Plastic Surgery Volume 6: Hand and Upper Extremity (4th Edition) – Peter C. Neligan

846
SECTION V
CHAPTER 37 • Restoration of upper extremity function in tetraplegia
hand without a sensibility is more useful with a grip than
without a grip.12 Today, static two-point discrimination of less
than 12–15 mm is acknowledged as indicating the presence of
proprioception. The IC accounts for the presence or absence
of proprioception by including codes to indicate whether
afferent control resides in the hands, termed “cutaneous”, or
“Cu”, or only in the eyes of the patient, termed “ocular”, and
abbreviated as “O”.
Later, the IC scheme was extended to include a determina­
tion of the presence or absence of active elbow extension. The
IC system is used by essentially all surgeons involved in the
care of the upper extremities of these patients.
Patient presentation and
patient selection
Forming a team
Moberg stressed the need to develop a “critical mass” of
likeminded professionals into a team that should include
physiatrists involved in the rehabilitation and long-term care
of people with tetraplegia. Critical to the success of an upper
limb team are well-trained therapists, either physical thera­
pists or occupational therapists (preferably both). The hand
and upper extremity surgeon provides the technical expertise.
Others including social workers and psychologists may offer
additional support to the team. The patient’s support group
including family or attendant is the key to success. The central
member of the team is the patient.14–16
The roles of the professionals in this team are relatively
clear. The physiatrists assist in determining the appropriate­
ness of the patient for surgery as well as when to time surgery
relative to overall rehabilitation goals and schedules. The
therapist frequently serves as the patient’s advocate. He or
she knows the patient better than anyone else and, most
importantly, the patient’s expectations, voiced or not.
For the patient, upper extremity surgery can have a large
emotional impact. Some patients are concerned about altering
their anatomy because they are waiting for the cure for SCI.
While the goal of surgical reconstruction for the upper extrem­
ity is greater function, the patient must be willing to lose
temporarily some of their hard-won independence during the
postoperative rehabilitation. For family and attendants, this
greater period of dependence translates into more inconve­
nience and effort. All the team members must play a role in
the decision-making process and must share in the frustra­
tions as well as the rewards.
The hand and upper extremity team should become part
of the routine evaluation of newly injured patients. The cervi­
cal cord injured patient arrives at a rehabilitation facility or
spinal cord injury unit usually with fairly supple upper limbs,
although with no or only minimal volitional movement. The
upper limb assessment becomes clearer. Once the patient’s
vertebral injury is stabilized and the patient can sit in a wheel­
chair, an assessment by the upper extremity team takes on
new meaning, and the rehabilitation of the hands starts. By
the fourth month following injury, the eventual functional
level is usually clearly established for the majority of patients.17
At this time, the training of the patient’s upper limb function
has mainly proceeded into training of managing daily life, by
classification system is too general for hand surgeons because
no two patients are exactly alike. Injury pattern can differ
between those with the same skeletal level of injury and each
patient often has different function between the right and left
arm. In order to develop useful algorithms for treatment of
the upper limb, it was necessary to develop a more precise
classification method of these patients upper limb issues.
From this need arose the International Classification (IC),
which is based on the limb’s remaining useful motor and
sensory resources (Table 37.1). The motor function identifies
the number of strong muscles under volitional control below
the elbow. To be counted, the muscle must have grade 4 or 5
Medical Research Council (MRC) strength. The grade 4 level
was chosen because a grade 4 muscle can be transferred with
the expectation that it will be able to perform useful work. A
grade 3 muscle loses so much of its power in transfer and is
not reliable as a donor for transfer.
Moberg10,11 encouraged also accounting for remaining
sensory resources. If sufficient proprioception remains in any
part of the hand (typically the thumb and index fingers), the
patient can control his/her hand without having to keep it in
view. If the hand lacks proprioception, the patient needs his/
her eyes to direct the hand. Lack of proprioception limits the
ability to perform bi-manual activities, but it is not a contra­
indication to reconstructive hand surgery. Patients benefit
from grip reconstruction even though they lack sensation. A
Table 37.1  International classification for surgery of the hand in
tetraplegia
ICHST group
Motor characteristics
Description/
function
0
No muscles below
elbow suitable for
transfer
Flexion/supination
of elbow
1
BR
2
ECRL
Extension of wrist
(weak or strong)
3
ECRB
Extension of wrist
4
PT
Extension and
pronation of wrist
5
FCR
Flexion of wrist
6
Finger extensors
Extrinsic extension
of fingers, partial
or complete
7
Thumb extension
Extrinsic extension
of the thumb
8
Partial digital flexors
Extrinsic flexion of
the fingers, weak
9
Lacks only intrinsics
Extrinsic flexion of
the fingers
X
Exceptions
Caution: it is not possible to determine ECRB strength without surgical
exposure.
Each patients is also checked for sensibility and placed in ocular or Cutaneous
groups.
O, Ocular; Cu, cutaneous; BR, brachioradialis; ECRL, extensor carpi radialis
longus; ECRB, extensor carpi radialis brevis; PT, pronator teres; FCR, flexor
carpi radialis.

847
Patient presentation and patient selection
may alter the position of the hand and fingers. After recon­
struction, the hand or arm must be protected in a splint. This
protection entails difficulties to perform critical daily activi­
ties such as wheelchair propulsion and bed transfers (Fig.
37.3). It is best for patients to plan for temporary greater
dependence and learn safe transfer techniques before surgery.
Fig. 37.1  A patient pushing her wheelchair after grip reconstruction.
Fig. 37.2  Postoperative results after single-stage grip release reconstruction.
(A) Writing before reconstruction; (B) writing after reconstruction.
A
B
Fig. 37.3  Splint to allow for as active rehabilitation as possible, e.g., propulsion of
wheelchair, use of computer or cell phone (with the little peg).
coordination training of perceived functions, adaptive grasp­
ing patterns, technical aids, and assistive devices.18–20 The aim
is optimal use of the hands to maximize independence, despite
lack of active grasp function.
Timing
Hand or upper extremity surgery is rarely indicated during
the initial months of rehabilitation following injury. The
patient needs time to experience neurologic, psychologic, and
social stability. From a practical standpoint, there are simply
too many more important rehabilitation activities going on.
On the other hand, a dogmatic philosophy such as “never
operate on a patient before 12 months” has no basis in science.
Some patients are clearly candidates for surgery prior to this
calendar date. For example, early surgical intervention to
relieve the pathologic effects of a fixed elbow flexion contrac­
ture may allow a patient to participate more vigorously in
necessary rehabilitation activities.8 Early release of a fixed
elbow flexion contracture can be done with a simultaneous
transfer of the contracted biceps muscle to the triceps. This
removes a pathologic or deforming force and reinforces or
restores some power to the antagonist. Botox is another
important tool in the early rehabilitation armamentarium. It
is especially helpful for patients with concomitant brain injury
who may not comply with splinting or therapy and have
increased tone.
Once the patient has achieved neurological and psycho­
logical stability, a formal evaluation to establish the appropri­
ateness of upper extremity surgery can be accomplished by
the team. The evaluation should focus on both tangible evi­
dence of recovery by assessing remaining motor and sensory
resources and the important intangibles such as motivation
and intelligence. There is increasing recognition of the
co-occurrence of traumatic brain injury with spinal cord injury
and the impact of brain injury on rehabilitation.21 Cognitive
deficits need to be understood before embarking on upper
extremity reconstruction given the intensive post-surgical
therapy. The initial patient assessment should include an
evaluation on how the patient uses the hand to accomplish
tasks of daily living (Figs. 37.1 & 37.2A,B). Tendon transfers

848
SECTION V
CHAPTER 37 • Restoration of upper extremity function in tetraplegia
the tightening of the tenodesis and movement of a more
distally located joint, e.g., thumb flexion.
3. Tendon transfer: the transfer of the power of an
expendable muscle–tendon unit under good volitional
control to compensate for the absence or ineffectiveness
of function of another muscle–tendon unit.
4. Nerve transfers: the transfer of functional nerve
branches from active muscles to paralyzed muscles to
provide muscle function.
5. Spasticity-reducing surgery: tendon lengthening or
muscle releases to reduce spasticity by making the
tendon–muscle unit longer. This allows for better
volitional control.
Tendon transfers are the workhorse procedures for recon­
struction of the upper extremity in tetraplegia. These tech­
niques have been refined over the last 80 years and several
basic principles have evolved: (1) First is correction of any joint
contracture. Tendon transfers are often biomechanically disad­
vantaged and will not be able to overcome a contracted joint.
(2) The donor muscle must have adequate strength. Transferred
muscles will generally lose a grade of strength after transfer.
Therefore it must be strong preoperatively to be able to
perform functional tasks postoperatively and should have a
MRC > 4. (3) The donor muscle must be expendable. (4) For the
best biomechanical advantage, the most effective routing of
muscle insertion is a straight line. (5) The soft tissue bed must be
stable. These surgeries must be performed in a supple bed
with adequate skin coverage. Scarred beds will prevent
tendon gliding and will impair the result. (6) The donor
muscle should have adequate excursion to perform the desired
function.
For patients with tetraplegia, spasticity must also be con­
sidered. The donor muscle must have volitional control and
not have too much tone. Overall level of spasticity can be
improved with physical therapy and medications. A small
amount of spasticity and tone is acceptable and sometimes
beneficial to reconstructive procedures. The surgeon should
assess the level of spasticity and make sure it is optimized
before intervention. Spasticity should always be treated before
tendon transfers are considered. Most patients with incom­
plete tetraplegia have spasticity and can be treated with
tendon lengthening and muscle releases when conservative
treatment is not sufficient.4
The surgical procedures can be grouped using the IC
system (Table 37.2). For these procedures, it is critical that each
patient, and indeed each upper extremity, be evaluated and
then each treatment plan individualized.24
For high cervical spinal cord injuries, there are no expend­
able muscles available for transfer in the arm. For patients
with lower injuries, such as a C7 injury, many potentially
expendable, and thus transferable, muscles of grade 4 or 5
power exist. The choice of procedure depends primarily on
the residual resources and, secondly, on the many intangibles
such as patient desires, motivation, and support. The surgical
techniques used in tetraplegia are the same procedures as
reconstructions after peripheral nerve injuries, but the differ­
ence between these procedures is the preoperative preparation
and matching the patient to the correct procedure. A cautious
approach while one gains experience pays great dividends in
terms of obtaining the acceptance of team members and
patients that surgery can promote greater independence. A
The timing of surgery is important and it is critical that the
patient has the right expectations and is motivated for not
only the surgery but also the rehabilitation. Some patients,
especially women, seem to wait longer before making a deci­
sion for surgery, probably due to family matters.22 Tendon
transfers can be performed a long time after the injury; our
record is 38 years post-injury with good outcomes. One caveat
to this is the emerging use of nerve transfers, which may have
a tighter time window than tendon transfers. Though the best
timing of nerve transfers for these patients remains unknown,
we believe it is somewhere around 18 months.
Patient evaluation/selection
The upper limb examination includes assessment of motor
strength and a sensory evaluation. The exam also identifies
pathologic conditions such as contracted, painful, or unstable
joints that may impact surgical results. There is also a sensory
evaluation, which includes measuring two-point discrimina­
tion in the digits to assess proprioception. The currently used
grip patterns are assessed. Occasionally, spinal cord injured
patients will have focal areas of severe neuropathic pain that
will make the exam painful and potentially limit surgical
results.
The patient’s global functional status in daily living is
assessed, including mobility, personal care, domestic life, type
of wheelchair, and other adaptive devices. Is s/he dependent
or independent in bed mobility? How are transfers performed?
Does s/he use a manual or electric wheelchair? What adap­
tive devices are used for dressing, grooming, feeding? If
surgery is to be performed, is there sufficient support to get
the patient through a period of greater functional dependence
or will the extra burden of care result in the patient’s attendant
quitting? For some patients, upper extremity surgery means
restriction to an electric-driven chair. Can this be made avail­
able? Does the home situation permit the use of an electric
wheelchair? Are the controls of the chair mounted on the
non-operated side? The patient’s primary caregiver can help
answer these questions. Most patients can use their manual
wheelchair provided that they use protective orthoses during
the postoperative rehabilitation time. Preparation before
surgery will prevent complications such as pressure sores and
social consequences such as divorce and make the patient able
to focus on the important postoperative rehabilitation.
Finally, the patient’s goals for surgery are reviewed. We
prefer using the Canadian Occupational Performance Measure
(COPM).23 It enables specific tasks to be identified, e.g., “I
want to eat the triple decker sandwich at Joe’s by myself.”
This instrument helps the surgeon and therapist understand
if the patient has reasonable expectations and can help tailor
the procedures. It also serves as an important evaluation tool.
Treatment/surgical technique
General guidelines for reconstruction
Five surgical procedures are applicable for improving upper
limb function in tetraplegia:
1. Arthrodesis: permits stabilization of joints lacking
muscle stabilization.
2. Tenodesis: performed to stabilize a joint or so that a
proximal movement, e.g., wrist extension, will result in

849
Surgical reconstruction
Biceps-to-triceps transfer
This
procedure
is
a
common
and
straightforward
technique.25–28 It is the procedure of choice when there is a
pre-existing flexion contracture of the elbow greater than 45°
because transferring the biceps also addresses the deforming
flexion force. The advantages of biceps-to-triceps transfer
include no need for an interposition graft and one tendon
repair site. Disadvantages include a more challenging reha­
bilitation program and the potential for loss of elbow flexion
strength.
Surgical technique
The biceps tendon is detached from its insertion on the greater
tuberosity of the radius, the muscle–tendon unit routed either
medially29 or laterally,30,31 and the tendon attached to the
triceps aponeurosis or directly into the olecranon.
The incisions that are employed depend in large measure
on whether a wide exposure to the anterior aspect of the elbow
joint is needed to allow adequate release of contracture. The
distal extent of the incision should allow complete dissection
of the tendon of the biceps allowing detachment at the level of
insertion on the bicipital tuberosity of the radius (Fig. 37.5A).
The incision is carried through the subcutaneous tissue,
protecting the large tributaries of the basilic and cephalic
veins. The soft tissues overlying the lacertus fibrosis are ele­
vated and the lacertus is either divided off the primary tendon
or dissected distally as far as possible to provide another point
of fixation to the triceps (see Fig. 37.5B).
The primary tendon of the biceps is dissected to its point
of insertion on the radius. Flexing the elbow and supinating
the forearm assists in this exposure. The tendon is sectioned
as far distally as possible. The biceps muscle is dissected
proximally from within its dense investing fascia, the dissec­
tion proceeding proximally until the cutaneous portion of the
musculocutaneous nerve is identified as it courses between
the overlying biceps and the deeper brachialis muscle. This
poor outcome early in the team’s experience creates a tremen­
dous hurdle.
Surgical reconstruction
Elbow extension
Erik Moberg highlighted the importance of active elbow
extension for the spinal cord injured patient. A wheelchair
user depends upon good shoulder and elbow power to push
a manual wheelchair, transfer from bed to chair, and to
perform pressure releases to prevent pressure sores. Without
active elbow extension, a patient cannot stabilize the arm in
space such that the hands fall into his face when lying supine,
which makes eating and daily hygiene challenging (Fig. 37.4).
Restoring elbow extension can increase the reachable space by
an additional 12 inches resulting in 800% more functional
space and can assist with simple tasks such as turning on a
light switch. There are two surgical procedures advocated
for restoring active elbow extension – biceps-to-triceps and
deltoid-to-triceps transfer.
Table 37.2  Algorithm for surgical treatment in tetraplegia
ICSHT group
O/Cu
Available muscles
below elbow
Suggested or possible
procedure
0
No muscles
Nerve transfer, triceps
reconstruction
1
BR
BR–ECRB, passive key
pinch, triceps
reconstruction, nerve
transfer
2-3
ECRL, ECRB
BR–FPL or FDP and
passive key pinch,
triceps reconstruction,
House procedure,
nerve transfers
4-5
PT, FCR
Single-stage grip release
procedure, triceps
reconstruction, nerve
transfer
6-8
EDC, thumb
extension, partial
finger flexors
Single-stage grip release
procedure with
options: EDM–APB,
active IO
9
Lack only intrinsics
Active interossei – FDS IV
to IO
x
Mixed pattern
Combinations
Spasticity
Mixed pattern
Tendon lengthening,
muscle release,
ECU-tenodesis, distal
ulna intrinsic release
ICSHT, international classification for surgery of the hand in tetraplegia; O,
Ocular; Cu, cutaneous; BR, brachioradialis; ECRL, extensor carpi radialis
longus; ECRB, extensor carpi radialis brevis; PT, pronator teres; FCR, flexor
carpi radialis; EDC, extensor digitorum communis; FPL, flexor pollicis longus;
FDP, flexor digitorum profundus; EDM, extensor digiti minimi; APB, abductor
pollicis brevis; IO, interosseus; FDS, flexor digitorum superficialis; ECU, extensor
carpi ulnaris.
Fig. 37.4  Postoperative elbow extension allowing for stabilization of the arm to
assist with combing the hair.

850
SECTION V
CHAPTER 37 • Restoration of upper extremity function in tetraplegia
sutures (see Fig. 37.5D). We have judged that the proper
tension is achieved when the biceps is pulled distally enough
to permit the end of the tendon to touch the olecranon with
the elbow in about 20° of flexion. Once the tendon-to-tendon
junctures are made, the elbow is fully extended to relax the
site of approximation.
Postoperative rehabilitation
Regardless of what elbow extension reconstruction technique
chosen, the elbow is immobilized in full extension using a
light plaster or fiberglass cylinder cast for 3 12 weeks. An
overhead, chair-mounted sling is fitted to the patient’s wheel­
chair and is used whenever the patient is in the wheelchair
and until the cast is removed.
The initial cast is left undisturbed for 3 12 weeks if preop­
eratively the elbow had normal passive extension. If the elbow
had a preoperative flexion contracture between 15° and 30°,
the elbow is extended as much as possible at the time of
surgery and casted in that position. This cast is then removed
between 10 and 14 days postoperatively. Great care must be
taken to keep the elbow extended during this maneuver. Typi­
cally, the elbow can then be further extended at this time by
Fig. 37.5  Biceps-to-triceps transfer by the medial route (A–D). (Redrawn from Hentz V, Leclercq C. Surgical Rehabilitation of the Upper Limb in Tetraplegia. London:
Harcourt Health Sciences; 2002, with permission.)
Radius
Lacertus fibrosus
Biceps
Biceps
Triceps
tendon
Medial
epicondyle
Olecranon
A
B
Biceps
Triceps
tendon
Medial epicondyle
Medial epicondyle
Olecranon
Longitudinal and lateral
head of triceps
Biceps
Longitudinal and lateral
head of triceps
Biceps
tendon
Biceps
tendon
C
D
nerve is protected while dissection of the biceps proceeds
proximally until the most distal motor branches coming from
the musculocutaneous nerve are visualized.
Both medial and lateral routing of the transfer have been
described. Since the ulnar nerve is typically non-functional in
this population, we have preferred to route the biceps medi­
ally. It is necessary to dissect widely the arcade of Struthers
and all other fascial communications about the medial inter­
muscular septum. One must be concerned about compression
of the radial nerve when the lateral route is chosen.
A second incision located posteromedially is made in order
to expose the medial aspect of the triceps insertion. Through
this incision, the medial border of the triceps is elevated and
dissected to its insertion on the olecranon. The biceps muscle
and tendon are then passed from the anterior to the posterior
incision through the widely dissected subcutaneous tunnel
(see Fig. 37.5C). The anterior incision may be closed at this
point.
The biceps tendon typically just reaches the tip of the
olecranon but there is often not enough tendon length to
permit a strong attachment into the olecranon. Instead, the
tendon of the biceps is woven into the medial border of the
triceps tendon and anchored in multiple locations with stout

851
Surgical reconstruction
the region including the course of the axillary nerve and the
circumflex humeral artery and the radial nerve and its rela­
tionship to the insertion of the deltoid.
The upper incision is centered half way between the
midaxial line of the humerus and the posterior margin of the
deltoid. The skin incision is carried to the level of the muscle
fascia and the skin and subcutaneous tissues are elevated
anteriorly to just past the midaxial line of the humerus. Pos­
teriorly, the skin flap is elevated to the confluence of deltoid
and the long head of the triceps. The plane between these two
muscles is developed by sharp or finger dissection. As the
finger strikes the humerus, the fingertip tip can be insinuated
upward through the fibers of the deltoid, separating the
muscle into relatively equal anterior and posterior halves.
At least a third of the posterior deltoid is needed for the
transfer.
Detaching the insertion of the posterior half of the muscle
from its point of insertion onto the humerus is done by sharply
incising a rectangle of periosteum at the point of attachment
and elevating the periosteum and the fibers of attachment off
the humerus. We include as much fascia and fibrous insertion
as possible, including some of the fascial origin of the brachia­
lis muscle. The radial nerve will be emerging from behind the
humerus several centimeters distal to this point. Injury to this
nerve has been reported as a rare but devastating complica­
tion of this procedure.
A suture is placed in the fibrous origin of the posterior half
of the deltoid muscle and the dissection is carried superiorly
until the branches of the axillary nerve are visualized. The
superior dissection should stop at this point.
Several methods have been proposed to attach the posterior
deltoid to the triceps or olecranon including:
■ Autogenous tissue such as fascia lata, toe extensors,33
tibialis anterior tendon,11 or extensor carpi ulnaris (ECU)34
■ A turned up strip of the central part of the triceps tendon
with synthetic reinforcement35
■ Bone to bone attachments36
■ Various synthetic materials.37
We prefer autologous tibialis anterior tendon because its
thickness and proximal fan shape, which matches the deltoid
aponeurosis well.
The tibialis anterior tendon is harvested through two inci­
sions, at the insertion site and a longitudinal incision lateral
to the tibia. The tendon is detached from the muscle, and
sutured with side-to-side sutures to the deltoid aponeurosis
and to the triceps tendon. The tibialis tendon graft does not
need to be tunneled through olecranon.
In walking patients with incomplete tetraplegia, the fascia
lata is preferable. The fascia is harvested through several
transverse incisions placed over the iliotibial band. The ideal
width is about 2.5 cm. The fascia lata is encircled about the
fibrous insertion of the deltoid using mattress sutures of non-
absorbable braided suture, tubed over its remaining length
and tunneled subcutaneously to the olecranon.
The olecranon is exposed just distal to the triceps insertion.
The triceps tendon is split longitudinally to further expose the
tip of the olecranon and a 5-mm drill bit is used to create an
oblique tunnel through the olecranon. A Bunnell tendon strip­
per is a useful instrument to “polish” this channel so that the
tubed fascia lata can be passed smoothly in a proximal to
distal direction.38 The fascia lata is passed into the distal
slow stretch and the arm is recasted, now typically in near full
extension. After removal of the cast, the elbow is slowly
allowed progressive elbow flexion in a specially designed
flexion-stop brace (Fig. 37.6). Although the biceps seems to be
an antagonist to elbow extension, by teaching the patient to
conjointly supinate the forearm and extend the elbow, the
patient can be re-educated to use the supinator function of the
biceps to extend the elbow. Electrical stimulation and biofeed­
back therapy has been used on occasion with improved
results. Six months of cautious use are necessary to prevent
overstretching of the transfer and maximal strength is obtained
after many months.
Deltoid-to-triceps transfer32
Surgical technique (Fig. 37.7)
Fig. 37.6  Hinged orthosis to protect the repair across the elbow. The degree of
flexion is gradually flexed over time.
Hints and tips
1. Detach the deltoid from the humerus with as much fascia
and fibrous insertion as possible, including some of the
fascial origin of the brachialis muscle.
2. Ensure the triceps fascia is intact to protect the radial
nerve.
3. Attach the deltoid to the triceps at maximum tension with
the shoulder abducted 90° and the elbow as straight as
possible and the forearm pronated. When the elbow is
flexed 10–15°, the tendon transfer should be maximally
tight. Make sure the elbow is not flexed more during the
procedure. Let the assistant keep the elbow extended.
4. Cast elbow in full extension and keep the arm abducted at
the shoulder during healing.
The surgical landmarks at the shoulder include the tip of
the acromion superiorly, the interval between the posterior
margin of the deltoid and the triceps muscle posteriorly, and
the estimated point of insertion of the deltoid on the humerus.
The landmark at the elbow is the tip of the olecranon. The
surgeon should keep in mind the neurovascular anatomy of

852
SECTION V
CHAPTER 37 • Restoration of upper extremity function in tetraplegia
A
B
Posterior cord
Axillary artery
Humeral
circumflex
artery
Axillary nerve
Deltoid
Anterior
Posterior
Biceps
C5
C6
C7
T1
T2
C
D
Deltoid
Humerus
Anterior
Posterior
Fig. 37.7  (A–H) Deltoid-to-triceps transfer with fascia lata. (Redrawn from Hentz V, Leclercq C. Surgical Rehabilitation of the Upper Limb in Tetraplegia. London: Harcourt
Health Sciences; 2002, with permission.)

853
Surgical reconstruction
lengthy, the functional gain is substantial, predictable, and
easily appreciated by the patient.39
IC groups 0, 1, and 2
For the IC group 0 patient with no muscles functioning at the
grade 4 or greater level distal to the elbow, few reconstructive
possibilities exist. These patients benefit from a triceps recon­
struction. A new procedure using nerve transfers to reconstruct
wrist extension has been introduced.40 When active wrist
extension is regained, a passive key grip can be added.
Improving wrist extension: the IC group 1 and
2 patient
In the IC group 1 patient, the brachioradialis (BR) is typically
the only muscle with grade 4 strength distal to the elbow.
However, grade 2+ to grade 3+ radial wrist extensor function
is typically present as well. The patient may be able to extend
the wrist against gravity but cannot generate useful force
between digits and thumb through any existing natural teno­
desis effect or cannot utilize a wrist-driven flexor hand splint
unless it is equipped with a ratchet mechanism. For this
patient, wrist extensor strength can be augmented by transfer­
ring the power of the BR into the more central of the radial
wrist extensors, the extensor carpi radialis brevis (ECRB)
tendon.41–43 From several biomechanical studies44,45 it has been
determined that the BR becomes a more effective wrist exten­
sor following transfer if the patient can stabilize the elbow in
space. If no active elbow extension is present, the BR may
waste some of its excursion and power by flexing the elbow
exposure, separated into two tails and the tails are passed
through the bone channel.
The shoulder is abducted about 90° and the elbow is
extended as much as possible. The two fascia lata tails are then
pulled to maximally tense the transfer and these tails are
turned proximally and woven into the fascia lata tube and
anchored with non-absorbable sutures. Once suturing is
complete, the fascial tube should be under moderate but defi­
nite tension. The wounds are closed and a cylinder cast is
placed as is described in the biceps-to-triceps transfer with the
elbow fully extended.
Postoperative rehabilitation
Postoperative care is quite similar to the biceps-to-triceps
transfer. However, for deltoid to triceps transfer, shoulder
position is more of a concern. The shoulder is kept somewhat
abducted and the patient and other caregivers are cautioned
to not allow the shoulder to accidentally flop across the
chest. The wheelchair frame is critical because it holds the
arm approximately 30° elevated and helps to keep the arm
approximately 30° abducted from the body. This position
relaxes the deltoid, prevents distal edema, and maintains
seating stability.
After 3 weeks, the patient gets a dynamic elbow orthosis
and start flexing the elbow 15° per week, starting at 30–45° of
flexion depending on where the first resistance appears. Full
load is allowed 8–10 weeks postoperatively. Complications
are rare provided the patient follows the exercise protocol and
does not overstretch the transfer by too rapidly regaining full
elbow flexion. Even though the rehabilitation can be relatively
E
F
G
H
Fig. 37.7, cont’d

854
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CHAPTER 37 • Restoration of upper extremity function in tetraplegia
rather than in extending the wrist. For this reason, we prefer
first to reconstruct active elbow extension and after that
transfer the BR to the ECRB for wrist extension, which will
work as a motor for a passive key grip. Further balancing of
the thumb can often be useful and additional procedures such
as arthrodesis of the first carpometacarpal (CMC) joint and a
split tenodesis of the flexor pollicis longus (FPL) to extensor
pollicis longus (EPL) can be considered. We will describe
these techniques later.
A wide dissection of the distal BR muscle and tendon from
its insertion at the radial styloid up to the very proximal
forearm level is necessary to obtain the most effective excur­
sion of the muscle. Fridén has shown that the BR tendon
needs to be released 12–15 cm to get an excursion of 4 cm of
the BR tendon.46 The tension on the BR should be adjusted to
re-establish the normal resting length of the muscle with care
taken not to overstretch this muscle. In adjusting the tension,
it is important to place the elbow in some flexion. Moberg11
recommended that the elbow be set at about 40° of flexion and
we have followed this guideline.
Postoperative rehabilitation
All patients start early active mobilization the first postopera­
tive day. (A prerequisite for early active training is side-to-side
suture technique: see next paragraph.) During the first 3–4
weeks, patients perform unloaded functional training to allow
for movement of the tendon transfers, tenodeses, or tendon
lengthening. This is important to avoid swelling, edema, and
adhesions. A resting splint protects the hand between training
sessions. The patients perform a self-directed training protocol
at home. After 3–4 weeks the patients return for task-oriented
training under supervision of a trained therapist. Night splints
and weight-bearing restrictions are kept until 10 weeks post­
operatively. The elbow is not splinted since data has shown
secure safety margins for tension of the BR.47
Side-to-side sutures
Side to side sutures are used in tendon transfers and in tendon
lengthening. The tendons are sutured side-to-side with cross-
stitches running along both sides overlapping 5 cm of donor
and recipient tendons (Fig. 37.8). In vitro studies have shown
that failure to load is more than 20 kg on this attachment,48
which is twice as strong as the Pulvertaft weave.49 In our unit
we have used side-to-side sutures for several years now for
all tendon transfers without any ruptures.
Restoring key pinch: the IC group 1 and 2 patient
Fig. 37.8  Side-to-side suture technique.
A
B
C
D
E
F
Hints and tips
1. Do not release the A1 pulley of the thumb if the
metacarpophalangeal (MP) joint flexes beyond 45°.
2. Routinely perform the split FPL-to-EPL transfer or the
extensor pollicis longus shortening procedure.
3. If the thumb collapses into supination as the wrist is
extended, perform the Brand modification of Moberg’s
procedure.
4. Always put a test suture to test the right tension in a
tenodesis or transfer.
Patients at the IC group 1 or 2 level are candidates for active
wrist extension, BR-to-ECRB transfer, and creation of a lateral
or key pinch as described by Moberg.32 Conceptually, this is
a very simple operative procedure and, importantly, it repre­
sents an automatic pinch in that the tendon of the thumb
flexor, the FPL, is anchored to the palmar surface of the radius
under such tension that with wrist extension the thumb tip is
pulled against the side of the index finger. The other fingers
are usually left supple and the patient frequently must learn
to roll these digits into some flexion in order to provide a
platform against which the thumb can act. Gravity is needed
to flex the wrist, releasing tension on the tenodesed FPL and
allowing opening of the grip.
Provided that wrist extension power is adequate, the key
steps of the procedure have evolved to currently include:
■ Stabilization of the interphalangeal joint of the thumb
■ Fixation of the tendon of the flexor pollicis longus to the
radius at the correct tension

855
Surgical reconstruction
the intervening skin, deep to the radial digital nerve and
brought out the dorsal incision.
The tendon slip is passed under the tendon of the extensor
pollicis longus and then brought back over onto itself (see Fig.
37.9D). The thumb interphalangeal joint is temporarily stabi­
lized in about 20° of flexion with a 0.045 Kirschner wire placed
across the joint. The transferred slip of tendon is pulled dis­
tally until a noticeable slackening of the remaining tendon
half is noted and then relaxed slightly so that there is equal
tension on the slip of transferred tendon and on the original
remaining half of the tendon (see Fig. 37.9E). Pinning the
interphalangeal joint before final adjustment of tension makes
this step much more easily accomplished. The transferred half
of the tendon is sutured to itself and to the extensor pollicis
longus with absorbable 4-0 sutures.
ELK-tenodesis
The interphalangeal joint of the thumb may also be stabilized
by a shortening the EPL tendon on the dorsum of the thumb51
(Fig. 37.10). The joint is supposed to hyperextended after the
procedure and will return to a more flexed position with the
addition of a BR motor to the FPL.
Flexor pollicis longus tenodesis
(passive key pinch)
The proximal tendon of the FPL is anchored to the distal
radius augmenting the natural tenodesis of the thumb pinch
with wrist extension.
The incision is made and in the interval between the flexor
carpi radialis (FCR) and the palmaris longus (PL). The FPL
muscle–tendon junction is just deep to this interval. The tendon
is identified and the muscle–tendon junction divided as far
proximal as possible. Next the FPL tendon is anchored to the
■ Usually stabilization of the thumb’s carpometacarpal joint
against excessive flexion.
The first step is stabilization of the interphalangeal joint of the
thumb. The split flexor pollicis longus transfer as described
by Mohammed et al.50 or the ELK-tenodesis described by
Fridén et al.51 These techniques eliminate the need for long-
term hardware and preserve some active and even greater
passive interphalangeal joint movement.
Split FPL-to-EPL interphalangeal stabilization
For an optimum result, the critical pulleys, including the
oblique pulley of the flexor sheath of the thumb, must be
preserved. The procedure may be carried out using the inci­
sions outlined in Fig. 37.9A, or using just one incision along
the radial midaxis of the thumb.
The zig-zag incision is made and the neurovascular bundle
on the radial side of the digit is dissected. The neurovascular
bundle is included within the skin flap to protect it. Frequently,
there is a small annular ligament or pulley located at the level
of the interphalangeal joint. This can be incised to visualize
the flexor pollicis longus tendon (see Fig. 37.9B,C).
A blunt probe is used to find the naturally occurring
midline split in the tendon’s structure. This split is lengthened
both distally and proximally. When the distal dissection
reaches the insertion of the tendon, the radial half of the split
flexor pollicis longus tendon is divided at its bony insertion.
The tendon end is delivered into the wound. The proximal
split is extended to the level of the MP joint. Finally, a small
window into the flexor sheath is created just proximal to the
oblique pulley and the detached radial half of the tendon is
brought through this window.
If a second incision is used, it is located on the mid-dorsum
of the thumb, over the course of the extensor pollicis longus.
The radial half of the flexor pollicis longus is tunneled under
Slip from flexor pollicis longus
Extensor pollicis longus
Flexor pollicis longus
Extensor pollicis longus
Oblique pulley
A1
A2
Oblique pulley
A2
D
B
C
A
E
Fig. 37.9  A very effective method to stabilize the interphalangeal joint of the thumb
without making it rigid. This procedure, attributed to Rothwell and Sinclair50 has
become universally accepted. (Redrawn after Hentz V, Leclercq C. Surgical
Rehabilitation of the Upper Limb in Tetraplegia. London: Harcourt Health Sciences;
2002, with permission.)

856
SECTION V
CHAPTER 37 • Restoration of upper extremity function in tetraplegia
Fig. 37.10  Extensor pollicis longus-loop-knot (ELK)-tenodesis. The extensor
pollicis longus is duplicated and sutured to itself, bringing the interphalangeal joint
into hyperextension. The brachioradialis to flexor pollicis longus transfer will correct
it into slight flexion.
Hints and tips
• Assess if arthrodesis of the thumb CMC joint will provide a
more functional position (Fig. 37.11).
• Avoid CMC fusion if there is a stiff MP joint.
• Take care setting the BR tension.
• Always stabilize the interphalangeal joint of the thumb (as
described earlier).
Fig. 37.11  Thumb carpometacarpal joint arthrodesis. Note the position of the
thumb ray.
radius at the proper tension. A 3- or 4-mm drill point is used to
drill a hole from volar to dorsal through the radius, avoiding
the radial wrist extensor tendons. A dorsal incision is designed
at the site where the drill point exits the dorsal aspect of the
radius. A loop of 30-gauge (3-0) monofilament wire is passed
through the drill hole in a dorsal to palmar direction and
the FPL tendon is placed in the loop and drawn through the
radius. By pulling on the tendon, the tension can be adjusted
so that the pulp of the thumb just contacts the radial side of the
flexed index finger when the wrist is in the neutral position.
When the wrist is flexed, the tension of the FPL is relaxed and
the thumb ray will extend in response to the dorsal tenodesis/
viscoelastic forces. After satisfactory tensioning of the FPL
tendon, the FPL is anchored to the radius.
Postoperative rehabilitation
On the first postoperative day the patient starts early active
mobilization of the new functions as described above. We
have found the results of this technique predictable. We can
measure the gain in pinch strength and it is typically propor­
tional to the strength of the wrist extensor power but some­
what depends on the stability of the thumb and finger joints.
Pinch strengths of 1–5 kg have been uniformly achieved.
IC group 2 and some IC group 3
Restoring active key pinch by brachioradialis
(BR)-to-FPL transfer
Patients in IC group 2–3 have by definition a functional BR
and active wrist extension. Below are steps for reconstruction
of the IC 2–3 (Fig. 37.12):
1. The CMC is evaluated and, if there is excess laxity, a
CMC arthrodesis is performed to pre-position the
thumb tip to contact the index finger middle phalanx.
2. The EPL tendon is anchored to the fibrous tissue in the
third compartment on the dorsum of the wrist.
3. The brachioradialis is transferred to the tendon of the
FPL.
4. The split FPL-to-EPL transfer or the EPL shortening is
performed.
5. Interosseus stabilization (described below) for fingers to
meet thumb in lateral key pinch.
Operative procedure
The operative steps are carried out via one longer and three
or four smaller incisions as illustrated in Fig. 37.12A. An FPL-
to-EPL interphalangeal joint stabilization procedure is com­
pleted as illustrated in Fig. 37.12B. If needed, the CMC joint
is then exposed through an incision made along the juncture
of the glabrous and hair-bearing skin over the palmar–radial
aspect of the thumb’s thenar eminence. The thenar muscles
are reflected off the capsule of the CMC joint and the capsule
opened. The adjacent joint surfaces are prepared for arthro­
desis by sharp excision of all cartilage and by perforating the

857
Surgical reconstruction
Fig. 37.12  A procedure to restore active key pinch. The carpometacarpal joint of the thumb is stabilized by fusion, the thumb interphalangeal joint by split flexor pollicis
longus (FPL) to extensor pollicis longus (EPL) tenodesis, the EPL is tenodeses to the radius so that the thumb extends with wrist flexion and the brachioradialis is
transferred to the FPL to provide potential voluntary pinch irrespective of wrist position. (Redrawn after Hentz V, Leclercq C. Surgical Rehabilitation of the Upper Limb in
Tetraplegia. London: Harcourt Health Sciences; 2002, with permission.)
A
B
C
D
Extensor pollicis longus
Extensor pollicis longus
Flexor pollicis longus
Split flexor pollicis longus transfer
Brachioradialis

858
SECTION V
CHAPTER 37 • Restoration of upper extremity function in tetraplegia
tension and the FPL tendon is pulled proximally so that the
pulp of the thumb just touches the radial side of the index
finger. The assistant maintains this posture of both tendons
while the surgeon joins together the two tendons with a test
suture. The tension of the FPL transfer and the EPL tenodesis
is tested by gently moving the wrist between 45° of flexion
and 45° of extension. It is important that the thumb still fully
extends at the MP joint with wrist flexion after BR transfer.
The wounds are closed and the limb solidly immobilized in
a below-elbow cast that maintains the wrist in a neutral posi­
tion and the thumb MP joint in some flexion. We typically
place the thumb in contact with the flexed index finger.
Other options
The BR can be transferred to the deep flexors (flexor digitorum
profundus [FDP] index–ring) for active grip and the thumb
may get a passive key pinch driven by an active wrist exten­
sion. We have done a few patients with this combination with
promising outcomes.
Postoperative rehabilitation
On the first postoperative day the patient starts early active
mobilization of the new functions as described above. At the
beginning of the third or fourth postoperative week, the
patient starts task-oriented training under supervision of a
trained therapist. The therapist constructs a small hand-based
splint to protect the CMC joint fusion. The use of night splints
and weight-bearing transfers on the hand are restricted until
about 10 weeks postoperatively.
IC groups 3, 4 and 5
Restoring active key pinch, grasp, and release in
one operative stage
Historically these patients were treated using a two-stage
technique first establishing hand opening and then a second
procedure for closing/grasp. However, the higher-volume
centers have found that this can be completed in a single
stage. Both techniques utilize two expendable muscles for
transfer, the ECRL and the BR may be performed.54 Outcomes
have shown stronger grip strength and better opening after
the single-stage procedure.55 Prerequisites for these proce­
dures include near-normal passive wrist movement and rea­
sonably flexible fingers. These patients may possess useful
triceps function. If not, this function should be restored.
The single-stage grip and release procedure54 (Video 37.1
)
dense subchondral bone in several areas on the metacarpal
base and the face of the trapezium. Bone is removed with a
small osteotome, curette, or powered burr equally from
both sides of the joint. This maintains the relative contours
of metacarpal base and trapezium and good bone-to-bone
contact between the two surfaces.
Correct positioning of the CMC fusion is a critical step.
Both palmar and radial abduction are considered and final
position is determined by the preoperative flexor tenodesis
pattern and the passive range of motion at the thumb’s MP
joint. The ideal position goal is to have the pulp of the thumb
contact the radial side of the index finger middle phalanx with
wrist extension. Opening of the grip depends upon wrist
flexion and occurs almost exclusively at the MP joint. The
ideal candidate has a well-preserved tenodesis pattern and
passive MP flexion exceeds the range of CMC extension. For
such a patient, the thumb ray should be positioned in only
about 20° of palmar abduction, and almost maximum radial
abduction. A thumb ray fused in too much palmar abduction
will interfere with transfers and pressure-relief efforts. If the
patient has poor finger flexion as the wrist is extended, the
CMC joint should be arthrodesed in a slightly less palmarly
abducted posture. If MP flexion is limited, the CMC joint
should be fused in less than maximal radial abduction. If too
radially abducted, the patient with a poorly flexible MP joint
will not achieve firm contact between pulp of thumb and
index finger.
The CMC joint is temporarily pinned with a 2-mm Kirsch­
ner wire to test positioning. If the position seems ideal, the
joint is further stabilized. A small four-corner plate or a
locking-plate has provided sufficiently rigid bone-to-bone
contact. Locking-plates provide more stable fixation and are
associated with fewer non-unions than conservative fixation
methods.52
The third step involves creating a firm tenodesis of the EPL.
Since the CMC joint is now fused, no particular EPL re-routing
is needed. Through a transverse incision made just proximal
to Lister’s tubercle, the tendon of the EPL is located and
divided at its muscle–tendon junction, withdrawn at the level
of the MP joint, passed proximally and under the tendons of
the first dorsal compartment, and then toward the third
compartment. This provides an extensor–abductor vector
when the wrist is flexed. The EPL is anchored to the dense
fibrous tissue between the third and fourth extensor compart­
ment using with several non-absorbable sutures. The thumb
should reach maximum extension as the wrist reaches 45° of
flexion but the pulp of the thumb should contact the radial
side of the index finger as the wrist reaches the neutral
position.
The last procedure involves BR-to-FPL transfer.53 The FPL
is identified in the volar forearm, either through the same
incision used to dissect the BR or through a separate volar
incision. The FPL is divided at its muscle–tendon junction and
the two tendons are directed in as straight a line as possible
toward one another. The end of the BR tendon is passed
through the FPL tendon and a side-to-side suture is performed.
The ideal tension for the transfer is established as described
for BR-to-ECRB transfer. The juncture is created with the
elbow in 40° of flexion, the wrist in a neutral position, and the
index finger held flexed at MP and proximal interphalangeal
joints. The BR is pulled distally to a point midway between
maximum passive stretch and fully relaxed (zero-tension)
Hints and tips
• It is critical to be certain of the true strength of the ECRB
before transferring the ECRL.
• Before detaching ECRL from its insertion the ECRB
insertion should be visualized to avoid mistakes.
• While tensioning the tendon slips in the House procedure
the position of joints are important: 60° flexion of
metacarpal joints (MCP) and fully extended interphalangeal
joints (IP).

859
Surgical reconstruction
Surgical order of procedures:
■ Split FPL-to-EPL transfer or EPL shortening51
■ Thumb CMC joint arthrodesis
■ Intrinsic substitution procedure (House56 procedure)
■ BR transfer to the FPL
■ ECRL transfer to the FDP II–IV
■ Re-routed passive tenodesis of the thumb (EPL)
■ ECU-tenodesis to correct for radial wrist deviation
deformity.57
The very strong IC group 3 patient will have at least one of
the two radial wrist extensors at MRC grade 5. The other will
probably be MRC grade 4. The surgeon must proceed with
care as it is a grave error to transfer the ECRL and lose strong
wrist extension. This is a real risk since it is impossible to
perfectly isolate and assess ECRB strength in preoperative
testing. However, these patients commonly have some func­
tion of the pronator teres (PT). If the PT is intact one can
assume both wrist extensors are functional.58 Another method
to assess if both wrist extensors are functional (grade 4 or
more) is that a groove occurs between the bellies of the ECRL
and ECRB, known as “Bean’s sign”.50 If there is any question
of the ECRB strength, it can be tested intraoperative. The
ECRB tendon is exposed just distal to the extensor retinaculum
under local anesthesia, a probe is slipped under the tendon
and the patient is asked to forcefully extend the wrist. If the
muscle is MRC grade 4 or 4+, the tendon cannot be displaced
by the surgeon’s probe. This can be done at the start of the
surgery and if the ECRB is judged to be sufficiently strong and
direct the next steps of the procedure.
The ECRL and BR tendon transfers start with a long dorsal
incision (as described for BR transfer). The ECRL and BR
tendons are mobilized and then passed volarly. The BR is
sutured to the FPL (side-to-side). The tendons of the FDP are
synchronized. Some advocate setting the finger cascade with
slightly more opening of the ulnar sided digits: a “reverse
cascade”. The theory is that this allows easier ability to get
hand around object. The tendon of the ECRL is passed
obliquely through the synchronized FDPs and attached with
side-to-side sutures. The FDP of the little finger is left out of
the transfer, but will be passively flexed by connections
between the muscles of the little and the ring finger. Tension
of this transfer is adjusted so that a relatively natural posture
of the fingers is achieved with wrist flexion and extension.
A bandage roll (4 cm in diameter) placed in the palm facilitates
the tensioning of the fingers and the creation of a normal
finger cascade. It is preferable to tension this transfer after
intrinsic stabilization is performed (see below.) The BR-to-FPL
transfer is tensioned so that with the wrist in neutral, the
thumb pulp just touches the side of the flexed index finger.
Early active mobilization is very important when performing
several simultaneous procedures.
Intrinsic stabilization
The intrinsic muscles are critical to hand function. Without
intrinsics, grip strength is considerably weakened and finger
abduction at the metacarpophalangeal joint is lost. Even
though the long flexors of the fingers can flex all the interven­
ing joints, without the synchronizing effects of the intrinsic
muscles, in flexion the fingertips touch only to the bases of
the fingers rather than the center of the palm. This rolling up
of the fingertip seen when intrinsics are lacking tends to push
large objects out of the grasp.
The second major biomechanical function of the intrinsic
muscles is assisting the extrinsic extensors to extend the
interphalangeal joints. Without intrinsic muscle activity, the
extrinsic muscle action at the metacarpophalangeal joint is
unopposed, hyperextending the MP joint. Furthermore, this
MP hyperextension increases the viscoelastic tone of the long
flexors, inducing flexion at the interphalangeal joints. This
imbalance gives rise to the “claw hand” characterized by
metacarpophalangeal hyperextension and interphalangeal
joint flexion.
For most people with tetraplegia, the absence of intrinsic
muscle function may also result in an imbalance between the
paralyzed extrinsic flexors and extensors. The preoperative
hand of patients in IC groups 1–5 possesses only residual
passive tenodesis grasp and release. For these patients, the
tendency for the finger to claw as the wrist is flexed may
represent only a cosmetic annoyance. However, reconstruc­
tive procedures to improve digital flexion and extension may
accentuate the clawed posture by adding tone to both extrinsic
extensors and flexors. In this circumstance, the claw deformity
frequently becomes a functional liability.
House and Walsh59 found that some type of intrinsic sub­
stitution improves the grasp in the tetraplegic patient who
undergoes candidate for a grasp-release procedure. Since
most people with tetraplegia do not possess sufficient trans­
ferable muscles to allow intrinsic substitution by standard
tendon transfer procedures, static procedures are utilized.
Two procedures have been described: the first attributed to
Zancolli60 and termed the “lasso” procedure, and the other
described by House et al.57
Zancolli “lasso” procedure
In IC groups 3, 4 and 5, the flexor digitorum superficialis
(FDS) muscles are paralyzed, typically at the upper motor
neuron level. As such, they retain some stretch reflexes
through the intact spinal reflex arc and relatively normal
viscoelastic properties. Zancolli60 proposed using these para­
lyzed muscles as an elastic tenodesis to reduce metacarpopha­
langeal joint hyperextension and lessen the clawed posture of
the tetraplegic hand (Fig. 37.13A–F). In this technique, super­
ficialis tendon of a clawed finger is released distally and
inserted into the flexor sheath at the distal margin of the A1
pulley or the proximal part of the A2 pulley. The tendon is
placed under slight tension. The superficialis tendon now
becomes a flexor of the MCP joint.
The mechanical basis for this dynamic tenodesis procedure
is debated. Zancolli believes that the transfer must be fixed
under significant tension in order to still provide MCP flexor
tone even with the wrist near-maximally flexed. If this transfer
is performed as part of the flexor phase, it is preferable to first
perform the “lasso” procedure before adjusting the tension of
the finger flexor transfer.
House intrinsic tenodesis
This procedure, described by House et al.,55 is a modification
of Riordan’s tenodesis procedure.61 In the patient with tetra­
plegia, the procedure (Fig. 37.14) is usually performed on all
four fingers. However, it is sometimes performed for only the
index and middle finger, since these fingers are the most

860
SECTION V
CHAPTER 37 • Restoration of upper extremity function in tetraplegia
A
C
B
A2 pulley
A1 pulley
Flexor digitorum
superficialis
Flexor digitorum
profundus
D
E
F
Fig. 37.13  The Zancolli “lasso” procedure (A–F). Either several longitudinal incisions or one longer transverse incision can be made. The flexor digitorum superficialis is
divided distal to the A1 pulley, looped about the pulley, and sutured to itself proximal to the pulley under strong tension. If the metacarpophalangeal joints remain nearly
fully flexed with the wrist in neutral, proper tension has been achieved. (Redrawn after Hentz V, Leclercq C. Surgical Rehabilitation of the Upper Limb in Tetraplegia. London:
Harcourt Health Sciences; 2002, with permission.)

861
Surgical reconstruction
Fig. 37.14  The House intrinsic substitution procedure. The tendon loops have to
go volar to the intermetacarpal ligaments.
B
A
critical in grasp and release functions. A tendon graft is
needed: PL or FDS ring is harvested and split into two slips.
Mediolateral or oblique incisions are made on the proximal
phalanx of each finger and two small incisions on the dorsum
of the hand. With the MCP in 60° of flexion and extended IP
joints, the first slip is tunneled from the radial side of the
phalanx of the index finger under the insertion of the first
dorsal interosseous, and then under tendons of the extensor
communis of the index and the extensor indicis proprius.
After that the tendon slip is tunneled through the lumbrical
canal, volar to the intermetacarpal ligaments, and sutured
onto the lateral and central band. The other tendon slip is
tunneled through lumbrical canals of the fourth and fifth
digits.
ECU-tenodesis
The ECU-tenodesis is a passive tenodesis.6 Patients with tet­
raplegia typically present with a radial deformity of the wrist,
which impairs grip strength.57 The correction starts with a
curved incision made over the ulnar head and the sixth exten­
sor compartment is opened. The dorsal sensory branch of the
ulnar nerve is protected. The wrist is ulnarly deviated and the
ECU is lifted with a tendon elevator, the tendon is then short­
ened until the radial deviation deformity is gone. The excess
tendon is secured onto the ulnar head with a couple of mat­
tress sutures (Fig. 37.15). This is usually the last procedure in
the single-stage grip release reconstruction.
Finally before closing the wounds the tenodeses and the
passive interosseous function should be tested to allow for
adjustments.
Postoperative rehabilitation
On the first postoperative day the patient starts early active
mobilization. After the intrinsic stabilization procedure, the
patient is restricted from full finger flexion for 4 weeks. The
protocol allows for flexion up to a digit–palm distance of
3 cm. After 4 weeks, the patient is allowed to gradually flex
all the way. Full load is allowed after 8 weeks. Despite the full
finger flexion restriction, the task-specific training starts at 3
weeks postoperatively including active wheelchair maneu­
vering and all types of daily activities. Complications are rare,
provided that the patient follows the rehabilitation protocol
and the gains are highly appreciated by the patients.62,63
Other procedures
In IC group 4, the PT is strong and available for transfer. In IC
group 5, the flexor carpi radialis (FCR) is strong, but experience
has shown that it should not be used as a transfer. Therefore,
the surgical options are similar for both IC groups 4 and 5.
The PT is the only functioning pronator muscle in these
IC group 4 and 5 patients. However after transfer, the PT
will retain most of its pronator function if the transfer pull
is the same direction as the original tendon’s pull. The PT
can be safely transferred to the FPL though an interposition
tendon graft may be needed. The BR is then available for
another functions, such as transfer to extensor digitorum
communis (EDC) and EPL for finger and thumb extension.
This is done if other techniques failed to provide adequate
hand opening and there is enough volar stabilization of the
wrist (FCR with MRC strength 3 or above). If BR-to-EDC/

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CHAPTER 37 • Restoration of upper extremity function in tetraplegia
and usually much appreciated by the patients. We have used
EDM with grade 3 muscle strength with satisfactory results;
as volar abduction does not require much strength.
Patients with an even greater number of remaining
resources, such as patients in IC groups 7–9, can be recon­
structed similarly to patients with a lower peripheral nerve
injury. The surgical procedures performed for these patients
are directed at reconstructing some aspects of hand intrinsic
muscle function and balance. The interosseus function can be
made active by using an active superficial flexor digitorum
(FDS) tendon of the ring finger, splitting it into four slips if
the tendon size allows it. Alternatively, FDS long and ring can
be split into two slips each. This Stiles–Bunnell transfer7 may
be considered in cases with incomplete tetraplegia or in group
8. There are relatively few patients with tetraplegia in these
categories compared to the IC 2–5 categories.
Group X and spasticity
Group X has a mixed pattern and many patients with incom­
plete tetraplegia belong to this group.
Up to 78% of patients with traumatic spinal cord injury
develop spasticity and this is primarily treated with conserva­
tive treatment methods such as physiotherapy, splints,
baclofen, and botulinum toxin A injections. Before surgery
is considered, conservative treatment must be thoroughly
explored. Surgical treatment reduces spasticity by lengthen­
ing of tendons, releasing muscles, and sometimes correcting
deformities.65 Short-term (1 year follow-up) outcomes are
encouraging. The patients open their hands well and also gain
grip strength even though the tendons are lengthened. We
have ongoing studies to evaluate the durability.
EPL is chosen, tension is set with the elbow in 40° flexion,
the wrist in a neutral position, and the MP joint in about
20° of flexion. Tension should be such that, during passive
flexion of the wrist, the MP joints start extending when the
wrist reaches neutral from an extended position. The tension
on the EPL tendon should be adjusted last and its tension is
typically set slightly looser than that of the EDC. The fingers
should exhibit full passive flexion when the wrist is fully
extended.
Alternative procedures for IC groups 4 and 5 include
various combinations of procedures already described. Since
patients differ, it is important to be able to plan for variations
in patient presentation and individual functional objectives.
The greatest variation in hand use has been a consequence
of the management of the thumb’s CMC joint. A fused CMC
joint, while predictably pre-positioning the thumb, does limit
the size of objects easily grasped within the first webspace.
If the CMC joint is left mobile, the postoperative position
of the thumb ray is less predictable, sometimes significantly
so, but larger objects can be pushed into the first webspace
and held.
IC groups 6, 7, 8 and 9
Patients classified at the IC 6 level possess active digital exten­
sion but lack thumb extension, interosseous function, and grip
strength. They require the multiple tendon transfers to achieve
balanced thumb pinch and strong finger grasp as described
earlier as well as adding an extensor force for the thumb.
Transfer of extensor digiti minimi (EDM) to abductor pollicis
brevis (APB) is a good option for better thumb movement.64
Volar abduction of the thumb is useful for fine motor skills
Fig. 37.15  Extensor carpi ulnaris tenodesis to correct for
wrist radial deviation deformity.
A
B
C

863
Future directions
Functional neuromuscular stimulation
Functional electrical stimulation (FES) is an exciting adjuvant
for improving arm function in these patients. The initial com­
mercially available system was an eight epimysial electro-
channel device called the Freehand System. This system
allowed patients with very high spinal injury to activate and
control a pre-programmed sequence of muscle contractions
and achieve a useful grasp for one hand.69–72 Research contin­
ues on this system and current models have the ability to
stimulate 12 muscles.73 These systems of electrodes are often
the only option to restore useful function in limbs heretofore
deemed unreconstructable by standard surgical techniques.
We hope that as further research proceeds, these devices may
again become commercially available (Fig. 37.16).
Outcomes and complications
These procedures have evolved over time and can provide
predictable improvement in function. The surgery also pro­
vides a great impact on activity and participation aspects in the
patient’s life.74,63,39 Both practical issues in daily life and psycho­
logical aspects have shown to improve.63 A systematic review
provided data on the average outcomes for the most common
of these procedures – posterior deltoid-to-triceps transfer and
procedures to restore pinch. For the deltoid to triceps, the
average postoperative strength was 3.3 MRC. This would cer­
tainly allow stabilization of the arm in space. Complications
were not infrequent at 25%, with the most frequent being
rupture or stretching of the repair. Since we implemented
side-to-side sutures we have not seen any ruptures or elonga­
tions of attachments. Pinch-reconstruction procedures were
divided into those with active motors, such as a BR, or those
that were simply a FPL tenodesis or Moberg procedure. The
mean postoperative strength after both types of pinch surgery
was 1.9 kg. The mean postoperative strength after FPL tenode­
sis was 1.17 kg, and for those using an active motor, postopera­
tive strength was 2.32 kg. There was a 40% rate of complications
Future directions
Nerve transfers
Nerve transfers have long been a treatment of choice for
patients with brachial plexus injuries, but have recently been
explored for the tetraplegic population. Bertelli described
using a brachialis nerve branch to triceps to restore elbow
extension in 2012.66 Fridén used a brachialis nerve branch to
restore wrist extension for a patient in IC group 0.40 Mackin­
non presented cases in 2013 using peripheral nerve transfers
for tetraplegia67 and Van Zyl described a triple nerve transfer68:
teres minor nerve branch to long head of triceps, brachialis
nerve branch to anterior interosseous, and supinator nerve
branch to posterior interosseous. These transfers successfully
restored elbow extension, grasp, release, and key pinch.
In our center we have performed supinator nerve branch
to posterior interosseous nerve transfer. This procedure
requires minimal postoperative restrictions: a plaster splint
for 2 weeks to protect the nerve coaptation. Preoperative
testing of muscle function and electromyography assesses
whether the target muscle can be stimulated. There is debate
as to what is the appropriate timing of nerve transfers in this
population. Early evidence suggests that timing of nerve
transfers for patients with tetraplegia is similar to peripheral
nerve injury (earlier reconstruction is better). However,
recruiting these complex patients so soon after their injuries
is challenging.
Another challenge for nerve transfers is the long wait
before functional gains are seen. After tendon transfer surgery,
the patient can see the new movement the day after surgery
whereas a year may pass before the patient sees results from
a nerve transfer. We believe an approach using all the avail­
able tools: nerve transfers combined with tendon transfers
will provide the best results.69 An active finger extension for
release combined with tendon transfers for a strong grip and
key pinch seems as an attractive combination.
Fig. 37.16  A multichannel functional electrical
stimulation. (Redrawn after Kilgore KL, Hoyen HA,
Bryden AM, et al. An implanted upper extremity
neuroprosthesis utilizing myoelectric control. J Hand
Surg Am. 2008;33:539–550.)
Transmitting/receiving coil
Implant stimulator/telemeter
In-line connectors
MES recording electrodes
Stimulation electrodes

864
SECTION V
CHAPTER 37 • Restoration of upper extremity function in tetraplegia
6. Hentz VR, Leclercq C. Surgical Rehabilitation of the Upper Limb in
Tetraplegia. London: Harcourt Health Sciences; 2002. This is the most
up-to-date monograph devoted to the field of upper extremity
reconstruction for tetraplegia. It delves into all of the nuances of these
procedures.
7. Bunnell S. Surgery of the Hand. Philadelphia, PA: JB Lippincott; 1944.
28. Kozin SH, D’Addesi L, Chafetz RS, et al. Biceps-to-triceps transfer
for elbow extension in persons with tetraplegia. J Hand Surg Am.
2010;35:968–975. This article presents the key technical details for biceps
to triceps transfer. The illustrations simplify the procedure. The
postoperative regimen is clearly described.
32. Moberg E. Surgical treatment for absent single-hand grip and elbow
extension in quadriplegia. J Bone Joint Surg Am. 1975;57:196–206.
This is the classic article that must be read by anyone contemplating
operating on a tetraplegic patient. It describes two key procedures, the
Moberg key pinch and deltoid to triceps transfer.
42. Freehafer AA. Gaining independence in tetraplegia. Cleveland
technique. Clin Orthop. 1998;355:282–289. This article represents a
summary of techniques and pearls.
47. Fridén J, Shillito MC, Chebab EF, et al. Mechanical feasibility of
immediate mobilization of the brachioradialis muscle after tendon
transfer. J Hand Surg Am. 2010;35:1473–1478.
48. Brown SH, Hentzen ER, Kwan A, et al. Mechanical strength of the
side-to-side versus Pulvertaft weave tendon repair. J Hand Surg Am.
2010;35:540–545.
50. Mohammed KD, Rothwell AG, Sinclair SW, et al. Upper-limb
surgery for tetraplegia. J Bone Joint Surg Br. 1992;74:873–879.
54. Fridén J, Reinholdt C, Turcsanyii I, et al. A single-stage operation
for reconstruction of hand flexion, extension, and intrinsic function
in tetraplegia: the alphabet procedure. Tech Hand Up Extrem Surg.
2011;15:230–235.
59. House J, Walsh T. Two stage reconstruction of the tetraplegic hand.
Master techniques in orthopaedic surgery. In: Strickland JW, ed. The
Hand. Philadelphia, PA: Lippincott; 1998:60.
Access the complete reference list online at

in this review. The most common complications were flexion
contracture of the elbow or of the thumb, stretching or rupture
of repair, and loosening of pins across the thumb IP joint. Two
of these complications, flexion contracture of the thumb and
loosening of pins, are no longer applicable as the procedures
have evolved to address these complications (we no longer
fuse the IP joint and do not release the A1 pulley).
These procedures are also very durable.22,75 Hentz et al.
examined 45 patients who had been operated at least 10 years
prior to evaluation. A total of 21 of these patients had under­
gone elbow extensor reconstruction; 15 patients had posterior
deltoid to triceps transfer; and 10 had bilateral transfers.
Fifteen required a motorized wheelchair as their primary
means of movement before surgery. At 10 years after surgery,
nine now used a pushchair as their standard chair and four
others used a pushchair at least some of the time. There were
three patients who had undergone bilateral posterior deltoid-
to-triceps transfer who were able to self-transfer in the early
postoperative period. All three continued to be able to perform
this monumental, for a tetraplegic, task. In the six patients that
had biceps-to-triceps transfer (all needing contracture release),
two could use a pushchair, but not exclusively so. None had
developed a recurrence of elbow contracture.
The second goal was the restoration of some hand function.
IC group 2 patients typically had key grip fashioned by
tenodesis of the FPL to the radius. Seven were evaluated for
more than 10 years. Five had maintained pinch strength
essentially equivalent to that demonstrated 6–12 months fol­
lowing surgery. The IC group 3 patients typically had transfer
of BR to FPL to restore dynamic voluntary key pinch. Six were
evaluated and all had maintained useful power, which aver­
aged 20 N.
Historically, groups 3, 4 and 5 were treated in two stages: the
flexor and the extensor phase. For 10 years a Swedish group
has performed the single-stage grip and release procedure as
described above (Video 37.2
). A traditional (staged) group
of 18 hands were compared with the single-stage procedure
(16 hands). All patients had early active mobilization. The
single-stage group had a significantly stronger grip strength
postoperatively, 6.5 kg, compared to the historical group,
1.6 kg, and significantly better opening of the hand: 5.5 cm
vs. 3.0 cm. The key pinch was about the same: 2.8 kg vs.
2.0 kg.55 Several surgeons found, as did House and Walsh,59
that those patients who had had some type of intrinsic stabi­
lization, either by Zancolli lasso60 or by House et al.’s intrinsic
reconstruction procedure,56 had, on average, more powerful
grasp. This may be a product of pre-selection as the stronger
patients may have been chosen for intrinsic substitution. The
last years have brought several case reports of different nerve
transfers. This is an exciting new field to be further researched
as it is still too early to assess the outcomes.
Conclusions
Carefully planned upper limb reconstructive procedures in
tetraplegia are both effective and durable. Systematic post-
injury evaluation of their upper limbs should become a
standard part of care of the person with tetraplegia. Aside
from their brain, the upper limbs remain the most important
residual resource for people with tetraplegia. The value of
greater independence is difficult to quantify, but many of our
patients express relief for being able to feed themselves and
perform their daily activities. Patients have said “Everything
goes faster now”; “I don’t need to bring my personal assistant
on dates anymore”; “ I can send my own texts”; “I’ve started
to work again”; “I can visit restaurants again and eat by
myself, even cutting beef.” These surgeries can be the pin­
nacle of hand surgery restoring function to those in great
need.

864.e1
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SECTION VI • Rehabilitation
38 
Upper extremity vascularized composite
allotransplantation
Jaimie T. Shores, Joseph Lopez, Gerald Brandacher, and W. P. Andrew Lee
SYNOPSIS
■ Vascularized composite allografts are composed of multiple tissue
components of variable immunogenicity such as skin, lymph nodes,
bone marrow, nerves, vessels, muscles, and bone.
■ After non-salvageable upper extremity loss, transplantation can restore
upper extremity appearance, anatomy, and function by replacing and
restoring missing tissue without compromising donor site morbidity or
requiring multiple reconstructions.
■ Vascularized composite allotransplantation (VCA) is not a life-saving
procedure but it can significantly enhance a patient’s quality of life.
Unlike solid organ transplantation, recipients are otherwise healthy
without significant comorbidities. The risk–benefit consideration for
patients must include the potential side effects of long-term
immunosuppression – treatment that is necessary for graft
survival.
■ The conventional immunosuppression protocols used in upper
extremity VCA are similar to those used in solid organ transplantation
and have prevented early graft loss but not acute rejection.
■ Acute rejection in vascularized composite allografts can be monitored
visually, which allows for timely intervention. Acute rejection events,
when properly managed, do not appear to impact long-term allograft
function or survival.
■ During the past two decades, over 100 upper extremity transplants
have been performed around the world in over 70 patients with
encouraging intermediate to long-term functional and graft survival
outcomes.
■ In order to broaden the application of this life-changing reconstructive
modality, future research should focus on investigating novel
immunomodulatory approaches that aim to enable long-term
allograft survival while minimizing the need for life-long
immunosuppression.
Access the Historical Perspective section online at

Fig. 38.1 appears online only.
Introduction
Millions of individuals each year sustain major upper extrem­
ity trauma, undergo resection of upper extremity tumors, or
are born with major congenital defects that require multiple,
complex reconstructive surgeries to repair large upper extrem­
ity defects. Conventional management of these tissue
deficiencies includes prosthetic rehabilitation or surgical
reconstruction (with autologous tissues), but these modalities
are often hampered by highly variable outcomes.64 There are
several factors that negatively impact surgical outcomes with
traditional approaches including the prolonged process and
cost of rehabilitation, multiple surgeries, limited autologous
tissue for reconstruction, and secondary morbidity from
extensive autologous donor-site surgery. For such complex
injuries not amenable to conventional reconstruction, vascu­
larized composite allotransplantation (VCA) can achieve
near-perfect primary restoration of tissue defects with
improved functional and aesthetic outcomes. VCA is a newly
developed focus area in transplantation medicine and com­
bines the time-tested techniques of reconstructive microsur­
gery with the immunologic principles of transplantation. The
overall goal of VCA is to improve the quality of life of patients
with significant composite tissue defects, and use the plastic
surgery principle of replacing “like with like” with the goal
of maximizing not only upper extremity functional outcomes
but also aesthetic results.
In the United States alone, approximately 1 285 000 upper
extremity amputations are performed per year.65 In 2005,
there were approximately 1.6 million individuals living in
the US with upper or lower extremity limb loss.66 Of these 1.6
million patients, nearly 540 000 individuals have had upper
extremity amputations. Even if only 1% of these patients were
deemed candidates for upper extremity allotransplantation,
this would mean that over 300 patients could potentially
benefit from this life-changing treatment. Thus far, only
over 70 patients have undergone upper extremity allotrans­
plantation in the last two decades. However, despite the
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865.e1
Historical development and milestones
Historical development and milestones
The earliest accounts of organ transplantation date to the
Chinese physician Pien Chi’ao, who in 500 BCE performed a
dual-heart transplant on warriors Gong Hu and Qi Ying.1 In
addition, in the Sušruta Samhita, a surgical report written by
the Indian surgeon Sušruta who lived around 480 BCE, Sušruta
describes in detail the techniques of rhinoplasty and pedicled
autografts from the forehead, neck, and cheek to restore
mutilating injuries of the nose and ear.2–4 About 870 years
later, the patron saints Cosmas and Damian are credited with
performing the first limb allotransplantation.5–9 Legend has it
that around the year 348, they successfully transplanted the
right leg of a dead Moor onto the Roman deacon, Justinian,
after amputating his cancerous/gangrenous leg (Fig. 38.1).
The first description of skin allografting was done by the 16th
century Italian surgeon, Gaspare Tagliacozzi, from Bologna,
who in his book De Curtorum Chirurigia per Insitionem (“On
the Surgery of Mutilation by Grafting”), described a novel
method of nasal and aural allo-reconstruction, where he used
skin from the inner aspect of the arm from a slave to recon­
struct the nose of a wealthy patient who injured it during a
sword fight.10–12 In this book, Tagliacozzi goes on to describe
one of the first description of tissue rejection, when he
discusses the practical difficulty of binding two different
individuals (referring to tissue rejection) to one another for a
sufficient length of time.
It took another 300 years before these “practical difficulties”
in transplantation began to be elucidated. During this time,
advancements in antisepsis, anesthesia, hemostasis, organ
preservation and, most importantly, microvascular surgery
led to the rapid progress of reconstructive microsurgery. Alexis
Carrell in 1902 described the surgical technique of vascular
anastomosis, thus laying the foundation for conventional
vascular and microsurgery.13 Carrell successfully obtained
the revascularization of experimental organ allografts,14,15 but
failed to achieve permanent graft acceptance. Carrell attrib­
uted this “organ failure” to vascular complications because
he had no knowledge of the process of rejection. In 1932
and 1937, the first attempts at skin grafting were performed
between identical twins.16,17 Again, no mention was made of
rejection. In 1944, Hall published the first detailed theoretical
account of cadaveric donor upper extremity transplantation
(at the mid-humeral level).18 In his protocol, Hall described
that an experienced surgical team within a well-equipped
hospital was needed to perform the procedure. Additionally,
his protocol included important and innovative descriptions
of organ preservation, osteosynthesis, and vascular anasto­
moses. Lastly, potential complications related to thrombosis
and infections were discussed, but, again, no reference was
made to the occurrence of rejection. Strikingly, Hall was not
aware that Sir Peter Brian Medawar, a young zoologist in
Britain, and Thomas Gibson, a plastic surgeon, had made the
historic discovery of the immunologic phenomenon of skin
allograft rejection that very same year (1944).19 The challenge
of skin transplantation led to the exploration of new frontiers
in organ transplantation. In 1954, a plastic surgeon, Joseph
E. Murray, with his team members – John P. Merrill and J.
Hartwell Harrison – in Boston, performed the first successful
human kidney transplantation between identical twins.20,21
This was followed, in 1957, by the first clinical attempt at
allotransplantation of an en bloc composite digital flexor
tendon mechanism by a plastic surgeon, Erle E. Peacock,
Jr.22,23 Indeed, it was Peacock who coined the term “composite
tissue allograft” to differentiate these transplants that were
composed of multiple tissues unlike solid organs.24
Our understanding of the immunologic behavior of
allografts lagged behind technical developments in surgery.
It was only the knowledge gained from landmark discoveries
in the past century25–33 that facilitated the manipulation or
suppression of the immune response, allowing successful
prolongation of graft survival. After Medawar’s demonstra­
tion that rejection was an immunologic event, the next logical
question was: Why not prevent this phenomenon by sup­
pressing the immune system? In the 1950s, corticosteroids
and irradiation were used for immunosuppression.34,35 In
the 1960s, the antimetabolites 6-mercaptopurine and its
derivative azathioprine were introduced, along with agents
such as antilymphocyte globulin. These drugs were used
either alone36,37 or in combination with corticosteroids.38–40
Graft survival improved, but surgical outcomes were
dismal because these drugs acted indiscriminately and were
associated with severe organ-specific and systemic adverse
effects.
In 1964, the first hand transplantation was performed
using pharmacologic immunosuppression.41–43 Dr. Gilbert
Fig. 38.1  St. Cosmas and Damian perform the first human extremity
allotransplantation. Per mythology, Christian Roman deacon Justinian had a
malignant growth on his leg and fell asleep while praying for a cure in the Church
of Cosmas and Damian in Rome. In his dreams, the saints amputated the diseased
limb and transplanted the leg of a Moor, brought to the church for burial. The
patient awoke and gratefully observed a now healthy leg, though black in color.
(Reproduction with permission from Württembergisches Landesmuseum, Stuttgart.)

865.e2
SECTION VI
CHAPTER 38 • Upper extremity vascularized composite allotransplantation
in Guayaquil, Ecuador, transplanted the right forearm of a
28-year-old sailor who had lost his limb at the wrist level
caused by a hand-grenade explosion the previous day. The
donor was a laborer who had died of hematemesis (with
gastric bleeding) a few hours earlier. The recipient was given
heparin, dextran, and a broad-spectrum antibiotic after the
surgery and was maintained on a combination regimen of
prednisone and 6-mercaptopurine (6-mercaptopurine was
replaced 24 h later by azathioprine). These drugs are con­
sidered primitive according to present day standards, and
unfortunately, signs of acute allograft rejection occurred after
2 12 weeks. The patient was then moved to Peter Bent Brigham
Hospital in Boston, where, at 3 weeks, aggressive rejection
set in, and the forearm had to be re-amputated at 4 cm above
the wrist level. Unfortunately, the advanced state of necrosis
prevented any histopathologic evaluation of the graft. This
bold and pioneering attempt at hand transplantation laid the
foundation to the successful attempts yet to come.
In 1976, another major breakthrough in transplantation
came with the discovery of the immunosuppressive proper­
ties of the calcineurin inhibitor cyclosporine A.44,45 In 1978,
cyclosporine was first used clinically in organ46 as well as bone
marrow transplantation with remarkable results. The US
Food and Drug Administration (FDA) approved cyclosporine
A in 1983. Cyclosporine A, along with agents like anti-CD3
antibody (OKT3, introduced in 1981),47 effectively reduced the
reliance on high-dose steroids for the prevention of rejection.
The calcineurin inhibitor tacrolimus (FK 506) was discovered
in 1987,48 clinical trials were conducted in 1989,49 and FDA
approval came in 1994. Tacrolimus led to dramatic improve­
ments in solid organ transplantation,50–53 allowing highly
immunogenic grafts such as the small bowel to be
transplanted.54–56 The success of the calcineurin inhibitors
cyclosporine A and tacrolimus made them the cornerstone
drugs of the modern era of transplantation.57 The 1990s saw
the introduction of novel drugs such as the antimetabolite
mycophenolate mofetil58 (MMF, approved by FDA in 1995)
and rapamycin59 (sirolimus, discovered in 1976 but FDA
approved only in 1999). Combining these drugs with a calci­
neurin inhibitor60–63 were found to significantly reduce rejec­
tion and improve solid organ graft survival with a reduction
in adverse effects.

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CHAPTER 38 • Upper extremity vascularized composite allotransplantation
and large animal (porcine, canine, and non-human primate)
VCA models.
Experimental background and scientific basis
for upper extremity transplantation
In early rodent limb transplantation studies, recipients treated
with various combinations of immunosuppressive doses of
6-mercaptopurine, or its derivative azathioprine, and predni­
sone all died from drug-induced side effects before the onset
of macroscopic signs of rejection.73 Even after the introduction
of cyclosporine A, the use of high doses of cyclosporine A
demonstrated no improvement in limb or animal survival.74–78
In fact, cyclosporine A monotherapy was found to be uni­
formly unsuccessful in prolonging vascularized composite
allograft survival in both small animal and non-human
primate models.79 Further studies in non-human primate
models demonstrated that acute rejection could only be pre­
vented with cyclosporine A when trough levels were 3–4
times the level achieved in human solid organ transplantation
– levels that are associated with significant peri-transplant
infections and malignancies.80–83
In 1996, Benhaim and colleagues demonstrated that a
combination of cyclosporine A with an antimetabolite (such
as mycophenolate mofetil) could successfully prolong rat
hindlimb allograft survival.84 Benhaim and his team were the
first to show that predictable, long-term, functional limb
allograft survival could be achieved. Using a similar regimen,
others went on to demonstrate, using a swine model, that
long-term survival of fully mismatched composite allografts
was technically feasible.85,86 Since swine and humans share
immunological similarities including the structure of MHC
and the expression of MHC class II antigens (on endothelial
cells, epithelial cells, and dendritic cells),87 these findings
provided sufficient sound evidence, in both small (rodent)88,89
and large animal VCA models,85,86 that human upper extrem­
ity allotransplantation was feasible.90
Our extensive experience with organ transplantation has
provided valuable information about the immunologic conse­
quences of organ transplantation and the efficacy and toxicity
of immunosuppressive drugs. The field of transplantation
evolved from transplanted kidneys91 and hearts92,93 to livers,94
lungs,95 pancreas,96 small bowel,97 multiple abdominal
viscera,98 bone marrow,99 and, most recently, vascularized
composite allografts.100,101 As expected, the initial results of
allograft and patient survival after organ transplantation in
the 1960s were poor. Editorials in major clinical journals,102
including the New England Journal of Medicine,103–105 questioned
the feasibility and ethical basis of organ transplantation. There
was great concern for the adverse effects of chronic immuno­
suppression, especially the risk of opportunistic infections
and malignancies. During the next four decades, due to
improvements in immunosuppression and in the manage­
ment of post-transplant complications, this pessimism abated.
Similarly, attempts at upper extremity transplantation,106,107
after three decades of quiescence since the first attempt in
Ecuador,46,47 has also been met with vigorous skepticism.
Interestingly, most of the criticism has come from hand
surgeons.108–114 Most argue that the risks of immunosuppres­
sive therapy are justifiable in potentially life-saving organ
transplantation, but not in upper extremity allotransplanta­
tion. Furthermore, many hand surgeons argue that the
fact that surgical, immunological, and functional results are
highly encouraging, the need for long-term and high-dose
immunosuppression to enable graft survival and to treat/
reverse acute skin rejection episodes remains a rate-limiting
obstacle towards widespread application.67,68 The risks of
immunosuppression are not benign. These include infection,
cancer, and metabolic derangements. All these risks greatly
affect the recipient’s quality of life, alter the risk profile, and
jeopardize the potential benefits of upper extremity transplan­
tation. Furthermore, unlike in solid organs, clinical success is
dictated not only by graft acceptance and survival but also
by nerve regeneration, which determines ultimate functional
outcomes. Novel strategies such as cellular and biologic thera­
pies that integrate the concepts of immune regulation with
those of nerve regeneration have shown promising results in
small and large animal models. Clinical translation of these
insights to upper extremity reconstructive transplantation
could further minimize the need of immunosuppression and
optimize functional outcomes, enabling greater feasibility and
wider application of these procedures as an option for upper
extremity amputees.
Evolution of upper extremity
vascularized composite
allotransplantation
Immunology of vascularized
composite allotransplantation
Research findings in small and large animal models have
vastly improved our knowledge of the immunologic aspects
of vascularized composite allografts. These studies have
demonstrated that the allograft is composed of different
tissues, each with its own degree of antigenicity as a result of
differing antigen expression and presentation mechanisms.69
Each component in a vascularized composite allograft
expresses different amounts of major histocompatibility
complex (MHC) and tissue-specific antigens – important
factors that elicit a recipient’s cellular-mediated immune
response.70 Antigen recognition and targeting by the recipi­
ent’s immune system also differs among the allograft tissue
elements due to differential vascular and lymphatic supply.
Altogether, these factors help explain the pattern of rejection
that is observed in whole limb transplanted allografts. For
instance, transplanted muscle evokes mainly a cell-mediated
immune response, whereas skin induces both cellular and
humoral responses.71 Furthermore, skin and bone marrow
appear to reject earlier and more aggressively than muscle,
bone, cartilage, or tendon. Having an appreciation and under­
standing of the relative antigenicity of vascularized composite
tissue components can facilitate the development of strategies
aimed at decreasing the antigenicity of these specific compo­
nents. In addition, understanding the relative antigenicity of
specific allograft components enables the tailoring of immu­
nosuppression, thus limiting the amount of immunosuppres­
sion needed when treating rejection.72 Over the last few
decades, our understanding of relative antigenicity and
humeral/cellular immunity has allowed the testing of several
tailored immunosuppressive regimens in small animal (rat)

867
Clinical experience with upper extremity allotransplantation
(plastic or orthopedic) and transplant surgeons, psychiatrists,
physical therapists, social workers, and transplantation
nursing staff to name a few. Although the transplant clinical
process is well established, it is also bound by tight regula­
tion; this may come as a surprise to reconstructive plastic/
hand surgeons who wish to start a hand program. Therefore,
the experience of the solid organ transplantation members is
essential when negotiating through the regulatory process.
Such a joint effort can overcome the challenges that are inherent
in a complex therapeutic option that integrates multiple spe­
cialties during the planning, procedural, and post-transplant
phases.
Donor and recipient selection
The overall success of VCA relies on many factors. However,
our own experience with upper extremity allotransplantation
has taught us that proper evaluation, selection, and manage­
ment of donors and potential recipients is probably the most
important determinant of outcomes. Recipient screening and
selection is a multistage process, which takes a multidisci­
plinary look into the patient’s past medical history and pre-
transplant life.130 Data on psychological and social factors
must be collected and evaluated prior to determining patient
eligibility. While these psychological and social aspects of
screening are critical, they are also the most difficult to assess.
The worldwide experience with upper extremity allotrans­
plantation has shown that only patients who are physically
and mentally healthy, with adequate psychological and social
support, and are highly motivated to undergo long-term (>6
months) intensive rehabilitation and therapy, are “good”
candidates for upper extremity transplantation.
Decades of experience with solid organ transplantation
has provided the field of transplantation medicine with well-
established criteria for donor and recipient selection. Given
that the field of upper extremity allotransplantation is still in its
infancy, parameters for inclusion and exclusion of donors and
recipients have yet to be fully established.131,132 Tables 38.1 and
immunological, ethical,115,116 and psychological117 issues asso­
ciated with hand transplantation still need to be addressed.118
The rationale for proceeding with clinical trials of upper
extremity transplantation using modern immunosuppression
have been based on scientific progress on: (1) the availability
of novel immunosuppressive drugs that have improved the
efficacy and lower risk profile of immunosuppression; (2) the
availability of highly efficacious treatments for opportunistic
fungal or viral infections (such as Pneumocystis carinii and
Cytomegalovirus); (3) the development of novel therapeutics
for post-transplant malignancies (such as rituximab for post-
transplant lymphoproliferative disorder, PTLD); (4) research
on immunosuppressive drug regimens based on years of
experience with solid organ transplantation; and (5) the
success of human transplantation of all individual component
tissues of the hand, including skin, muscle, tendons, vessels,
nerve, bone and joint.119
Chronology of clinical upper extremity
allotransplantation
In September 1991, the first conference on VCA was held in
Washington, DC to “determine the clinical feasibility of trans­
planting limbs in patients with limb loss” and the “direction
in which clinically oriented limb transplantation research
should head.”120 In November 1997, the first International
Symposium on VCA was convened in Louisville, Kentucky,
to discuss the “scientific, clinical and ethical barriers standing
in the way of performing the first human hand transplant.”
International experts at the meeting predicted that limb
transplantation was not far from “becoming a clinical
reality”.121 Within the next 22 months, 34 years after the first
hand transplantation was performed,46,47 surgeons in Lyon,
France, performed the world’s second unilateral hand trans­
plant in September 1998.106,107,122,123 In January 1999, the first
unilateral hand transplant in the United States was performed
in Louisville, Kentucky.124,125
Following these attempts, numerous centers in Europe,
Asia, and the US have performed over 70 upper extremity
transplantations. Most of these transplantations were wrist to
mid-forearm amputations, except for two partial hand grafts
in China, one partial hand graft in the US, and two cases of
above-elbow transplantation.126,127
Clinical experience with upper
extremity allotransplantation
Program, patient, procedural and protocol-
related considerations
Program establishment and implementation
Starting a hand transplant program poses numerous chal­
lenges.128,129 Solid organ transplantation and hand replantation
are time-tested procedures and are now the standard of care.
Hand transplantation is the amalgamation of the scientific
principles of reconstructive surgery and the concepts of organ
transplantation. Therefore, the success of any hand transplant
program lies on its ability to foster collaboration between a
multidisciplinary team comprised of a core group of hand
Table 38.1  Donor considerations in upper extremity
allotransplantation
Demographic and phenotypic characteristics
Skin color, tone, and texture match
Limb size and dimension (bone length and diameter match)
Age, sex, race and ethnicity match if possible
Donors must be deceased (brain death declared)
Donor limb dissection and procurement must not interfere with
organ recovery
Limb usually prepped first, perfused under isolated tourniquet,
dissected after cross clamp and retrieved in sequence with
heart and lung recovery. This minimizes overall ischemia time
History of malignancy (recent or remote) may be an exclusion
Paralysis of ischemia or traumatic origin, inherited peripheral
neuropathy, infectious, post-infectious or inflammatory
neuropathy, toxic neuropathy (i.e., heavy metal poisoning,
drug toxicity, industrial agent exposure) or mixed connective
tissue disease, severe deforming rheumatoid, or osteoarthritis
in the limb may be exclusions

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CHAPTER 38 • Upper extremity vascularized composite allotransplantation
38.2 highlight the general selection criteria that has been used
in upper extremity allotransplantation. Patients below the age
of 18 years are generally excluded due to issues of informed
consent of an experimental procedure. Furthermore, from
experience in solid organ transplantation, it is known that pedi­
atric patients are more likely to develop immunosuppression-
related complications like PTLD than adults.133 Patients over
the age of 65 are also generally excluded because of increased
immunosuppression-related complications, limited years of
potential gain from the transplant, and decreased nerve regen­
eration potential. Medical screening of recipients includes a
complete medical history and physical examination; routine
laboratory studies; blood typing and cross-matching; human
leucocyte antigen (HLA) typing; testing for panel-reactive anti­
bodies; and serology for Epstein–Barr virus, cytomegalovirus,
HIV, and viral hepatitis. Other tests include radiography (to
plan for osteosynthesis), angiography (to exclude abnormal
vascular patterns), electromyography, nerve conduction veloc­
ity, and functional magnetic resonance imaging (fMRI).
Procedural aspects
Donor limb procurement
Once an immunologically appropriate donor has been
identified by the Organ Procurement Organization (OPO),
further “matching” is necessary to ensure adequate skin
color, gender, age, and length/circumference.134 The level of
procurement depends on the specific deficit on the recipient.
Each recipient should receive a “custom” operation tailored
to its respective anatomical deficits. For distal forearm and
mid-forearm transplants, an elbow disarticulation provides
enough soft tissue, vessel length, nerve length, and extra
skin/bone for transplantation. For proximal trans-humeral
transplants, a proximal humeral procurement at the most
proximal level possible that can still maintain tourniquet
control is usually adequate.135 Proximal arm procurements
may often require intra-thoracic cannulation and control of
the subclavian vessels by the thoracic procurement team. The
limb is perfused with cold histidine–tryptophan–ketoglutarate
(HTK, Custodiol) or University of Wisconsin (UW) solution
based on the individual center preference. Depending on the
stability of the donor, level of procurement, and operating
room space, upper extremity procurement may occur con­
currently, before, or after standard organ procurement. We
recommend procurement of the upper extremity before vis­
ceral organ procurement to minimize ischemia time as much
as possible. Upon completion of hand retrieval (Fig. 38.2),
the donor stump is closed, and the body can be fitted with
a cosmetic prosthesis, allowing the family the option of an
open-casket funeral. Following retrieval, the limb (wrapped
in moist sterile gauze and placed in a polyurethane bag) is
transported in a sterile container (provided by the OPO)
with iced water at 4–6°C. Donor spleen and lymph nodes
are collected and cell suspensions cryopreserved for future
immune assays.
Recipient surgery
The recipient operation is carefully planned prior to procure­
ment and involves close communication between donor and
recipient teams. After confirming donor match, the recipient
undergoes placement of regional blocks, preparation for
general anesthesia and induction therapy (most commonly
with basiliximab, Simulect; anti-thymocyte globulin (ATG);
or alemtuzumab, Campath-1H). Hand transplantation does
not differ greatly from replantation. Instrumentation and
technique are similar. A two-team approach is used. The
donor team prepares the donor limb once received on the
back table, tailoring the graft to the needs of the recipient
and tagging the structures (Fig. 38.3). The two main hand
transplant surgeons and assistant hand transplant surgeons
(dissecting the donor limb) are assisted by one scrub nurse
per extremity, two circulators per room, and at least one
anesthesiologist. Based on the preoperative assessment of the
recipient, tissue requirements from the donor will be known.
The team dissecting the recipient must know exactly what
measurements are necessary for the donor team to proceed.
The recipient team will need to clearly identify the amount
Table 38.2  Recipient considerations in upper extremity
allotransplantation
Subjects can be of any race, color, ethnicity in good health
Age range for eligibility is variable but usually over 18 years and
under 65 years
Subjects with congenital defects (e.g., transverse arrest) are
currently excluded
The impact of the lack of pre-existing cortical recognition is
unknown
Blindness is an exclusion in some programs
Eyesight necessary to follow the rigorous rehabilitation process.
Additionally, visual feedback is critical for functional recovery
Rigorous psychosocial assessment is mandatory
Used to determine the motivation for transplantation, emotional
and cognitive preparedness for the procedure, body image
adaptation, level of realistic expectations regarding post-
transplant outcomes, anticipated comfort with the transplant,
personality organization/risk of regression, history of medication
compliance/substance abuse, potential for compliance, and
social support system/family structure
Use or attempted use of prostheses prior to transplant is a
suggested requirement
Fig. 38.2  Donor graft after isolated perfusion and disarticulation.

869
Clinical experience with upper extremity allotransplantation
Fig. 38.3  Tagging of structures in the donor graft following back-table dissection
improves technical success and reduces ischemia time.
Fig. 38.4  Reperfusion after extensor tendon reconstruction but prior to flexor
tendon reconstruction.
of nerve, artery and veins required for transplantation. The
sequence of tissue repair is to minimize ischemia time and
could depend on surgical preference (Fig. 38.4). Commonly,
it includes bony fixation → artery repair → vein repair
(revascularization) → tendon repair → nerve repair → skin
closure.
Our experience over the past two decades has elucidated
specific principles that are important for the recipient opera­
tion. In general, nerve approximation should be performed
as distally as possible. Over-dissection of donor arteries
should be avoided to prevent postoperative bleeding and
to minimize the risk of a persistent inflammatory reaction.
The limb should be kept on sterile ice at all times with an
interface between the ice and tissue to prevent thermal
injury. Lastly, the authors typically use an implantable
venous Doppler on the anastomosed veins and use pulse-
oximetry probes on the transplanted hand for oxygenation
monitoring.
Clinical tips
Distal forearm allotransplantation
Distal forearm allotransplantation often relies on the recipient’s
native extrinsic musculature, but this requires the careful
approximation of median and ulnar motor fascicles for
recovery of intrinsic function. Recipient incisions should create
volar and dorsal skin flaps, while donor incisions should create
radial and ulnar skin flaps for interdigitation. Tendon
approximation can be performed using the Pulvertaft weave
technique, facilitating immediate postoperative active/passive
range of motion. The osteosynthesis can be performed with
standard distal radius and ulna fixation techniques. The
authors typically perform osteosynthesis first, taking great care
to create a stable distal radioulnar joint (DRUJ), followed by
arterial and venous anastomoses, followed by reconstruction
of the extensors, then flexors, then nerves.
Clinical tips
Mid-forearm allotransplantation
Mid-forearm transplants require a critical assessment of
recipient flexor and extensor tendons/muscle (Fig. 38.5). If the
flexors and extensors are considered of adequate length with
minimal damage, then muscle/epimysial/fascial/tendon repairs
can be performed. Unfortunately, these repairs do not lend
themselves to vigorous immediate postoperative therapy. The
same sequence described above for the distal forearm
allotransplantation procedure is used for the mid-forearm
procedure. If the recipient extensors and flexors are deemed
inadequate, the mid-forearm procedure follows the steps as
performed in the proximal forearm allotransplantation
procedure (see below), while maintaining the distal level of
skeletal osteosynthesis.
Clinical tips
Proximal forearm allotransplantation
Proximal forearm allotransplantation requires the
transplantation of donor flexor/extensor muscle groups in
order to obtain meaningful digital excursion and strength in
the hand. Volar and dorsal skin flaps are created on the
recipient limb to protect the antecubital fossa and olecranon
while donor limb skin flaps are elevated radially and ulnarly.
The new flexor/pronator origins are fixed with bone anchors
and sutures on top of the native flexor/pronator muscle mass
at the medial epicondyle (Fig. 38.6A–D). Similarly, the extensor
origin is fixated with bone anchors into the lateral epicondyle.
Additionally, the annular ligament and radiocapitellar joint
capsule of the donor are sutured to the extensor origin of the
recipient. The radial nerve can be usually dissected to
individual muscle groups such as the extensor carpi radialis
branch, posterior interosseus branch, and extensor carpi
radialis longus branch. We use an end-to-side brachial-to-
brachial artery anastomosis to preserve maximum blood flow
to the proximal ulna, radius, and native flexor/extensor motor
groups. Veins are anastomosed in end-to-end fashion.

870
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CHAPTER 38 • Upper extremity vascularized composite allotransplantation
Fig. 38.5  (A,B) Mid-forearm
allotransplantation.
A
B
Fig. 38.6  Proximal forearm and trans-humeral
transplantation: (A) left forearm proximal
transplantation –preop; (B) possible donor forearm
incisions indicated; (C) post-fixation X-rays;
(D) inset of skin flaps; (E) right upper arm
transplantation – preop; (F) donor arm procured
and demonstrating skin flap incisions;
(G) post-fixation X-rays; (H) inset of skin flaps.
A
B
C
D
F
E
G
H

871
Clinical experience with upper extremity allotransplantation
Clinical tips
Trans-humerus allotransplantation
Trans-humeral transplants can be categorized as distal,
middle, and proximal. Distal humerus allotransplantation is
performed with primary repair of the donor brachialis fascia
and biceps/triceps tendon to the recipient brachialis fascia
and biceps/triceps tendons (see Fig. 38.6E–H). End-to-end
brachial artery/vein anastomoses (in addition to several
superficial vein anastomoses) are performed. Fixation is
achieved by utilizing single-plate osteosynthesis with the
authors preferring a tapered 4.5/3.5 mm stainless steel locking
compression plate. Skin flaps are elevated while maintaining
skin integrity at the antecubital fossa and olecranon. In
mid-humerus transplantation, one must decide whether the
remnant flexor/extensor muscle groups will be adequate for
active elbow motion. If one decides to maintain the native
biceps and triceps to power the elbow, then muscle-to-muscle
approximation is performed with as much tendon/fascia
substance as possible. The use of fascial/tendon graft or
allograft may be beneficial for strengthening the repair. The
brachialis, due to its extensive origin on the humerus, can be
transferred with the donor limb and be expected to function if
the musculocutaneous nerve is adequately coapted. The
same osteosynthesis, nerve repair, and vascular
reconstructions are performed as described for the proximal
humerus procedure. If one decides to transplant the donor
flexor and extensor masses, then the steps for the proximal
humerus allotransplantation are followed.
For proximal humerus allotransplantation, one may be
required to transplant the entire flexor/extensor muscle
compartments of the antebrachium (Fig. 38.7). Both the
biceps short head and the biceps long head tendons are
dissected off their origins on the donor limb. Both of these
muscles can be sutured or woven into the recipient short head
and long head/conjoint tendons, respectively. This level of
transplantation also requires the division of the recipient
pectoralis tendon with tagging for future repair. Osteosynthesis
is performed utilizing a 4.5 mm locking compression plate,
which is placed anterolaterally. Once osteosynthesis is
complete, the most posterior compartment structures are
reconstructed with the recipient and donor triceps muscle/
tendons sutured to one another with some tension with the
elbow in extension. Next, the radial, ulnar, and median nerves
are coapted. Attention is then directed to the arterial and
venous anastomoses. The brachial artery on the recipient is
anastomosed to axillary artery of the donor limb and the
brachial and cephalic veins are anastomosed proximally as
well. Lastly, after reperfusion is complete, the biceps long and
short head proximal tendons are woven and/or sutured with
the elbow in flexion and under some tension, followed by
musculocutaneous nerve coaptation. Once this is complete,
the pectoralis tendon may be repaired or reinserted with bone
anchors if necessary.
Fig. 38.7  (A,B) Use of the high non-pneumatic tourniquet for proximal trans-
humeral procurement.
A
B
Protocol-related considerations
Maintenance immunosuppression
The current immunosuppression protocols applied to upper
extremity allotransplantation are extrapolated from regimens
used in solid organ transplantation. The overall amount of
immunosuppression required to ensure graft survival is
comparable with that used in renal transplantation. Such con­
ventional immunosuppression has resulted in >95% patient
and graft survival at 1 year after upper extremity transplanta­
tion.126 The majority of hand transplant patients received either
polyclonal (ATGs) or monoclonal (alemtuzumab, basiliximab)
antibody preparations as induction therapy followed by a
high-dose triple-drug combination for maintenance therapy
including tacrolimus, mycophenolate mofetil (MMF), and ste­
roids, although the dose and trough levels of each drug differs
by center. Such regimens have proven sufficient to prevent
early immunologic graft loss but have yet to prevent acute
rejection episodes. Some programs follow steroid-avoidance
regimens, while others rely on monotherapy immunosup­
pression. Successful reversal of acute rejection episodes
(see Fig. 38.8) has been achieved using topical clobetasol or
tacrolimus ointment with or without short-term bolus steroid
doses.136,137

872
SECTION VI
CHAPTER 38 • Upper extremity vascularized composite allotransplantation
in rehabilitation after surgery. At our institution, a rigorous
rehabilitation regimen has been implemented in all patients
with 3–6 h of supervised therapy, 5 days a week during the
first 3–6 months postoperatively, depending on the nature and
upper extremity level of the transplant. Therapy must consist
of passive and active ROM exercises with appropriate static
and dynamic splinting to allow for gentle active flexion/
extension, limit adhesions, and promote healing. Hand-based
splints such as dynamic extension outrigger splints (Fig. 38.9)
and anti-claw splints should be used in all patients. The
outrigger allows for an intrinsic-plus position, protects flexors
and extensors, and enables constant tension throughout the
range of controlled motion. Compression gloves are useful in
patients with lymphedema. Qualitative and quantitative tests
for hand and upper extremity function such as the Carroll
score,139 the DASH140 score, and the Hand Transplantation
Score System141 may be utilized, along with standard tests
that evaluate motor and sensory recovery (Tinel’s, Semmes–
Weinstein monofilaments, 2PD, dynamometry, peg board
tests, etc.). After discharge at 3–6 months postoperatively,
communication and coordination with a certified local thera­
pist is critical to ensure follow-up continuity of an intensive
regimen and a home therapy exercise routine that is para­
mount to achieving functionality.
Assessment for rejection (host-versus-graft reaction)
Acute rejection (AR) is a T-cell- and/or antibody-mediated
attack of the transplant by the recipient’s immune system
resulting in damage and ultimately loss of the graft. The skin
has been demonstrated to be the prime target of rejection and
monitoring of the skin by inspection is therefore considered
most important for monitoring. Protocol graft-skin biopsies
must be routinely performed until the first year plus whenever
clinically indicated (visible signs of rejection such as a macu­
lopapular rash). Biopsy samples may be analyzed by means
Rehabilitation and functional assessment after upper
extremity allotransplantation
Rehabilitation and functional assessment are integral compo­
nents of successful upper extremity allotransplantation.138 A
fully-trained hand therapist should be involved in the entire
process from initial screening of prospective patients through
final discharge. The goal is functional integration of the trans­
planted hand into the patient’s daily activities. Successful
rehabilitation of upper extremity transplant patients follows
guidelines similar to replant protocols. There are several sig­
nificant differences, however, such as the screening process
for an ideal candidate and the monitoring for signs of
rejection.
The preoperative evaluation process involves patient
acceptance of the amputation, attempted prosthetic use, and
the establishment of realistic goals for surgery and outcomes.
This includes a full history and physical exam to document
the range of motion (ROM) of the available joints; manual
muscle testing (MMT) of available muscles; response of the
residual forearm musculature to electrical muscle stimulation;
documentation of pain and sensitivity complaints; scar
quality; level of amputation; sensation; edema; skin and soft
tissue integrity; and circumference of the forearms at varying
levels, as well as length of the forearms. Different tests, ques­
tionnaires or instruments can be used to evaluate preoperative
functional level and the status of residual muscles that
will power the transplanted hand. As appropriate, electrical
muscle stimulation, as well as isometric exercise, can help in
preoperative strengthening of these muscles.
The goals of postoperative therapy, bracing, and splinting
are similar to the goals in replantation surgery. Knowledge of
the exact level of nerve repair, type of osteosyntheses, and
details of tendon repairs are essential in planning of splinting
and therapy. Uniquely, the hand therapist can help monitor
for signs of rejection as the patient spends considerable time
Fig. 38.8  (A–C) Clinical manifestations of acute skin rejection. These can range from discrete or diffuse maculopapular rash with or without edema and palmar
involvement.
A
C
B

873
Clinical experience with upper extremity allotransplantation
triphosphate (ATP) synthesis in CD4 cells. Immune responses
are reported in ng/mL of ATP and categorized as strong (>525)
moderate (226–524) or low (<225). The desirable target zone
for all transplant recipients is 280 ng/mL ATP, with a 96%
negative predictive value for rejection or infection.
World experience and surgical outcomes
The International Registry of Hand and Composite Tissue
Transplantation (IRHCTT) () tracks
upper extremity allotransplants around the world. The 2008
and 2010 reports146 indicated that the average age of recipients
is 32 years (range 19–54 years), usually male, with time from
injury to transplant ranging between 2 months and 34 years.
Follow-up ranged from 1 month to 11 years. Patient survival
following hand transplantation stands at 100% in the United
States. Long-term graft survival among patients in Europe
and the United States is approximately >80%, with only a
few graft losses. The first French patient who received an
upper extremity transplant underwent amputation following
irreversible graft rejection secondary to medication non-
compliance. Two American patients lost the upper extremity
allograft due to medication non-compliance as well, while
another lost bilateral upper extremity allografts immediately
postoperative due to sepsis.147 Lastly, another American
patient loss the upper extremity allograft due to ischemia
secondary to vascular intimal hyperplasia.148
Highly compliant (with respective to immunosuppressive
medication and rehabilitation) hand transplant recipients
show highly encouraging early and intermediate functional
outcomes (Video 38.1
). However, these excellent results are
dependent on intensive and continuous rehabilitation. Protec­
tive sensation has been achieved in all patients within 12
months. Furthermore, the transplanted upper extremity limbs
show restored abilities not otherwise afforded by prosthe­
ses.149 These include grasping small objects, pouring water
from pitchers, tying shoe laces, playing chess, throwing a ball,
and using hands in activities of daily living. Recipients have
also demonstrated rapid progression of their Tinel’s sign and
of histology and immunohistochemistry (staining for CD3,
CD4, CD8, CD20, and CD68) for quantification and character­
ization of cellular infiltrates. Scoring for severity of acute
rejection is accomplished using established standard grading
criteria such as the Banff classification (Fig. 38.10 & Table
38.3).142,143 Important clinical characteristics of AR include
edema, erythema, escharification, and necrosis. Atypical rejec­
tion in the form of scaling, leuconychia or nail dystrophy can
also occur (Fig. 38.11).137 Biopsies must also be examined for
evidence of chronic rejection (CR), including intimal hyper­
plasia and sub-intimal foamy histiocytes in the vessels of the
skin, or muscle and tissue fibrosis (Fig. 38.12).
Immunomonitoring
Recipient and donor cells must be typed before transplanta­
tion for human leukocyte antigens (HLA).144,145 Additionally,
DNA samples from recipient/donor must be stored for
future typing for MICA (MHC class I chain A-related) genes
in those patients in whom anti-MICA antibody is detected.
All sera should be screened by antihuman globulin-enhanced
complement-dependent cytotoxicity assays (AHG-CDC), by
enzyme-linked immunosorbent assay (to identify immuno­
globulin G anti-HLA class I- and class II-specific antibodies
independently) and by Luminex (allows for the identifica­
tion of anti-MICA antibodies, as well as ascertainment of
their donor specificity). The MICA and MICB antigens are
expressed on surface of endothelial cells and epithelial cells
and elicit a strong antibody response in recipients of solid
organ transplants. Cell-mediated immunity may be measured
by the ImmuKnow (Cylex) assay that detects adenosine
Fig. 38.9  Dynamic extension (crane) outrigger splint.
Table 38.3  Banff grading scale
Grade
Histopathology of skin
Grade 0
None. Rare inflammatory infiltrates
Grade I
Mild. Mild perivascular lymphocytic and eosinophilic
infiltration. No involvement of the overlying
epidermis
Grade II
Moderate. Moderate-to-severe perivascular
inflammation with or without mild epidermal and/
or adnexal involvement (limited to spongiosis and
exocytosis)
Grade III
Dense inflammation and epidermal involvement with
epithelial apoptosis, dyskeratosis, and/or
keratinolysis
Grade IV
Necrotizing acute rejection. Necrosis of single
keratinocytes and focal dermal–epidermal
separation
(Reproduced with permission from Cendales LC, Kanitakis J, Schneeberger S,
et al. The Banff 2007 working classification of skin-containing composite tissue
allograft pathology. Am J Transplant. 2008;8:1396–1400.)

874
SECTION VI
CHAPTER 38 • Upper extremity vascularized composite allotransplantation
Fig. 38.10  The Banff histopathology grading system for acute rejection in skin: grades IVa and IVb are variants in severity of rejection (Banff grade IV).
Normal skin
Grade I
Grade II
Grade III
Grade IVa
Grade IVb
Fig. 38.11  Atypical manifestations of acute rejection: (A) palmar scaling, (B) nail dystrophy, and (C) pitting and leuconychia.
A
B
C

875
Emerging insights in vascularized composite allotransplantation
transplantation, provides a unique opportunity for potential
immunomodulation and tolerance induction.151,152
Unlike solid organ transplants that are immediately
functional after revascularization, a vascularized composite
allograft is dependent on peripheral nerve regeneration for
functional recovery. Following transplantation, the recipient’s
nerves/axons have to regrow and reinnervate allograft
muscles and other sensory end organs. This process allows
the recipient to establish motor control and receive sensory
input from the allograft. As a result, neuroregeneration repre­
sents a unique challenge in VCA. Interestingly, the use of
immunosuppressive drugs like tacrolimus has been shown to
not only prolong the survival of limb allografts but also to
augment nerve regeneration in animal models.153–155 However,
at this time there are no available agents applicable in upper
extremity allotransplantation that may augment the periph­
eral nerve regeneration process. Although our current clinical
experience has been promising, future studies that seek to
improve nerve generation in VCA could ultimately translate
into improved function in transplant recipients, making the
risk and costs associated with upper extremity allotransplan­
tation more acceptable.
Emerging insights in vascularized
composite allotransplantation
Cortical plasticity and neuro-integration
A unique phenomenon observed after upper extremity trans­
plantation is the reassignment of portions of the recipient’s
brain to control the limb. This is known as brain “reorganiza­
tion” or “plasticity”. Previous studies have demonstrated that
changes in cortical organization occur after amputation.
However, the impact of limb transplantation on spatial reor­
ganization of the motor cortex is just now being revealed.156
After an upper extremity amputation, the area of the brain
that was once receiving signals from the hand is gradually lost
and is “molded” for use in other functions. However, after an
upper extremity transplant, the area of the brain that once
controlled upper extremity function can re-establish its origi­
nal function.157 Such neural integration of the transplant into
the pre-motor cortex has been demonstrated using fMRI
studies and high-definition fiber tracking with diffusion
tractography.
Chronic rejection
In solid organ transplantation, CR is defined as low-grade
injury to the vascular endothelium of the allograft leading to
irreversible allograft damage (see Fig. 38.12).148 The hallmark
of CR shared by all solid organs is concentric generalized
sclerosis and low-grade perivasculitis of graft arteries leading
to obliterative arteriopathy. These histologic changes are the
result of both immunologic and non-immunologic factors.
According to the latest report of the IRHCTT (www
.handregistry.com), over a dozen patients have undergone
upper extremity transplantation and have been followed
for 5–10 years post-transplantation without any objective
measurable vascular changes suggestive of myointimal
hyperproliferation (or other indirect signs of CR). However,
experimental animal studies have demonstrated that, although
Fig. 38.12  Intimal hyperplasia of the ulnar artery following hand transplantation.
(Courtesy of Dr. Warren Breidenbach, Christine M. Kleinert Institute.)
Hyperplastic intima
Occluded lumen
early return (at 1 year) of temperature and pressure sensation,
touch localization, and pain sensation in the hand and fingers.
Return of motor power and grip strength has also been
observed. Electrophysiologic testing has confirmed clinical
evidence of motor function return in the transplanted intrinsic
muscles of the hand, and, in a few cases, true recovery of
partial intrinsic function. Early objective testing using the
Carroll test has also demonstrated return of function in upper
extremity transplant recipients similarly to what is achieved
after replantation and superior to what is achieved with
prostheses.149,150
Immunosuppression protocols currently used in solid
organ transplantation have proved to be sufficient to prevent
allograft loss. However, the use of these immunosuppression
regimens have been associated with adverse effects including
opportunistic infections (i.e., cytomegalovirus, Clostridium,
herpes, cutaneous mycosis) and Staphylococcus aureus-
mediated ulnar osteitis; and metabolic complications such as
hyperglycemia, hyperlipidemia, impaired renal function,
arterial hypertension, and aseptic hip necrosis requiring
bilateral hip replacement. Of note, no life-threatening compli­
cations or malignancies have been observed thus far.146
Unique aspects of vascularized composite
allotransplantation
Unlike solid organ transplantation, upper extremity trans­
plantation allows the continuous visual monitoring of the
allograft for rejection. This facilitates early diagnosis by
directed biopsy, unbiased pathologic confirmation of the earli­
est stages of acute rejection, and timely intervention with
precise and individualized tailoring of immunosuppressive
medications. When treated adequately and effectively, acute
rejection does not seem to impair graft function or long-term
survival. Studies from our own group have shown that whole
limb allografts elicit a less intense alloimmune response than
its individual components.69 In addition, vascularized com­
posite allografts contain immunocompetent elements such as
bone marrow and lymph nodes, which some argue may
hasten the rejection processes or, conversely, result in graft-
versus-host disease (GvHD). Unlocking the special immune
reactivity of these allogeneic tissues, unlike solid organ

876
SECTION VI
CHAPTER 38 • Upper extremity vascularized composite allotransplantation
development of tolerance is of utmost importance in order to
reduce the toxicities associated with chronic immunosuppres­
sion. Although tolerance has been difficult to define, an
“operational” definition is “the long-term functional survival
of an allograft in a patient without the need for maintenance
immunosuppression”.162 Such a tolerant state is characterized
by hyporesponsiveness to donor tissue with the preservation
of the recipient’s immune responses to microorganisms (bac­
teria, viruses) and tumor antigens. The strategies for induction
of allograft tolerance can be broadly divided into two
approaches: (1) central deletional mechanisms or (2) periph­
eral regulatory strategies.163
When considering development of novel therapeutic
strategies for minimization or avoidance of maintenance
immunosuppression after upper extremity allotransplanta­
tion, cell-based protocols, including mixed chimerism induc­
tion using donor bone marrow cells, mesenchymal stem cells
(from various sources such as bone marrow or fat), regulatory
T and B cells, or tolerogenic dendritic cells (TolDCs) have all
demonstrated potential for inducing tolerance in preclinical
animal models.164 For example, in the case of bone marrow-
derived stem cell therapy, stem cells are transplanted into the
recipient, and the newly developing recipient T cells begin
to see these donor cells as “self”. Therefore, the recipient
perceives an organ from the same marrow donor as “self” and
accepts it without immunosuppression. The mixed chimerism
model involves induction of allograft tolerance by establishing
long-term mixed chimerism, a state in which both donor and
recipient hematopoietic cells coexist.165 This strategy requires
engraftment of donor stem cells. Some vascularized compos­
ite allografts, in particular limb transplants, bring with them
vascularized bone marrow in its microenvironment enabling
a sustainable, renewable source of donor bone marrow cells
that could potentially promote immunoregulation without
the need for engraftment.166,167 In solid organ transplanta­
tion, infusion of donor-derived bone marrow cells has been
shown to reduce/avoid maintenance immunosuppression
required for graft survival.168 Bone marrow is critical for the
establishment of macrochimerism, microchimerism, or mixed
less likely to occur than solid organ transplantation, chronic
rejection can be induced in VCA animal models. Unadkat et al.
using a rat hindlimb transplant model, reported histological
changes consistent with chronic rejection after repeated epi­
sodes of acute rejection.158 Similarly, using a non-human
primate facial allotransplantation model, Mundinger et al.
demonstrated that multiple acute rejection episodes can result
in chronic rejection.159 Furthermore, more recent reports by
Kaufman and colleagues provide clinical evidence for chronic
rejection in six hand transplant recipients who show signs of
arterial vasculopathy.160 Aggressive and severe intima hyper­
proliferation was observed in the early postoperative period
in two of the six recipients in their patient series. Morelon et al.
reported clinicopathological findings and the first clinically
documented evidence of chronic rejection in one of their face
transplant recipients.161 This case demonstrated that chronic
rejection is a complex multifactorial process in VCA. Chronic
rejection of the skin seems to be driven by the recipient’s
cellular immune effectors, which can lead to the development
of scleroderma-like features, resembling chronic GvHD. In
contrast, graft vasculopathy is probably more dependent on
the humoral arm of the alloimmune response, as evidenced
also in solid organ transplantation. Additional mechanistic
studies in reliable small and large animal settings are needed
to explore these complex rejection processes. With prolonged
survival of upper extremity transplants, we will inevitably see
over the next 1–2 decades more allografts develop signs of
chronic rejection. We will then be able to better define, diag­
nose, and grade this condition. Meanwhile, we are limited to
minimizing the known risk factors (from the solid organ
experience) that may contribute to a postulated increase
of chronic rejection in upper extremity allotransplantation
(Table 38.4).
Tolerance approaches and
immunomodulatory strategies
VCA is different to solid organ transplantation in that it is a
life-enhancing, not a life-saving, procedure. Therefore, the
Table 38.4  Recommendations to reduce risk of acute and chronic rejection in hand transplantation
Immunologic factors
1.
Prevention of AR
Use selective, specific and safer immunosuppressive drugs. Potent and targeted
induction agents like Campath-1H (alemtuzumab) could maximize AR prevention,
allowing monotherapy maintenance and steroid avoidance
2.
Treat steroid-resistant or CD20-positive AR
Campath-1H (anti-CD52) or rituximab (anti-CD20)
3.
Monitor and curb medication non-
compliance
Suggested methods include electronic measurements of pill container opening, regular
monitoring of blood drug levels, frequent clinical examinations, repeated biopsies or
immune monitoring
4.
Reduce risk factors
Exclude patients with high PRA, avoid sex/racial mismatch between donor/recipient
and exclude hand allografts from CMV+ donors.
Non-immunologic factors
1.
Choose younger donors and exclude donors with systemic atherosclerosis
2.
Avoid prolonged cold ischemia
3.
Treat recipient risk factors aggressively (antidiabetic, antihypertensive, or lipid lowering drugs with dietary or lifestyle changes if
necessary).
AR, Acute rejection; PRA, panel reactive antibody; CMV, cytomegalovirus.

877
Emerging insights in vascularized composite allotransplantation
is achieved, conventional immunosuppression, as used in
solid organ transplantation, will remain the “gold standard”
in VCA.
Future directions of upper extremity
reconstructive transplantation
VCA has emerged as a viable option to treat patients with
severe defects not amenable to traditional autogenous recon­
struction. Although surgical outcomes over the last two
decades show great promise, the long-term results with this
innovative procedure are still emerging. The main obstacles
that limit the success of upper extremity VCA are the current
immunotherapy requirements as well as current limits to
peripheral nerve regeneration, thus limiting functional out­
comes with very proximal defects. However, with current
advances in cell-based therapy and the increasing immuno­
logical understanding of vascularized composite allografts,
research in reconstructive transplantation is uniquely poised
to make significant breakthroughs in transplant immunology,
with the potential to make the application of this innovative
reconstructive treatment modality widely available.
chimerism after organ transplantation, and is a known pre­
requisite for donor-antigen-specific tolerance induction.169,170
Allograft rejection is caused by activated T cells and cannot
occur in their absence. Campath-1H (alemtuzumab) is an
antibody that binds to the CD52 receptor, critical for T-cell
function in humans.171 Campath-1H leads to peri-transplant
depletion of T cells, B cells, and monocytes, but spares bone
marrow stem cells. Renal transplant trials with Campath-1H
have demonstrated that allograft survival could be prolonged
but with low doses of maintenance immunosuppression.172,173
Such a state of tolerance is called “prope-tolerance” or
“tolerance-lite”. Campath 1H has been used an induction
agent in several upper extremity transplant programs toward
the goal of minimizing maintenance immunosuppression;
however, its efficacy is still unknown.
Over the past five decades, more than 50 different methods
of tolerance induction have succeeded in small or large animal
models. Yet tolerance protocols have not widely replaced
immunosuppression in clinical transplantation. The transition
of experimental tolerance protocols to the clinical transplant
arena is fraught with questions: Can experimental tolerance
protocols meet the stringent fail-safe clinical standards of
reliability and efficacy? How durable or persistent is the toler­
ant state? How immunocompetent will the recipient be? What
is the universally accepted test or “assay” for tolerance? What
are the long-term adverse effects of tolerance induction?
However, the few tolerance strategies that have been trans­
lated to the clinic hold great promise for becoming more
widespread and clinically routine in the near future. Until this
Bonus image for this chapter can be found online at

Fig. 38.1 St. Cosmas and Damian perform the first human extremity
allotransplantation.
15. Carrel A. Results of the transplantation of blood vessels, organs
and limbs. JAMA. 1908;51:1662.
21. Merrill JP, Murray JE, Harrison JH, et al. Successful
homotransplantation of the human kidney between identical
twins. JAMA. 1956;160:277.
26. Gibson T, Medawar PB. The fate of skin homografts in man. J
Anat. 1943;77:299. This is a classic landmark paper by Thomas Gibson
and Sir Peter Medawar that provides the first insights into the immune
behavior of skin transplants and laid the foundations for tissue
transplantation.
41. Anonymous. Historic cadaver-to-man hand transplant. Med World
News. 1964;5(6):60.
69. Lee WP, Yaremchuk MJ, Pan YC, et al. Relative antigenicity of
components of a vascularized limb allograft. Plast Reconstr Surg.
1991;87:401–411. This is a highly cited study that addresses the
differential antigenicity of limb transplants, establishing that whole-limb
allografts elicit lesser immune response than their individual components
(skin, subcutaneous tissue, muscle, bone, and blood vessels) in terms of
cell-mediated and humoral immune responses as well as the timing and
intensity of rejection.
90. Breidenbach WC, Tobin GR, Gorantla VS, et al. A position
statement in support of hand transplantation. J Hand Surg Am.
2002;27:760–770. This is a comprehensive review of emerging outcomes
in upper extremity transplantation with emphasis on the early
developments in the field, experimental, scientific, and clinical
considerations and the ethical debate surrounding initial human trials.
126. Petruzzo P, Lanzetta M, Dubernard JM, et al. The International
Registry on Hand and Composite Tissue Transplantation.
Transplantation. 2010;90:1590–1594.
128. Amirlak B, Gonzalez R, Gorantla V, et al. Creating a hand
transplant program. Clin Plast Surg. 2007;34:279–289. This is
essential reading to understand the basic requirements to establish an
upper extremity composite tissue transplant program. The planning,
preapproval, personnel, protocol and public relations related aspects and
the program, procedural, and patient considerations are discussed.
142. Cendales LC, Kanitakis J, Schneeberger S, et al. The Banff 2007
working classification of skin-containing composite tissue allograft
pathology. Am J Transplant. 2008;8:1396–1400.
162. Starzl TE. Immunosuppressive therapy and tolerance of organ
allografts. N Engl J Med. 2008;358:407–411. Authored by one of the
pioneers in organ transplantation, this paper discusses the concepts and
clinical applications of immunosuppression, immunomodulation and
tolerance, highlighting the paradigm shifts in the field.
Access the complete reference list online at

877.e1
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SECTION VI • Rehabilitation
39 
Hand therapy
Christine B. Novak and Rebecca L. Neiduski
SYNOPSIS
■ In optimal situations, hand therapists work closely with hand surgeons
to maximize non-operative and postoperative outcomes for patients
with upper extremity conditions.
■ Assessment in the area of impairment and body structures includes
edema, wound, vascularity, pain, range of motion, strength, and
sensibility.
■ Following nerve injury and with chronic nerve compression,
rehabilitation strategies should be directed not only to the distal
recovery but also to re-establishing normal movement patterns and
cortical remapping.
■ Active motion regimens following flexor tendon repair are becoming
more prevalent in both research and practice. The inclusion of a
controlled arc of motion with the wrist positioned in extension creates
an optimal force/excursion ratio.
■ Hand fractures are challenging and require careful attention to bony
integrity and maintenance of the flexor and extensor tendon-gliding
systems.
Introduction
Tenets of hand therapy
According to the Hand Therapy Certification Committee
(), the specialty of hand
therapy is defined in the following manner:
Hand therapy is the art and science of rehabilitation of the upper
limb, which includes the hand, wrist, elbow, and shoulder girdle.
It is a merging of occupational therapy and physical therapy
theory and practice that combines comprehensive knowledge of
the structure of the upper limb with function and activity. Using
specialized skills in assessment, planning and treatment, hand
therapists provide therapeutic interventions to prevent
dysfunction, restore function and/or reverse the progression of
pathology of the upper limb in order to enhance an individual’s
ability to execute tasks and to participate fully in life situations.
In optimal situations, hand therapists work closely with
hand surgeons to maximize non-operative and postopera­
tive outcomes for patients with upper extremity conditions.
The purpose of this chapter is to provide the plastic surgeon
with an overview of the evaluative and rehabilitative
approaches for patients with nerve, tendon, skeletal, and soft-
tissue conditions as afforded by collaboration with a hand
therapist.
Evaluative guidelines
A comprehensive evaluation provides valuable diagnostic
and prognostic information to the plastic surgeon and hand
therapist prior to intervention, and serves to inform clinical
decision-making for management (non-operative and postop­
erative) of patients with upper extremity conditions. In concert
with the International Classification of Functioning, Disability
and Health,1 hand therapists are well versed in the clinical
assessment of patients in areas of impairment, activity, and
participation.
Clinical tips
Assessment
• Comprehensive evaluation can provide diagnostic and
prognostic information and inform clinical decision making
for non-operative and postoperative management.
• Self report questionnaires provide important information to
assess impact of injury, activity and participation
• Pain experiences should be documented with subjective
report of intensity, quality and impact on function.
• Physical impairments can be assessed related to muscle
weakness with manual muscle testing or dynamometers
and sensory dysfunction with measures of threshold and
discrimination
  Access video content for this chapter online at expertconsult.com

879
Rehabilitation following nerve injury/surgery
discomfort.25 The influences of hand size and span have also
been identified as factors to consider when selecting the
grip handle position.29–31 Calibrated gauges are also used to
measure both lateral and tip pinch.
A paradigm shift towards increased incorporation of quali­
tative and patient-reported data into outcomes assessment is
strongly encouraged as a means of assessing participation.32
Clinical evaluation tools that assess physical impairments,
such as range of motion, have demonstrated limited respon­
siveness and weak association to patient self-report measures,
which may indicate that these types of assessments evaluate
different constructs.33–36 Research has also shown a weak
relationship between patient perception of health-related
quality of life and ratings from healthcare providers.37 Patient
perception of ability has been suggested as more valuable
than functional evaluations.38 In addition, patient assessment
of the importance of change in health status is preferable to
that interpreted by the healthcare professional.39 Despite
numerous tools and support in the literature, the incorpora­
tion of self-report outcome measures is inconsistent in clinical
practice.40
The Disabilities of the Arm, Shoulder, and Hand (DASH),
one of the most recognized self-report outcome measures for
the upper extremity, was published as a joint effort of the
American Academy of Orthopedic Surgery and the Institute
for Work and Health.41 The DASH was created as a tool to
assess upper extremity disability that would allow compari­
son of conditions throughout the upper extremity while
considering it a single, functional unit.41,42 Careful develop­
ment of this tool, including an extensive literature review and
consideration of questions and attribution, has made it a
popular tool in upper extremity research and clinical practice.
However, uniform application in different pathologies and
timing of assessments is necessary for valid comparisons of
upper extremity disability scores.43 Other studies that investi­
gated the DASH questionnaire as a single construct using
factor analysis found a three-factor structure was the best
model fit.44
Rehabilitation following nerve
injury/surgery
Following nerve injury and with chronic nerve compression,
neural changes occur in the peripheral and central nervous
system. The primary focus has been on the alterations that
occur to the nerve and the distal sensory receptors and muscle
fibers. The proximal changes that occur in the central nervous
system have been less emphasized. Cortical remapping and
cell body changes have been documented with nerve injury
and nerve compression. Therefore to optimize outcome,
rehabilitation strategies should be directed not only to the
distal recovery but also to re-establishing normal movement
patterns and cortical remapping. This section will review
postoperative management following surgery for carpal and
cubital tunnel syndrome, nerve repair, and nerve transfers.
Compression neuropathies
Postoperative care following surgery for compression neu­
ropathies is a balance between protecting the surgical repair
site and maintaining neural mobility. To minimize adhesions
Assessment in the area of impairment and body structures
includes edema, wound, vascularity, pain, range of motion,
strength, and sensibility. Edema is most commonly assessed
with circumferential measurement. However, it is more accu­
rately assessed using volumetric displacement with a reported
test–retest reliability within ±3 mL.2 Wound assessment is
characterized by both descriptive and objective components,
including a detailed patient history and observation of wound
size, color, drainage, odor, and temperature. Vascularity can
be assessed both proximally and distally in the upper extrem­
ity using provocative maneuvers. In addition to the Allen’s
test for circulation via the radial and ulnar arteries at the wrist,
vascularity may be assessed more proximally using Adson’s
maneuver at the subclavian artery; the costoclavicular maneu­
ver and hyperabduction test assessed via the radial pulse; and
the elevated arm stress test, as described by Roos.3–5 Pain is a
subjective and multifaceted construct, and should be assessed
before, during, and after therapeutic interventions. Numeric,
verbal, and visual analog scales are commonly used to rate
pain intensity and have been identified as having good con­
struct validity.6 Simple measures and scales that assess only
pain intensity may be inadequate to capture and measure the
multidimensional aspects of the pain. The McGill Pain Ques­
tionnaire and the Short-Form McGill Pain Questionnaire
(SF-MPQ) are the most widely used pain questionnaires to
assess the multidimensional qualities of the pain experience
and overall have been shown to possess good to excellent
psychometric properties.7–10 The SF-MPQ consists of a pain
intensity visual analog scale, the present pain intensity index,
and 15 pain adjectives (11 sensory, four affective) to calculate
the pain-rating index.
Goniometric measurement (Video 39.1
) is used to assess
passive and active range of motion. While electrogoniometers
and costly systems are available for clinical use, standard
manual goniometers are easily portable and inexpensive. In
a study assessing wrist motion, high intra-rater reliability
was reported using multiple techniques to assess wrist range
of motion, with a dorsal volar approach demonstrating
the highest inter-rater reliability.11 Ellis and Bruton found
composite finger flexion measurements to be as reliable as
manual goniometry between raters, with manual goniometry
demonstrating increased intra-rater reliability for measure­
ment of the proximal interphalangeal joint.12 Manual muscle
testing is employed to isolate strength of individual muscles
and often graded using the Medical Research Council (MRC)
grade 0–5 classification.13 In a review, Cuthbert and Goodheart
reported good evidence to support the use of manual muscle
testing for patients with neuromusculoskeletal dysfunction.14
Sensory impairment is most often assessed using monofila­
ments for threshold testing (Video 39.2
) and/or two-point
discrimination for innervation density.15–19 Using standardized
techniques, good validity and reliability have been shown
using these types of assessment tools.15,17,20–23 The Ten Test
was introduced as a quick assessment of light touch sensation
and has been shown to be a valid measure as compared to
monofilament testing.24
Clinical evaluation may also include assessment of grip
and pinch strength.25–28 A calibrated, hand-held dynamometer
is used to measure grip strength in a standard position of
glenohumeral adduction, elbow flexion, and neutral forearm
rotation.26 One trial has been identified as equally reliable to
the best or average of three trials and elicits less patient

880
SECTION VI
CHAPTER 39 • Hand therapy
soft tissue surrounding the ulnar nerve (i.e., least immobiliza­
tion for simple decompression). In most cases, the postopera­
tive dressing may be removed 2–3 days after surgery and then
a postoperative method of immobilization may be used if
required. For patient comfort, a sling may be used at night to
restrict upper extremity motion while the patient is sleeping.
The postoperative care following a intramuscular or submus­
cular transposition will be described.47 In our experience,
patients may begin range-of-motion exercises (fingers, wrist,
forearm, elbow, and shoulder) when the dressing is removed
at postoperative day 2 or 3. Patients are cautioned to perform
these exercises slowly and initially to avoid full forearm
supination combined with full elbow extension because this
motion will place the most stress on the soft-tissue repair.
Initially elbow extension is performed with the forearm in
pronation and then, as a separate exercise, forearm supination
is performed with the elbow flexed at 90°. When the patient
is able to move comfortably into full supination, forearm
supination is combined with elbow extension. A sling is used
at night for patient comfort to avoid rapid elbow extension
and may be discontinued when the patient has achieved full
elbow extension with full forearm supination. The emphasis
in the early postoperative period is to regain full range of
motion and it is anticipated that this is achieved within the
first 2–3 weeks following surgery. If the patient appears to be
progressing slowly and lacking improvements in range of
motion, more structured hand therapy is recommended.
Strengthening exercises are instituted 1 month following
surgery and full activity is permitted at 8 weeks.
Concomitant soft-tissue muscle imbalances and other sites
of nerve compression in the upper extremity may require
rehabilitation therapy to achieve full recovery. Some patients
may also have restricted neural excursion, cervicoscapular
discomfort, and/or rotator cuff tendinitis associated with
muscle imbalances in this region. Specific exercises to address
these more proximal soft-tissue and neural structures will
help to ameliorate these types of symptoms in patients with
more diffuse upper extremity discomfort, paresthesia, and/or
numbness.49–54
Nerve repair
Changes in the peripheral and central nervous system begin
shortly after nerve injury and continue through recovery.
The ultimate functional outcome depends upon reinnerva­
tion of the sensory receptors and motor end plates and the
appropriate remapping of the motor and sensory cortex.
Based upon these proximal changes, rehabilitation is maxi­
mized by including strategies directed towards these cortical
alterations.
Early postoperative care
In the immediate postoperative period, the primary goal is to
protect the nerve repair site. Initially, a bulky dressing is used
and, if required by the operative procedure, more rigid
support can be utilized. The patient is instructed in edema
control and range-of-motion exercises for the joints that are
not immobilized by the bulky operative dressing. The initial
dressing is removed within a few days following surgery.
Immobilization is continued with the use of a custom-made
or prefabricated orthosis or, in some cases, a sling or shoulder
and scarring, early motion is advocated. However, the defini­
tion of “early motion” following release of an entrapment site
is variable and is determined by the surgical procedure per­
formed and surgeon preference.45,46 Compared to the historical
reports in the literature, the tendency has been to decrease the
length of time of immobilization and to use less restrictive
postoperative dressings.47,48 Range-of-motion exercises are
instituted and restoration of muscle balance is also a goal of
postoperative care.
In the acute postoperative stage, consideration is given to
edema control and pain management, and the patient is
instructed in strategies to minimize edema and pain. Even in
the early stages following surgery, nerve-gliding exercises are
instituted with range-of-motion exercises to the distal and
proximal joints that are not included in the bulky dressing.
These types of exercise will provide some longitudinal move­
ment of the nerve to minimize adhesions.
Carpal tunnel syndrome
Postoperative care
Historically, following release of the carpal tunnel, immobili­
zation was used to protect the wound and to prevent bow­
stringing of the flexor tendons by restricting motion at the
wrist. With recognition of the importance of early motion, the
duration and type of immobilization following carpal tunnel
release have substantially decreased. In our practice, a bulky
dressing is used for restriction of wrist movement and for
patient comfort in the immediate postoperative period. Fol­
lowing surgery, the patient is instructed in range-of-motion
exercises for the fingers, elbow, and shoulder. Two days fol­
lowing surgery, the bulky dressing is removed and the patient
is instructed in range-of-motion exercises for the fingers,
wrist, elbow, and shoulder. For patient comfort, an orthosis in
a wrist neutral position may be used at night. The sutures are
removed 12–14 days following surgery. Return to work is
dependent upon the type of job and specific patient factors.
However, at 4 weeks after surgery, patients should have full
range of motion and may lift up to 2 lb (0.9 kg) and, by 2
months following surgery, full activity without restrictions is
expected.47 Depending on the severity of nerve compression,
the duration of time required to achieve full sensory and
motor recovery may vary.
Cubital tunnel syndrome
With failure of non-operative treatment, there are numerous
surgical procedures performed for the operative treatment of
cubital tunnel syndrome, ranging from simple decompres­
sion, medial epicondylectomy, to various types of anterior
transposition of the ulnar nerve.47 With each procedure, there
are numerous protocols for the postoperative management
and many vary depending upon surgeon preference. In
general, early motion is recommended to minimize adhesions
and scarring of the ulnar nerve and surrounding soft tissue.
Postoperative care
There is wide variability in the duration of immobilization
following surgery for cubital tunnel syndrome and this
depends upon the operative procedure performed and
surgeon preference. The period of immobilization is increased
for those procedures that involve more complex release of the

881
Rehabilitation following nerve injury/surgery
The integration of function between the sensory and motor
cortex is essential for restoration of sensorimotor control and
to optimize outcome. The concept of cortical plasticity and its
importance to recovery following nerve injury have gained
increased attention in the past decade.
Sensory re-education
Following sensory nerve reconstruction, sensory re-education
is commonly included in the rehabilitation program to
improve hand sensibility and function. These strategies have
been used to maximize sensory recovery, to decrease pain and
for desensitization related to allodynia and/or hyperalgesia.66–70
Desensitization exercises using different textures and vibra­
tion techniques may be used to decrease allodynia and/or
hyperalgesia. The concept of vibration for desensitization
relates to the gate control theory of pain and stimulation of
large A-beta fibers with vibration.71 The use of small-amplitude
vibration for desensitization is best tolerated by patients and
may be achieved by using an electric shaver with the cap on
it. This will provide an easy technique for the patient to
continue this exercise in a home program. With decreasing
sensitivity, the area of allodynia may be challenged with dif­
ferent types of texture to promote sensory re-education and
appropriate cortical mapping.
With evidence of reinnervation of the sensory receptors,
sensory re-education is advocated.66 This typically includes a
structured program with an emphasis on textures, localiza­
tion, and discriminatory tasks.66 The exercises are progressed
to challenge the sensory system as the patient’s sensation
improves, beginning with varying textures, localization exer­
cises, and then discriminatory tasks. However, strategies to
enhance and promote cortical remapping have been also
advocated in the earlier phases following surgery. Rosen and
Lundborg have described re-education programs using mirror
imagery, visuotactile training, and audiotactile interaction to
enhance the functional reorganization of the sensory cortex in
the early phases of recovery before there is evidence of sensory
receptor reinnervation.72,73
Mirror visual feedback has been extensively used for treat­
ment in patients following stroke and with amputation injuries
and has been more recently reported for use in patients with
pain syndromes or nerve injury.74,75 The concept of mirror
visual feedback is that patients observe their reflected image
in the mirror, which would appear as the contralateral limb
(Fig. 39.1) and thus activate the brain. Patients may perform
specific exercises or movements with the unaffected hand or
extremity and in the mirror it would appear as normal move­
ment to the affected hand or extremity. With improvement in
sensory function or decreased pain, more complex activities
may be introduced and also combined with motor re-education.
Motor re-education
The goals of treatment for motor function are directed towards
re-establishment of normal movement patterns and muscle
balance. Following nerve injury, motor re-education is not
as frequently advocated compared to sensory re-education.
Alterations in cortical mapping and motor patterns occur
following injury to a motor nerve.76,77 With reinnervation of
the denervated muscles, muscle imbalances will remain due
to weakness of the reinnervated muscles compared to the
immobilizer may provide sufficient support to restrict forces
on the repair site. Nerve repairs compared to nerve grafts or
nerve transfers are typically immobilized for longer periods
of time – in some cases up to 3 weeks. The timing of immo­
bilization will depend upon the location of the nerve repaired
and the amount of nerve mobility and stress on the nerve
coaptation site. In some cases, such as with digital nerve
injuries, some surgeons have advocated no immobilization
after the initial operative dressing has been removed.55 With
a nerve graft or transfer, there is excessive nerve length at the
repair site and lack of tension with these reconstructions and,
as such, these types of reconstruction require less rigid immo­
bilization and may be mobilized earlier (7–14 days) compared
to nerve repairs. However, other soft tissues (tendons, muscles,
or ligaments) that may have been released or repaired in
the operative procedure may prolong the period of immobi­
lization. For example, repair of the pectoralis major with
exploration of the brachial plexus may require 4 weeks of
immobilization in internal shoulder rotation using a shoulder
immobilizer to avoid tension on the soft-tissue repair or, with
acute injuries that may involve a tendon repair, a tendon
rehabilitation protocol would be followed.
Early postoperative pain resulting from the operative
procedure may be controlled with analgesics, edema control,
early motion, and hand therapy. However, ongoing severe
neuropathic pain may negatively impact outcome and there­
fore early pain management intervention is recommended.56,57
Neuropathic pain following trauma may require a compre­
hensive multidisciplinary approach and, as such, referral to a
pain management team may be warranted.
The use of electrical muscle stimulation is often advocated
following nerve injury to prevent muscle degeneration and to
protect the muscle fiber until regeneration occurs. However,
the literature does not present strong evidence for the use
of this modality following nerve injury.58,59 Historically, the
rationale for electrical stimulation of denervated muscles has
been to retain integrity of the muscle fibers while waiting for
muscle reinnervation. Studies using animal models with
denervated muscles and electrodes implanted directly into
the muscle have shown preservation of some normal muscle
properties.60,61 However, no efficacy trials have provided evi­
dence of these benefits in humans. Evidence presented in the
literature suggests that longer durations of axotomy and
Schwann cell denervation are predictive of poor functional
outcome.62,63 Low-frequency stimulation of the nerve follow­
ing nerve transection and repair in animal models has shown
an increase in axonal regeneration into the appropriate neural
pathway.63,64 In patients after carpal tunnel release, 1 h of low-
frequency nerve stimulation resulted in significantly faster
motor reinnervation.65 This evidence provides the impetus for
future investigation into the benefits of direct nerve stimula­
tion to improve recovery following a motor nerve injury.
However, the use of direct current stimulation for denervated
muscles has not been shown to be efficacious in humans and,
as such, is not advocated by the authors.
Late rehabilitation
In the later phases of rehabilitation, sensory re-education
has been recognized as an integral component of therapy
following nerve injury; however, the importance of motor
re-education following nerve injury has been less emphasized.

882
SECTION VI
CHAPTER 39 • Hand therapy
depend not only on the number of regenerating motor axons
and reinnervation of muscle fibers but also on cortical plastic­
ity, remapping, and functional integration. Previously estab­
lished motor patterns and cortical maps are no longer relevant
because a new proximal nerve source is used with a nerve
transfer. Studies have evaluated cortical mapping following
nerve transfers, muscle transfers, and toe-to-thumb trans­
fers.76,77,89–91 Collectively, these studies have illustrated shifts
in the motor cortex following transfers and the importance of
effective relearning to optimize outcome. Therefore, rehabili­
tation programs after nerve transfer should include not only
range-of-motion and strengthening exercises to regain muscle
balance, but also motor re-education to promote normal
movement patterns and appropriate cortical mapping.92,93
uninjured muscles and also compensatory movement pat­
terns that have been performed since the injury. Particularly
in patients with brachial plexus injuries, the duration of time
from injury until muscle reinnervation occurs may be pro­
longed (12–18 months) and abnormal movement patterns are
established. Therefore motor re-education will provide the
opportunity to focus on appropriate muscle recruitment and
muscle balance. Even in patients with only sensory loss fol­
lowing median nerve injury, there will be alteration of the
motor pattern due to compensation in movements as a result
of numbness to the sensory distribution of the median nerve.
Therefore, the emphasis should be on restoration of the inte­
gration of motor and sensory re-education following nerve
injury. Sensorimotor control to perform upper extremity tasks
requires the coordination of both the sensory and motor
systems.78 Alteration in either motor or sensory function as a
result of nerve injury will impact sensorimotor control in the
upper extremity. Improvement in hand function may occur
with increased use of the hand, but progress may be enhanced
with the use of activity-based sensorimotor retraining,
emphasis on control, and appropriate feedback learning. As
with any new task learning, repetition and feedback are
essential and therefore patient education and an effective
home program should be emphasized.
Nerve transfers
Historically, motor nerve transfers were used as a salvage
procedure when nerve repair or graft was not possible, such
as in the case of an avulsion of the proximal nerve source, and
there was limited potential for excellent outcome. However,
the utilization of nerve transfers has increased, particularly
with proximal peripheral nerve injuries, where recovery is
limited due to the lengthy distance from the injury to target
muscle fibers and prolonged time for reinnervation.79,80
Because a nerve transfer utilizes an innervation source closer
to the target muscle, the distance and time for reinnervation
are shorter and the results following these types of transfer
have been very encouraging.81–88 However, optimal results
Fig. 39.1  Re-education can be optimized with the use of mirror imagery. This
allows the patient to visualize the uninjured hand as the contralateral hand and
perform the task. (Courtesy of Christine B. Novak, PT, PhD.)
Clinical tips
Retraining after motor nerve transfer
• Following nerve injury, rehabilitation should be directed not
only to the distal motor and sensory recovery but also to
cortical remapping and normal movement patterns.
• Immobilization for 7–10 days after nerve transfer.
• Initially contract muscle from the “donor” muscle to contract
reinnervated recipient muscle.
• Utilize synergistic movement patterns and sensorimotor
re-education.
• Be aware of antagonistic muscle co-contraction.
• Restore muscle balance.
With nerve transfers, there is alteration of the proximal nerve
source, therefore muscle contraction is initially recruited with
“contraction” of the muscle from the donor nerve because of
the established motor pattern. The new recruitment pattern
from the new proximal nerve source from the donor nerve has
yet to be recognized. Even with evidence of muscle reinnerva­
tion, the newly innervated muscle may not contract with
initiation of the intended action, but rather requires “contrac­
tion” of the muscle from the donor nerve. To facilitate relearn­
ing, contraction of the muscles on the uninjured contralateral
side will provide cortical input of a normal movement. The
relearning associated with nerve transfers is similar to relearn­
ing following tendon transfers. In general, relearning is more
straightforward following a transfer (nerve, muscle, or tendon)
when the donor is from a muscle with a synergistic action.
While it is possible to relearn an action that is from a muscle
with an antagonistic action (such as triceps-to-biceps muscle
transfer), the relearning is more difficult compared to a syn­
ergistic muscle action.
In patients with brachial plexus avulsion injuries, an
intercostal-to-musculocutaneous nerve transfer is often per­
formed to restore elbow flexion.94 Postoperative education
often includes deep-breathing exercises to provide a stimulus
to the intercostal nerves for contraction of the biceps and
brachialis muscles, which are innervated via the musculocu­
taneous nerve. While deep breathing does initiate contraction
of the newly innervated elbow flexors, it is difficult to provide
a prolonged contraction for re-education and strengthening.
The abdominal muscles and intercostal muscles are activated
with core abdominal exercises. Therefore core-strengthening
exercises will also provide contraction of the biceps and

883
Rehabilitation following nerve injury/surgery
brachialis muscles in patients who have had an intercostal-to-
musculocutaneous nerve transfer. The muscle activity in the
elbow flexors associated with trunk flexion has been shown
by Chalidapong and colleagues.95 Core exercises which use
the abdominal and intercostal muscles may begin early in the
rehabilitation stages (Fig. 39.2) and with early reinnervation
will recruit the muscle fibers in the brachialis and biceps.
More recent descriptions of nerve transfers to restore
elbow flexion have included donor pectoral nerves and
fascicles from the median and ulnar nerves.83,88 To assist
with the retraining following these types of nerve transfer,
re-education may begin preoperatively with education on
the unaffected extremity and contraction of the muscles
from the donor nerve and recipient muscle. In this way, the
patient may practice co-contraction of these muscle groups
to understand better the re-education that will be required
with reinnervation of the denervated muscles. For a medial
pectoral-to-musculocutaneous nerve transfer, the patient will
simultaneously contract the pectoral and the biceps (and bra­
chialis if included) muscles (Fig. 39.3). This is initially done
bilaterally and then only to the injured side. Using place-
and-hold positioning in 90° of elbow flexion, an isometric
contraction is performed. Once the patient is able to hold
this contraction against gravity, the degree of flexion may
be altered and progressed through a full range of motion. A
double fascicular transfer from the median and ulnar nerves
to restore elbow flexion will require contraction of the wrist
flexors to initiate contraction of the biceps and brachialis
muscles (Fig. 39.4).
To restore innervation to the ulnar nerve intrinsic muscles,
an anterior interosseous nerve (AIN) to deep motor branch of
the ulnar nerve transfer may be performed.84 With an AIN to
deep motor branch of the ulnar nerve transfer, attempts by
the patient to pinch must be initially combined with forearm
pronation to recruit the newly innervated intrinsic muscles
from the AIN proximal source (Fig. 39.5). With evidence of
ulnar innervated actions, fine dexterity exercises and tasks can
be incorporated into the rehabilitation program and the
Fig. 39.2  Following an intercostal-to-musculocutaneous nerve transfer, the patient
is performing an abdominal crunch to initiate contraction of the intercostal muscles
and thus initiate contraction of the biceps and brachialis muscles. (Courtesy of
Susan E. Mackinnon, MD.)
Fig. 39.3  To facilitate understanding and relearning following a motor nerve
transfer, re-education begins with a muscle contraction on the unaffected side.
(A) With a medial pectoral-to-musculocutaneous nerve transfer, the patient begins
on the unaffected side with contraction of the pectoralis major muscle and (B) then
contraction of both the pectoralis major and the biceps muscle. (C) This is
followed by simultaneous contraction of the pectoralis major muscle on the affected
side, (D) followed by bilateral contraction of these muscles. (E) The contraction is
then isolated to the affected side and (F) finally dissociation of the donor muscle
from the target muscle.
A
B
C
D
E
F
patient will be able to complete the ulnar motor nerve actions
independent of the action of forearm pronation. A compre­
hensive motor retraining program combined with cortical
remapping, and relearned motor patterns will provide the
opportunity for optimal outcomes after nerve transfer.
As outlined previously in this chapter, the evidence in the
literature does not support the efficacy of direct current elec­
trical stimulation with denervated muscles. With evidence of
muscle reinnervation, some have advocated the use of electri­
cal muscle stimulation using an alternating current to increase
the force of the muscle contraction and thereby increase
muscle strength. Theoretically, with an innervated muscle, it
is possible to use an alternating current to elicit a muscle
contraction. However, with a reinnervated muscle, there may
be scarcity of reinnervated fibers to produce the intended
muscle contraction via electrical stimulation. Passive muscle
contraction will not assist in the relearning of motor patterns.
Therefore, it is our recommendation that these types of
modalities should not be considered as the primary treatment
but may be used as an adjunct to therapy as a “sensory stimu­
lus” for relearning if necessary.
Functional relearning may be facilitated with visual or
auditory feedback, which can provide immediate response to
the patient regarding the muscle contraction. Simple biofeed­
back units with external surface electrodes may be used
to facilitate muscle contraction or to minimize aberrant
co-contraction of an antagonistic muscle action. Using a two-
channel or four-channel biofeedback unit, the electrodes may

884
SECTION VI
CHAPTER 39 • Hand therapy
the patient to reproduce the action in the newly reinnervated
muscles. With adequate muscle reinnervation, the patient will
receive feedback by observing and “feeling” the muscle con­
traction. Specific exercises to promote muscle contraction
without a specific biofeedback unit will allow the patient to
perform the exercises more frequently as a home program.
Muscle physiology and biomechanics should be considered
when structuring rehabilitation programs following nerve
repair or transfer. Because of the weakness and associated
fatigue in newly reinnervated muscle, exercise sessions should
be of short duration. A slow-onset contraction with a longer
duration hold of 10–15 s is recommended to increase muscle
endurance and strength. To minimize the muscle forces
required initially, muscle contraction in mid-range is sug­
gested. Place-and-hold exercises or gravity-eliminated posi­
tions may be used and then progressed to different degrees of
motion as the patient is able to sustain a muscle contraction.
With MRC grade 3 strength, progressive resistance exercises
can be implemented. The focus of strengthening is to regain
muscle balance. Because of the relative weakness between the
uninjured and reinnervated muscles, it is important to regain
good motor control of the reinnervated muscles before resis­
tance exercises are instituted, otherwise learned compensatory
motor patterns will be maintained.
Upper extremity movement requires composite motor pat­
terns involving the glenohumeral and scapular muscles.51,54
While distal nerve injuries may not include the shoulder
complex, strength of uninjured upper extremity muscles may
be weakened from disuse or from compensatory movement
patterns. Similarly, brachial plexus nerve injuries may not
include direct injury to the scapular muscles; however, these
muscles (such as the middle and lower trapezius and serratus
anterior muscles) may be weak from disuse and thus compro­
mise upper extremity function. Assessment of muscle strength
and length in the cervicoscapular region should be performed,
and then a rehabilitation program to address these muscle
imbalances implemented to optimize outcome.
Rehabilitation programs following nerve injury and nerve
compression surgery must include sensorimotor re-education
and the inclusion of normal movement patterns for appropri­
ate cortical remapping. Bimanual tasks will encourage use of
the injured extremity and input normal movement patterns
and purposeful movements involving self-care, recreation,
and work will facilitate the resumption of normal activities.
In some cases, vocational rehabilitation will be necessary to
assist in future planning and employment opportunities.
Patient education and an effective home program are neces­
sary to optimize learning of new motor/sensory tasks and to
optimize outcome.
Rehabilitation following tendon
injury/surgery
Flexor tendon injuries
Surgical and rehabilitative approaches following flexor tendon
injury can be described as one of the most researched, contro­
versial, and clinically complex aspects of hand therapy. While
originally eschewed as excessively progressive or risky by
many surgeons, active motion regimens are becoming more
Fig. 39.4  The relearning associated with a partial ulnar and median nerve transfer
from the forearm to the elbow flexors is illustrated. Initially, simple grip-
strengthening exercises and/or gentle wrist flexion will initiate contraction of the
biceps and brachialis muscles. (A) The patient begins on the unaffected side with a
contraction of the forearm flexors and (B) then simultaneously contracts biceps/
brachialis muscles and the forearm flexors. (C,D) The next step is bilateral
contraction of these muscles and (E) then the exercise is isolated to the affected
side. (F) The final exercise is to dissociate contraction of the donor muscle from
the target muscle.
A
B
C
D
E
F
Fig. 39.5  With an anterior interosseus nerve to deep motor branch of the ulnar
nerve transfer, forearm pronation is combined with pinching to recruit the innervated
intrinsic muscles and facilitate relearning. (Courtesy of Christine B. Novak, PT,
PhD.)
be placed on the appropriate muscles to increase or decrease
muscle contraction. To facilitate relearning, the action should
be performed on the unaffected side first to allow the patient
to understand the strategies necessary to enhance or minimize
the intended action. It is also useful to perform these actions
simultaneously with the affected and unaffected extremity.
This will provide immediate feedback on the “normal” con­
traction and motor pattern and provide the opportunity for

885
Rehabilitation following tendon injury/surgery
the caveat that any compressive dressings should be removed
prior to exercise.
The position of the wrist in the postoperative orthosis can
also create a potential limitation for therapeutic intervention.
The impact of wrist positioning has been comprehensively
studied as it pertains to force and excursion of the flexor
tendon system.105–108 The position of metacarpophalangeal
(MP) flexion coupled with wrist extension has been suggested
to produce the least passive tension in the extensor tendons,
thereby decreasing the minimal active tension of the flexor
tendons.107 Synergistic motion has also been observed to
create the greatest amount of flexor digitorum superficialis,
flexor digitorum profundus, and differential excursion,105
serve as an effective pulling force to create proximal glide,108
and result in low force with high excursion.109,110 Synergistic
motion can be safely and effectively initiated with a hinged,
dorsal blocking splint that allows the patient to create wrist
extension prior to flexing the digits (Fig. 39.6). The literature
indicates that asking patients to perform digit flexion when
the wrist is flexed actually demands more force than the same
motion performed with the wrist extended.
Prior to 2005, the most commonly used postoperative
protocols maintained the wrist in a flexed position both
during and between exercise for the first 6 weeks following
repair.111–113 More recent flexor tendon rehabilitation regimens
have been built with consideration of the wrist and have
progressed to varying levels of active motion. The Mass
Protocol114 includes immediate postoperative positioning of
the wrist in 20° of extension paired with active digital flexion
through the “available range”. Comparatively, the Nantong
Protocol115 reverts back to a conservative wrist-flexed position
for the first 212 weeks while the patient focuses on full exten­
sion to the dorsal block. Despite the inherent risks, this pro­
tocol does suggest completion of active motion through the
first two-thirds of full range. The Saint John Protocol116 affords
a similar approach, modifying the wrist to an extended posi­
tion and the active motion to mid-range.
The most current and progressive approach to postopera­
tive immobilization is the Manchester Short Splint.117 This
protocol includes a hand-based, dorsal blocking orthosis that
allows wrist extension up to 45° (Fig. 39.7A,B) On the fourth
or fifth postoperative day, active motion of the digits within
the first third of the range is paired with active wrist exten­
sion; the patient is instructed to focus on initiation of distal
common in both research and clinical practice. Three primary
factors have emerged as crucial in informing postoperative
decision-making: (1) early initiation of rehabilitation; (2) the
impact of wrist position on excursion and force; and (3) the
use of controlled active motion to create safe and effective
tendon glide.
Clinical tips
Rehabilitation after flexor tendon injury and repair
• Specificity and timing of exercise following flexor tendon
repair can be optimally arranged to facilitate high-excursion/
low-force rehabilitation.
• Communication of the operative details between the
therapist and plastic surgeon is essential to guide initiation
and progression of exercise following flexor tendon repair.
• Early controlled motion should be initiated on the fourth or
fifth postoperative day when work of flexion is likely
decreased.
• Edema should be considered an objective means by which
to inform therapeutic progression including range,
frequency, and speed of exercise.
• Place-and-hold measurement is a safe and effective way to
monitor tendon glide, progress treatment, and measure
outcomes.
• Synergistic motion facilitates excursion while decreasing
force.
• Tendon excursion occurs in both proximal and distal
directions, and can be influenced both by type of exercise
and antagonistic musculature.
Fig. 39.6  Synergistic motion can be safely and effectively initiated with a hinged,
dorsal blocking splint that allows the patient to create wrist extension prior to
flexing the digits.
The timing of rehabilitation following flexor tendon repair can
readily be identified as a topic of historical and continued
controversy. The study of tendon healing over time has dem­
onstrated that early controlled motion is beneficial to tendon
healing and preferable to immobilization.96–98 The timing of
early motion following flexor tendon repair continues to be
researched; however, some consistency is evident. Postopera­
tive day 4–5 is suggested as a time during which work of
flexion is decreased and preferable for the initiation of
rehabilitation.99–101
Edema is a postoperative symptom that often impedes the
initiation of rehabilitation. Current research specific to edema
and the flexor tendon system has identified numerous factors
that can be effectively modulated by therapists in order to
begin rehabilitation.100,102,103 In a series of studies by Cao and
colleagues, their results indicated that the area and severity
of edema following flexor tendon repair increased both
gliding resistance and work of flexion.100,102,103 However, slow
and gentle motion decreased the work of flexion. Decreasing
both the arc of motion and frequency of exercise were methods
to safely begin motion in the presence of edema. Conversely,
recent literature has identified an intervention that should not
be utilized when faced with edema after flexor tendon repair.
While many therapists use self-adherent wrap as a postopera­
tive dressing and for edema management, leaving this wrap
in place during active motion significantly increases the work
of flexion.104 In summary, gentle and controlled motion at a
lower frequency is suggested for patients with edema with

886
SECTION VI
CHAPTER 39 • Hand therapy
of standard protocols based on the anatomy and biomechanics
of the extensor apparatus has led to consistent and favorable
results throughout all zones of the extensor musculature.
Fig. 39.7  (A,B) A hand-based, dorsal blocking orthosis allows wrist extension up
to 45°.
A
B
Table 39.1  Analysis of tendon excursion and force
Exercise
Excursion
Force
Passive protected
extension
3–8 mm
Distal
Duran and Houser111
200–300 g
Urbaniak et al.119
Place-and-hold
digital flexion
during wrist
extension
FDS 26 mm
FDP 33 mm
Proximal
Wehbe and Hunter120
900 g
Lieber et al.110
Active straight fist
Wrist neutral
FDS 28 mm
FDP 27 mm
Maximum FDS
Proximal
Wehbe and Hunter120
1100 g
Greenwald et al.121
Active hook fist
Wrist neutral
FDS 13 mm
FDP 24 mm
Maximum differential
Proximal
Wehbe and Hunter120
1300 g
Greenwald et al.121
Active composite
fist
Wrist neutral–extension
FDS 24–26 mm
FDP 32–33 mm
Maximum FDP
Proximal
Wehbe and Hunter120
400–4000 g
Schuind et al.118
Active, isolated
PIP flexion
~13 mm (calculated)
FDP
Proximal
900 g
Schuind et al.118
Active, isolated
DIP flexion
~6.5 mm (calculated)
FDP
Proximal
1900 g
Schuind et al.118
FDS, Flexor digitorum superficialis; FDP, flexor digitorum profundus; PIP, proximal
interphalangeal; DIP, distal interphalangeal.
interphalangeal (DIP) joint motion to maximize differential
tendon glide. In an comparative outcome study, patients (n =
40) who completed rehabilitation with the Manchester Short
Splint demonstrated significantly less flexion contractures at
the proximal interphalangeal (PIP) joint at 6 and 12 weeks,
had significantly greater arcs of flexion at the DIP joint, and
had a greater proportion of excellent and good results com­
pared to patients (n = 62) treated with forearm-based ortho­
ses.117 As all of the protocols presented here have been
published within the past 10 years, it will be interesting to
observe their integration into clinical practice.
Once the initial rehabilitative choices have been made, the
progression of therapeutic exercise requires careful consider­
ation as it pertains to the force exerted and consequential
excursion of the tendon relative to adjacent structures. Studies
have suggested that postoperative exercise should create the
least possible force to achieve tendon excursion that will deter
peri-tendinous adhesions.99–101 From a rehabilitative perspec­
tive, it is important to recognize that tendon excursion occurs
in both proximal and distal directions, and can be influenced
by both types of exercise and antagonistic musculature.110,118,119
A working knowledge of the force and excursion produced
by specific exercises facilitates clinical progression following
tendon repair (Table 39.1).120,121
The use of straight fist, hook fist, composite fist, and iso­
lated joint exercises is suggested as a sequential regimen for
controlled force once synergistic motion has been initiated
(Fig. 39.8). Consistent communication between the therapist
and plastic surgeon is essential to both initiation and progres­
sion of exercise for the patient following flexor tendon repair,
beginning with a detailed operative report outlining the
number of strands crossing the repair site and perceived
integrity of the repair.
Extensor tendon injuries
Care of the patient following an extensor tendon injury is a far
less complicated pursuit compared to flexor tendon injury. Use
Clinical tips
Rehabilitation after extensor tendon injury
• For a mallet finger, non-operative treatment includes
continuous immobilization of the DIP joint in full extension
for 6 weeks.
• For a boutonnière deformity, non-operative management
includes PIP joint at 0° extension for 6–8 weeks and
following surgical management, a short arc motion protocol
may be initiated within 48 h.
• With zone VI–VII injuries, attention to anatomic specificity is
very important and isolation of specific musculature to
produce joint extension. Edema must be managed
immediately to avoid tendon adhesions. A passively mobile
joint with an active extensor lag is best managed via active
tendon gliding in both proximal and distal directions.