Management of Upper Extremities in Tetraplegia

Current Concepts

Michael S. Bednar, MD; Julie C. Woodside, MD


J Am Acad Orthop Surg. 2018;26(16):e333-e341. 

In This Article

Abstract and Introduction


Individuals with tetraplegia face many obstacles with activities of daily living. Although approximately 65% to 75% of individuals with tetraplegia would benefit from upper extremity surgery that could make many of their activities of daily living more spontaneous, only 14% of patients who are surgical candidates undergo tendon transfer procedures. A good surgical candidate has an injury at one of the cervical spine levels and an International Classification for Surgery of the Hand in Tetraplegia group of 1 or better, has functional goals, and is committed to the postoperative rehabilitation process. Surgery primarily consists of tendon transfers, tenodesis, and arthrodesis to restore elbow extension and hand pinch, grasp, and release. Nerve transfers and functional electrical stimulation are also options for treatment.


The estimated incidence of spinal cord injury in the United States is 40 cases per million or 12,500 new cases per year.[1] Approximately 276,000 individuals were living with spinal cord injuries in the United States in 2015. Nearly half of all injuries occur in individuals aged 16 to 30 years and approximately 80% occur in men. Those with tetraplegia have an injury at one of the cervical spine levels, and since 2010, the most frequent diagnosis at discharge is incomplete tetraplegia (45%). Approximately 14% of spinal cord injuries are complete tetraplegia. The estimated cost attributable to the injury for patients with C5-8 tetraplegia is $769,351 for the first year and $113,423 for each subsequent year. The lifetime cost for a person injured at age 25 is estimated to be $3.4 million.

Individuals with tetraplegia face many obstacles performing activities of daily living (ADLs) such as feeding, bathing, and dressing. Although it is estimated that approximately 65% to 75% of these patients would benefit from upper extremity surgery that could make many of these tasks more spontaneous, <400 of these surgeries are performed per year.[2,3] In other words, only 14% of patients who are surgical candidates actually undergo tendon transfer procedures.[4] Factors that explain why few patients undergo surgery include a lack of communication between rehabilitation specialists, physiatrists, and surgeons; poor access to care; and poor knowledge that such procedures are possible. A lack of coordinated cross-specialty collaboration seems to be the greatest barrier to appropriate use of upper extremity reconstruction in patients with cervical spinal cord injury.[4] Patients state that the cost of the procedure, time away from work, and the belief that the cure for paralysis is imminent are major deterrents to undergoing the procedure. Patients who have defined goals and are educated on expected outcomes seem to have the highest satisfaction after tendon transfer procedures.[5]