Operative Technique in Plastic Surgery – Kevin C.Chung

NATURAL HISTORY
■ Early presentation of Dupuytren disease causes isolated nodules and skin
pitting.
■ With progression of disease, pathologic cords will form.
■ As cords contract, the MCP and PIP joints may be drawn into flexion.
■ Fixed PIP joint contractures may develop over time.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ Patients with Dupuytren disease are commonly older men with northern
European ancestry but can present in all ethnic groups and both genders.
■ Dupuytren diathesis describes a predisposition toward aggressive disease and
increased recurrence after surgical treatment. Five factors1:
■ Male gender
■ Age of onset younger than 50 years
■ Family history with one or more affected siblings/parents
■ Ectopic lesions in the dorsal hand (Garrod pads)
■ Bilateral disease
■ Palpate for thick, diffuse disease in the palm and finger, compared to discrete
well-defined cords.
■ Document the degree of MCP and PIP joint contracture.
■ If the cord spans the MCP and PIP joints, assess for fixed PIP contracture by
testing passive PIP extension with the MP joint in maximal flexion.
■ Examine for web space contracture.
■ Carefully document the sensory examination, particularly if the patient has had
previous surgery.
IMAGING
■ Radiographs are obtained if there is a significant PIP joint flexion contracture.
■ Assess for articular congruency or arthritic change.
NONOPERATIVE MANAGEMENT
■ Observation is appropriate for mild disease without compromise of function
and minimal contracture.
■ Percutaneous needle aponeurotomy (PNA) is mechanical division of a
Dupuytren cord with the bevel of a hypodermic needle.
■ Collagenase Clostridium histolyticum (CCH; Xiaflex, Auxilium

Pharmaceuticals, Inc., Malvern, PA) is an enzyme used for nonsurgical
chemical division of Dupuytren cords. CCH therapy received Food and Drug
Administration approval in 2010.2
■ Consider CCH and PNA as a minimally invasive option for patients with
discrete cords who meet indications for surgery. Patients may:
■ Wish to avoid the recovery associated with surgery
■ Have significant medical comorbidities precluding surgery
■ We offer these minimally invasive options to patients with discrete palpable
cords.
SURGICAL MANAGEMENT
■ Limited fasciectomy excises diseased palmar and digital fascia. This is the
most widely used surgical technique for Dupuytren contracture.
■ We prefer limited fasciectomy for patients with diffuse disease and severe
PIP joint contractures or those who have failed PNA and/or CCH therapy.
■ Indications for limited fasciectomy include the following:
■ Palpable disease with flexion contracture of the MCP joint greater than 30
degrees
■ Palpable disease with flexion contracture of the PIP joint greater than 15
degrees
■ The “surgical techniques” discussed in this chapter include minimally invasive
techniques discussed in nonoperative management (CCH and PNA).
Preoperative Planning
■ Long-standing PIP joint contractures may persist after cord division or
excision.
■ Consider PIP joint capsulotomy and checkrein release if residual contracture
is present.
■ Review hand radiographs if the patient has significant contractures of the PIP
joint. Consider arthrodesis in the setting of severe contracture or articular
degeneration.
Positioning
■ PNA
■ This procedure can be performed in an office procedure room or in the
operating room.
■ Explain the procedure to the patient so that he/she will be prepared to

participate.
■ Supine positioning with a hand table or padded Mayo stand.
■ CCH
■ The patient is positioned sitting upright with the affected hand on the
examination table.
■ Alternatively, position the patient supine with the hand on a Mayo stand.
■ Limited fasciectomy
■ Upper arm tourniquet
■ Regional or general anesthesia
■ Supine positioning with a hand table
Approach
■ PNA
■ The importance of reporting paresthesias or numbness to the fingertips is
reviewed with the patient. Establish a baseline “normal sensation” to light
touch of the radial and ulnar finger pulp.
■ Have the patient demonstrate short arc motion of the PIP and DIP joints; this
will be useful to rule out intratendinous needle placement.
■ Cords are approached from distal to proximal for nerve monitoring.
■ Anesthetic is injected intradermally to avoid digital nerve anesthesia.
■ CCH
■ Initial on-label use involved the injection of one cord at a time, and finger
extension manipulation was recommended post injection day one. Recent
studies broadened this approach.
■ Coleman et al.3 concluded that two affected joint contractures can be
effectively and safely treated with concurrent injections. The incidence of
multiple adverse events was higher, but the incidence of severe adverse events
was not greater than single cord injection.
■ Compared to 1-day postinjection manipulation, 7-day postinjection
manipulation had no significant differences in correction, pain, or skin tears.4
This suggests manipulation can be scheduled within the first 7 days after
injection.
■ Limited fasciectomy
■ Surgical incisions are variable and depend on the location of the cord (FIG
5).
■ Hand: For extensive palmar disease, make a transverse incision at the distal

palmar crease.
FIG 5 • Skin incisions for palmar fasciectomy.
■ If there is significant MCP contracture, the distal palmar crease is left open to
heal by secondary intention.
■ Consider PIP joint volar capsulotomy if there is residual joint contracture
after fasciectomy.
T E C H N I Q U E S
■ Percutaneous Needle Aponeurotomy
■ Prepare the hand with antiseptic solution.
■ Plan and mark fasciotomy portals in areas with supple skin overlying a
discrete linear cord (TECH FIG 1A). The cord should change from soft to

firm with joint extension.
■ Portals are placed directly over the cord or along each side of the cord if it
is broad.
■ Space portals out at least 5 mm.
■ Avoid portals over nodules.
■ Avoid portals in skin creases because of:
■ Risk of skin tears
■ Proximity to flexor tendons
■ Use a small probe to evaluate portals near skin dimples. To avoid entering a
pit, avoid making the portal too close to the dimple sinus.
■ Use a 30-gauge needle and inject 0.05 to 0.10 mL of anesthetic at the most
distal portal site (TECH FIG 1B).
■ Penetrate into the dermis and then inject as the needle is withdrawn.
■ Do not inject subcutaneously.
■ Place a 5/8-in. 25-gauge needle into the portal, with the needle bevel
perpendicular to the cord fibers (TECH FIG 1C).
■ Nerve assessment: Ask the patient if he or she feels pain, paresthesia, or
electric shocks along the finger. Reassess sensation to light touch along the
side of the digit.
■ Tendon assessment: Have the patient slightly flex and extend the PIP and
DIP joints. The needle should be withdrawn more superficial if there is
needle bowing with flexor tendon excursion.
■ Repeatedly check nerve and tendon proximity to ensure the safety of the
current portal.5
• If the fingertip is numb, remove needle from current portal and move to a
proximal portal.
• If it is not, and the finger AROM does not catch the needle, continue with
the current portal.
• However, if the fingertip is not numb and the finger AROM does catch the
needle, remove needle from current portal and move to a proximal portal.
■ Hold tension on the cord by pulling adjacent skin or nodules.
■ Tension allows the needle to cut and moves the cord away from underlying
structures.
■ The cutting edge of the needle is used as a scalpel to divide the cord fibers
deep to the dermis. Three maneuvers are performed (TECH FIG 1D)5:

■ Clear: Use a side-to-side motion to clear a plane between the dermis and
cord.
■ Perforate.
• Orient the needle vertically with the bevel transverse, and perforate the
needle through the cord.
• Pull the needle back superficial to the cord but still deep to dermis.
• Using this up-and-down motion, move the needle radially and ulnarly to
make multiple perforations at the level of the portal along the width of the
cord.
• Tactile feedback is important during this procedure, as one should feel a
crackly or grating sensation as the bevel cuts the fascia.

TECH FIG 1 • Percutaneous needle aponeurotomy. A.
Cords and portals. B. Start distally with portal
anesthetic injection. C. Insertion of 25-gauge needle
with bevel perpendicular to cord. Left thumb is used to
hold tension on the cord without extending the digit. D.
Needle maneuvers. E. Ring finger manipulation to
rupture cord.
■ Sweep
• Once the cord is defined and perforated, use the needle bevel to

transversely sweep across the width of the cord, from superficial to deep.
• Tactile feedback should include a scraping sensation with the needle.
• Avoid being overaggressive to avoid neurovascular or tendon injury deep
to the cord.
• Rupture can be achieved without complete needle transection of the cord.
■ If the patient reports shooting or electric pain along the finger at any time,
reposition the needle to avoid nerve injury.
■ Move from distal to proximal portals and repeat the anesthetic injection and
needle process.
■ Passively stretch after each portal release to attempt to rupture the cord
(TECH FIG 1D).
■ If a portal looks concerning for skin tear, avoid manipulation until more
proximal portals are established.
■ When the cord ruptures, an audible “pop” may be heard.
■ Reassess for residual flexion contracture.
■ If there is still palpable cord proximally, reassess for more portal placement
and further fasciotomy.
■ Remember to monitor the nerve and tendon.
■ Once the procedure is complete, apply a Band-Aid on the portal sites. If a
skin tear occurs, apply a soft bandage.
■ Collagenase Therapy6
■ Before use, allow the vial containing the powder form of collagenase and the
vial containing the diluent for reconstitution to stand at room temperature for
15 to 60 minutes. Remove the flip-off caps and clean the surface of the vials
with alcohol (TECH FIG 2A).
■ Using a 1-mL syringe with a 27-gauge 0.5-in. needle, withdraw the
appropriate volume of diluent from the diluent vial (see package insert):
■ 0.39 mL for cords affecting the MCP joint
■ 0.31 mL for cords affecting the PIP joint
■ Inject the diluent slowly into the sides of the vial containing the powder
form of Xiaflex.
■ Slowly swirl the vial to ensure the powder is in solution. The reconstituted
solution should be clear.

■ Using a new 1-mL syringe with a 27-gauge 0.5-in. needle, withdraw the
appropriate volume of reconstituted solution (containing 0.58 mg of Xiaflex):
■ 0.25 mL for cords affecting the MCP joint
■ 0.20 mL for cords affecting the PIP joint
■ Do not inject local anesthetic as the tumescence may interfere with proper
placement of the Xiaflex injection.
■ Confirm the cord to be injected. The ideal site should be where the cord is
maximally separated from the underlying flexor tendon and where the skin is
not intimately adhered to the cord (TECH FIG 2B).
■ Clean the injection site with an antiseptic.
■ With the nondominant hand, secure the patient’s hand and apply tension to
the cord.
■ With the dominant hand, place the needle into the cord, taking care to keep
the needle within the cord.
■ If there is concern that the needle is in the flexor tendon, passively move
the distal interphalangeal joint to assess for tension on the needle.
■ Reposition the needle as necessary.
■ Once you are satisfied with needle placement, inject one-third of the dose
into the cord (TECH FIG 2C).
■ Next, withdraw the needle and reposition it slightly more distally in the cord
(2–3 mm) and inject another one-third of the dose.
■ Finally, withdraw the needle and position it in the cord proximal to the initial
site of injection (2–3 mm) and inject the remaining dose into the cord.
■ When administering two concurrent injections, use separate vials and
syringes for each cord.
■ For multiple digit injections, begin with the more ulnar digit.
■ For multiple cords in one digit, begin injections in the proximal cord and
move to the more distal cord (move from the MCP joint to the PIP joint).
■ Place the treated hand in a soft bulky dressing.
■ Patient should follow up 1 to 7 days post injection.
■ Assess the cord for autorupture.
■ Assess the involved joint range of motion.
■ Apply local anesthetic to the area of manipulation.
■ For MCP joint cords, apply extension force to the MCP joint while the wrist
is held in a flexed position.

■ For PIP joint cords, perform the finger extension maneuver with the MCP
joint in a flexed position.
■ Hold moderate extension pressure for 10 to 20 seconds.
■ If the cord is not disrupted, second and third manipulation attempts are
performed at 5- to 10-minute intervals.
■ If the cord does not disrupt after three attempts, additional collagenase
injections and manipulation are performed after 4 weeks.
TECH FIG 2 • Collagenase therapy. A. Powder,
diluent, and needles for reconstitution and injection. B.
Palpation of a pretendinous ring finger cord. C.
Collagenase injection. Note multiple sites of injection
along the cord.
■ Limited Fasciectomy
■ If there is widespread disease in the palm, make a transverse incision in the
distal palmar crease to allow access (see FIG 5).
■ Make an oblique longitudinal incision proximally toward the apex of the

palmar aponeurosis.
■ Make an incision from the distal palmar crease to the palmodigital crease.
■ This incision can be extended distally in the digit if there is digital
involvement.
■ If there is digital extension of disease, we prefer to extend the incision using
modified Bruner incisions or a longitudinal midline incision with V-shaped
extension (TECH FIG 3A,B).
■ Raise skin flaps off the diseased fascia, taking care not to buttonhole through
the dermis.
■ Identify the neurovascular bundles proximally.
■ Release the pretendinous cord proximally (TECH FIG 3C).
■ The MCP joint should extend, allowing better access and visualization
distally.
■ In the digit, raise full-thickness skin flaps and identify the neurovascular
bundle proximally.
■ Carefully dissect the neurovascular bundle from the cord from proximal to
distal.
■ If the pretendinous cord extends into a spiral cord, the neurovascular
bundle will be displaced proximal, toward the midline of the ray, and
superficial. The cord will spiral deep and from central to lateral to the
neurovascular bundle as it extends into the lateral digital sheet (TECH FIG
3C; see FIG 4).
■ Once the neurovascular structures are identified and protected along the
involved cord (TECH FIG 3D), separate and excise the diseased cord from
the surrounding tissue.
■ Reassess for residual joint contracture.
■ If there is a persistent PIP joint contracture after fasciectomy, consider
volar capsulotomy.
■ After fasciectomy and any other concurrent procedures, release the
tourniquet.
■ Hemostasis is critical to prevent hematoma formation.
■ If a longitudinal incision is made, make a Z-plasty at the flexion creases to
prevent scar contracture (TECH FIG 3E).

TECH FIG 3 • Limited fasciectomy. Preferred digital
incisions: modified Bruner incision (A) and longitudinal
incision with V-Y advancement distally (B). C. Release
of pretendinous cord proximally. Note course of ulnar
spiral cord (blue, dorsal to nerve) and digital nerve
(yellow, superficial). D. After excision of spiral cord. E.
Closure of incision after Z-plasty across flexion
creases.
■ Close the skin loosely.

■ Leave the transverse palm incision open to heal with secondary intention if
there is significant tension with MCP joint extension.
■ The open palm technique will also decrease the risk of hematoma
formation.
■ Apply a volar forearm-based extension splint.
■ If digital perfusion is compromised in full extension, allow the digit to
remain slightly flexed. This can occur after correction of severe
contractures.
■ PIP Joint Volar Capsulotomy
■ If there is persistent PIP joint flexion contracture after fasciectomy, consider
volar plate release.
■ Identify and release the A3 pulley.
■ Retract the flexor tendons with a Ragnell retractor.
■ Identify the proximal volar plate, and release the checkrein ligaments
(TECH FIG 4).
■ If necessary, release the accessory collateral ligaments, which course from
the condyle to the lateral edge of the volar plate.
■ Gentle passive extension of the PIP joint should be achieved after sufficient
release.
■ Reassess the vascularity of the digit with the joint fully extended. Splint in
as much flexion as necessary to preserve perfusion to the digit.

TECH FIG 4 • Checkrein ligament release.
PEARLS AND PITFALLS
Indications
■ Consider PNA or CCH in patients with discrete cords who will
accept a higher recurrence rate in order to avoid surgery.
■ Diffuse, matted disease without a defined cord is better suited
for surgical fasciectomy.
PNA portal
placement
■ Avoid portals over flexion creases, nodules, and matted skin.
PNA nerve
monitoring
■ Use anesthetic sparingly to avoid nerve blockade. A sensate
nerve with a cooperative patient will help avoid digital nerve
injury.
PNA technique
■ Do not pull on the fingertips to gain tension on the cord. This
will place the flexor tendons under tension, increasing risk of

tendon injury during needling.
■ Replace needles regularly, as a dull bevel impairs tactile
feedback and will not cut cord fibers.
CCH injection
technique
■ Avoid injection into the flexor tendon; injection should be
superficial within the involved cord.
■ Slight resistance to injection is normal.
PNA and CCH
finger extension
technique
■ Isolate and extend each involved joint individually to minimize
risk of skin tears.
■ Hold other joints in a flexed position to minimize skin tension.
Limited
fasciectomy
■ Neurovascular bundles can be displaced to the midline by
spiral cords.
■ Take care to dissect the nerve from proximal to distal prior to
excision of diseased tissue.
■ Meticulous hemostasis and loose wound closure (or open palm
technique) minimizes hematoma formation.
■ Hematoma formation can cause painful swelling and skin flap
ischemia.
FIG 6 • A–C. Two-week postoperative visit after

percutaneous needle aponeurotomy of ring and small
fingers, showing full active range of motion.
POSTOPERATIVE CARE
■ PNA and CCH
■ Immediate active digital flexion and extension is encouraged (FIG 6).
■ No formal therapy is prescribed.
■ Skin tears are managed with local wound care.
■ Patients perform activities as tolerated.
■ Limited fasciectomy
■ Remove the splint one week postoperatively.
■ Begin range of motion exercises.
■ For open palm wounds, local wound care with nonadherent gauze is initiated
after splint removal.
■ For contractures involving the PIP joint, night extension splints are worn for
6 months postoperatively.
OUTCOMES
■ PNA has a high rate of immediate contracture correction (less than 5-degree
residual contracture).7
■ 98% success of MCP joint correction
■ 67% success of PIP joint correction
■ PNA contracture recurrence rate is higher and occurs sooner compared to open
fasciectomy.8
■ With CCH, the overall rate of clinical success (residual contracture 0–5
degrees) ranges from 44% to 64%.2,9,10
■ Higher success is reported for treatment of MCP contractures (65%–77%)
compared to PIP contractures (28%–40%).
■ CCH disease recurrence (20 degree or greater increase of joint contracture in
the presence of a palpable cord) after 5 years is reported at 39% for MCP joints
and 66% for PIP joints.11
■ 16% of recurrent contractures underwent additional procedures, most
commonly fasciectomy or repeated CCH therapy.
■ 94% of MCP and 47% of PIP joints achieved clinical success with limited
fasciectomy, with deformity correction to within 0 to 5 degrees of full
extension.8

■ 6 months postoperatively after limited fasciectomy, 73% of patients are
satisfied with their hand function.12
■ Volar capsulotomy is controversial, as combined volar capsulotomy and
fasciectomy does not have better results than fasciectomy alone.13
■ Recurrence rates vary due to inconsistent definitions, but a recent study
demonstrates a 20.9% recurrence rate (defined as worsening of total passive
extension deficit of 30 degrees or more in a ray) at 5 years postoperatively after
limited fasciectomy, which is significantly lower than recurrence after PNA
(85%).8
COMPLICATIONS
■ PNA: Overall complication rate is low.7
■ 3.4% skin tear
■ 1.2% transient neuropraxia
■ 0.1% nerve laceration
■ CCH14:
■ Skin tear
■ Peripheral edema
■ Contusion
■ Drug ineffective
■ Injection-site hematoma
■ Lymphadenopathy
■ Pain in extremity
■ Blood blister
■ Injection-site pain
■ Tenderness
■ Localized rash/pruritus
■ Flexor pulley injury
■ Flexor tendon rupture can occur with injection into the flexor tendon; care
must be taken when treating the small finger.
■ Limited fasciectomy
■ Hematoma
■ Infection
■ Skin flap necrosis
■ Postoperative stiffness
■ Subjective paresthesias
■ Digital nerve injury

■ Digital ischemia
■ Tendon injury
REFERENCES
1. Hindocha S, Stanley JK, Watson S, et al. Dupuytren’s diathesis revisited:
evaluation of prognostic indicators for risk of disease recurrence. J Hand Surg
[Am]. 2006;31(10):1626-1634.
2. Hurst LC, Badalamente MA, Hentz VR, et al. Injectable collagenase
Clostridium histolyticum for Dupuytren’s contracture. N Engl J Med.
2009;361:968-979.
3. Coleman S, Gilpin D, Kaplan FT, et al. Efficacy and safety of concurrent
collagenase Clostridium histolyticum injections for multiple Dupuytren
contractures. J Hand Surg [Am]. 2014;39(1):57-64.
4. Mickelson DT, Noland SS, Watt AJ, et al. Prospective randomized controlled
trial comparing 1- versus 7-day manipulation following collagenase injection
for Dupuytren contracture. J Hand Surg [Am]. 2014;39(10):1933-1941.
5. Eaton C. Percutaneous fasciotomy for Dupuytren’s contracture. J Hand Surg
[Am]. 2011;36(5):910-915.
6. Auxilium Pharma. Xiaflex: Prescribing information and medication guide.
Retrieved from:
content/themes/xiaflex/assets/pdf//PI-and-MedGuide-Combined.pdf
7. Pess GM, Pess RM, Pess RA. Results of needle aponeurotomy for Dupuytren
contracture in over 1,000 fingers. J Hand Surg [Am]. 2012;37A:651-656.
8. van Rijssen AL, Linden HT, Werker PM. Five-year results of a randomized
clinical trial on treatment in Dupuytren’s disease: percutaneous needle
fasciotomy versus limited fasciectomy. Plast Reconstr Surg. 2012;129(2):469-
477.
9. Gilpin D, Coleman S, Hall S, Houston A, et al. Injectable collagenase
Clostridium histolyticum: a new nonsurgical treatment for Dupuytren’s disease.
J Hand Surg [Am]. 2010;35A:2027-2038.
10. Witthout J, Jones G, Skrepnik N, et al. Efficacy and safety of collagenase
Clostridium histolyticum injection for Dupuytren contracture: short-term
results from 2 open-label studies. J Hand Surg [Am]. 2013;38(1):2-11.
11. Peimer CA, Blazar P, Coleman S, et al. Dupuytren contracture recurrence
following treatment with collagenase Clostridium histolyticum (CORDLESS
study): 5-year data. J Hand Surg [Am]. 2015;40(8):1597-1605.
12. Engstrand C, Krevers B, Nylander G, et al. Hand function and quality of life

before and after fasciectomy for Dupuytren contracture. J Hand Surg [Am].
2014;39(7):1333-1343.
13. Weinzweig N, Culver JE, Fleegler EJ. Severe contractures of the proximal
interphalangeal joint in Dupuytren’s disease: combined fasciectomy with
capsuloligamentous release fasciectomy alone. Plast Reconstr Surg.
1996;97(3):560-566.
14. Peimer CA, McGoldrick CA, Fiore GJ. Nonsurgical treatment of Dupuytren’s
contracture: 1-year US post-marketing safety data for collagenase clostridium
histolyticum. Hand. 2012;7:143-146.

58
CHAPTER
Section XII: Spastic
Conditions
Elbow Extension
Procedures
Paymon Rahgozar and Kevin C. Chung
DEFINITION
■ The impairment suffered by patients with spastic conditions can be quite
debilitating, robbing them of their ability to perform basic activities of daily
living and independence.
■ Depending on the level of spinal cord injury, the deficits, and, in turn, the
options for reconstruction, can vary. Spinal segments C5 through T1 innervate
the upper extremity.
■ The International Classification for Surgery of the Hand in Tetraplegia (ICT)1
is a useful way to group tetraplegic patients based on functioning muscles with
strength of grade 4 or higher to determine the potential donors for tendon
transfer:
■ Group 1: Brachioradialis (BR)
■ Group 2: Extensor carpi radialis longus (ECRL)
■ Group 3: Extensor carpi radialis brevis (ECRB)
■ Group 4: Pronator teres (PT)
■ Group 5: Flexor carpi radialis (FCR)
■ Group 6: Extensor digitorum communis (EDC) and finger extensors
■ Group 7: Extensor pollicis longus (EPL) and thumb extensors
■ Group 8: Finger flexors
■ Group 9: All except intrinsic muscles
■ With spinal cord injury at the C5/C6 level, patients will maintain shoulder

function through an innervated deltoid muscle and maintain elbow flexion
through innervated biceps and brachialis muscles.
■ The role of the shoulder and elbow is to move the hands in a functional
“workspace.” The forearm and wrist then position the hand in preparation for
specific tasks of daily living.
■ In spinal cord injury, a spastic elbow flexion contracture may develop from
spasticity of the elbow flexors and an absence of elbow extension. The patient
becomes entirely dependent on the weight of the forearm for stability, limiting
the effective “workspace.” The ability to extend the hand an additional 12 in.
from the body will provide an additional 800% of workspace.2
■ An elbow extension deficit severely interferes with performing activities of
daily living and with wheelchair propulsion. Active elbow extension gives the
patient the ability to transfer and to provide pressure relief, reducing the risk of
developing ischial or sacral pressure ulcers.
■ In cases of cerebral palsy, stroke, or traumatic injury, an elbow extension
deficit may also result from a fixed elbow flexion contracture from biceps,
brachialis, or brachioradialis muscle contracture.
■ The first priority in patients with spasticity and/or tetraplegia is to improve
elbow extension. The outcome of any other reconstruction for improvement of
wrist or hand function will be entirely dependent on the patient having a usable
workspace to perform new functions.
ANATOMY
■ The deltoid originates from the scapula and inserts on the lateral shaft of the
humerus.
■ The axillary nerve and the posterior circumflex humeral artery supply the
deltoid posteriorly after passing through the quadrangular space (FIG 1).
■ The average fiber length is nearly twice that of the triceps muscle giving it a
large amount of excursion and a good potential donor for transfer.
■ The biceps originates from the coracoid process and the supraglenoid tubercle
inserting on the radial tuberosity and the bicipital aponeurosis.
■ It is innervated by the musculocutaneous nerve that travels between the
biceps and the brachialis.
■ The boundaries of the cubital fossa are the pronator teres medially and the
brachioradialis laterally. The brachial artery and the median nerve are medial
to the biceps brachii tendon. Lateral to it is the lateral cutaneous nerve of the
forearm (FIG 2).

■ The biceps muscle has a large physiologic cross-sectional area and long
fibers empowering it to exert large amplitudes of force.
■ Transfer requires the biceps tendon to curve around the humerus either
laterally across the radial nerve or medially across the ulnar nerve.
■ The triceps originates from the infraglenoid tubercle of the scapula and the
posterior superior humerus.
■ It has three heads that converge to form the central tendon of the triceps
inserting on the posterior olecranon (FIG 3).
■ The radial nerve passes through the triangular space and travels posterior to
the lateral head of the triceps from a medial to lateral direction in the radial
groove of the humerus.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ Factors that influence functional ability must be considered during the
examination:
■ Whether the injury is neurologically complete
■ Cognitive impairment from brain injury
■ Age of the patient
■ Concomitant upper extremity injuries
■ Presence of uncontrolled spasticity
■ Contractures limiting mobility
■ Patient depression
FIG 1 • A. Posterior view of the deltoid. It originates

from the scapula and inserts on the anterolateral
humerus to abduct the arm. B. It is supplied by the
axillary nerve and the posterior circumflex humeral
artery emerging from the quadrangular space.
■ Patients with motor levels of C5 or higher (ICT ≥ 1) will have deltoid, biceps,
and brachialis function.
■ The exam should include an accurate assessment of the range of motion of the
elbow, including the strength of the deltoid and biceps muscles. Supple joints
and a Medical Research Council (MRC) grade of 4 or higher are a prerequisite
for tendon transfer.
■ To test the posterior deltoid, the examiner places one palm on the patient’s
posterior humerus with the patient’s arm in 90 degrees of abduction and the
elbow in flexion. The patient is asked to push as hard as possible against the
examiner’s palm while the examiner places the other hand against the posterior
half of the deltoid assessing its tension and mass.
FIG 2 • Biceps anatomy. A. The brachioradialis and the
pronator teres form the respective lateral and medial
boundaries of the cubital fossa. Note the relationship of
the biceps with the median nerve and brachial artery. B.
Transfer of the biceps tendon can be done laterally

crossing the radial nerve or medially crossing the ulnar
nerve. Medial transfer is more often performed,
particularly if the patient does not have ulnar nerve
function.
FIG 3 • Triceps anatomy. The triceps tendon is identified
and used for the deltoid and biceps transfers.
■ If the examiner can easily push the patient’s arm out of this position, the
posterior deltoid likely does not have sufficient strength for transfer.2
■ The role of the biceps muscle is to flex the elbow and supinate the forearm.
Therefore, prior to consideration of the biceps as a donor muscle, examination
of the supinator and brachialis muscles are imperative to ensure adequate

postoperative flexion and supination.
■ Forearm supination without resistance activates the supinator, which can be
palpated along the proximal radius. Similarly, elbow flexion without resistance
will activate the brachialis, and it is palpable along the anterior humerus.
■ If the exam is equivocal, the biceps may be paralyzed with injection of local
anesthetic around the musculocutaneous nerve, facilitating an independent
evaluation of the supinator and brachialis.3
■ The patient’s overall psychosocial and mental state must be evaluated.
■ This includes consideration of the patient’s social support network and
personal motivation for improvement of function.
■ There will be a long period of postoperative rehabilitation, and without long-
term cooperation from the patient and adequate assistance, a successful
outcome is unlikely.
IMAGING
■ Plain radiography can identify the presence of heterotopic ossification, a
potential cause of joint contracture that must be ruled out or treated before any
tendon lengthening or transfer.
■ If, despite clinical examination, the examiner is still uncertain of whether a
muscle is under volitional control, electromyography focusing on the muscle of
interest can help identify spastic and flaccid muscles and determine phasic
activity.
NONOPERATIVE MANAGEMENT
■ Attempts to control the position of the elbow can be done with serial splinting
or casting. Phenol motor blocks have been used to alleviate spasticity.
■ Patients who are many years from their injury may be well adapted to their
deficits. For example, some will learn to substitute the biceps to propel
themselves in a wheelchair and do not wish any surgical intervention.
■ It is important to thoroughly question each individual patient to determine
what the postoperative goal is and whether surgery can realistically attain that
goal.
SURGICAL MANAGEMENT
■ The primary goal of surgical intervention in spasticity is to achieve, maintain,
or maximize the patient’s physical independence. Any treatment that can
improve a level of function will have a dramatic effect on the patient’s

independence.
■ The goals of reconstructing elbow extension are to provide improvement in the
following activities4:
■ Reaching for an object above shoulder level
■ Driving
■ Handwriting
■ Wheelchair propulsion
■ Pressure relief when seated
■ Using the hand while supine
■ In patients with multiple levels of deficits, the reconstitution of active elbow
extension should be performed first. It not only will stabilize the elbow and
facilitate the transfer of other muscles in the future, such as the brachioradialis,
but also gives the patient confidence in the rest of his or her treatment.5
■ The following principles of tendon transfers apply in reconstruction of spastic
conditions:
■ Supple joints with a functional arc of motion
■ Sufficient strength of donor muscle for its new function
• Although an MRC ≥ 4 is recommended, a muscle will lose one grade of
strength after transfer, and therefore, an MRC of 5 is preferable.
■ Comparable force of contraction and excursion between the donor muscle
and the muscle to be replaced
■ Synergy—motions that are synchronized during functional activity (finger
flexion with wrist extension)
■ Transfer should occur across a healthy bed of tissue with minimal
inflammation or scarring
■ Stabilization of a joint whenever a transfer spans multiple joints
■ Straight line of pull for the transfer whenever possible
■ Minimal morbidity from loss of the donor muscle
■ Elbow extension can be restored with a posterior deltoid or biceps transfer to
the triceps. In cases of contracture as a result of spasticity, tendon lengthening
is another treatment option.
■ Deltoid to triceps transfer
■ The deltoid transfer uses the posterior half of the deltoid muscle. There is
minimal to no functional loss of the donor muscle, as arm abduction is
preserved postoperatively.
■ The deltoid and the triceps are synergistic muscles. Reaching for an object

overhead involves abduction of the arm (deltoid) and extension of the elbow
(triceps).
■ One significant disadvantage of the posterior deltoid muscle is that it does
not have sufficient length to be directly inserted into the triceps tendon.
Therefore, the gap must be bridged with a free tendon graft.
■ The deltoid transfer is also prone to stretching, particularly at the proximal
suture repair between the deltoid and the tendon graft. The tendon elongation
most commonly occurs during the first 4 to 6 weeks after surgery but has been
found to occur months after surgery. Tendon elongation will result in a loss of
strength and excursion for elbow extension. Thus, a strict and rigorous
postoperative rehabilitation program is essential to optimize results.6
■ Absolute contraindications include a fixed elbow contracture or inadequate
posterior deltoid strength on clinical examination.
■ Biceps to triceps transfer
■ A biceps to triceps transfer can be considered in cases where there is less than
grade 4 strength of the posterior deltoid but biceps with strength of 4 or
greater.
■ Patients with elbow contracture less than 20 degrees may benefit from biceps
transfer over a deltoid transfer, because biceps lengthening would likely be
necessary to correct the elbow contracture.
■ Although there is a postoperative reduction in elbow flexion power of up to
47% after biceps transfer, patients report that the significant functional
improvement with added elbow extension far outweighs the decrease in
flexion strength.7,8 Again, it is important to confirm that the patient has active
supinator and brachialis muscles to minimize the elbow flexion deficits after
biceps transfer.
■ Advantages of the biceps transfer over the deltoid transfer include a shorter
operation, ability to use a tourniquet for a portion of the operation, avoiding
the need for a tendon interposition graft, and the need to heal only one tendon
junction to permit earlier mobilization.
■ Biceps transfer is not without its disadvantages. The transfer requires routing
the biceps tendon around the humerus resulting in a drop in power across the
transfer.
■ Furthermore, the biceps and triceps are antagonist muscles. Normally, with
triceps contraction and elbow extension, the biceps muscle relaxes. However,
after biceps to triceps transfer, biceps contraction is necessary to activate
elbow extension. The patient will require a longer period of rehabilitation to

train the biceps to function as an elbow extensor.
■ Tendon lengthening procedures for contracture
■ Patients with volitional control of the elbow and hand and with more than 40
degrees of contracture are candidates. Additionally, those without volitional
control and more than 100 degrees of contracture would also benefit for help
with personal hygiene.
■ Patients recovering from strokes are typically older with weaker muscles,
resulting in poor recovery of motor function regardless of the surgical
procedure. Stroke patients with contractures will likely have some benefit in
correction of the contracture, but less likely to have a significant improvement
in function.
■ For biceps or brachialis lengthening procedures, a fractional lengthening can
be performed for mild contractures, whereas a Z-lengthening (step cut) is
indicated for more severe contractures.
Preoperative Planning
■ A local nerve block is a useful preoperative tool differentiating muscle
spasticity from muscle contracture. In the case of contractures, movement will
not improve with neuromuscular blockade.
■ The underlying cause of the spasticity will guide preoperative preparation.
■ Cerebral palsy
• Voluntary hand use, sensibility, intelligence quotient, and presence of
athetosis must be measured. An uncooperative patient with limited
preoperative function is unlikely to have significant postoperative functional
improvement.
■ The examiner must confirm the cause of contracture: joint contracture,
muscle contracture, or muscle spasticity. Unlike muscle or joint contractures,
muscle spasticity presents with full range of motion of the affected joint. The
contractures should be treated with either therapy or surgery before a tendon
transfer.
• Older patients may have learned to compensate for their disability, and
reconstruction in those cases must be considered carefully.
■ Stroke
• Patients often present with hemiplegia of the upper extremity and less
spasticity than younger patients.
• Surgery should be delayed until there is maximal neurologic recovery,

typically around 12 to 18 months.
■ Traumatic brain injury
• On average, patients are younger than stroke patients and will present with a
greater degree of spasticity.
• Trauma patients may also have concomitant injuries, heterotopic
ossification, deformities from other fractures, and possible quadriplegic
involvement that can complicate postoperative functional improvement.
Each patient must be considered individually.
• Similar to cerebral palsy, patient cognition and cooperation is variable and
must be carefully assessed preoperatively to predict likelihood of patient
cooperation and a successful postoperative outcome.
■ If the patient has had a contracture treated preoperatively, it is important to
repeat examination of the range of motion on the day of surgery to confirm
there is no contracture recurrence.
Positioning
■ The patient is placed in a lateral decubitus position for the deltoid to triceps
transfer.
■ Alternatively, the patient can be supine with a surgical “bump” placed
beneath the torso to elevate the shoulder anteriorly.
■ The supine position is appropriate for the biceps to triceps transfer and the
biceps/brachialis lengthening.
■ A high proximal tourniquet can be applied for the biceps and brachialis
lengthening, as well as for a portion of the biceps to triceps transfer.
Approach
■ A variety of tendon grafts can be used for the deltoid to triceps transfer,
including toe extensors, tensor fascia lata, tibialis anterior, extensor carpi
ulnaris, or the central third of the triceps tendon.
■ The deltoid to triceps incision can be made as two separate incisions, one
overlying the posterior deltoid and one over the triceps, or it can be made as
one continuous incision.
■ The biceps to triceps transfer can be performed by tunneling the biceps tendon
either laterally or medially, though medially is the preferred method to avoid
compression of the radial nerve.8,9

T E C H N I Q U E S
■ Posterior Deltoid to Triceps Transfer
■ To reach the triceps, the posterior deltoid must be lengthened with a free
tendon graft harvested from the surgeon’s preferred donor site. A free tensor
fascia lata graft has sufficient length and strength and leaves minimal donor-
site morbidity (TECH FIG 1A,B).
■ Make an S-shaped incision from the posterior tip of the acromion to the
deltoid insertion on the humerus (TECH FIG 1C).
■ Dissect along the posterior edge of the deltoid from proximal to distal.
Identify the tendinous band marking the separation between the middle and
posterior parts of the deltoid.
■ Sharply dissect the posterior muscle fibers from their insertion on the
humerus. This measures an area of approximately 1 × 6 cm (TECH FIG 1D).
Include the periosteum and a small rectangular strip of fascia to include tissue
with sufficient strength to hold suture for the tendon repair and to provide as
much length as possible.
■ Take care to avoid dissection too far distal. The radial nerve emerges
several centimeters distal to the deltoid insertion and can be injured with
overzealous dissection.
■ Completely separate the posterior deltoid muscle fibers from the remainder
of the muscle, providing approximately 3 cm of excursion (TECH FIG 1E).
■ Avoid injury to the axillary nerve and the posterior circumflex pedicle,
located approximately 10 cm proximal to the insertion on the humerus.
■ To expose the triceps tendon and fascia, make a separate lazy-S incision
along the distal third of the humerus lateral to the olecranon process (see
TECH FIG 1A,B).
■ Create a subcutaneous tunnel connecting the proximal and distal incisions
(see TECH FIG 1E).
■ First, interweave the graft proximally to the deltoid. Then, secure the tendon
graft to the triceps tendon under moderate tension with the elbow fully
extended and the shoulder slightly abducted. Secure the repair with two
double rows of 4-0 nonabsorbable, running suture (TECH FIG 1F).
■ Ensure adequate hemostasis and close the incisions primarily.

■ Apply a splint with the elbow in 5 to 10 degrees of flexion.

TECH FIG 1 • A,B. The gap between the deltoid
tendon and the triceps tendon must be bridged with a
tendon graft. C. The deltoid is palpated and marked
out with a dashed line. The incision is a lazy-S,
spanning from the proximal extent of the muscle to
near its insertion. The triceps incision is similarly S-
shaped and is placed lateral to the lateral epicondyle
to avoid potential pressure necrosis. D. The posterior
deltoid is freed from its attachments to the humerus
and will be transferred posteriorly toward the triceps
tendon. E. The posterior deltoid (held by left clamp)
after dissection has an approximate 3-cm excursion.
The triceps tendon (held in right clamp) is prepared for

the transfer. The free tensor fascia lata graft has
sufficient length and strength for transfer. F. Suture
repair of the tendon graft to the deltoid proximally (left)
and the triceps distally (right).
■ Biceps to Triceps Transfer
■ Make an anterior longitudinal incision over the medial biceps muscle belly.
Extend the incision obliquely across the antecubital fossa (TECH FIG 2A).
■ Dissect and expose the biceps muscle. Identify and protect the
musculocutaneous nerve.
■ Divide the lacertus fibrosus while avoiding injury to the brachial artery and
the median nerve lying deep to it. If the lacertus fibrosus has a substantial
antebrachial fascia, preserve to use as an additional tail for subsequent tendon
weaving (TECH FIG 2B).
■ Identify the biceps tendon and trace it distally to its insertion on the radial
tuberosity. To identify the radial tuberosity, flex the elbow and supinate the
forearm.
■ Detach the biceps tendon from its insertion as far distally as possible. Avoid
injury to the recurrent radial vessels, as they are the main blood supply to the
brachioradialis and the extensor carpi radialis, which may be donor muscles
for potential future transfers.
■ Place a braided, nonabsorbable suture through the substance of the biceps
tendon.
■ Make a second incision overlying the distal triceps aponeurosis. Ensure that
the incision is lateral to the olecranon to avoid pressure ulceration and a
narrow medial skin bridge.
■ After exposing the triceps tendon, split it over the tip of the olecranon. Drill
a unicortical hole into the medullary canal from the olecranon tip. This hole
can be sequentially drilled to an appropriate size to receive the biceps tendon
(TECH FIG 2C).
■ From the posterior incision, create a generous subcutaneous tunnel medial to
the humerus and deep to the ulnar nerve, traveling toward the anterior
incision. The medial intermuscular septum may need to be resected to create
the tunnel.

TECH FIG 2 • A. Anterior incision for exposure of the
biceps. B. Elevation of the biceps tendon and the
lacertus fibrosus. If the lacertus fibrosus is of
substantial thickness, it can be preserved and used for
the tendon weave. C. The biceps tendon is brought
from the medial incision to the lateral incision through
a subcutaneous tunnel. Sufficient proximal dissection
of the biceps is necessary. D. The biceps tendon is
brought through a slit in the triceps (posterior view). A
unicortical hole is drilled in the proximal olecranon
large enough to fit the biceps tendon. Two smaller
distal holes are drilled in continuity with the proximal
hole large enough to pass through a Keith needle with
each end of the suture holding the biceps tendon. The

two ends of the suture are secured and tied over the
olecranon.
■ Free the biceps muscle as far proximally as possible to provide the
straightest line of pull possible toward the olecranon. The tourniquet must be
removed for this portion to permit adequate proximal exposure. Avoid injury
to the vascular pedicle to the biceps, which enters the deep surface of the
proximal third of the muscle. Proximal dissection should stop once the distal
motor branches of the musculocutaneous nerve entering the biceps are
identified.10
■ Transfer the biceps tendon from the anterior incision medially toward the
posterior incision (TECH FIG 2D).
■ Pull the biceps tendon through the slit in the triceps tendon and secure with a
Pulvertaft weave with a braided nonabsorbable suture. The tail of the biceps
tendon should remain free to be brought through the olecranon.
■ Drill two small holes through the opposite cortex of the olecranon to permit
passage of a Keith needle. Secure a suture in the tail of the biceps and bring
each end of the suture through each of the distal olecranon holes with a Keith
needle. With the elbow in full extension, tie the two ends of the suture
together over bone (TECH FIG 2E).9
■ Place additional braided nonabsorbable sutures between the biceps and
triceps tendon to further secure the transfer. If a tail of lacertus fibrosus was
preserved, it can be secured at this time, either to the biceps tendon or to the
triceps tendon.
■ Set the tension maximally with the elbow held in full extension, such that the
elbow cannot be passively flexed beyond 30 degrees when the arm is
abducted about 30 to 40 degrees.8
■ Achieve hemostasis, and close all skin incisions primarily. A suction drain
can be placed at the surgeon’s discretion.
■ Place a splint holding the arm in 10 degrees of elbow flexion and the wrist in
30 degrees of extension. The shoulder is not immobilized.
■ Biceps and Brachialis Lengthening
■ Make a 15-cm S-shaped incision across the antecubital fossa beginning
laterally above the elbow and curving distally in an anteromedial direction

(TECH FIG 3A).
■ Dissect from medial to lateral, exposing the lacertus fibrosus, biceps brachii
tendon, median nerve, brachial artery, and the lateral antebrachial cutaneous
nerve (see FIG 2).
■ Identify the bicipital aponeurosis medial to the biceps brachii tendon, and
resect it completely (TECH FIG 3B).
■ Identify the lateral antebrachial cutaneous nerve between the biceps and
brachialis lateral to the biceps tendon and retract it laterally. Expose the
biceps completely and dissect distal to its insertion.
■ For a fractional lengthening, make two cuts in a slightly oblique direction,
spaced approximately 1 to 2 cm apart. One cut is made on the lateral side of
the tendon, and the other is made on the medial side. The cuts should be no
more than halfway through the tendinous portion of the musculotendinous
junction, leaving the muscle fibers intact (TECH FIG 3C). Gently extend the
elbow facilitating separation of the tenotomy sites, keeping the muscle in
continuity.
■ After release of the biceps, the brachialis can be visualized. Similarly,
perform a fractional lengthening. Again, if two releasing incisions, space
them approximately 1 to 2 cm apart and perform the proximal incision first.
If the distal incision is made first, proximal migration of the brachialis will
make it challenging to make the second incision (TECH FIG 3D).
■ To perform a Z-lengthening of the biceps, make a transverse cut halfway
through the tendon on the proximal side. Make a second distal transverse cut
halfway through the opposite side of the tendon. The two cuts are connected
longitudinally completely releasing the tendon with each end representing
half the Z limbs (TECH FIG 3E).

TECH FIG 3 • A. Incision for biceps and brachialis
lengthening. An S-shaped incision starts on the lateral
arm and crosses the cubital fossa transversely to the
medial forearm. B. Exposure of the bicipital

aponeurosis. C. Fractional lengthening of the biceps
tendon. D. Fractional lengthening of the brachialis. E.
Markings for Z-lengthening of the biceps tendon. F.
Repair of the two ends of the biceps following Z-
tenotomy and lengthening of the biceps.
■ The elbow is extended to 30 degrees of flexion lengthening the tendon to the
appropriate length. The two ends are sutured together where they remain
overlapping using a Pulvertaft weave with 3-0 braided, nonabsorbable sutures
(TECH FIG 3F).
■ Be certain to perform the Z-lengthening over as much of the tendon length as
possible to maximize the amount of tendon available for reattachment.
■ If adequate lengthening of the brachialis cannot be obtained with fractional
lengthening or Z-lengthening, the muscle can be completely transected.
■ If preoperative evaluation revealed a spastic brachioradialis, it can be
assessed for partial or complete release at this time. Dissect between the
brachialis and brachioradialis to identify the origin of the brachioradialis.
Perform the release (partial or complete) at the origin, permitting the muscle
to slide distally. Be certain to identify and protect the radial nerve before
performing a brachioradialis release.
■ Release the tourniquet, achieve hemostasis, and close the wound primarily.
■ Place the arm in a splint with the elbow at 30 degrees of flexion.
PEARLS AND PITFALLS
Incision
■ Avoid making incisions directly over the olecranon to prevent
pressure ulceration.
■ Make a longitudinal incision on the lateral elbow for patients with
contractures greater than 100 degrees facilitating skin closure with
multiple Z-plasties if necessary.
Deltoid to
triceps
transfer
■ A tendinous band in the intermediate part of the deltoid can be
used to help demarcate the separation between the middle and
posterior portions of the deltoid.
■ Include the periosteum when dissecting the deltoid insertion from

the humerus to better hold sutures for repair.
■ The axillary nerve is approximately 10 cm proximal to the humeral
insertion of the deltoid and must be avoided.
Biceps to
triceps
transfer
■ Identify and protect the lateral cutaneous nerve of the forearm.
■ If using a tourniquet, release will be necessary to achieve adequate
proximal dissection of the biceps.
■ Create a generous subcutaneous tunnel to avoid any compression
or loss of strength of the transferred biceps tendon.
■ If the lacertus fibrosus has substantial fascia, it can be preserved
and used as a second tail to further strengthen tendon weaving.
■ Medial routing of the biceps tendon avoids the potential for radial
nerve palsy.
■ Avoid injury to the recurrent radial vessels so that the blood supply
to potential donor muscles for future transfers is not compromised.
Biceps and
brachialis
lengthening
■ Perform a fractional lengthening in cases of mild contractures and
a Z-lengthening for more severe contractures.
■ When performing a double incision release of the brachialis,
perform the proximal incision first.
■ Avoid placing the elbow in full extension in patients with
volitional control, as this may result in postoperative problems with
elbow flexion.
POSTOPERATIVE CARE
■ Deltoid and the biceps to triceps transfer
■ Immobilization is continued for 4 weeks. The patient is then placed in an
active exercise program gradually increasing elbow flexion at a rate of 15 to
20 degrees per week with a daytime dial-hinge brace and a nighttime splint in
full extension.
■ Occupational therapy is used to train biceps activation for elbow extension
and to incorporate functional activities of daily living.8
■ The dial-hinge brace is continued until the patient is at 90 degrees of elbow
flexion. The nighttime splint is used for 12 weeks, after which strengthening
can begin.
■ Biceps and brachialis lengthening
■ The wound is inspected and sutures removed in 10 to 14 days.
■ If a fractional lengthening was performed, the patient can begin mobilization
immediately.

■ For biceps Z-lengthening, the elbow is splinted in 30 degrees of flexion for 4
weeks to protect the tendon repair. Active and passive range of motion can
then begin with nighttime splints worn for an additional 3 weeks for
protection.
OUTCOMES
■ The biceps comprises one of the two strong elbow flexors. Therefore, transfer
does result in an approximate 47% reduction of preoperative strength.4,8
■ The biceps is an antagonist to the triceps, leading to a longer rehabilitation
period to learn to activate it as an elbow extensor. This learning curve can vary
from 2 to 6 months.4,8
■ Patients typically regain full or near full elbow extension against gravity with
both tendon transfer techniques.2,3 In cases where patients do not,
myofeedback with electrical stimulation can be used with good success.4
■ On average, fractional lengthening of the biceps leads to a 10- to 30-degree
improvement in flexion contracture with minimal loss of flexion power.
■ For patients with a Z-lengthening procedure, there is on average a 45- to 60-
degree improvement of elbow flexion contracture albeit with a loss of flexion
power.
COMPLICATIONS
■ Wound breakdown, infection, iatrogenic nerve injury, or inappropriate
tensioning of a tendon transfer are all uncommon but possible surgical
complications.
■ For tendon transfers, tendon rupture or stretching of the repair can occur
postoperatively leading to ineffective elbow extension. This can best be
avoided with a strict postoperative immobilization and rehabilitation regimen.
■ Tendon pullout from the olecranon is another potential complication that can
best be prevented with a secure fixation.
■ Though rare, compartment syndrome is a potential complication and can easily
be missed in a patient with lack of preoperative sensation.3
REFERENCES
1. McDowell CL, Moberg EA, House JH. The second International Conference
on Surgical Rehabilitation of the Upper Limb in Tetraplegia (quadriplegia). J
Hand Surg [Am]. 1986;11:604-608.
2. Leclercq C, Hentz VR, Kozin SH, Mulcahey MJ. Reconstruction of elbow

extension. Hand Clin. 2008;24(2):185-201.
3. 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(6):968-975.
4. Ejeskär A. Elbow extension. Hand Clin. 2002;18(3):449-459.
5. Allieu Y. General indications for functional surgery of the hand in tetraplegic
patients. Hand Clin. 2002;18(3):413-421.
6. Friden J, Ejeskar A, Dahlgren A, Lieber R. Protection of the deltoid to triceps
tendon transfer repair sites. J Hand Surg [Am]. 2000;25(1):144-149.
7. Mulcahey MJ, Lutz C, Kozin SH, Betz RR. Prospective evaluation of biceps
to triceps and deltoid to triceps for elbow extension in tetraplegia. J Hand Surg
[Am]. 2003;28(6):964-971.
8. Revol M, Briand E, Servant JM. Biceps-to-triceps transfer in tetraplegia: the
medial route. J Hand Surg Br. 1999;24(2):235-237.
9. Kuz JE, Van Heest AE, House JH. Biceps-to-triceps transfer in tetraplegic
patients: report of the medial routing technique and follow-up of three cases. J
Hand Surg [Am]. 1999;24(1):161-172.
10. Endress RD, Hentz VR. Biceps-to-triceps transfer technique. J Hand Surg
[Am]. 2011;36(4):716-721.

59
CHAPTERWrist Extension Procedures
Paymon Rahgozar and Kevin C. Chung
DEFINITION
■ Patients with tetraplegia may have difficulty with wrist extension, constantly
assuming a partially flexed posture.
■ A flexed wrist position diminishes the tenodesis effect on the digital flexors,
leading to a weakened grip, difficulty with hygiene, and obstructed visual
feedback when grabbing objects.
■ After elbow extension, the second priority in reconstruction for tetraplegia or
spinal cord injury is the restoration of wrist extension. Augmentation of wrist
extension can indirectly enable passive thumb and finger flexion by improving
pinch and grasp. This tenodesis effect is valuable in patients who do not have
enough donor muscles to reconstruct active grasp and pinch.
■ Those patients with an International Classification for Surgery of the Hand in
Tetraplegia (ICT) score of 1 have an active brachioradialis that can be used for
tendon transfer to augment wrist extension (see Table 1 from Elbow Extension
chapter).
ANATOMY
■ Tetraplegic patients with an active brachioradialis typically have an innervated
biceps and brachialis muscle. Therefore, there is minimal donor-site morbidity
on elbow flexion with its use for tendon transfer, making it a versatile
workhorse muscle in tetraplegia reconstruction.
■ The brachioradialis originates from the lateral supracondylar ridge of the
humerus and the lateral intermuscular septum and inserts on the lateral base of
the radial styloid beneath the tendons of the abductor pollicis longus and
extensor pollicis brevis.

■ It is innervated by a branch from the radial nerve entering the deep portion of
the muscle, proximal to the elbow.
■ The superficial branch of the radial nerve (radial sensory nerve) runs deep and
medial to the brachioradialis between it and the supinator muscle. In the mid to
distal forearm, the radial artery can be found between the brachioradialis and
the flexor carpi radialis tendon (FIG 1).
■ The brachioradialis is a long muscle with good excursion and a large
circumference, giving it a high force of contraction.1 Its tendon is bound with
fascial coverings and does not glide freely past the mid-forearm (FIG 2).
■ Releasing the tendon fascial attachments and freeing the muscle belly from
the surrounding muscle significantly increases its excursion.2
■ The extensor carpi radialis brevis (ECRB) attaches to the long finger
metacarpal and is a more efficient wrist extensor than the extensor carpi
radialis longus (ECRL), whose tendon attaches to the radial side of the second
metacarpal, resulting in both extension and radial deviation of the wrist (FIG
3).
PATIENT HISTORY AND PHYSICAL FINDINGS
■ As for all patients with spastic conditions considering surgical reconstruction,
there are a variety of anatomic, functional, and psychosocial factors that must
be examined (see Elbow Extension chapter).
■ The strength of the brachioradialis must have a Medical Research Council
grade 4 or higher. To test the brachioradialis, position the patient’s elbow in a
midprone position and have the patient flex against resistance contracting the
brachioradialis. Palpate and attempt to move the belly of the muscle. If the
muscle is tight, the brachioradialis has adequate strength for transfer (FIG 4).

FIG 1 • Relevant volar anatomy. Note the relationship of
the brachioradialis with the sensory branch of the radial
nerve and the radial artery.
■ Examination also includes the wrist and metacarpophalangeal joints to ensure
a full passive range of motion with good passive tenodesis of the fingers with
wrist flexion and extension.3
IMAGING
■ Electromyography can confirm volitional activity of the brachioradialis if the
exam is equivocal. It will identify whether the muscle is spastic or flaccid and
will determine its phasic activity.

FIG 2 • Excursion from dissection of the brachioradialis.
A. A mark is placed on the distal tendon of the
brachioradialis and extended to the surrounding tissue
as a reference point. B. After ligation of the distal
tendon and freeing the tendon and muscle attachments,
there is approximately 3 cm of advancement beyond
the reference point.
SURGICAL MANAGEMENT
■ The goal of surgery is to improve pinch and grasp by taking advantage of the
tenodesis effect. Wrist extension effectively lengthens the palmar surface of the
wrist by increasing tension on the digital flexors and reducing tension on the
digital extensors. This results in bringing the thumb and fingers into passive

flexion4 (FIG 5).
■ With restoration or augmentation of active wrist extension, the patient can
grasp light objects and pinch to hold and write with a pencil.
■ Prerequisites include an active brachioradialis muscle and full range of motion
of the wrist and MCP joints.
■ The transfer can be performed with a number of other procedures as described
by Moberg to maximize lateral pinch tenodesis5:
■ Resection of the thumb annular ligament to release the flexor pollicis longus
(FPL) tendon over the metacarpophalangeal joint, increasing its mechanical
advantage
■ Stabilization of the thumb interphalangeal joint with a buried Kirschner wire
to prevent interphalangeal flexion with pinch (Froment sign)
■ Tenodesis of the FPL by attaching it to the volar radius
■ It is best to delay tendon transfer for at least 1 year following injury to
facilitate maximal recovery prior to surgical reconstruction.6
FIG 3 • Dorsal forearm anatomy. Note the location of

the extensor carpi radialis longus (ECRL) and the
extensor carpi radialis brevis (ECRB).
FIG 4 • To examine the brachioradialis, place the
patient’s forearm in neutral position and ask the patient
to flex the elbow against resistance. The prominence of
the muscle belly is evident along the proximal radial
forearm (arrow). Difficulty to displace the muscle with
the examiner’s hand confirms adequate strength for
transfer.

FIG 5 • Active wrist extension results in finger flexion
and automatic pinch via the tenodesis effect.
Preoperative Planning
■ The patient’s underlying cause of spasticity and the current psychosocial state
must be carefully assessed before proceeding with surgical reconstruction (see
Elbow Extension chapter).
■ Any preoperative contractures must be diagnosed and treated with tendon
transfer. A local nerve block can differentiate spasticity from contractures.
Paralysis of the muscle will have no effect on contractures but will improve
range of motion with spasticity.
■ Contractures can be treated with occupational therapy, progressive splinting,
or surgery depending on the severity.
■ On the day of surgery, full range of motion must be confirmed before
proceeding with a tendon transfer, particularly in patients who were treated for
preoperative contractures.
Positioning
■ The patient is positioned in the supine position with the arm extended on an
armboard. A nonsterile upper arm tourniquet is applied to provide a bloodless
operative field.
Approach
■ The brachioradialis can be transferred to the ECRB or to both the ECRB and
ECRL. Transfer to the ECRL alone is not advised, as this can lead to more
radial deviation than wrist extension.3,6
T E C H N I Q U E S
■ Brachioradialis to Extensor Carpi Radialis Brevis
Tendon Transfer
■ Make a longitudinal dorsoradial incision from the midforearm to the wrist
(TECH FIG 1A).
■ Identify the brachioradialis, ECRL, and ECRB tendons (TECH FIG 1B).

■ Longitudinally incise the paratenon of the brachioradialis. Sharply divide the
terminal tendon as distal as possible under the abductor pollicis longus and
the extensor pollicis brevis.
■ Dissect along the deep aspect of the brachioradialis freeing it from its fascial
connections proximally to the midforearm (TECH FIG 1C).
■ Take care to identify and protect the superficial branch of the radial nerve
and the radial vessels during the dissection.
■ Continue proximal dissection until an approximate 3 cm of excursion is
obtained. If necessary, dissection can continue proximally to just distal to the
elbow crease. The radial recurrent vessels traveling transversely on the deep
aspect of the muscle mark the extent of the proximal dissection.
■ Dissect the ECRB tendon proximally and sharply divide it at the level of the
mid-forearm (TECH FIG 1D).
■ Avoiding compression of the radial sensory nerve, transfer the
brachioradialis dorsally toward the ECRB superficial to the ECRL.
■ In an end-to-end fashion, perform a Pulvertaft weave between the
brachioradialis and the ECRB using multiple 2-0 nonabsorbable braided
sutures.
■ Place the elbow in 90 degrees of flexion, the forearm in neutral, and the
wrist in 45 degrees of extension prior to suturing the tendons.7 Do not pull up
on the tendons when placing the first suture to avoid a lax repair once the
tendon falls back to its natural position.
■ Set the tension on the brachioradialis so that the normal resting length is re-
established. To estimate this, passively stretch the muscle to its initial length
relative to the radius. Place a mark on the brachioradialis tendon at its most
proximal intersection with the ECRB tendon. Confirm that the mark remains
in the same location after placement of all the sutures between the
brachioradialis and ECRB.4
■ The tension should be set such that the wrist is in a neutral to slightly
extended position but passive flexion is still possible (TECH FIG 1E).
■ Release the tourniquet, achieve hemostasis, and close the incision primarily.
■ Place a splint holding the elbow in 90 degrees of flexion, the forearm in
neutral rotation, and the wrist in 45 degrees of extension.