Management of Upper Extremities in Tetraplegia

Current Concepts

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

Disclosures

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

In This Article

Surgical Techniques

Elbow Extension Reconstruction

Approximately 75% of patients with tetraplegia lose elbow extension. Elbow extension improves mobility in bed, independence with transfers, safety with driving, balance while sitting, weight shifting, overhead reach, and manual wheelchair use. The triceps functions as an antagonist to the BR, improving the ability of this muscle to function after transfer. The two methods to improve elbow extension are the posterior deltoid-to-triceps transfer[12] and the biceps-to-triceps transfer.[13]

In the posterior deltoid-to-triceps transfer, the posterior one third to one half of the deltoid is elevated from its humeral insertion. Splitting the deltoid too far proximally can injure the axillary nerve. The deltoid insertion is a broad, short tendon, which makes a secure tendon transfer difficult. The deltoid insertion may be elevated with a bony segment of the humerus to make a more secure point of fixation of the transfer. If the deltoid insertion is elevated without bone, the transfer is supplemented with a tibialis anterior free tendon graft, fascia lata, or Dacron tape. The deltoid is woven into the triceps by raising the central third of triceps tendon with a flap from the olecranon in a distal-to-proximal direction. In one study, 17 posterior deltoid-to-triceps transfers resulted in improved deltoid strength from zero preoperatively to grade 4 (47%), grade 3 (47%), and grade 2 (6%).[14] Wangdell and Fridén[15] reported on the outcomes of deltoid-to-triceps transfer at 6 months and 1 year after surgery. Improvement in the ability to perform all activities was reported, especially propelling a wheelchair and positioning the hand and arm in space. No patient rated any goals lower than before surgery. Reported complications include poor tendon quality of the posterior deltoid, which leads to tendency for elongation of weave.[16] Because of this, positioning of the arm is crucial to success of the procedure. The patient's arm is placed into a long arm splint in extension, which is removed on postoperative day 3 to 5 and changed to a constrained elbow brace. This is locked into full extension for 4 weeks and worn continuously for 11 weeks. Beginning the fifth postoperative week, elbow flexion in the constrained brace is increased 15° per week by changing the setting on the constrained mechanism. The patients are cautioned to not allow the arm to cross the midline for 11 weeks and to use a wheelchair trough and abduction bar. In bed, the shoulder should be abducted 30° and the arm elevated on pillows.

Candidates for a biceps-to-triceps transfer must have an intact brachialis and supinator to allow flexion and supination postoperatively.[17] The procedure begins with creation of an anterior incision along the distal 50% of the medial biceps, curving over the antecubital fossa to harvest the biceps tendon. After the release of the lacertus fibrosus is performed, the biceps tendon is transected to within 1 cm of the tendon insertion. Proximally, the fascial attachments of the biceps muscle are detached to reveal the distal most motor branches of the musculocutaneous nerve where they enter the muscle. The posterior incision is created 6 cm proximal to the olecranon along the midline. The incision curves laterally about the olecranon to the subcutaneous border of the ulna. To avoid compressing the radial nerve, the biceps tendon should be passed subcutaneously along the medial side. Wide dissection of the fascial attachment between the anterior and posterior compartments of the upper extremity is required to facilitate passage of the biceps muscle belly through this area. Although the risk of median and ulnar nerve compression exists, it is not concerning because these two nerves typically do not function in patients undergoing this procedure.

The triceps tendon is divided over the olecranon's tip, and a 10-mm drill bit is used to drill a hole through the proximal cortex of the olecranon. The drill should be aimed toward the lateral cortex with care taken not to perforate it. At the end of the biceps tendon, two No. 2 braided sutures (different colors) are secured 90° from each other using the Krackow technique. The different color sutures facilitate identification of the sutures that will be tied together to secure the transfer. Pulling on the sutures, the surgeon weaves the tendon through the triceps tendon two times. After the second weave, the bicep tendon exits where the triceps tendon was split near the hole drilled in the olecranon. Two large Keith needles are threaded with different colored sutures and are passed through the drilled hole and are then pulled through the lateral cortex of the olecranon. Tension on the biceps tendon is set to allow passive elbow flexion of no more than 45° postoperatively. Two or three No. 2–0 nonabsorbable sutures are placed between the biceps and triceps tendons to reinforce the tendon transfer. The postoperative course for biceps-to-triceps tendon transfer is similar to that for deltoid-to-triceps tendon transfer; however, the precaution against the arm crossing the midline is not pertinent with the biceps-to-triceps transfer. The patient learns to make the biceps muscle contract by supinating the forearm.

In a study comparing eight deltoid transfers with eight biceps tendon transfers performed to improve triceps extension, seven of eight biceps transfers had a grade of 3 or more at 2-year follow-up, whereas only one deltoid transfer had a grade of 3.[18] Substantial loss of elbow flexion torque was reported with both tendon transfer techniques (deltoid, 32%; biceps, 47%); however, this loss was not considered clinically significant.

Hand Reconstruction

Hand reconstruction goals depend on what muscles are functioning and expendable. Active dorsiflexion of the wrist is necessary before surgery to improve hand function. Using the ICSHT to evaluate possible surgeries to restore hand function is helpful.

In ICSHT group 0, no branches are intact below the elbow and therefore has no muscles available for transfer. Static splints and orthoses can aid function.

In group 1, transferring the BR can improve hand function by providing active wrist extension. The patient will be able to use tenodesis to move the digits. The power of the tenodesis can be augmented with a dynamic orthosis.[19]

In the Moberg procedure, wrist extension is achieved via transfer of the BR to the ECRB, and tenodesis of the FPL to the ulnar side of the distal radius provides a measurable thumb pinch with active wrist extension. The interphalangeal (IP) joint of the thumb is stabilized to allow the thumb tenodesis to pass through the metacarpophalangeal (MP) joint. Hentz et al[2] reported good results in 18 limbs (55%), and the patients were able to do functional activities (eg, self-care, communication, mobility). Three of 11 patients required revision to tighten the FPL tenodesis, further stabilize the MP joint, or to replace extruded IP joint pins.

The BR and ERCL are functioning in group 2. The BR is transferred to the FPL to provide active pinch. The IP joint of the thumb is stabilized. A tenodesis of the extensor pollicis longus (EPL) tendon is done at the wrist to provide thumb extension with wrist flexion. Waters et al[20] reviewed 15 patients (16 thumbs) with posttraumatic tetraplegia treated with a BR transfer to the FPL. Functional improvements were seen in 15 hands, and 80% were able to postoperatively perform a minimum of four ADLs that they could not perform before surgery. A direct correlation was observed between pinch strength and amount of triceps and wrist extensor strength.

In group 3, the BR, ECRL, and ECRB function. Controversy exists as to whether group 3 patients should be treated like group 2 patients, in which only pinch is restored or like group 4 patients in which pinch and grasp are restored. Typically, grasp is restored by transferring the ECRL to the FDP and preserving the ECRB to provide more centralized wrist extension. If the strength of the ECRB is overestimated, it may not be strong enough to provide active wrist extension.

The BR, ECRL, ECRB, and pronator teres are functioning in group 4 patients. The goals of surgical reconstruction are to restore elbow extension and hand pinch, grasp, and release. Group 5 patients have a functioning flexor carpi radialis, which is usually retained for better wrist control. The functions needed in this group are finger extension, thumb extension, intrinsic function, finger and thumb flexion, and thumb carpometacarpal stability. The procedures are performed in two stages, but some authors report good results with a single stage procedure.[21]

Stage 1 is the extensor phase.[19] Procedures performed in this stage include an EPL split tenodesis to stabilize the IP joint of the thumb and extensor digitorum communis (EDC) and EPL extrinsic extensor tenodeses. A static intrinsic tenodesis is done when excessive clawing of the digits is present. Controversy exists as to whether the thumb carpometacarpal should be fused. The fusion prepositions the thumb for active pinch against the radial index finger (20° to 25° extension, 40° to 45° abduction, slight pronation). The potential complication is that the thumb position may interfere with manual wheelchair use.

The EDC tenodesis is composed of two parts. First, the cascade of the fingers is reversed so in a resting posture, the index is more flexed than the middle, which is more flexed than the ring, which is more flexed than the small. A 2–0 nonabsorbable suture is placed most distally in the extensor tendon of the index finger and then 5 to 8 mm more proximally in each of the ulnar extensor tendons. Second, an ulnarly based U-shaped trough is made using a burr and curettes on the dorsoradial side of the distal radius proximal to the Lister tubercle (Figure 2). The sutured EDC tendons are placed into the trough for the tenodesis. The tenodesis is properly tensioned when the fingers begin to extend as the wrist flexes from extension to neutral.

Figure 2.

Photographs showing an extensor digitorum communis (EDC) tenodesis. A, An ulnarly based U-shaped trough is made using a burr and curettes on the dorsoradial side of the distal radius proximal to the Lister tubercle. The closed end of the U should be placed as radial as possible to keep the tendons from extruding. A vessel loop is passed through the trough to make sure that all cancellous bone had been removed. An Allis clamp holds the EDC tendons. The transected extensor pollicis longus tendon is grasped with a hemostat under the remaining extensor retinaculum at the Lister tubercle. B, The EDC tendons are passed through the bony trough.

The intrinsic tenodesis uses two free tendon grafts, one placed dorsal to the metacarpal neck of the index finger to extend the index and middle fingers and the other placed dorsal to the ring metacarpal neck to extend the ring and small fingers.[19] The grafts are passed deep to the deep transverse metacarpal ligaments in the second, third, and fourth web spaces and deep to the retinacular tissue of the index finger. The grafts are routed through the lumbrical canals. The location of the insertion of the graft depends on the integrity of the central slip, tested by the Bouvier maneuver. In this maneuver, as the MP joints are actively extending, full active extension is blocked. When the Bouvier maneuver is positive and the central slip is intact, the PIP joint extends through the intact central slip. In this case, the grafts are sewn to the lateral bands. If the central slips are incompetent, the graft must extend to the central slip at the proximal interphalangeal joint. Tension is then applied to the graft, and the opposite end is sewn to the corresponding structure in the middle finger. The other method to improve intrinsic function is through the "lasso" procedure, in which the flexor digitorum superficialis tendon is transferred to the first annular pulley of the flexor sheath.[22] This prevents MP joint hyperextension and increases IP extension when the wrist is flexed.[24] The lasso procedure is usually done during stage 2.

Thumb extension is achieved through EPL tenodesis and FPL split tenodesis (Figure 3). An incision is made over the radial border of the proximal phalanx. The FPL is split, and the radial half is transected distally, taken outside the oblique pulley and woven into the EPL. This equalizes the pull palmarly and dorsally of the FPL at the IP joint and causes the FPL to flex the MP joint.[10] The EPL tenodesis is done by transecting the EPL at its musculotendinous origin. The extensor retinaculum of the third compartment is left intact only over the Lister tubercle (Figure 2). The cut tendon is woven to the tendon distal to the Lister tubercle. Sewing the proximal tendon end to the tendon distal to the Lister tubercle using a Pulvertaft weave forms a stronger repair than sewing the tendon to the extensor retinaculum. Tension is set to allow thumb extension with the wrist neutral.

Figure 3.

Photograph showing a flexor pollicis longus (FPL) split tenodesis. The FPL is split and the radial half is transected distally, taken outside the oblique pulley, and woven into the extensor pollicis longus.

After the procedure, the wrist is placed into a dorsal blocking splint in 30° wrist extension, 60° MP flexion, and 20° to 30° IP flexion, with thumb position dictated by fusion position. Tenodesis motion is initiated at 4 weeks by gently moving the wrist through passive range of motion. Restoration of full passive motion is required before stage 2 surgery is done, usually 3 to 4 months after the first procedure (Figure 4).

Figure 4.

A and B, Clinical photographs showing extensor tenodesis of the thumb and fingers with the wrist in flexion. C and D, Clinical photographs showing full passive flexion of the fingers and thumb with wrist extension. Note the reversal of the cascade of the digits in flexion, which will provide a more stable base for pinch.

Stage 2 is the flexor phase, with the goal of restoring lateral pinch and grasp. The ECRB will provide wrist extension. The BR is transferred to the FPL, and the ECRL is transferred to the FDP (Figure 5). The FDP tendons are first sewn together, reversing the cascade of the digits. The tension should be set so that when the wrist is flexed, the fingers and thumb should be fully extended, and when the wrist is extended, the fingers should be flexed and the thumb pulp resting on the side of the middle phalanx of the index finger. The fingers must flex before the thumb adducts to prevent a thumb-in-palm deformity.

Figure 5.

A through C, Clinical photographs demonstrating stage 2 surgery. A, A 2–0 nonabsorbable suture is placed distally in the flexor tendon of the index finger and another suture is placed 5 to 8 mm more proximally in each of the ulnar flexor tendons. B, The flexor digitorum profundus (FDP) tendons are grasped with an Allis clamp. The clamp is twisted to set the tension on the digits. The extensor carpi radialis longus (ECRL) tendon is passed twice through the tendons and pulled distally. C, Final result of transfer of the brachioradialis to the flexor pollicis longus (top) and ECRL to FDP (bottom). After the third pass of the Pulvertaft weave is completed, the remaining tendon is folded over the weave and the repair is reinforced with a running, locking 2–0 nonabsorable suture on the radial and ulnar borders.

A dorsal blocking splint with the wrist in neutral, MPs in 60° flexion, IPs in slight flexion, and thumb in lateral pinch is worn for approximately 4 weeks. Fridén et al[23] reported a load failure of >10 times the expected loads at the transfer site for BR to FPL transfer using a reinforced weave. Reinholdt and Fridén[21] begin active training on postoperative day 1, with functional training to allow motion during the first 4 weeks and resting splints are used when the patient is not exercising. At 4 weeks, they began task-oriented training until weeks 8 to 12 when restrictions for loading and splint use were discontinued. The authors of the study reported that grip strength and first web space were markedly greater in the single-stage group than in historical control groups, but pinch strength was not markedly different.

House and Shannon[19] showed notable improvement in pinch and grasp strength and speed in performing ADLs. The ability to button, tie shoes, dress, and transfer were all improved. Wangdell and Fridén[24] reviewed patient satisfaction and performance of identified activity goals after thumb and finger flexion reconstruction at an average 7 years after BR to FPL and ECRL to FDP transfers and reported improvement in the performance of all groups of activities in the Canadian Occupational Performance Measure. The most improvement was observed in the activity of eating, but substantial improvement was seen in more complex activities such as housework and leisure activities.

In a meta-analysis of pinch strength after reconstruction procedures, Hamou et al[25] reported an adverse outcome rate of approximately 40%, including 35% elbow or thumb contracture, 22% stretching or rupture of repair, 21% loosening of pins at thumb IP joint, and 10% malalignment of pinch. Overall, mean postoperative pinch strength was 2 kg (1 kg for tenodesis and 2 kg with active motor).[25] They noted a positive risk-benefit ratio of greater than two with notable improvement in upper limb function versus adverse outcomes.

Long-term Outcomes

In a study of 67 patients with tetraplegia who underwent upper extremity surgery, Wuolle et al[26] reported that 77% reported a positive impact on their lives and 70% were satisfied with surgery. Mohammed et al[10] reported 70% good or excellent results in 57 patients with tetraplegia who underwent upper extremity reconstruction procedures, and 84% of patients reported that surgery improved their quality of life. Patients report that surgeries do not always improve independence but do provide increased spontaneity, speed, and ease of picking up objects and other specific tasks.

Dunn et al[27] looked at changes in hand strength over time after tenodesis or active tendon transfer surgery. They previously reported that patients maintained or improved pinch and grip strength 12 to 18 years after surgery and reevaluated 19 of these patients 11 years later.[28] They found that the active key pinch strength decreased 14% on the right hand and 1% on the left hand. The authors reported that the decrease in strength of those with active transfers was within the reported loss associated with aging for the normal population. Most patients reported little change in function over 11 years, but 50% reported a decrease in ability to propel their wheelchair and approximately 35% reported a decrease in their ability to raise themselves from the seat.

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