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

Patient Evaluation

Basic evaluation begins with a history of the spinal cord injury, which includes dates, method of injury, spinal cord injury level, other associated injuries, and surgical history. The patient's functional goals should be discussed to determine what activities the patient would like to regain. Active and passive range of motion of the joints are assessed, and contractures and spasticity are noted. All muscles of the upper extremity are graded with manual motor testing.

The brachioradialis (BR) is palpated with the elbow bent to 90° and the forearm in neutral rotation while active elbow flexion is resisted with a downward force applied to the distal forearm. If the muscle bulk easily displaces, it is likely too weak for transfer. It is important to determine whether both the extensor carpi radialis longus (ECRL) and extensor carpi radialis brevis (ECRB) are functioning. When one is transferred, the patient will rely on the other to extend the wrist. Both are usually intact if the wrist extension strength is 5/5 and there is a groove or depression between the muscle bellies of the ECRL and ECRB with strength testing (Bean sign)[10] (Figure 1). If the ECRL alone is functioning, the wrist radially deviates with extension because it inserts on the second metacarpal and wrist extension is 4/5.

Figure 1.

Photographs showing posterior deltoid-to-triceps transfer. A, The central third of the triceps tendon is elevated over the proximal ulna and olecranon. Dissection is continued proximally to the musculotendinous junction. B, No. 5 umbilical tape is placed in a drill hole in the olecranon. The tapes are woven in a shoestring pattern into the medial and lateral borders of the triceps tendon to close the gap created with the central third of the tendon elevated. C, A proximal incision is made over the posterior border of the deltoid. The umbilical tapes and triceps tendon are passed subcutaneously to the proximal incision. D, Both the triceps tendon and umbilical tapes are sewn to the deltoid tendon and muscle.