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

Treatment Principles

When considering any surgery on the limb of a patient with a cervical spinal cord injury, Moberg[11] discussed the importance of maintaining a supple hand for human contact, transfers, and wheelchair mobility and using reversible procedures that do not impair function.

Early treatment begins with inpatient rehabilitation to maintain passive range of motion, prevent injury/overstretch of the thumb, increase functional use of hands, and maximize wrist and elbow strength and finger tenodesis. It is important to prevent development of destructive patterns that would lead to tendon and ligament incompetence. Intermittent splinting provides functional hand position for natural tenodesis and the prevention of contractures. The final part of early treatment is to educate patients and their families on surgical alternatives to increase upper extremity function.

Patients should be evaluated early to determine their ICSHT class, which will aid in treatment decision making. A good surgical candidate has functional goals, is motivated, understands the benefits and limitations of surgery, demonstrates emotional and psychological stability/adjustment to disability, and is committed to the postoperative rehabilitation process. Surgical candidates have an injury at one of the cervical spine levels (C5-8) and should have an ICSHT class 1 or better. Patients are ideally evaluated by a multidisciplinary team, which consists of a physiatrist, spinal cord therapist, hand therapist, social worker, and surgeon. When the team decides that a patient is a good candidate, surgical options and postoperative therapy are discussed with the patient and family. The timing of surgery is a balance between stabilization of the patient's neurologic, emotional, and social recovery from his or her spinal cord injury and undergoing surgery, which will decrease a patient's independence during the rehabilitation process. In the United States, surgery is usually delayed for about a year after injury.