Phẫu Thuật Tạo Hình Grabb & Smith’s (Bản Cập Nhật – Kevin C. Chung)

History and Examination
The first visit to the peripheral nerve surgeon is frequently several weeks after the time of trauma, as care
for multitrauma or life-threatening conditions will be prioritized. The decision to proceed with surgery is
guided by clinical evaluation (history, physical examination, electrodiagnosis, and radiographic imaging
[chest X-ray, CT myelography, and magnetic resonance imaging (MRI)]).
Elements of the patient’s history can give clues to the type and location of injury to expect. The energy of
the injuring mechanism (e.g., high-speed motor vehicle, motorcycle, train, moped at high or low speed,
fall from height) is a relevant detail for estimating the severity of nerve injury. Concomitant injuries
caused by the injuring mechanism are important to consider. Anterior shoulder dislocation and scapular
fracture are associated with posterior cord damage. 12 Spine fractures indicate a more proximal focus of
energy from the injury mechanism; thus, the site of nerve rupture or avulsion is likely nearby as well. 13
The position of the patient’s head, neck, and arm at the time of impact (if they were conscious) can direct
the surgeon to suspect an upper trunk versus lower trunk foci of damage. 14
The first goal of the physical examination is to determine where upon the brachial plexus the nerve
ruptures or avulsions have occurred. To localize the deficit in axonal circuitry, it is helpful to use a chart
to systematically examine the dermatomes of sensation and motor function of the shoulder girdle and
upper extremity (Figure 72.5). Examination should proceed in a distal to proximal fashion. Deficits in the
motor and sensory examination delinate approximately where the zone of injury is. The Hoffmann-Tinel
sign is an indicator of regeneration of neurons and is also an indirect indicator of the site of nerve rupture
during the early period of time after trauma. 15 Horner syndrome (pupillary miosis, upper eyelid ptosis,
and anhidrosis upon the face of the ipsilateral side) indicates disruption of the sympathetic pathways
(and a likely presence of a root avulsion involving the lower plexus which is situated just adjacent to the
sympathetic plexus). 16 Deafferentation pain (a.k.a. phantom limb pain and sensation) is a sign that root
avulsion has occurred. Deafferentation pain is sometimes described as causalgia (pain that is severe,
burning in nature, and lancinating). 17 Examination at 1 month intervals from the time of trauma until 3 to
5 months after trauma is an acceptable schedule.
FIGURE 72.5 Worksheet for systematic physical examination of the brachial plexus patient.
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Radiographic imaging is used in conjunction with physical examination. On chest X-ray, diaphragmatic
muscle paralysis (hemidiaphragmatic elevation on the injured side) suggests a likely involvement of the
upper plexus as the diaphragmatic innervation (C3, C4, and C5) that is involved in the zone of injury is
located near the upper trunk. Diaphragmatic function also provides information to the surgeon for
consideration about whether the phrenic and intercostal nerves may be used as donor nerves. Some will
argue that the phrenic nerve should never be used as a donor nerve because of respiratory morbidity,
whereas others believe that using the phrenic donor nerve is safe in lower-BMI patients. 18 Also, some
surgeons argue against use of the intercostal nerves for donor innervation if the phrenic nerve on that
side is not functional, for fear of respiratory morbidity. 19 MRI and CT myelography can both detect the
presence of pseudomeningoceles adjacent to the vertebrae, which develop when the dura tears in
conjunction with avulsion spinal nerve roots. MRI can also show various signal changes that suggest
nerve injury. However, at the current time, MRI has not yet been proven as a reliable modality for
delineating nerve rupture or injury within the plexus. 20
Electrodiagnosis consists of both nerve conduction studies and needle electromyography (EMG). Nerve
conduction studies use stimulating and recording electrodes to measure various parameters from both
motor and sensory nerves. Needle EMG involves insertion of a needle (intramuscular recording
electrode) into a muscle to record insertional, spontaneous, and voluntary electrical activity (useful tips in
Table 72.2). The baseline nerve conduction study and EMG should be performed no earlier than 3 to
4 weeks after trauma, as certain acute phase injury changes take that amount of time to become
detectable. A follow-up electrodiagnostic study should be repeated at approximately 2-month intervals to
monitor for spontaneous recovery versus stable denervation. 21
TABLE 72.2
Tips for Interpreting Electrodiagnostic Studies (EDSs)
Basics
Nerve Conduction Studies (NCSs)
NCSs evaluate larger myelinated nerves.
SNAP = sensory nerve action potential (sensory nerve)—begins to decrease at day 6 after injury and reach nadir at day 10–11.
Beware that sensory NCS tends to overestimate severity of injury.
CMAP = compound muscle action potential (motor nerve)—begin to decrease at day 2 or 3 after injury and reach nadir at day 7.
CMAP amplitudes are the most useful for quantifying the amount of axon loss (at an early time point before collateral
reinnervation occurs-collateral reinnervation occurs from the remaining nerve fibers when there is an incomplete nerve transection). Once
collateral reinnervation starts to occur, the CMAP amplitude will appear to improve even though the number of degenerated
motor nerve fibers is unchanged.
Amplitude reflects the total number of conducting axons.
Needle Electromyography (EMG)
MUAP = (voluntary) motor unit action potential. (A needle electrode is stuck into the muscle, and the patient voluntarily contracts the
muscle; then action potentials are measured). MUAP dropout is proportional to the number of motor axons disrupted; however,
MUAP dropout is challenging to quantify and thus less useful for estimating severity.
At the late time point (after collateral reinnervation has occurred), MUAP changes (duration and recruitment patterns) are
better indicators for motor fiber loss than CMAP changes. However, at least 50% of the motor nerve must be disrupted before
these MUAP changes can be discernible.
The distal stump of a transected nerve can conduct action potentials for ∼6 d (motor) and ∼10 d (sensory).
Diagnostic Tips
If muscle is innervated, there are no spontaneous discharges (fibrillations and positive sharp waves).
If EDS shows decreased amplitude (not normal but also not severely decreased), then it suggests that the lesion is not a
preganglionic avulsion; it is probably a postganglionic rupture and partial rupture of the sensory fibers too.
PSW (positive sharp waves)—acute phase injury sign (should subside by 1 y post injury).
Fibrillations—acute phase injury sign (does not appear until 2–3 wk after injury; they should subside by 1 y post injury).
Fibrillation potentials tend to overestimate the severity of injury—fibrillations may be quite prominent even when the lesion is
minimal.
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Complete denervation (chronically fibrotic muscle will show no spontaneous discharge)—completely reinnervated muscle will also
return to the state of no spontaneous discharge.
Polyphasic waves: if more than five phases occur, the presence of motor unit is likely. Polyphasic waves are a pathologic finding, but
the nerve is still alive.
Fasciculations = irregular, normal, or complex MUAP. These can be exercise induced, or they can be indicative of lower motor
neuron disorders or peripheral/metabolic neuropathy. (We do not really look at this parameter with acute nerve injury.)
Voluntary motor units = reflect any presence of motor units (e.g., if empty, then no meaningful recovery; a poor prognostic
indicator).
Recruitment = reflects how many motor unit potentials have survived (e.g., Rare = only a few motor units are surviving; a poor
prognostic indicator).
Velocity will indicate demyelination (large fibers [radial nerve] should normally conduct 50–60 m/s; smaller fibers conduct 25–
40 m/s).
Degeneration of motor fibers is faster than sensory.
If the EMG suggests no recording at all, then it is probably more accurate than physical examination (in cases where one thinks there
may be a faint M1 strength on physical examination).
If motor nerve conduction (amplitude) is absent at 4 months after injury, this as a bad prognostic indicator, and surgical exploration
is warranted.
A lack of improvement in motor function with progressive examinations combined with electrodiagnostic
data consistent with stable denervation points to a state of irrecoverable nerve injury that can only be
improved upon by surgical intervention. Contraindications to surgery include traumatic brain or spinal
cord injuries that may prevent productive participation in a rehabilitative protocol. Also, medical
comorbidities prohibitive of a prolonged general anesthetic session (>6–8 hours) must be considered
before committing the patient to a surgical course. Joint contractures also need to be addressed
concomitantly if they exist. The surgeon should also take careful consideration of the patient’s willingness
and ability to comply with postoperative rehabilitation for any patient who has already developed
substantial joint contractures during the initial posttrauma time period.
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Categories of Surgical Treatment
There are three general categories of surgical management of adult brachial plexus injury:
Proximal exploration and reconstruction
Distal (close target) nerve transfers
Biomechanical restorations (tendon transfers and functioning free muscle transplantations [FFMTs])
Before nerve exploration and repair was possible, there was the biomechanical restorative approach
(tendon transfers) that was being done as early as the 1930s with applications to brachial plexus injuries
by the 1960s. 22 We have also included the functioning FFMTs that developed in the 1970s in this group. 23
The next approach to surgical intervention for brachial plexus injury was by proximal exploration and
visualization of the site of injury directly with concomitant nerve reconstruction (nerve grafting or nerve
transfers). Although surgery for the brachial plexus was first attempted in 1900, the field did not see
significant advances until the advent of microsurgical techniques in the 1960s. 14 The most recent addition
to the toolbox for brachial plexus reconstruction is the distal nerve transfers that utilize intact nerves
remote to the zone of injury. With this category of technique developed in the 1990s, a portion of the
intact innervation is used to replace the innervation that has been injured. 24 Certain factors affect the
selection among these four strategies: time since trauma, surgeon comfort with technique, extent of zone
of injury, and availability of donor nerves or musculotendinous units. To note, two or more of these
therapeutic categories may be used on the same patient. Furthermore, these surgical categories may be
used sequentially in time.
Proximal exploration is performed via a neck incision to gain access to the supraclavicular brachial
plexus. The incision can be carried infraclavicularly onto the chest for access to the cords and terminal
branches of the brachial plexus. This approach allows for both diagnostic and therapeutic objectives.
Typically, nerve ruptures will require cable-grafting between the proximal and distal nerve stumps by
using sural, saphenous, median antebrachial cutaneous, or lateral antebrachial cutaneous nerves
harvested as nerve grafts. Allografts should not be used in this setting. Occasionally, osteotomy of the
clavicle is necessary if the zone of injury terminates retroclavicularly, necessitating coaptation directly
behind the clavicle. Root avulsions or spinal nerve ruptures with proximal stumps that are too short to
support coaptation can be managed by nerve transfers using intraplexus transfer from proximal stumps
of neighboring spinal nerves or from extraplexus donors (e.g., CN XI, contralateral C7, intercostal nerves,
phrenic, or cervical motor branches of C3/C4). Proximal exploration is often thought of as the most
technically daunting approach to brachial plexus injury because of the need for surgical dissection
through the fibrotic scar tissue within the zone of injury. Exploration of the lower trunk can be risky in
this regard, as adhesions to the pleural cavity and the proximity to great vessels in this case can
sometimes also lead to pneumothorax or vessel injury. Postoperative neck immobilization is crucial, as
head-turning can potentially disrupt the delicate nerve coaptations. Proximal exploration with the intent
of nerve reconstruction should be done within the posttrauma 3- to 5-month timeframe, to ensure
opportunity for reinnervation before the time of motor endplate fibrosis at the neuromuscular 
 junction 9
(Table 72.3).
TABLE 72.3
Reconstructive Options With Proximal Exploration
Donor Nerve
Recipient Nerve
Technical Aspects
Functional
Objective
CN (cranial
nerve) XI
(spinal
Suprascapular/posterior division of
C5/C6
Use with phrenic (+/-cervical motor branches [CMBs])
Shoulder abduction
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accessory)
CMBs, (C3,
C4)
Suprascapular/posterior division of
C5/C6
Use with phrenic and CN XI. (CMBs are too weak to use
alone)
Shoulder abduction
Phrenic
Suprascapular/posterior division of
C5/C6
(+/-) CN XI and CMB. Phrenic is strong enough to use
alone
Shoulder abduction
C5-ruptured
proximal
stump
Suprascapular/posterior division of
C5/C6 versus anterior division upper
trunk, median nerve
Will require cable grafting by sural nerve. Pick one target
to avoid cross-innervation
Shoulder abduction,
elbow flexion, or
finger flexion
C6-ruptured
proximal
stump
Median nerve, C8
Will require cable grafting by sural nerve
Finger flexion
C7-ruptured
proximal
stump
Median nerve
Will require cable grafting by sural nerve
Finger flexion
Contralateral
C7
Suprascapular/posterior division of
C5/C6, anterior division upper trunk,
median nerve
For five root injuries without other suitable donors.
Needs a vascularized nerve graft (ulnar nerve). Pick one
target to avoid cross-innervation
Shoulder abduction,
elbow flexion, or
finger flexion
Intercostal (T3,
T4, T5)
Musculocutaneous nerve
Minimum of two intercostals needed. No nerve grafting
Elbow flexion
Distal (close target) nerve transfers are viable options in cases that are within the 3 to 9 month posttrauma
timeframe and also with viable donor nerves available that can be used for reinnervating the deficit. The
great benefit of this approach is that the operative site is outside of the zone of injury, and thus the
surgeon can avoid the difficulty of operating through fibrotic tissue. Furthermore, the time period in
which surgical intervention must be performed can be extended by 2 to 3 months (surgery at 6–9 month
post trauma is reasonable) because of the much shorter distance that the innervating axons must travel to
the target muscle. However, this category of surgical technique is also limited by the severity of injury.
For instance, for total root (C5-T1) injuries, only intercostal nerves will be available for use. The
disadvantage of distal motor nerve transfer is that it weakens the intact functional portions of the upper
extremity in order to restore an incomplete amount of the original function to the injured portion of the
upper extremity. Cortical adaptation with postoperative motor reeducation is also required for regaining
the use of the reconstructed innervation 24 (Table 72.4). A number of accompanying sensory nerve
transfers also have been described for restoring sensation (Table 72.5).
TABLE 72.4
Distal (Close-Target) Motor Nerve Transfer Options
Deficit
Donor Nerve
Recipient Nerve
Functional Objective
Radial
FDS or FCR/PL fascicles of median
nerve
ECRB branch of radial; PIN
Wrist extension, thumb/finger
extension
PT branch of median
FCR branch of median
ECRL branch of radial; PIN
Wrist extension, thumb/finger
extension
Median
Supinator or ECRB branches of
radial nerve
AIN
Finger flexion, thumb flexion
FCU branch ulnar nerve
AIN
Finger flexion, thumb flexion
ECRB branch radial nerve/FCU
branch ulnar nerve
AIN/PT branch median
Finger flexion, thumb flexion;
pronation forearm
ECRB radial
ECRB/supinator radial
PT
AIN
Pronation forearm
Finger flexion, thumb flexion
Brachialis branch of
musculocutaneous
AIN
Finger flexion, thumb flexion
Distal median
Terminal branch of AIN
Recurrent motor branch median nerve
Thumb opposition
Third lumbrical branch ulnar
Thenar branch median
Thumb opposition
Ulnar
Terminal branch of AIN
Ulnar motor branch
Ulnar intrinsic muscles
EDQ/ECU branches of radial nerve
Ulnar motor branch
Ulnar intrinsic muscles
Musculocutaneous
Median and ulnar branches
Musculocutaneous
Elbow flexion
Axillary/suprascapular
Triceps branch of radial
CN XI
Anterior branch of axillary nerve;
suprascapular nerve
Shoulder abduction, external
rotation
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AIN, anterior interosseous nerve; CN, cranial nerve; ECU, extensor carpi ulnaris; EDQ, extensor digiti quinti; ECRB, extensor carpi radialis
brevis; FCR, flexor carpi radialis; FCU, flexor carpi ulnaris; FDS, flexor digitorum superficialis; PIN, posterior interosseous nerve; PL, palmaris
longus; PT, pronator teres.
TABLE 72.5
Distal Sensory Nerve Transfer Options
Deficit
Donor Nerve
Recipient Nerve
Sensory Objective
Median
Dorsal cutaneous branch or fourth web space branch
ulnar
First web space branch of
median
First web space
Superficial radial
Median nerve
Thumb, index, first web space
Ulnar digital nerve ring finger
Radial digital nerve index finger
Radial aspect index finger
Dorsal sensory branch radial
Radial digital nerve index finger
Radial aspect index finger
Lateral antebrachial cutaneous
Median sensory
Thumb, index, middle fingers
Ulnar
Third web space median
Ulnar sensory branch
Little finger and ulnar aspect of
ring
Third common digital nerve
Ulnar sensory branch
Little finger and ulnar aspect of
ring
Palmar branch median
Ulnar sensory branch
Little finger and ulnar aspect of
ring
Posterior interosseous nerve (PIN)
Ulnar sensory branch
Little finger and ulnar aspect of
ring
Biomechanical restoration (tendon transfers and functioning free 
 muscle transplantation) are the third
category of reconstruction. This is usually the chosen reconstructive strategy for cases of late presentation
(>9 months after the time of injury) that have no opportunity for axonal regrowth within the timeframe
before fibrosis of the motor endplates will occur at the neuromuscular junction. The option of tendon
transfer or functioning free muscle transplantation is often used as the lifeboat for the aforementioned two
categories or for augmentation of function after previous reconstruction. To note, conventional tendon
transfers are only viable options for incomplete brachial plexus injury, when there are available donor
musculotendinous units innervated by uninjured portions of the brachial plexus. Tendon transfers are
often paired with arthrodeses (shoulder or wrist) for an enhanced functional result. 25 The gracilis
myocutaneous flap is the most popular option for the FFMT for the upper extremity 26 (Tables 72.6 and
72.7).
TABLE 72.6
Biomechanical Restoration: Tendon Transfer and Functioning Free Muscle Transplantation—Shoulder and Elbow
Anatomic
Region
Surgical Intervention
Functional Objective
Alternate Intervention
Shoulder
Upper trapezius transfer
Shoulder abduction
Shoulder arthrodesis
Lower trapezius transfer
External rotation
Shoulder arthrodesis
Contralateral lower trapezius transfer
External rotation
Shoulder arthrodesis
Latissimus dorsi transfer
Shoulder abduction, external rotation
Shoulder arthrodesis
Elbow
Biceps to triceps transfer
Elbow extension
Brachialis to triceps transfer
Elbow extension
Triceps to biceps transfer
Elbow flexion
Latissimus dorsi transfer
Elbow flexion
Pectoralis major transfer
Elbow flexion
Steindler flexorplasty
Elbow flexion
Gracilis FFMT (functioning free muscle transplantation)
Elbow flexion
TABLE 72.7
Biomechanical Restoration: Tendon Transfer and Functioning Free Muscle Transplantation—Wrist and Hand
Deficit
Anatomic Region
Surgical Intervention
Functional Objective
Alternate Intervention
Radial nerve
Wrist
PT ECRL/ECRB
Wrist extension
Wrist arthrodesis
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Hand
FDS III/IV → EDC
Finger extension
FCU → EDC
Finger extension
FCR → EDC
Finger extension
PL → EPL
Thumb extension
Thumb arthrodesis
FDS → EPL
Thumb extension
Thumb arthrodesis
Median nerve
Hand
Gracilis FFMT
Finger flexion
ECRL → FDP (index/long)
Finger flexion
FDP side/side (index/long → ring/small)
Finger flexion
BR → FPL
Thumb flexion
PL (Camitz)
Thumb opposition
Thumb arthrodesis
EIP → APB
Thumb opposition
Thumb arthrodesis
FDS via FCU loop → APB
Thumb opposition
Thumb arthrodesis
ECRL → APB
Thumb opposition
Thumb arthrodesis
ADM → APB
Thumb opposition
Thumb arthrodesis
EDM → APB
Thumb opposition
Thumb arthrodesis
ECU → EPB
Thumb opposition
Thumb arthrodesis
Ulnar nerve
Fowler wrist tenodesis
Claw correction
Zancolli (MCPJ) palmar capsulodesis)
Claw correction
EIP/EDM → extensor apparatus
Claw correction
FDS III/IV → lateral bands
Claw correction
ECRB or ECRL → lateral bands
Claw correction
PL → lateral bands
Claw correction
ECRB → ADP
Thumb pinch
Thumb arthrodesis
FDS → ADP
Thumb pinch
Thumb arthrodesis
EIP → ADP
Thumb pinch
Thumb arthrodesis
ADM, abductor digiti minimi; ADP, adductor pollicis; APB, abductor pollicis brevis; BR, brachioradialis; ECRB, extensor carpi radialis brevis;
ECRL, extensor carpi radialis longus; ECU, extensor carpi ulnaris; EDC, extensor digitorum communis; EDM, extensor digiti minimi; EIP,
extensor indicis proprius; EPB, extensor pollicis brevis; EPL, extensor pollicis longus; FCR, flexor carpi radialis; FCU, flexor carpi ulnaris;
FDP, flexor digitorum profundus; FDS, flexor digitorum superficialis; FFMT, functioning free muscle transplantation; FPL, flexor pollicis
longus; MCPJ, metacarpophalangeal joint; PL, palmaris longus; PT, pronator teres.
Complications across these three categories can range from serious to more localized and minor. Proximal
exploration can incur lymphatic leak, large vessel injury, or pneumothorax. Distal transfers are typically
much safer with a less morbid complication profile with limited exceptions (pneumothorax for intercostal
nerve transfer). Tendon transfers have similarly more localized failure consequences (tendon
bowstringing, joint posture deviation, etc.). Functioning free muscle transplantations have the
complication profile associated with microvascular free flap transfer—vascular pedicle thromboses with
partial or total flap loss. Furthermore, the flap donor site can have local complications such as seroma,
hematoma, or infection. FFMTs also require a donor nerve for neurotization, which can incur serious
complications such as pneumothorax in cases where the intercostal nerves are used.
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Multidisciplinary Approach
Brachial plexus injuries demand a multidisciplinary approach with the involvement of physical medicine
and rehabilitation, pain management, and psychiatry teams. From the time of the initial trauma, there is a
need for physical therapy and occupational therapy involvement to maintain supple joints—
reconstructive intervention is contraindicated if joints are ankylotic. The rehabilitative protocol must be
diligently followed for several years after the surgical intervention in order to reap the full benefits of the
surgery. Rehabilitative regimens include temperature therapy to aid with dysesthesia and pain, electrical
stimulation to minimize atrophy of muscles, and range of motion exercises to maintain supple joints.
Orthotic devices may help with shoulder stability and for providing a more natural posture so that the
impairment of the injured extremity is less apparent. Involvement of a pain management team is
frequently beneficial as the extreme causalgia associated with root avulsion injuries can be debilitating.
Pain management therapy will involve pharmacologic agents such as opioid medications,
anticonvulsants (e.g., gabapentin, pregabalin), or cannabinoids. A high percentage of the brachial plexus–
injured population develops chronic pain problems, and there are data suggesting the benefit of pursuing
nonopioid therapy instead of narcotic medication. Gabapentin (Neurontin), pregabalin (Lyrica), and
cannabinoids have been shown in rat studies to have trophic effects for regenerating neurons after sciatic
nerve injury in rats. 27–29 Furthermore, opioids have been shown to have a neurotoxic effect with spinal
neuron apoptosis in rats. 30 Psychiatric consultation has been shown to have a beneficial effect in the
brachial plexus population (39% of peripheral nerve patients are depressed). 31
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Obstetric Brachial Plexus Palsy
Obstetric brachial plexus palsy (OBPP), neonatal brachial plexus palsy, brachial plexus birth palsy, and
pediatric brachial plexus injury all refer to the brachial plexus injury incurred during childbirth, most
commonly vaginal delivery. Fortunately, owing to better prenatal monitoring with more stringent criteria
for conversion to cesarean section delivery, the incidence of birth-related brachial plexus injury in
developed countries has continued to decrease in recent years. 32,33 There are numerous risk factors for
OBPP (Table 72.8). The strongest risk factor is undoubtedly shoulder dystocia (approximately 8.3%
chance of sustaining brachial plexus palsy with an occurrence of shoulder dystocia). However, 55% of
cases of OBPP had no identifiable risk factor. 33 The most commonly encountered OBPP injury overall
(46% of all OBPP) is a classic Erb palsy (C5 and C6 palsy). 34 Fortunately, OBPP has a high frequency of
spontaneous resolution (77% to 90%). 32 The most common pattern of injury that necessitates operative
exploration is a combination of root avulsions and extraforaminal ruptures of C5, C6, and C7 34,35 . Table
72.9 describes the other common patterns of OBPP injury presentation. With the greater potential for
spontaneous recovery from obstetric-related brachial plexus trauma, it is not surprising that there is much
disagreement upon the optimal management of these cases. There are still some practitioners who rarely
choose surgical intervention.
TABLE 72.8
Risk Factors and Protective Factors Associated With Obstetric Brachial Plexus Palsy (OBPP)33
Risk Factors (Odds Ratio)
Shoulder dystocia (113.2)
Birth weight >4.5 kg (26.8)
Excessive fetal weight per gestational week (8.22)
Breech delivery (3.56)
Birth hypoxia (3.08)
Instrumented delivery (3.05)
Protective Factors (Odds Ratio)
Multiple gestation (0.45)
Cesarean delivery (0.16)
TABLE 72.9
Injury Patterns for Obstetric Brachial Plexus Palsy (OBPP)
Cases (n)
Percentage 
 of Cases
(n)
Ruptures
47
39%
UT rupture
17
14%
UT and MT ruptures
24
20%
UT, MT, and LT ruptures
6
5%
Ruptures and Avulsions
72
61%
Single-root avulsion
18
15%
Two-root avulsion
28
24%
Three-root avulsion
17
14%
Four-root avulsion
9
8%
MT, middle trunk; LT, lower trunk; UT, upper trunk.
Data compiled from David C.C. Chuang’s operations from 1994 to 2004.
Deciphering the clues of the brachial plexus–injured infant is challenging. Rather than a systematic
catalog of the presence or absence of each sensory and motor function, the practitioner must use various
clever investigative aids to identify deficits and monitor for signs of return of function because the infant
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is unable to willingly cooperate with a directed examination. The tickle test can elicit upper extremity
movement. The towel test is a similar ruse to trigger the baby to move the upper extremity by placing a
towel over his or her eyes. There are differing opinions upon the threshold for surgical intervention.
Terzis advocated surgical exploration if total palsy with Horner syndrome was present at 2 months of
age. 36 Gilbert’s threshold was 3 months of age without elbow flexion. 37 Clarke and Curtis described
9 months as the limit for recovery of motor function in response to the “cookie test”. 37 Chuang found no
difference in the recovery of elbow and shoulder function when surgical intervention was carried out at 2
versus 11 months, but Chuang’s threshold for surgical intervention was at 3 months if there was little to
no wrist extension and finger flexion. He also determined that a persistent lack or stagnation of
improvement in elbow or shoulder function warranted intervention at 6 to 12 months. 35 Electrodiagnosis
in infants is notoriously unreliable because of its tendency to overestimate the axonal function that is
present. 35,38 Surgical intervention within the first year of life involves either proximal exploration with
nerve reconstruction or distal nerve transfers in similar fashion as detailed for adult palsy. The notable
differences are that the phrenic nerve is generally not used for OBPP, and conventional nerve grafting
will frequently involve saphenous, median antebrachial cutaneous , or lateral antebrachial cutaneous
nerves in addition to the sural nerves, given the short length of the sural nerve in an infant.
The hallmark stigmata and primary challenge of OBPP patients later in childhood is aberrant
reinnervation manifesting in cocontraction of the muscles of the shoulder girdle and elbow. Several forms
exist: Axons of the shoulder abductors may aberrantly reinnervate the shoulder adductors, leading to a
limitation of shoulder abduction and eventually causing an adduction contracture of the 
 shoulder
girdle. There also is cross-innervation of the elbow flexors (brachialis, biceps) and elbow extensors
(triceps) which weakens both elbow flexion and extension movements. There can be cross-innervation
between elbow flexors and shoulder abductors (which causes the trumpet sign). There can also be cross-

innervation of the shoulder abductors and the elbow flexors/finger 
 flexors, leading to involuntary elbow
and finger flexion with attempted shoulder abduction. The development of aberrant reinnervation
ultimately leads to muscle imbalance that often causes joint deformities. 39
Interventions for these sequelae of OBPP include biomechanical reconstructions for the shoulder, elbow,
and hand and forearm. Shoulder reconstruction involves release of adduction contractures at the
shoulder girdle (by releasing both of the hypertrophic pectoralis major and teres major muscles) and
performing tendon transfers to augment arm abductors (teres major transferred to infraspinatus). 40–42
Elbow reconstruction should prioritize restoration of elbow extension first, as extension can only be
augmented effectively by biceps or brachialis tendon. Biceps to triceps tendon transfer or brachialis to
triceps tendon transfers has the two-fold effect of restoring extension at the elbow while concomitantly
releasing some of the contracture from the unopposed hypertrophy of the biceps and brachialis. If the
preexisting elbow flexion is strong, sacrifice of either the biceps or brachialis can often be tolerated
without excessively weakening elbow flexion. However, if necessary, elbow flexion can be augmented by
either Steindler flexorplasty or FFMTs. 43–46 To note, prior to undergoing tendon transfer or FFMT
reconstruction, the articular integrity of the elbow joint must be excellent. Both shoulder and elbow
reconstructions are typically done in the range of 4 to 6 years of age. Hand and forearm function often
accommodates surprisingly well. Therefore, waiting until age 6 to 13 years before undertaking hand
reconstructive procedures is advisable. Tendon transfers in this regard are highly individualized. Flexors
such as PL or FCR may be transferred to the EDC to augment finger extension. A Zancolli procedure
might be used for supination contracture. Functioning free muscle transplantation may be required for
restoration of finger flexion. 47
Excellent family participation and investment in the child’s postoperative therapy is critical. Surgery
without rigorous rehabilitation can render the intervention fruitless, as joint contractures will recur
without diligent therapy and continuous lifelong maintenance exercises.
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Outcomes
Reporting of outcomes in the field of brachial plexus reconstruction currently lacks standardization. This
may be attributed to the highly variable combinations of injury circumstances and severity. Most brachial
plexus outcomes investigations focus upon motor recovery with little emphasis upon sensory return or
quality of life. 48 OBPP outcome evaluation is also confounded by the use of multiple different evaluation
systems (e.g., Mallet score, 49 Gilbert and Tassin Muscle Grading System, Clarke and Curtis Active
Movement Scale, Narakas’ Grading System). 50 Even the MRC grading system may vary substantially
among practitioners as it is ultimately a clinical description that is subject to each individual examiner’s
interpretation. There is currently a focus upon incorporating patient-reported outcome measures (e.g.,
quality of life, function, pain, satisfaction) into investigations so that we can better understand the effect
of brachial plexus injury and reconstruction.
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Conclusion
Brachial plexus injuries are permanently physically disabling events. Even the best possible therapeutic
interventions are only partially restorative, and the therapeutic course often involves multiple surgeries.
Future investigations in the field will focus upon comparing the categories of surgical therapy (proximal
exploration and reconstruction, distal nerve transfers, and biomechanical restorations by tendon
transfers, or FFMTs) by using standardized outcome measures that involve patient-reported outcome
measures. Technological advancements in the area of minimally invasive diagnostic techniques are
currently poised to transform the field of brachial plexus reconstruction. Da Vinci robot surgery and MRI
are both being actively explored for better application to allow early and more accurate diagnosis of
brachial plexus injuries. Developing these modalities into reliable tools for early diagnosis can potentially
allow earlier surgical intervention to give more time for nerve regeneration before fibrosis of the motor
endplates of the neuromuscular junction occurs. Also, emerging technologies in the area of targeted
muscle reinnervation and prosthetic replacement that had initially been applied to upper extremity
amputees are now being directed to restoration of limb function for the brachial plexus-injury population.
Perhaps, we will now begin to see advancements in the field of brachial plexus treatment brought about
by technological advances that outpace our efforts to find new surgical techniques to maximize the
notoriously limited healing potential of nerves.
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Acknowledgments
The work was supported by a Midcareer Investigator Award in Patient-Oriented Research (2 K24-
AR053120-06) to Kevin C. Chung. The content is solely the responsibility of the authors and does not
necessarily represent the official views of the National Institutes of Health.
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Questions
1. A 20-year-old male was hit by a train traveling approximately 80 mile per hour. His injuries
include subdural hematoma, open pelvic fracture, bilateral hemopneumothoraces, and a suspected
brachial plexus injury of his left upper extremity. Three months after the injury, he still has no
sensation to the left upper extremity on a C5-T1 dermatomal sensory examination, and there is also
no detectable motor function of muscles in the left upper extremity. His electrodiagnostic studies are
notable for the results shown in Tables 72.10 and 72.11.
His EMG and nerve conduction studies are most consistent with which of the following?
TABLE 72.10
Needle Electromyography (EMG) Results
Muscle 
 (Left Side)
Insertional
Activity
Fibrillations
Positive Sharp
Waves
Amplitude
(mV)
Duration
(ms)
Polyphasic
Waves
FDP
Absent
2+
2+
Absent
No MUPs
APB
Absent
2+
2+
Absent
No MUPs
FCR
Absent
2+
2+
Absent
No MUPs
Biceps
Absent
2+
2+
Absent
No MUPs
Triceps
Absent
2+
2+
Absent
No MUPs
Deltoid
Absent
2+
2+
Absent
No MUPs
Cervical paraspinal 

muscles
Decreased
2+
2+
Decreased
APB, abductor pollicis brevis; FCR, flexor carpi radialis; FCU, flexor carpi ulnaris; FDP, flexor digitorum profundus; MUPs, motor unit
potentials.
TABLE 72.11
Nerve Conduction Study Results
Left
Right
Sensory
Latency
Amplitude
Latency
Amplitude
Median (index finger)
3.1
18.1
3.0
26.3
Ulnar (small finger)
2.7
16.5
Superficial radial
2.4
22.8
2.5
20.7
LABC
2.4
7.7
2.5
16.3
Median (thumb)
3.2
9.7
3.2
24.8
MABC
2.5
14.0
Motor
Median—APB
Not recorded
Ulnar—ADM
Not recorded
Radial—ED
Not recorded
14.9
Axillary—deltoid
Not recorded
12.4
Musculocutaneous—biceps
Not recorded
8.7
ADM, abductor digiti minimi; APB, abductor pollicis brevis; ED, extensor digitorum; LABC, lateral antebrachial cutaneous; MABC,
median antebrachial cutaneous.
a. Five root neuropraxia
b. Ruptures of C5 and C6; avulsions of C7, C8, and T1
c. Avulsions of C5 and C6; ruptures of C7, C8, and T1
d. Postganglionic ruptures of C5-T1
e. Root avulsions of C5-T1
2. A 25-year-old gang member presents to the trauma center with severe bleeding after a stab wound
to the right shoulder region by a knife. The initial exploration by vascular surgery accomplished
repair of the axillary artery laceration. Three days after presentation, the patient is hemodynamically
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stable and without any further transfusion requirement. The trauma team is preparing to discharge
the patient to home. The physical examination shows M0 elbow flexion, M3 finger flexion, and
anesthesia to the thumb and index fingers. What is the most appropriate next course of action?
a. Immediate reexploration of the site of nerve injury for primary repair
b. Transfer of intercostal nerves (T3-T5) to musculocutaneous nerve for restoration of elbow
flexion
c. Double fascicular transfer of expendable flexor carpi ulnaris (FCU) fascicle of ulnar nerve and
expendable motor fascicle of median directly to biceps and brachialis branches of the
musculocutaneous nerve, for restoration of elbow flexion
d. Functioning free muscle transplantation of gracilis muscle to arm for restoration of elbow
flexion
e. Aggressive physical therapy, occupational therapy, electrostimulation, and follow-up in
1 month to monitor for motor and sensory recovery
3. A 6-month-old girl whose birth weight was 5060 g (11.1 lbs) is being followed at your clinic for
obstetric brachial plexus palsy. Her birth was notable for vaginal delivery with shoulder dystocia,
and forceps were required to facilitate delivery. Initially at birth, she had no abduction of the arm at
the shoulder and very weak flexion at the elbow. Currently, she has some evidence of arm abduction
and elbow flexion is improving. There has always been good hand function. Of the following factors,
which is the strongest risk factor for OBPP?
a. Birth weight >4.5 kg
b. Shoulder dystocia
c. Instrumented delivery (forceps or vacuum)
d. Breech presentation
e. Hypoxia/fetal distress
4. A 38-year-old man was involved in a roll-over motor vehicle accident as an unrestrained driver
with loss of consciousness and lower extremity fracture as well. One month after the trauma, he has
M0 strength of abduction of the arm at the shoulder and M0 strength of flexion at the elbow.
Sensation is severely diminished in the distribution of C5 and C6. What is most appropriate next
course of action?
a. Physical therapy and return visit in 1 month
b. Double fascicular transfer of expendable FCU fascicle of ulnar nerve and expendable motor
fascicle of median directly to biceps and brachialis branches of the musculocutaneous nerve, for
restoration of elbow flexion
c. Surgical exploration with resection of neuroma and nerve grafting
d. Functioning free muscle transplantation of gracilis muscle to arm for restoration of elbow
flexion
e. Steindler flexorplasty
5. A 24-year-old man presents to your clinic with M0 strength of elbow flexion and M0 strength of
shoulder abduction. It is now 14 months after he developed these deficits after he had landed upon
his shoulder when he fell off a roof. What is the most reasonable management strategy for improving
his upper extremity function?
a. Aggressive physical therapy and electrostimulation therapy
b. Double fascicular transfer of expendable FCU fascicle of ulnar nerve and expendable motor
fascicle of median directly to biceps and brachialis branches of the musculocutaneous nerve, for
restoration of elbow flexion
c. Surgical exploration with resection of neuroma and nerve grafting
d. Upper trapezius tendon transfer to restore abduction at the shoulder with functioning free
muscle transplantation of gracilis for elbow flexion
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e. Shoulder arthrodesis
1. Answer: e. The complete absence of motor unit action potentials on the needle EMG and
undetectable motor nerve conduction in combination with the normal amplitude on the sensory
nerve conduction studies reflect that the ventral rootlets of the motor innervation and dorsal rootlets
of the sensory innervation have all been disrupted. The dorsal root ganglion is still viable, leading to
the detectable sensory nerve conduction and amplitudes. However, there is no connection between
the peripheral nerve and the spinal cord, so there is no sensation and no motor function detectable in
the patient. These EMG and nerve conduction findings are pathognomonic for the occurrence of a
preganglionic root avulsion injury.
2. Answer: a. Sharp lacerations of the brachial plexus should be explored within the first week for
direct repair if at all possible. Beyond 2 or 3 weeks after injury in the infraclavicular region, the nerve
ends will retract, and nerve grafting will likely be necessary to achieve a tension-free coaptation.
Repairing within the first week allows for a direct repair (with only a single coaptation site) which
will theoretically minimize the loss of regenerating axons (straying away through the discontinuity
of the epineurium at the coaptation sites) and maximize the potential for functional recovery.
3. Answer: b. Shoulder dystocia is the factor with the highest odds ratio (OR = 113.2) for occurrence
of OBPP. Birth weight >4.5 kg (OR = 26.8), breech presentation (OR = 3.56), instrumented delivery
(OR = 3.05), and hypoxia/fetal distress (OR = 3.08) all have substantially lower correlation with OBPP.
Much disagreement exists over the criteria and timing by which surgical exploration and
intervention should be performed.
4. Answer: a. Closed injuries of the brachial plexus are monitored for the first 3 months. During this
time, it is essential to have excellent physical therapy and occupational therapy to keep joints in the
hand and upper extremity supple. A baseline electrodiagnostic study may be obtained at
approximately posttrauma week 4 and repeated at approximately posttrauma week 12 to monitor for
any nerve regeneration. Until month 3, monitoring for motor and sensory recovery at a monthly
interval in the clinic is appropriate.
5. Answer: d. At 14 months after injury, nerve surgeries to restore innervation to the native muscles
of the shoulder and arm are not an option due to that fibrosis of the motor endplates of the
neuromuscular junction will have occurred by the time that axons have the time to regenerate.
Salvage procedures such as upper trapezius tendon transfer and FFMT are the only options for
improving motor function. Physical therapy and electrostimulation alone without surgical
intervention would not be expected to have any significant positive effect upon function. Shoulder
arthrodesis may be considered for less-motivated patients or older patients. Arthrodesis leaves the
shoulder with a very limited arc of motion with the remaining scapulothoracic muscles driving
movement.
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References
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Chuang, DC. Adult brachial plexus reconstruction with the level of injury: review and personal experience. Plast Reconstr Surg.
2009;124:E359-E69.Excellent overview with tips and insight from the most prolific brachial plexus surgeon currently in practice.
Mackinnon, SE. New directions in peripheral nerve surgery. Ann Plast Surg. 1989;22:257-273.
Samardzic, MM, Rasulic, LG, Grujicic, DM. Gunshot injuries to the brachial plexus. J Trauma. 1997;43:645-649.
Travlos, J, Goldberg, I, Boome, RS. Brachial plexus lesions associated with dislocated shoulders. J Bone Joint Surg Br. 1990;72B:68-71.
Narakas, A. Injuries of the brachial plexus and neighboring peripheral nerves in vertebral fractures and other trauma of the cervical spine.
Orthopade. 1987;16:81-86.
Tung, TH, Mackinnon, SE. Brachial plexus injuries. Clin Plast Surg. 2003;30:269-287.
Buck-Gramcko, D, Lubahn, J. The Hoffmann-Tinel sign. J Hand Surg Eur Vol. 1993;18:800-805.
Al-Qattan, M, Clarke, H, Curtis, C. The prognostic value of concurrent Horner’s syndrome in total obstetric brachial plexus injury. J Hand
Surg. 2000;25:166-167.
Teixeira, MJ, Da Paz, MG, Bina, MT, et al. Neuropathic pain after brachial plexus avulsion–central and peripheral mechanisms. BMC Neurol.
2015;15:73.
Socolovsky, M, Di Masi, G, Bonilla, G, et al. The phrenic nerve as a donor for brachial plexus injuries: is it safe and effective? Case series and
literature analysis. Acta Neurochir. 2015;157:1077-1086.
Terzis, JK, Kostas, I, Soucacos, PN. Restoration of shoulder function with nerve transfers in traumatic brachial plexus palsy patients.
Microsurgery. 2006;26:316–324.
Fuzari, HKB, Dornelas De Andrade, A, Vilar, CF, et al. Diagnostic accuracy of magnetic resonance imaging in post-traumatic brachial plexus
injuries: a systematic review. Clin Neurol Neurosurg. 2018;164:5-10.
Ferrante, MA. Electrodiagnostic assessment of the brachial plexus. Neurol Clin. 2012;30:551-580.
Granberry, WM, Lipscomb, PR. Tendon transfers to the hand in brachial palsy. Am J Surg. 1964;108:840-844.
Ikuta, Y, Kubo, T, Tsuge, K. Free muscle transplantation by microsurgical technique to treat severe Volkmann’s contracture. Plast Reconstr
Surg. 1976;58:407-411.
Tung, TH, Mackinnon, SE. Nerve transfers: indications, techniques, and outcomes. J Hand Surg Am. 2010;35:332-341.Overview of the “distal
nerve transfer” techniques from one of the primary groups that pioneered and popularized this technique.
Berger, A, Brenner, P. Secondary surgery following brachial plexus injuries. Microsurgery. 1995;16:43-47.
Chuang, DC. Nerve transfer with functioning free muscle transplantation. Hand Clin. 2008;24:377-388.Description of the application of FFMTs to
brachial plexus pathology with a comprehensive description of options for neurotization.
Camara, CC, Araujo, CV, De Sousa, KKO, et al. Gabapentin attenuates neuropathic pain and improves nerve myelination after chronic sciatic
constriction in rats. Neurosci Lett. 2015;607:52-58.
Celik, M, Kose, A, Kose, D, et al. The double-edged sword: effects of pregabalin on experimentally induced sciatic nerve transection and
crush injury in rats. Int J Neurosci. 2015;125:845-854.
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transection in neonatal rats. Eur J Neurosci. 2013;38:3424-3434.
Mao, J, Sung, B, Ji, RR, Lim, G. Neuronal apoptosis associated with morphine tolerance: evidence for an opioid-induced neurotoxic
mechanism. J Neurosci. 2002;22:7650-7661.
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Hand Surg Am. 2009;34:1682-1688.
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Defrancesco, CJ, Shah, DK, Rogers, BH, Shah, AS. The epidemiology of brachial plexus birth palsy in the United States: declining incidence
and evolving risk factors. J Pediatr Orthop. 2019;39(2):e134-e140.
Al-Qattan, MM, El-Sayed, AA, Al-Zahrani, AY, et al. Narakas classification of obstetric brachial plexus palsy revisited. J Hand Surg Eur Vol.
2009;34:788-791.
Chuang, DC, Mardini, S, Ma, HS. Surgical strategy for infant obstetrical brachial plexus palsy: experiences at Chang Gung Memorial
Hospital. Plast Reconstr Surg. 2005;116:132-142; discussion 43-44.
Terzis, JK, Papakonstantinou, K. Surgical treatment of obstetrical brachial plexus paralysis: the Norfolk experience. Semin Plast Surg.
2004;18:359.Comprehensive overview of obstetric brachial plexus palsy from one of the pioneers of the field.
Gilbert, A. Brachial Plexus Injuries. Philadelphia, PA: Taylor & Francis; 2001.
Slooff, AC. Obstetric brachial plexus lesions and their neurosurgical treatment. Microsurgery. 1995;16:30-34.
Chuang, DC, Ma, HS, Wei, FC. A new evaluation system to predict the sequelae of late obstetric brachial plexus palsy. Plast Reconstr Surg.
1998;101:673-685.
Chuang, DC, Ma, HS, Wei, FC. A new strategy of muscle transposition for treatment of shoulder deformity caused by obstetric brachial
plexus palsy. Plast Reconstr Surg. 1998;101:686-694.
Narakas, AO. Muscle transpositions in the shoulder and upper arm for sequelae of brachial plexus palsy. Clin Neurol Neurosurg.
1993;95(suppl):S89-S91.
Price, AE, Grossman, JA. A management approach for secondary shoulder and forearm deformities following obstetrical brachial plexus
injury. Hand Clin. 1995;11:607-617.
Chuang, DC, Epstein, MD, Yeh, MC, Wei, FC. Functional restoration of elbow flexion in brachial plexus injuries: results in 167 patients
(excluding obstetric brachial plexus injury). J Hand Surg Am. 1993;18:285-291.
Chuang, DC, Hattori, Y, Ma, HS, Chen, HC. The reconstructive strategy for improving elbow function in late obstetric brachial plexus palsy.
Plast Reconstr Surg. 2002;109:116-126.
Haerle, M, Gilbert, A. Management of complete obstetric brachial plexus lesions. J Pediatr Orthop. 2004;24:194-200.
Al-Qattan, MM. Elbow flexion reconstruction by Steindler flexorplasty in obstetric brachial plexus palsy. J Hand Surg Br. 2005;30:424-427.
Chuang, DC, Ma, HS, Borud, LJ, Chen, HC. Surgical strategy for improving forearm and hand function in late obstetric brachial plexus palsy.
Plast Reconstr Surg. 2002;109:1934-1946.
Dy, CJ, Garg, R, Lee, SK, et al. A systematic review of outcomes reporting for brachial plexus reconstruction. J Hand Surg Am. 2015;40:308-
313.
Tse, R, Kozin, SH, Malessy, MJ, Clarke, HM. International Federation of Societies for Surgery of the Hand Committee Report: the role of
nerve transfers in the treatment of neonatal brachial plexus palsy. J Hand Surg Am. 2015;40:1246-1259.
Pondaag, W, Malessy, MJ. The evidence for nerve repair in obstetric brachial plexus palsy revisited. Biomed Res Int. 2014;2014:434619.
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C H A P T E R 7 3
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Tetraplegia
Jennifer F. Waljee and Kevin C. Chung
Key Points
Over half of spinal cord injuries (SCIs) involve the cervical spine, and restoration of upper extremity
function is consistently rated a top priority by patients.
Surgical reconstruction of upper extremity function provides an important opportunity to restore
independence with transfers and activities of daily living. Reconstruction is considered among
patients with pain-free, supple joints and who are able to meet the demands of postoperative
rehabilitation once the SCI has plateaued, which typically occurs within 1 year.
The International Classification for Surgery of the Hand in Tetraplegia (ICSHT) level describes the
number of muscles present below the elbow available for tendon transfer and provides the
framework for surgical planning.
Critical functions to restore among patients with SCIs include elbow extension, forearm pronation,
wrist extension, key pinch, digit flexion and extension, and intrinsic balance.
Approximately 17,000 new spinal cord injuries (SCIs) occur in the United States each year and are
particularly concentrated among young individuals. 1 Most injuries occur among males from trauma,
including motorcycle and motor vehicle collisions. Roughly 2,800,000 individuals in the United States live
with SCI, and the rates of injury among the elderly due to falls and underlying spinal degenerative
disease is increasing. 2 Patients commonly present with concomitant injuries, and over half will develop
complications during their initial hospitalization, such as shock, respiratory compromise, and
pneumonia. 3 Fortunately, mortality related to SCI has declined considerably in recent decades.
Nonetheless, late complications, such as pressure ulceration, sepsis, and venous thromboembolism,
remain important causes of death. 4–6
Of all SCIs, 56% affect the cervical spine. 1 SCI resulting in tetraplegia is a devastating injury, and optimal
upper extremity function is consistently rated as a top priority to achieve independence with activities of
daily living. 7–12 Upper extremity reconstruction, which can include both nerve and tendon transfers,
offers a viable way to restore some elements of upper extremity motion and strength. 13–15 Multiple
studies indicate that upper extremity reconstruction can effectively improve hand pinch and grasp,
enabling recipients to better perform activities of daily living. 7,16–19 Yet despite these established benefits,
rates of procedures are often lagging. 19–21 In this chapter, we will review the principles of upper extremity
reconstruction for SCI and common techniques.
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Pathophysiology of Injury
Tetraplegia results from traumatic injuries to the cervical spine causing the loss of upper motor and
sensory neurons. SCI results from 2 phases of injury: primary and secondary injury. The peripheral and
central nervous systems are discontinuous because of blunt, sharp, crushing, or avulsion forces. 22
Secondary injury includes the physiologic events that occur due to disruption of the vasculature, edema,
ischemia, and hemorrhage, which further compounds the injury. 23 Above the level of the injured spinal
cord, nerve function is normal. However, nerve function below the level of injury is absent. Hyper-
reflexia is common and characteristic of the upper motor nerve injury; nerve function can be elicited at
levels below the injury if the lower motor neuron unit is intact.
Level of injury is determined by physical examination of motor and sensory function. Symmetry or skip
paĴerns can occur with certain injury types (central cord syndrome, Brown-Séquard syndrome, anterior
cord syndrome). Notably, the manifestations of injury may vary between individuals with the same level
of injury, and it is important to perform a full examination of the upper extremity muscle units when
planning reconstruction. 24 Within the zone of injury, stabilization of recovery occurs as the edema,
ischemia, and hemorrhage resolves. In general, the greatest gains of motor and sensory function occur
within 6 to 9 months following SCI, after which neurologic stability typically occurs. 25,26
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Clinical Evaluation
Following SCI, loss of function occurs according to the injured segment, and the pattern of function
follows the order of innervation by anterior horn cells from cephalad to caudad (Figure 73.1). The
American Spinal Injury Association (ASIA) Impairment Scale classification further describes the spinal
cord elements related to upper extremity function, and the most common levels of cervical spine injury
are at C5 and C6, marked by a loss of elbow extension, wrist flexion, and finger flexion and extension. In
general, patients with upper cervical spine injuries have shoulder motion, but absent wrist and hand
function. Individuals with midcervical injury typically have elbow flexion, but may have varying degrees
of wrist extension, forearm pronation, and hand motion. Patients with lower cervical spine injuries
typically have nearly full function of their shoulder, elbow, and wrist, but without intrinsic muscle
function. However, there is often variation in the manifestations of each injury, and a full upper extremity
examination is necessary to determine reconstructive options.
FIGURE 73.1 Spinal cord innervation of upper extremity motor elements and the American Spinal Injury Association (ASIA)
Impairment Scale classification.
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Management of Tetraplegia
The management of patients with tetraplegia is multidisciplinary, including surgical care, neurologists,
and physical medicine and rehabilitation specialists. Immediately following injury, prevention of
contractures ensures options for later reconstruction. Contractures are common, with over half of SCI
patients developing a contracture within 1 year of injury, most commonly of the shoulder 43%, elbow and
forearm 33%, and wrist and hand 41%. 27 Contractures arise due to spasticity or pathologically increased
muscle tone caused by a loss of upper motor neuron innervation and inhibitory control. 28 Stiffness of the
soft tissues is caused by shortening and loss of elasticity occurs and can include the skin, subcutaneous
tissue, joint capsule, supporting ligaments, tendon, muscle, and neurovascular structures. Mobilization
can prevent contractures by providing tensile stress that incites collagen reorganization. Splinting
between mobilization exercises is critical, although compliance is variable. 29 The hand should be splinted
in a functional position to maximize the potential for tenodesis, with the digits extended and the
metacarpophalangeal (MCP) joints in gentle flexion. In addition, the forearm should be positioned in
pronation to avoid supination contractures. Medical therapy can also help with prevention of
contractures, including the use of spasmolytics (intrathecal, oral, and injected), motor blocks, and targeted
electrical stimulation. For patients with severe, refractory spasticity in a nonfunctional limb without
expected recovery, motor neurectomy may be considered. 30
Reconstructive procedures including tendon transfers, tenodesis procedures, nerve transfers, joint release,
and selective arthrodesis can significantly enhance the upper extremity function of patients with
tetraplegia. The primary goal of reconstruction is to provide greater independence for SCI patients with
activities of daily living. Prior to surgical reconstruction, it is important to ensure that neurologic recovery
has plateaued, typically at 1 year after injury, and that the patient has sufficient social support for
recovery. In addition, patients should have reasonable expectations for the potential gains provided from
reconstructive procedures, demonstrate emotional adjustment to their injury, and have motivation and
support to participate in postoperative therapy. 31 Finally, patients should have minimal pain in the upper
extremity that may preclude participation in rehabilitation or use of the hand. Traumatic brain injuries
commonly occur among patients with SCI, as well as concomitant mood disorders. It is important to
ensure that cognition, depression, anxiety, and other mental health conditions are optimized
preoperatively. 32
Prior to any reconstructive procedure, it is essential to ensure that the upper limb is free of contractures,
with full passive motion, and in particular the shoulder, elbow, forearm, wrist, MCP, and proximal
interphalangeal (PIP) joints. In general, surgical procedures for tendon transfers are delayed for at least 6
to 9 months following injury to establish a baseline for function and identify the motor units that will
recover. 26 However, there is no upper limit with respect to timing of tendon transfers from injury for
patients who are good candidates. Donor muscles should be strong (M4 or M5 strength) and beyond the
zone of injury. Like other tendon transfers, the ideal donor provides synergistic function with a straight
line of pull and adequate excursion, and glide through a healthy bed of tissue free of scar.
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Reconstructive Options for Tetraplegia
Surgical planning is informed by the patient’s International Classification for Surgery of the Hand in
Tetraplegia (ICSHT) level, which describes the number of muscles present below the elbow with at least
grade 4 strength that are available for tendon transfer (Table 73.1). Muscles are listed in the order in
which recovery is expected in complete tetraplegia. A muscle is considered functional if the strength is
grade 4 or higher based on manual testing (Table 73.2). For sensory function, two-point discrimination of
10 mm or less is needed for cutaneous control. Ocular control is needed for patients with wider two-point
discrimination. Without adequate sensory input, even the best reconstruction is ineffective because the
patient cannot feel or detect how much force is impacted on an object.
TABLE 73.1
International Classification for Surgery of the Hand in Tetraplegia
Sensibility
Level of
Injury
Motor
Group
Muscles Available for
Transfer
Functional Ability
Reconstructive Priorities
O or Cu
C4 and
higher
0
No muscle below elbow suitable for transfer
O or Cu
C5
1
Brachioradialis (BR)
Flexion and
supination of the
elbow
Elbow extension: deltoid to triceps; biceps to
triceps
Wrist extension: BR to extensor carpi radialis
brevis (ECRB)
Key pinch: flexor pollicis longus (FPL)
tenodesis; Split distal FPL tenodesis
O or Cu
C6
2
Extensor carpi radialis
longus (ECRL)
Extension of the wrist
Elbow extension: deltoid to triceps; biceps to
triceps
Key pinch: BR to FPL or FPL tenodesis; Split
distal FPL tenodesis
Thumb extension: extensor pollicis longus
tenodesis
Grasp: BR to flexor digitorum profundus
(FDP) or ECRL to FDP
Release: extensor digitorum communis (EDC)
tenodesis
O or Cu
C6
3
ECRB
Extension of the wrist
O or Cu
C6
4
Pronator teres (PT)
Pronation of the wrist
Key pinch: BR to FPL; PT to FPL
Split distal FPL tenodesis
Grasp: ECRL to FDP; PT to FDP
Release: PT to EDC
Intrinsic balancing
O or Cu
C7
5
Flexor carpi radialis
Flexion of the wrist
O or Cu
C7
6
Finger extensors
Extrinsic extension of
the fingers
O or Cu
C7
7
Thumb extensor
Extrinsic extension of
the thumb
O or Cu
C8
8
Partial finger flexors
Extrinsic flexion of the
fingers
Thumb opposition: ECU to FCU to FPL using
flexor digitorum superficialis
Intrinsic balancing
O or Cu
C8
9
Lacks intrinsics
Extrinsic flexion of the
fingers
O or Cu
x
Exceptions
TABLE 73.2
Muscle Grading System: British Medical Research Council
Grade a
Description
0
No contraction
1
Trace contraction
2
Active motion without gravity
3
Active motion against gravity
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4
Active motion against gravity and resistance
5
Normal
a Only muscles of grade 4 or greater are available for transfer. Tendon transfer results in decline of 1 point due to loss of efficiency.
The decision for and type of reconstruction planned is then informed by three questions: what muscles
are missing, what critical functions are needed, and what donor muscles are available. Critical functions
include restoration of elbow extension to facilitate transfer and expand the space around an individual for
manipulation of the hand. Other needs are key/lateral pinch, forearm pronation, wrist extension, digit
flexion and extension for grasp and release, and hand posture for patients with loss of intrinsic function.
33
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ICSHT Levels
Group 0
Patients with injury levels of C4 and higher are able to elevate their shoulders as the spinal accessory
nerve innervating the trapezius muscle is uninjured. However, these individuals are often ventilator
dependent, given the potential injury to the phrenic nerve, and without upper extremity function.
Unfortunately, for group 0 patients, there are no muscles below the elbow with sufficient strength for
transfer and no options for tendon transfer for upper extremity reconstruction.
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Group 1
Patients with C5 injuries (group 1) typically have preservation of elbow flexion and shoulder abduction
through the biceps and deltoid. Brachioradialis (BR) is the only muscle below the elbow available to
transfer, and critical functions to restore for this group of patients include wrist extension and key pinch.
Voluntary active wrist extension and flexion are essential functions for tetraplegia patients as it provides
tenodesis that can impart gross grip and lateral pinch with wrist extension, and release with wrist flexion.
To accomplish wrist extension, BR is transferred to extensor carpi radialis brevis (ECRB). 34 ECRB is
chosen as the recipient because it inserts on the base of the long finger metacarpal and provides
centralized wrist extension. BR function is tested by selectively testing the strength of this muscle in a
neutral position to avoid the action of biceps and brachialis. The muscle belly is palpated lateral to the
biceps tendon at the elbow. The transfer should not be set with excess tension, but should allow the wrist
to flex when the elbow is in extension for release with tenodesis. Transfers should also be tensioned to
position the wrist in neutral when the elbow is in flexion.
For group 1 patients, flexor pollicis longus (FPL) tenodesis may be performed following BR transfer to
restore wrist extension. Key pinch is then accomplished with active wrist extension, with release by
passive wrist flexion. To accomplish this, the IP joint of the thumb is stabilized, the A1 pulley around the
FPL is released, and the FPL is fixed to the radius. The IP joint of the thumb can either be pinned or fused
or a split FPL transfer can be performed (Figure 73.2). In addition, tenodesis of extensor pollicis longus
(EPL) and extensor pollicis brevis may be performed to further stabilize the metacarpophalangeal joint. 35
Stabilizing the interphalangeal joint can be accomplished by splitting the FPL tendon and transferring the
radial half of the tendon to the EPL. This allows the IP joint to remain straight and stable during
attempted key pinch. Alternatively, the EPL tendon may be sutured onto itself in a loop configuration to
provide IP joint stability. 36
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FIGURE 73.2 A. Split FPL to EPL tendon transfer to stabilize the thumb interphalangeal joint. B,C. Split FPL to EPL tendon
transfer to stabilize the thumb interphalangeal joint. FPL, flexor pollicis longus; EPL, extensor pollicis longus.
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Groups 2 and 3
Group 2 patients have preservation of extensor carpi radialis longus (ECRL) and group 3 patients
preservation of ECRB. Patients with C6 injuries are able to perform wrist extension which affords the
benefits of tenodesis for rudimentary grasp and release. Therefore, key pinch is a critical function to
restore. Key pinch has three components 37 :
Allowing FPL to provide active pinch through tenodesis or tendon transfer
Stabilizing the interphalangeal joint
Position in the thumb in an effective posture of abduction
Approximately 2.2 kg of strength are needed for effective key pinch, grasp, and release for common
activities of daily living such as manipulating adaptive transportation devices and catheter management.
For patients in groups 2 and 3, a one-stage key pinch and release procedure is typically performed, and
BR is transferred to FPL (Figure 73.3). Similarly, EPL tenodesis can be performed by creating a loop
around the third extensor compartment. The EPL tendon is divided at its musculotendinous junction and
sutured to itself distal to the extensor retinaculum and Lister tubercle. 13 Carpometacarpal (CMC)
arthrodesis in a position for key pinch is performed to provide stability. To position the thumb, CMC
arthrodesis is commonly performed, which may provide greater strength with tendon transfers to
actively achieve key pinch, but care is taken not to limit passive and active opening of the hand. 38
FIGURE 73.3 Brachioradialis to flexor pollicis longus transfer to restore thumb flexion.
In addition, for groups 1 to 3, pronosupination imbalance can occur due to innervation of the biceps and
supinator among patients without function of the pronator teres (PT) or pronator quadratus (groups 1–3).
39–41 Supination deformities impair the ability to position the hand in space for grasp and release and can
exacerbate wrist extension contractures due to gravity in the setting of weakened flexors.
37
Reconstruction of pronation provides for more effective tenodesis, grip, and key pinch. Supination
contractures often occur in conjunction with elbow flexion contractures, and mild to moderate
contractures can be improved with serial casting and splinting. For patients with contracture, correction
of a supination deformity can be accomplished by biceps rerouting transfer to the opposite side of the
radius with interosseous membrane release as described by Zancolli, which converts the biceps from an
active supinator to a pronator. 42,43 Alternatively, derotation osteotomy of the radius can be performed to
place the forearm into pronation, and combined with anterior elbow capsule release and fractional
lengthening of the biceps and brachialis for patients with elbow flexion contractures. 39
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Groups 4 and 5
Patients in group 4 have preservation of PT and patients in group 5 have preservation of flexor carpi
radialis (FCR). Although tenodesis is critical for grasp and release, tenodesis only provides a force around
1 to 2N, and 2N or greater is required to accomplish most activities of daily living. 12 Therefore, in groups
4 and 5, the presence of these additional muscles provides more reconstructive options that can be used
to restore the critical functions of finger flexion for grasp and thumb flexion for pinch to hold objects. For
these patients, grasp, pinch, and release are accomplished in two phases, an extensor phase (release) and
a flexor phase (grasp), and require thumb stability. Reconstruction can be performed in multiple stages in
either order (flexion or extension reconstruction) or a single stage depending on surgeon preference and
level of injury. 44
Flexion is restored by transferring ECRL to the flexor digitorum profundus (FDP) tendons, and either BR
or PT to the FPL 45 (Figure 73.4). The action of PT is tested by examining the patient’s forearm in
pronation with resisted supination while palpating the lateral aspect of the forearm distal to the
antecubital fossa. ECRL is chosen to restore function to FDP given its greater excursion and strength
compared with BR and PT (Figure 73.5). These tendon transfers predictably restore grasp for activities of
daily living (Figure 73.6). Extension is accomplished by an extensor digitorum communis (EDC)
tenodesis, in which the digit extensors are anchored to the radius. In the forearm, the fourth compartment
is exposed, and the periosteum is elevated as a flap. The extensor tendons are sutured together and then
anchored to the shaft of the radius. The tension is set in a reverse cascade, to allow the index finger in the
most flexed position for finer pinch, with the MCP joints in extension with the wrist in neutral. 13 The
reverse cascade is critical when posturing tendon transfers for patients with SCI as the ulnar digits are
less likely to reach the thumb for key pinch. Similar to patients in groups 2 and 3, EPL tenodesis may be
performed by constructing a loop around the extensor retinaculum of the third compartment.
FIGURE 73.4 Brachioradialis and extensor carpi radialis longus tendons for transfer.
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FIGURE 73.5 Extensor carpi radialis longus to flexor digitorum profundus of the index, middle, ring, and small fingers.
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FIGURE 73.6 Grasp following reconstruction of flexion by extensor carpi radialis longus to flexor digitorum profundus transfer.
The thumb can be stabilized using either an opponensplasty or by performing CMC arthrodesis. 46 Given
the limited number of donor tendons, this is performed by transferring PT or BR to the flexor digitorum
superficialis (FDS) of the ring finger. The distal aspect of the FDS is then transected at the decussation,
routed through a loop of fascia, and transferred to the abductor pollicis brevis insertion at the MCP joint
of the thumb. 45 If thumb CMC arthrodesis is performed, the thumb is positioned for lateral pinch in
approximately 20° of extension, 45° abduction, and slight pronation. 13 For patients in whom bilateral
reconstruction is planned, opponensplasty may be selected for one side and CMC arthroplasty may be
selected for the contralateral side, pending on the patient’s needs for fine pinch or stronger grip. 46
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Group 6 and 7
For patients in group 6, EDC function is preserved, and patients in group 7 EPL function is preserved.
Similar to groups 4 and 5, BR, ECRL, and PT remain available for transfer, and critical functions to restore
include restoration of strength for pinch and grasp with finger and thumb flexion. In general, FCR is not
used as a donor tendon as its power improves the capacity of the tenodesis effect with the release phase
and enhances the ability to power a wheelchair. Grasp and pinch can be reconstructed in one stage to
restore the flexor phase, given that the extensors are intact. To do this, ECRL is transferred to FDP to
restore finger flexion and BR is transferred to FPL to restore thumb flexion. ECRB is not used as a donor
as it provides centralized wrist extension. With respect to the thumb, EPL tenodesis is performed as
described above with CMC fusion for patients in group 6. For patients in group 7, EPL is intact, and
opponensplasty alone is performed by transferring PT to FDS to the ring finger for power. The FDS
tendon to the ring finger is then transferred to the abductor pollicis brevis to provide adduction and
opposition.
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Group 8
Patients in group 8 have function of digit flexors of the index and middle fingers but lack function of the
ring and small fingers. Restoration of full finger flexion is an important reconstructive priority. To do this,
side-to-side FDP transfer is performed. In this procedure, the flexor tendons of FDP are anchored together
as a single unit to provide finger flexion using either sutures or a free tendon graft.
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Restoration of Elbow Reconstruction
Reconstruction of elbow extension is a top priority to restore the ability to reach, provide stability of hand
function, and will augment tendon transfers performed for wrist extension, pinch, and grip. For patients
with poor triceps function and injuries at levels of C5 and C6 (typically Groups 1–4), common tendon
transfers to achieve elbow extension are the posterior deltoid to triceps transfer, which is achieved with
supplemental tendon grafting, and biceps to triceps transfer. 47 It is critical that patients have functional
brachialis and supinator muscles to ensure elbow flexion and supination following biceps transfer. The
brachialis muscle is palpated during elbow flexion in supination for patients without wrist extension. For
patients with strong wrist extension, biceps may be used as the level of injury is below the innervation of
the brachialis and supinator. Biceps to triceps transfer is performed through a medial approach and
routing, rather than posterolaterally, to avoid injury or compression to the radial nerve. The tendon is
tunneled in a subcutaneous plane and anchored to the olecranon and/or woven to the triceps tendon. 48
The transfer should accommodate 60° to 90° of elbow flexion passively with tensioning.
Alternatively, the posterior third to half of the deltoid can be transferred to the triceps muscle to provide
elbow extension among patients. 49 Typically, an interposition graft of fascia is required (e.g., tensor fascia
lata; Figure 73.7). The deltoid is raised distally to proximally, protecting the axillary nerve, and a
subcutaneous tunnel or open incision can be used for the interpositional graft. The graft is woven from
the distal aspect of the deltoid into the distal aspect of the triceps (Figure 73.8). Overall, biceps to triceps
transfers are favored, given the earlier mobilization possible in the rehabilitation period and the potential
for stretch of the interposition graft for deltoid to triceps transfer with resultant loss of strength.
FIGURE 73.7 Harvest of tensor fascia lata graft for posterior deltoid to triceps transfer.
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FIGURE 73.8 Posterior deltoid to triceps transfer.
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Intrinsic Reconstruction
For patients in groups 6 through 9, intrinsic reconstruction can augment hand function by balancing the
digit posture in a better position for grasp and release. Patients with intrinsic weakness will have a
clawed posture of their hand. The PIP joints are often flexed due to FDS spasticity and hyperextension of
the MCP joints due to loss of intrinsic function which provides MCP joint flexion. In addition, an
uncoordinated rolling phenomena can occur when grasp is initiated, in which the distal interphalangeal
and PIP joints will flex prior to the MCP joint. For the thumb, patients will present with a Froment’s sign,
in which FPL is flexed with thumb adduction to overcome weakness of the adductor pollicis.
To address intrinsic weakness of the thumb that interferes with key pinch, a portion of the radial aspect of
FPL may be transferred to EPL to balance the force across the interphalangeal joint. 50 To create intrinsic
balance in the fingers, Zancolli described the creation of a lasso to flex the MCP joints first, followed by
the interphalangeal joints, to provide more coordinated movement. To create the lasso, the FDS is
released distally and looped onto itself at the A1 pulley to create flexion force at the MCP joint with wrist
extension.Alternatively, for patients with central slip deficiencies, free tendon grafts may be used for
tenodesis. The integrity of the central slip is identified by the extent to which the digits extend with wrist
flexion, and patients with central slip deficiencies will not have digit extension with wrist flexion. Free
tendon grafts can be passed around the metacarpal neck volar to the intermetacarpal ligaments and
attached to the lateral bands or central slip at the same time EDC tenodesis is performed to provide
extension of the PIP joints with flexion of the MCP joints. Overall, intrinsic reconstruction has been shown
to greatly enhance hand function and quality of life among patients with SCI and should be considered
among patients with clawing or MCP joint hyperextension after flexor reconstruction due to intrinsic
weakness. 51
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Future Directions
More recently, nerve transfer procedures have been applied to SCI reconstruction. 52 Nerves that
innervate muscles from spinal cord segments above the level of the injury and do not provide essential
function can be used as donor nerves for transfer among SCI patients. Nerve transfer procedures may be
time dependent, in which the recipient muscle is within the zone of injury, and time independent, in
which the recipient muscle is lower than the zone of injury. 52 Nerve conduction studies and
electromyography can confirm appropriate recipient and donor nerves.
Nerve transfer procedures have been described to restore elbow extension, wrist extension, finger
extension, and finger flexion. Donor nerves to restore elbow extension include branches of the axillary
nerve to the teres minor or posterior deltoid transferred to the triceps branches of the radial nerve. 15,52–57
Nerve transfers have also been described to restore finger flexion using branches of the
musculocutaneous nerve to the brachialis that are transferred to the anterior interosseous nerve.
Additionally, transfer of the branches innervating either BR or ECRB have also been described for
transfer to the anterior interosseous nerve to restore finger flexion, achieving up to M4 strength in most
patients. 52,58 Although long-term comparative studies of outcomes between nerve transfers and
traditional transfers are not yet available, these procedures provide an innovative approach to include in
the armamentarium of reconstructive options for SCI.
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Summary
Although surgical reconstruction remains underutilized 
 among individuals who suffer cervical SCIs,
tendon and nerve transfer procedures can offer substantial gains in upper extremity function and quality
of life in properly selected patients 
 (Table 73.3). Restoration of upper extremity function is consistently
described as a top priority for SCI patients, and integrating surgical care into the multidisciplinary
management of these 
 injuries is important to ensure that patients have access to all potential treatment
options.
TABLE 73.3
Summary of Reconstruction of Upper Extremity Function for Tetraplegia
Available Donors
Reconstructive
Priorities
Procedures
Group
1
Brachioradialis (BR)
Wrist extension
Pinch
BR to extensor carpi radialis brevis (ECRB)
Extensor pollicis longus (EPL) and flexor pollicis longus (FPL)
transfer into ECRB, FPL tenodesis, and interphalangeal fusion
Group
2 & 3
BR, extensor carpi radialis longus
(ECRL), ECRB
One-stage key
pinch and
release
BR to FPL
EPL tenodesis
Carpometacarpal (CMC) fusion
Group
4 & 5
BR, ECRL, ECRB, Pronator teres (PT),
Flexor carpi radialis
Two-stage
grasp, pinch,
release
Flexor phase: BR/PT to FPL
ECRL to flexor digitorum profundus
Extensor: EPL, extensor digitorum communis tenodesis
Thumb: BR or PT to flexor digitorum superficialis (FDS) ring
CMC fusion
Intrinsic: FDS lasso
Group
6 & 7
BR, ECRL, ECRB, PT, flexor carpi
radialis, extensor digitorum communis,
EPL
One-stage grasp
and pinch
ECRL to flexor digitorum profundus
BR/PT to FPL
CMC fusion + EPL tenodesis or transfer
PT/BR opponensplasty
Intrinsics: FDS lasso
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Acknowledgments
The work was supported by a Midcareer Investigator Award in Patient-Oriented Research (2 K24-
AR053120-06) to Kevin C. Chung. The content is solely the responsibility of the authors and does not
necessarily represent the official views of the National Institutes of Health.
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Questions
1. A 27-year-old man with a history of SCI from a motor vehicle collision 3 years ago presents for
consultation to improve his ability to power his wheelchair. On physical examination, he is able to
flex his elbow and extend his wrist. He has M5 strength of biceps, brachialis, BR, extensor carpi
radialis longus and brevis, and PT. He is unable to extend his elbow. Which of the following
procedures would best enhance his upper extremity function?
a. Wrist arthrodesis
b. Abductor digiti minimi to abductor pollicis brevis transfer
c. Biceps to triceps transfer
d. Extensor indicis proprius to EPL transfer
e. Side-to-side FDP transfer
2. A 22-year-old woman who suffered a SCI 1 year ago presents for reconstruction to optimize her
hand function. She would like to have better hand control to pick up objects. On examination, she
has intact elbow flexion and centralized wrist function but is unable to pronate her forearm. She has
stiffness with passive motion of her digits and a pressure ulcer across her olecranon. Which of the
following options is indicated to optimize her hand function?
a. Directed physiotherapy for donor muscle strengthening
b. Biceps to triceps transfer
c. BR to FPL transfer
d. Extensor carpi radialis brevis tenodesis
e. Directed physiotherapy for range of motion
3. A 38-year-old man presents for consultation to improve grip approximately 2 years following SCI.
On examination, he has intact elbow flexion, wrist extension and flexion, and digit extension. He has
weakness with thumb extension and digit flexion. Which of the following procedures would best
improve his grasp ability?
a. ECRB to FDP transfer
b. ECRL to FDP transfer
c. FCR to FDP transfer
d. BR to FDP transfer
e. FDS lasso procedure
4. Which of the following physical examination maneuvers will best assess strength of BR?
a. Palpation over the lateral aspect of the mobile wad with the patient abducting the arm in
extension
b. Palpation over the lateral aspect of the mobile wad with the patient flexing the elbow in
neutral
c. Palpation over the lateral aspect of the mobile wad with the patient flexing the elbow in
supination
d. Palpation over the lateral aspect of the mobile wad with the patient flexing the wrist in neutral
e. Palpation over the lateral aspect of the mobile wad with the patient flexing the wrist in
pronation
5. A 32-year-old patient who suffered a SCI 3 years earlier presents for upper extremity
reconstruction. Biceps to triceps transfer to restore elbow extension is planned. The preferred
technique for this tendon transfer includes the following:
a. Routing the biceps tendon laterally with a supplemental tendon graft (e.g., tensor fasciae
latae)
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b. Routing the biceps tendon medially
c. Routing the biceps tendon medially with a supplemental tendon graft (e.g., tensor fasciae
latae)
d. Routing the biceps tendon laterally
e. Routing the biceps tendon posteriorly through the triceps muscle
1. Answer: c. This individual has intact strength of his PT and is classified in the ICSHT group 4.
Critical functions to restore in this group include elbow extension, key pinch, grasp and release, and
intrinsic balancing. For this patient, biceps to triceps transfer or posterior deltoid to triceps transfer
would provide strength of elbow extension to position the upper extremity in space and facilitate
transfer and mobility. Wrist arthrodesis is not performed in SCI patients as it would result in the loss
of tenodesis, which is critical for rudimentary key pinch, grasp, and release. Abductor digiti minimi
to abductor pollicis brevis insertion at the thumb MCP joint transfer is a commonly used
opponensplasty technique for patients with congenital thumb hypoplasia but would not be
appropriate or possible for this patient given the level of injury. Extensor indicis proprius transfer is
performed for attritional rupture of EPL but is not performed for patients with tetraplegia. Side-to-
side FDP transfer is performed among patients with partial innervation of FDP among group 8
patients in whom flexion of the index and long finger is preserved but not of the ring and small
finger. However, this option would not be suitable given this patient’s level of injury.
2. Answer: e. This individual has intact strength of his PT and is classified in the ICSHT group 3, as
she is noted to have function of her BR and wrist extensors but does not have recovery of her PT
following injury. For this patient, critical functions to restore include elbow extension, forearm
pronation, key pinch, and intrinsic balancing. Reconstruction of key pinch could offer this patient a
greater ability to pick up objects, including a one-stage key pinch and release procedure including BR
transfer to FPL, EPL tenodesis, and CMC arthrodesis. However, this patient has notable stiffness of
her hand and a pressure wound across her elbow. Reconstructive options are most appropriate for
patients with a pain-free upper extremity without evidence of contracture or neglect. Therefore,
physiotherapy to overcome contractures, ensure appropriate pressure offloading, and support and
compliance with therapy is indicated first prior to undertaking surgical reconstruction. Biceps to
triceps transfer is appropriate for suitable patients to restore elbow extension which can allow
patients improved reach for objects. Directed therapy for donor muscle strengthening is an important
component of rehabilitation following injury but would not specifically address the wrist
contractures or pressure offloading in this patient. ECRB tenodesis would not be recommended as it
would reduce the ability of wrist flexion and impair tenodesis, which is critical for release of objects.
3. Answer: b. This individual has intact strength of his digital extensors, but not his thumb extensor,
and is classified in the ICSHT group 6. For this patient, critical functions to restore include digit
flexion and thumb flexion for grasp. BR, ECRL, and PT are available for transfer. Common transfers
to restore digit flexion include ERCL to FDP or PT to FDP, and BR to FPL to FPL to restore thumb
flexion with EPL tenodesis to provide balance. ECRB is not used as a donor as it provides centralized
wrist extension. FCR is not commonly used as a donor tendon as its power facilitates the tenodesis
effect and release. The FDS lasso procedure creates a static sling around the A1 pulley to provide
improved posture among patients with intrinsic weakness and place the MCP joints in flexion.
Although this procedure can facilitate grip by providing better coordination of interphalangeal joint
flexion, it would not specifically address restoration of strength to the digital flexors.
4. Answer: b. BR is innervated by roots C5 and C6 via the radial nerve. It originates along the
proximal aspect of the lateral supracondylar ridge of the humerus and the lateral intermuscular
septum and inserts on the radial styloid. BR serves to flex the elbow with the forearm in neutral or
pronation. It can be palpated lateral to the biceps tendon along the mobile wad. It is best assessed by
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placing the patient’s elbow in 90° and the forearm in neutral and asking the patient to flex the elbow.
Maintaining the forearm in pronation or supination is critical to isolate the action of BR from other
elbow flexors and supinators including biceps and brachialis.
5. Answer: b. Reconstruction of elbow extension is a top priority following SCI among patients
without triceps strength to restore the ability to reach, power assistive devices, and facilitate
independence with activities of daily living. Biceps to triceps tendon transfer is commonly performed
to accomplish this after action of the brachialis is confirmed to maintain elbow flexion. The biceps
tendon is routed medially and anchored to the olecranon and woven to the triceps tendon. Routing
the tendon laterally is avoided to prevent injury and compression of the radial nerve. Biceps to
triceps tendon transfer typically does not require supplemental tendon grafting but is needed for
posterior deltoid to triceps transfer, an alternative procedure to restore elbow extension among SCI
patients.
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Fox, IK. Nerve transfers in tetraplegia. Hand Clin. 2016;32:227-242.
Jaspers Focks-Feenstra, JH, Snoek, GJ, Bongers-Janssen, HM, Nene, AV. Long-term patient satisfaction after reconstructive upper extremity
surgery to improve arm-hand function in tetraplegia. Spinal Cord. 2011;49:903-908.
Meiners, T, Abel, R, Lindel, K, Mesecke, U. Improvements in activities of daily living following functional hand surgery for treatment of
lesions to the cervical spinal cord: self-assessment by patients. Spinal Cord. 2002;40:574-580.
Wangdell, J, Friden, J. Satisfaction and performance in patient selected goals after grip reconstruction in tetraplegia. J Hand Surg Eur Vol.
2010;35:563-568.This study examined patient perspectives of grip reconstruction following spinal cord injury. Using the Canadian Occupational
Performance Measure, the authors describe susbstantial gains in activities of daily living, with an improvement from 36% of achievable tasks to 78%.
Fox, PM, Suarez, P, Hentz, VR, Curtin, CM. Access to surgical upper extremity care for people with tetraplegia: an international perspective.
Spinal Cord. 2015;53:302-305.
Curtin, CM, Hayward, RA, Kim, HM, et al. Physician perceptions of upper extremity reconstruction for the person with tetraplegia. J Hand
Surg. 2005;30:87-93.
Curtin, CM, Gater, DR, Chung, KC. Upper extremity reconstruction in the tetraplegic population, a national epidemiologic study. J Hand
Surg. 2005;30:94-99.
Hachem, LD, Ahuja, CS, Fehlings, MG. Assessment and management of acute spinal cord injury: from point of injury to rehabilitation. J
Spinal Cord Med. 2017;40:665-675.
Tator, CH, Fehlings, MG. Review of the secondary injury theory of acute spinal cord trauma with emphasis on vascular mechanisms. J
Neurosurg. 1991;75:15-26.
Coulet, B, Allieu, Y, Chammas, M. Injured metamere and functional surgery of the tetraplegic upper limb. Hand Clin. 2002;18:399-412.
Burns, AS, Ditunno, JF. Establishing prognosis and maximizing functional outcomes after spinal cord injury: a review of current and future
directions in rehabilitation management. Spine. 2001;26:S137-S145.
Waters, RL, Adkins, RH, Yakura, JS, Sie, I. Motor and sensory recovery following complete tetraplegia. Arch Phys Med Rehabil. 1993;74:242-
247.This study prospectively examined the motor and sensory recovery of 61 patients with spinal cord injury. The authors identified that the greatest
potential for recovery occurs within the first 6 months, and majority of patients reach plateau of motor recovery between 6 and 9 months following
injury.
Diong, J, Harvey, LA, Kwah, LK, et al. Incidence and predictors of contracture after spinal cord injury – a prospective cohort study. Spinal
Cord. 2012;50:579-584.
Botte, MJ, Nickel, VL, Akeson, WH. Spasticity and contracture: physiologic aspects of formation. Clin Orthop Relat Res. 1988;(233):7-18.
Krajnik, SR, Bridle, MJ. Hand splinting in quadriplegia: current practice. Am J Occup Ther. 1992;46:149-156.
Strommen, JA. Management of spasticity from spinal cord dysfunction. Neurol Clin. 2013;31:269-286.
Hentz, VR. Surgical strategy: matching the patient with the procedure. Hand Clin. 2002;18:503-518.
Macciocchi, S, Seel, RT, Warshowsky, A, et al. Co-occurring traumatic brain injury and acute spinal cord injury rehabilitation outcomes. Arch
Phys Med Rehabil. 2012;93:1788-1794.
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Wangdell, J, Friden, J. Activity gains after reconstructions of elbow extension in patients with tetraplegia. J Hand Surg Am. 2012;37:1003-1010.
Johnson, DL, Gellman, H, Waters, RL, Tognella, M. Brachioradialis transfer for wrist extension in tetraplegic patients who have fifth-cervical-
level neurological function. J Bone Joint Surg Am. 1996;78A:1063-1067.
Mohindra, M, Sangwan, SS, Kundu, ZS, et al. Surgical rehabilitation of a tetraplegic hand: comparison of various methods of reconstructing
an absent pinch and hook. Hand (NY). 2014;9:179-186.
Friden, J, Reinholdt, C, Gohritz, A. The extensor pollicis longus-loop-knot (ELK) procedure for dynamic balance of the paralyzed thumb
interphalangeal joint. Tech Hand Up Extrem Surg. 2013;17:184-186.
Friden, J, Gohritz, A. Tetraplegia management update. J Hand Surg Am. 2015;40:2489-2500.
Coulet, B, Waitzenegger, T, Teissier, J, et al. Arthrodesis versus carpometacarpal preservation in key-grip procedures in tetraplegic patients:
a comparative study of 40 cases. J Hand Surg Am. 2018;43:483.
Coulet, B, Boretto, JG, Allieu, Y, et al. Pronating osteotomy of the radius for forearm supination contracture in high-level tetraplegic patients:
technique and results. J Bone Joint Surg Br. 2010;92B:828-834.
Friden, J, Reinholdt, C, Gohritz, A, et al. Simultaneous powering of forearm pronation and key pinch in tetraplegia using a single muscle-
tendon unit. J Hand Surg Eur Vol. 2012;37:323-328.
Ward, SR, Peace, WJ, Friden, J, Lieber, RL. Dorsal transfer of the brachioradialis to the flexor pollicis longus enables simultaneous powering
of key pinch and forearm pronation. J Hand Surg Am. 2006;31:993-997.
Zancolli, EA. Paralytic supination contracture of the forearm. J Bone Joint Surg Am. 1967;49A:1275-1284.
Gellman, H, Kan, D, Waters, RL, Nicosa, A. Rerouting of the biceps brachii for paralytic supination contracture of the forearm in tetraplegia
due to trauma. J Bone Joint Surg Am. 1994;76A:398-402.
Friden, J, Reinholdt, C, Turcsanyii, I, Gohritz, A. 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.
House, JH, Gwathmey, FW, Lundsgaard, DK. Restoration of strong grasp and lateral pinch in tetraplegia due to cervical spinal cord injury. J
Hand Surg Am. 1976;1:152-159.This study describes the reconstruction of grasp and pinch in 7 patients with C6 and C7 level injuries including
surgical techniques for the extensor and flexor phase. All patients at follow-up reported gains in activities of daily living, social self-image, and
wheelchair use and achieved an average grasp and pinch force of 5.5 and 3.0 kg.
House, JH, Shannon, MA. Restoration of strong grasp and lateral pinch in tetraplegia: a comparison of two methods of thumb control in each
patient. J Hand Surg Am. 1985;10:22-29.
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 retrospective study examined the outcomes of 45 patients who underwent medial biceps to triceps transfer to restore elbow
extension. The majority of patients were able to achieve elbow extension against gravity with functional overhead elbow extension.
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;24:161-172.
Bonds, CW, James, MA. Posterior deltoid-to-triceps tendon transfer to restore active elbow extension in patients with tetraplegia. Tech Hand
Up Extrem Surg. 2009;13:94-97.
Mohammed, KD, Rothwell, AG, Sinclair, SW, et al. Upper-limb surgery for tetraplegia. J Bone Joint Surg Br. 1992;74B:873-879.The authors
review the outcomes of 57 patients undergoing reconstruction for elbow extension, hook grip, and key pinch. This retrospective study highlights the
effectiveness of split FPL tenodesis to balance the thumb interphalangeal joint.
McCarthy, CK, House, JH, Van Heest, A, et al. Intrinsic balancing in reconstruction of the tetraplegic hand. J Hand Surg Am. 1997;22:596-604.
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2015;10:60-67.
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preliminary outcomes. Plast Reconstr Surg. 2015;136:780-792.
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C H A P T E R 7 4
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Management of Hand Fractures
Joshua M. Adkinson and Kevin C. Chung
Key Points
All patients evaluated for a hand fracture should also undergo examination of the skin, tendons, and
neurovascular structures.
Metacarpal fractures typically assume an apex dorsal deformity, whereas proximal phalangeal
fractures result in an apex volar deformity. Middle phalanx fracture deformity depends upon the
location relative to the flexor digitorum superficialis insertion.
Operative intervention is indicated for intra-articular incongruity, rotational malalignment, angular
deformity, substantial shortening, multiple fractures, and fractures with soft tissue injury or bone
loss.
Select the least invasive method that will achieve satisfactory fracture reduction and stability.
Prolonged immobilization will invariably lead to stiffness that may be worse than a malunion
resulting from no treatment.
Fractures of the hand are common, accounting for 10% of all fractures 1 and 41% of upper extremity
fractures. 2 Phalanx fractures occur approximately twice as often as metacarpal fractures 2 and most
commonly affect the distal phalanx. 3 The economic impact of hand fractures is substantial, and estimated
lost productivity alone exceeds $2 billion per year. 4 Given the individual and societal burden of hand
fractures, the ideal treatment is timely, minimizes recovery time, and expedites return to work and other
activities. This chapter outlines the most common hand fracture patterns and recommended treatment
options.
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Principles of Management
A thorough initial history and examination are mandatory. The type of trauma will offer insight into the
likelihood of associated injuries as well as any social barriers to effective treatment and an optimal
outcome. The time since injury should be determined, as this may influence the timing of surgery. Patient
age, hand dominance, occupation, hobbies, comorbidities, and previous hand injuries or surgical
procedures should be elicited. Furthermore, the treating physician should discuss patient goals of care
and, when possible, ascertain the ability to comply with postoperative instructions and therapy.
The hand is then thoroughly and systematically examined for deformity, tenderness, swelling, open
wounds, digital malalignment, tendon integrity, and neurovascular status. Rotational deformity may be
subtle, yet clinically significant, and is evaluated through active range of motion or wrist tenodesis; all
digits should point to the scaphoid without overlap or rotation (Figure 74.1). Seemingly small amounts of
fracture malrotation can result in digital overlap (e.g., 5° of metacarpal rotation leads to 1.5 cm of digital
overlap). 5 Range of motion assessment may be facilitated by digital or wrist neuroblockade after sensory
evaluation. Three-view (posteroanterior, lateral, oblique) plain radiographs of the hand are mandatory to
assess fracture anatomy and any concomitant degenerative, oncological, or rheumatological pathology. 3
FIGURE 74.1 A. Black lines indicate normal alignment of the digits, with the fingertips pointing to scaphoid (S). White line
indicates malrotation and digital overlap resulting from a fracture. B. Malrotation of ring finger after proximal phalanx fracture.
Open fractures of the hand are relatively common and are at an increased risk for infection. Management
consists of tetanus administration, antibiotics, irrigation, debridement, and sterile temporary or definitive
(e.g., flap) coverage. 6 Definitive fracture treatment is performed when the wound is clean and stable soft
tissue coverage can be ensured.
Nearly all closed hand fractures can be initially managed with closed reduction and splinting. Stable,
nondisplaced fractures may be definitively treated in this manner. The patient is seen within 7 to 10 days
for reexamination and new plain radiographs to confirm stability and to rule out fracture displacement.
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In general, metacarpal and phalangeal fractures are adequately treated by 3 to 4 weeks of continuous
immobilization and judicious use of immobilization beyond this period only for specific activities. There
always exists a balance between adequate immobilization to optimize fracture healing and mobilization
to counteract the inevitable onset of stiffness. Prolonged immobilization may be worse than no treatment;
the duration of immobilization should be as short as possible to allow fracture healing.
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