis alone, without proper release of contractures and dimunition of spasticity and without reinforcement of the abductor and extensor muscles, will not in itself eliminate the "thumb-in-palm" deformity. In performing metacarpophalangeal joint arthrodesis in children, damage to the epiphyseal line can be avoided by use of smooth fixation pins. Ill); and (7) metacarpophalangeal capsuloplasty. 1-:1. II This represents an excellent procedure to correct hyperextension deformity of this joint. The proximal end of the volar plate, 1. 11 or the radial sesamoid" is firmly fixed to the metacarpal neck in 10° to ISO of flexion. A Kirschner wire is placed obliquely across the joint to maintain the desired degree of flexion. Flexion contracture of the wrist and fingers. This deformity basically results from the spasticity and occasional myostatic contracture of the flexor muscles of the wrist and fingers and of the pronator teres muscles. The goal of surgery is to improve the opening of the hand without affecting voluntary closure of the digits and grasping functions. This is
The 10urnal of HAND SURGERY
achieved by improving the muscular balance between the flexor and extensor muscles of the hand. Preoperatively, it is important to note the degree of wrist flexion needed to enable the patient to extend the fingers completely or partially. It is also important to note if the wrist can be extended with the fingers flexed. These tests demonstrate the degree of spasticity of the flexor muscles of the wrist and fin,gers, the functional condition of the wrist extensors. and the voluntary control I. " needed to correct the deformity. This evaluation allows classi fication (grouping) of grasp and release patterns and selection of the most appropriate surgical procedure for each patient. Arthrodesis of the wrist joint should be the exception rather than the rule in the spastic hand 2 . "; it is occasionally indicated in cases of predominant athetosis and only if the patient can voluntarily extend the fingers with the wrist held in neutral or mild flexion (5° to 10°). Wrist arthrodesis should never be done as an initial procedure in a spastic hand where the fingers completely close owing to spasticity when the wrist is passively held in extension. Therefore, wrist arthrodesis is contraindicated in a patient who requires wrist flexion in order to obtain finger extension. According to the patterns of pathologic hand function. previously presented. the most frequently encountered surgical indications to correct flexion contracture of the wrist and fingers are as follows: Pattern I. In this group, flexion spasticity is mild and mainly affects the flexor carpi ulnaris muscle and long muscles of the fingers. The procedures usually indicated are: (I) tenotomy of the distal tendon of the flexor carpi ulnaris" and (2) aponeurotic or musculoaponeurotic release of the medial epicondyle muscles."ln this procedure. 3 cm offascia and its septum are excised at the proximal part of the forearm. 6 cm distal to the medial epicondyle (aponeurotic release). Occasionally some muscle fibers need to be released because of myostatic contracture (musculoaponeurotic release). Pattern II. Surgical indications basically depend on the severity of the muscle spasticity and the functional condition of the wrist extensor muscles. The usual procedures follow: I. Tendon transfer of the flexor carpi ulnaris to the extensor carpi radialis brevis. This is indicated only when active wrist extensors are very weak or completely paralyzed (pattern group II. B). It is not indicated in group II. A. where active wrist extension is present. In the classic technique. '2 . '" the flexor carpi ulnaris tendon is passed around the ulnar border of the wrist and is fixed to the extensor carpi radialis brevis tendon since this muscle is the major dorsiflexor of the hand. The goal is to obtain wrist extension and supination of the forearm. The other wrist flexors. flexor carpi radialis and palmaris longus. must remain in place to avoid undesirable permanent wrist hyperextension postoperatively. If wrist extension is required without supination. the flexor carpi radialis can be passed through the interosseous membrane and sutured to the wrist extensor. 2. " 2. Aponeurotic or musculoaponeurotic release of the medial epicondyle muscles. In this procedure. the major part of the proximal end of the medial epicondyle muscles is left intact. It is indicated when finger extension is possible with less than 50° of wrist flexion.:! 3. Flexor muscle origin release procedure. '4 - IH This is indicated when extension of the fingers is possible but only with more than 50° of wrist flexion. This surgical technique allows the flexor muscles to reattach distally without inter-
Vol. 8, No.5. Part 2 September 1983
rupting their main neurovascular supply. This procedure decreases strength. spasticity. overactive stretch reflex. and myostatic contracture of the flexor-pronator muscle mass. Occasionally the lacertus fibrosus is sectioned. Additional release of the pronator teres at its distal end is most useful to improve the frequently associated pronation deformity. The proximal origin of the flexor carpi ulnaris muscle is left intact when this muscle is used for Green 's transfer. Pattern III. Patients with severe flexion of the fingers into the palm and total inability to extend the fingers even with full wrist flexion can be candidates for mulTiple Tendon releases in The forearm. As previously mentioned . these patients have a poor functional potential and inadequate sensibility and do not have voluntary grasp and release patterns. Multiple tendon lengthenings will allow the fingers to remain permanently out of the palm for cosmetic and hygienic reasons. In this procedure, the flexor superficialis tendons are divided distally. near the wrist, and the flexor digitorum profundus tendons are sectioned proximally at the mid forearm leve!l!'· 20; the fingers are then extended to a median flexed position. and while maintaining this position . the proximal end of the flexor superficialis tendons is sutured to the distal end of the flexor digitorum profundus tendons with laterolateral tenoraphies . The flexor tendons of the wrist are lengthened. Severe pronation contracture is improved by distal division of the pronator teres tendon. In severe contracture of the elbow, the biceps tendon is lengthened. Thumb deformities are corrected by the procedures previously discussed. Swan-neck deformity. Swan-neck deformities are commonly present in the cerebral palsied hand. In the classic spastic flexion-pronation deformity , the main deformity results from a muscle imbalance caused by permanent flexion of the wrist and metacarpophalangeal joints of the fingers and secondarily by intrinsic spasticity. I. :I . " Stretching of the volar plate of the proximal interphalangeal joint results in its hyperextension and in flexion of the distal interphalangeal joint. The fingers frequently lock in extension. and the ability and force of pinch and grasp are impaired. Once the finger develops severe swan-neck collapse deformities. surgical treatment is indicated. Mild swan-neck deformities can improve spontaneously with correction of flexion contracture of the wrist. because this decreases the traction of the digital extensor tendons over the middle phalanx . When the deformity is severe. it must be corrected . preferably by flexor tendon tenodesis" at the same surgical stage as correction of the flexor-pronation deformity. Tenodesis of the flexor sublimis tendon to the neck of the proximal phalanx" creates a checkrein to hyperextension; the tendon is fixed to bone and the tension should be adjusted to allow 20° to 40° of extension lag at the proximal interphalangeal joint. A small Kirschner wire is inserted across the joint to maintain the desired angle of flexion through the healing period. Flexion contracture of the elbow. Flexion contracture of the elbow is a common finding in the spastic upper limb and it is frequently influenced by emotional stimuli. Correction of marked flexion contracture of the elbow improves the appearance and function of the upper limb. A flexor muscle origin release or aponeurotic release of the medial epicondyle muscles produces a partial correction of the deformity. In severe flexion contracture of the elbow, a Z lengthening of the biceps tendon is indicated along with release of the origin of the long flexor muscles of the hand. Pronation contracture of the forearm. A pronated posi-
Spastic hand ill cerebral palsy
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Table I Excellent: I. Complete digital extension with less than 20° of wrist flexion 2. Complete thumb opening with good tip, lateral, and pulp pinch 3. Complete finger flexion 4. Active supination of more than 45° 5. Stable joints 6. Complete elbow extension 7. Good activities of daily living 8. Good voluntary control of muscles 9. Complete independence in the use of (he affected hand (usually with normal sensibility) Good: I. Complete digital extension with 20° to 50° of wrist flexion 2. Partial thumb opening with good lateral pinch 3. Complete or almost complete finger flexion 4. Active supination between 0° and 45° 5. Stable joints 6. Partial elbow extension; flexion contractures between 0° and 20° 7. Fair activities of daily living 8. Good voluntary control of muscles 9. Partial independence in the use of the affected hand (sensibility defects in proprioception and stereoception) Fair: I . Partial finger extension in spite of complete wrist flexion 2. Partial thumb opening and defective lateral pinch 3. Partial finger flexion with defective grasping 4. No active supination 5. Pronation contracture between 0° and 30° 6. Unstable joints 7. Flexion contracture of the elbow between 20° and 45° 8. Poor activities of daily living 9. Fair muscular control 10. Helping hand in bimanual activities (fair sensibility) Poor: I. Hand passive 2. Poor thumb function 3. No grasping 4. No active supination 5. Pronation contracture of more than 30° 6. Unstable joints 7. Flexion contracture of the elbow of more than 45° 8. No activities of daily living 9. Poor helping upper limb in bilateral activities (poor sensibility)
tion is more useful and desirable than a permanent supinated position. An origin release procedure of the flexor muscles and transfer of the flexor carpi ulnaris muscle around the ulnar border of the wrist (Green's procedure) improve mild pronation contractures. In severe cases , a tenotomy of the distal tendon of the pronator teres muscle can be coupled with the above procedures. Tenotomy of the pronator teres is indicated for fixed contractures that cannot be corrected by passive manipulation; it is also indicated if the patient desires improved supination and notices difficulties in carrying out activities of daily living. Classification of assessment of results The results of operative procedures for cerebral palsy in the upper extremity are difficult to predict and reproduce. Careful preoperative and postoperative evaluations are important in these patients. Results can be classified as excellent, good, fair, and poor, according to the function of the hand and correction of deformities and as suggested by Swanson' (Table I) .
The Journal of Zancolli et al.
HAND SURGERY
SPASTIC HAND EVALUATION COMMITTEE (CONGENITAL AND STROKE) Eduardo A. Zancolli, Chairman Sante Fe 954 4015 Buenos Aires, Argentina
Richard M. Braun, U.S.A. J. Leonard Goldner, U.S.A. Allan E. Inglis, U.S.A.
REFERENCES I. Swanson AB: Surgery of the hand in cerebral palsy .In Flynn JE, editor: Hand surgery, ed 3. Baltimore, 1982, The Williams &
Wilkins Co, pp 476-88 2. Goldner JL: The upper extremity in cerebral palsy. In Samilson RL, editor: Orthopaedic aspects of cerebral palsy. New York, 1975, Harper & Row, pp 221-57 3. Zancolli EA: Structural and dynamic bases of hand surgery, ed 2. Philadelphia, 1979,18 Lippincott Co 4. Zancolli EA, Zancolli ER: Surgical management of the hemiplegic spastic hand in cerebral palsy. Surg C1in North Am 61:395-406, 1981 5. Samilson RL, Morris JM: Surgical improvement of the cerebral-palsied upper limb. J Bone Joint Surg [Am] 46: 1203-16, 1964 6. Swanson AB: Surgery of the hand in cerebral palsy and the swan-neck deformity. J Bone Joint Surg [ Am] 42:951-64, 1960 7. Twitchell TE: Sensation and the motor deficit in cerebral palsy. Clin Orthop 46:55-62, 1966 8. Goldner JL: Reconstructive surgery of the hand in cerebral palsy and spastic paralysis resulting from injury to the spinal cord. J Bone Joint Surg [Am] 37:1141,1955 9. McCue FC, Honner R, Chapman we: Transfer of the brachioradialis for hands deformed by cerebral palsy. J Bone Joint Surg [Am] 52:1171-80, 1970 10. Matev I: Surgical treatment of the spastic "thumh-in-palm" deformity. J Bone Joint Surg [Br] 45:703-8, 1963
Rene Malek, France Alfred B. Swanson, U.S.A.
II. Filler BC, Stark HH, Boyes J: Capsulodesis of metacar-
12.
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14. 15.
16.
17.
18. 19.
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pophalangeal joint of the thumb in children with cerebral palsy. J Bone Joint Surg [Am] 58:667-70, 1976 Green WT: Tendon transplantation of the flexor carpi ulnaris for pronation-flexion deformity of the wrist. Surg Gynecol Obstet 75:337-42, 1942 Green WT, Banks HH: Flexor carpi ulnaris transplant and its use in cerebral palsy. J Bone Joint Surg [Am] 44:148343-52, 1962 Page CM: An operation for the relief of flexion contracture in the forearm. J Bone Joint Surg [Am] 5:233-4, 1923 Inglis AE, Cooper W: Release of the flexor-pronator origin for flexion deformities of the hand and wrist in spastic paralysis. J Bone Joint Surg [Am] 48:847-57, 1966 Swanson AB: Surgery of the hand in cerebral palsy and muscle origin release procedures. Surg Clin North Am 48: 1129-38, 1968 Keats S: Surgical treatment of the hand in cerebral palsy: Correction of thumb-in-palm and other deformities. J Bone Joint Surg [Am] 47:274, 1964 White WF: Flexor muscle slide in the spastic hand. The Max Page operation. J Bone Joint Surg [Br] 54:453-9, 1972 Zancolli EA: Un nuevo metodo de correction de las contracturas congenitas de los musculos flexores digitales (alargamiento intertendinoso). Prensa Med Argentina 44:279-81,1957 Braun RM, Guy TV, Roper B: Preliminary experience with superficialis-to-profundus tendon transfer in the hemiplegic upper extremity. J Bone Joint Surg [Am] 52:466-72, 1974
Report of the Committee on Spinal Cord Injuries Erik A. Moberg, M.D.,* Chairman
This report will deal only with upper limb problems secondary to spinal cord injuries. Recent advances have clearly shown l - 15 that the continued prevailing negative attitude toward arm and hand surgery for improvement of function in tetraplegia secondary to spinal cord injury is no longer justified. This viewpoint was stressed by all the members of the International Group Conference in Edinburgh, 1978.10 However, this field of upper extremity surgery has to be approached with great care and knowledge. A new way to think, different from the concepts routinely used in everyday hand surgery, is required. Under such circumstances, the risk of
Correspondence: Erik Moberg, M.D., Terrassgatan 15, 411 33 Goteborg, Sweden. *Professor Emeritus of Orthopedic and Hand Surgery and Former Chief, Department of Orthopedic and Hand Surgery, Sahlgren's Hospital, University of Goteborg.
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further loss of function is almost nonexistent, especially if reversible procedures are used whenever possible. The old classification based on the so-called neurologic levels, for example, C5-C6, etc., is too crude for this field. Every arm must be classified separately.9-11 The classification must include and, according to most workers in the field, be built upon the presence or absence of afferent impulses, either from vision, or from cutaneous sensibility, or from both. The two-point discrimination test is to be used in this work, as ordinary sensory modalities are not a reliable base for classification of surgery. The classification is further completed by listing the available below-elbow muscles (including the brachioradialis) that have enough power to be used as transfers. The triceps muscle must also be evaluated and included. Generally, it is agreed that a classification should explain to the reader exactly what has been lost and what has been left. Important differences exist between various groups of patients according to geographic distribution: In the United