We will present concepts of reconstructive surgery of the hand for patients with tetraplegia secondary to spinal cord injury. According to the international classification, tetraplegia functional groups are characterized by sensibility and certain key muscles or muscle groups that retain function at MRC grade 4. Group 1 has function in the brachioradialis. Group 2 adds the extensor carpi radialis longus. Group 3, extensor carpi radialis brevis. 4, pronator teres. 5, flexor carpi radialis. 6, extensor digitorum communis. 7, extensor pollicis longus. 8, partial digital flexion. Group 9 patients lack only the intrinsics. X includes exceptions such as Brown-Saquard syndrome, partial lesions, transverse myelitis or syringomyelia. Patients from several functional groups will be presented demonstrating their function before and after surgical reconstruction according to the following surgical plan. Group 1 patients can be provided wrist extension by transfer of the brachioradialis to the extensor carpi radialis brevis. Selected patients may also have reconstruction of key pinch. This patient is in group 1 and she lacks two-point discrimination in her thumb and is therefore a group 0, meaning ocular 1. She sustained a spinal fracture dislocation at C4-5 in a gymnastics injury resulting in complete spinal cord injury at that level. We'll now demonstrate her pre-op muscle test. Super. Okay. I'm going to show you brachioradialis, the muscle right here. I'm going to have you bring your arm straight up towards your shoulder. Okay. And now I'm going to pull down on it this way. Hold on to your hand. One, two, three. Also an excellent muscle. Okay. Now your wrist extensors. Okay. Can you bring your wrist straight up like that? Okay. Not much. Okay. How about if we do it this way? Can you bring it out that way? Okay. A little bit. Okay. And once more this way. Okay. Can you bring your wrist up? A little bit on the radial side. Okay. Now flip over. This is a tensiometer to see if you have any measurable strength there when you do that. Okay. And using what it takes, can you squeeze that at all? Okay. Nothing measurable. Okay. Maybe later. Try bigger yet. Can you pick up a cone? to feed yourself? Okay. This one. Okay. Are you able to put that on by yourself? No. Okay. Is that too far? Okay. And you don't really need to eat this piece of bread, but can you just demonstrate how you would? Okay. And then you can reach up to your mom. Okay. Okay. Do you use any other forms of makeup in here? Yeah, I use everything, mascara, eyeliner, lipstick, blush, whatever. Everything. And they've all been adapted with Velcro to stick into here. Surgery was performed in one stage. Wrist extension was restored by transfer of the brachioradialis to the extensor carpi radialis brevis. She also had a one stage key pinch and release procedure. Thumb position was obtained by arthrodesis of the carpometacarpal joint. Extensor pollicis longus tenodesis provided thumb extension. Flexor pollicis longus tenodesis provides thumb flexion. To restore balance for finger flexion at the metacarpophalangeal joints, a lasso procedure was performed transferring the flexor digitorum superficialis around the A1 pulley for the four fingers to provide better position for key pinch. It's been eight weeks since you had your cast taken off and I suppose you've discovered some new things that you're able to do with your hands. How have things been going for you since the surgery or since the cast removal? Well, I'm more happy with it since I've gotten the cast off. I can tell that I can use my hand a lot more than I could before. It's not as much as I hope to be able to use it in the future, but as far as eight weeks have gone, I think it's working pretty well. Can you show me what you can do with it now? Okay, nice opening. Super. Nice wrist extension. Okay, how about if, let's start like this, can you? Okay, anti-gravity almost to neutral. Super. And then now if you bring your wrist this way. Okay, nice pinch there. Nice tenodesis. Once more. Great. Actually, you don't need me to hold it. You can do it once more. Great. How about power? Is there much power in the pinch? No, there isn't much power. There isn't any resistance at all. If I was holding a piece of paper and you pulled it away, I couldn't pull back on it at all. Let's try if there's any power on there at all. No, there's still a zero reading. Are you able to pick up a cone now? Super. Yeah. The things I used splints for before, like feeding and putting on my makeup, I can still do. I can do the same things. I can only do the same things now as like before, but before I didn't have any wrist extension, so when I had my splints on, they had to come up practically to my elbow to hold my wrist up besides holding like the fork or holding, you know, whatever my lipstick or whatever it was that I was holding at the time. But now, since I can hold my wrist up myself, I just need a little teeny splint that just slips right on over my hands and it looks a whole lot nicer. I don't feel so bulky and so conspicuous with it on. Do it? Well, I used to do it the same way before, except that once again I had splint that came up practically to my elbow because I needed to hold up my wrist. Now I can hold up my wrist myself, so I just have just a little one that just slips on really easy. Okay. And you can reach up in your wrist. Great. Yeah. Super. Since the surgery and since the time you had the cast taken off, you've been wearing this splint. Can you show the splint? Okay. And the purpose of this splint has been to protect where your thumb was fused. Okay. And can you still do things with the splint on? Like, can you? Great. Boy, now that's something you weren't able to do before. No. So you can pick up a cup and set it down and release it. Great. Renee, after eight weeks, can you summarize how you feel about what the surgery's done for you? Sure. Well, it's made me feel a whole lot better about myself, especially, like I said before, in public, like in class, like when it comes to writing, I can just use the little splint instead of the long splints. And going out, I feel more comfortable going out to restaurants and eating in the cafeteria in front of other people because I can just use the short little cuff instead of the high splint again. I also like the way my hand looks. It looks a whole lot nicer. The other one's more kind of like just flat and kind of weird looking. This one's more normal. And I think the way it bends around real nice. I like, another part I like is during, like in class, like if the teacher's handing out papers, instead of trying to go, like when she hands it to you, instead of trying to grab the paper in between two hands, you just reach out and just take it from her, just like anyone else. The following patient from Group 6-7 has excellent potential for a one-stage reconstruction of grasp and pinch. Hi. I'm Eric Carlson. I broke my neck about C-7 16 months ago down in the Cayman Islands. In about a week, I'm going to have hand surgery by Dr. House done on my right hand. Let me give you an idea of my hand function right now. My wrists are equally strong and effective both extending and flexing. You can see they work fine. My left hand is the hand I use the most for all my ADLs. I have good, good extension, good strong extension in all my fingers in my left hand. My flexion is about there. With tenodesis, I can pick up things that are a little heavier, and you'll see how I can manipulate things pretty well with my left hand. But there really isn't much flexion. It's really pretty weak. There's not much there. This finger's legs behind these. In my right hand, I have flexion in my four fingers, but my thumb has no flexion in. And as far as I'm in extension, as far as flexion goes, I have none in my fingers. And some, if you can see my thumb, will move in a little bit. That's the extent of my hand function. I'd like you to test your grasp strength, see how strong you are. This is my left, which is my better hand. I have some flexion in this hand. And in my right hand, although you can't see any measurable grip, there is some there, so I can pick up things. And in my right hand, which this first surgery's going to be on, I can hold this thing up, but I can't pinch any seeable grip. Okay, for pinch strength? One pound of lateral pinch on the left. I think the main thing you'll see in this pre-surgery tape is that although I don't have a lot of grip, especially, I mean I have none in my right hand, I've adapted so I can actually function pretty independently. There are things that are going to be much better, though, after surgery, such as, well let's see if I can open this pop can. With a little leverage with the edge of the pop can, I guess I can maybe. But that's kind of cheating. As far as peeling an orange goes, it's one of the more tedious processes. But once again, I have figured out ways to do it. If I really want an orange bed and I'm by myself, I use a spoon and just kind of pry it open, make a lot of orange juice out of the way. It can be done, but you can see it would be a rather frustrating experience. If I had to open these crackers, I wouldn't have a prayer. With any pinch, what I'd do is use my teeth and just bite it off and have some crackers. But I'd rather not do that in a restaurant with the grip I have. Hammering is pretty much a two-handed experience and not a very efficient one. Same I expect with a screwdriver. Actually, I haven't attempted to do any of these at home anyway. But you develop ways in a year's time of handling things. So I can screw it in. I'm going to show you a toothbrush. I would probably not be able to get this open just on my own with both hands. I probably could using my teeth, maybe. Once again, you make do with what you've got. I'd have to just push down on the table to get this toothpaste out. And I'm not going to brush my teeth for you, but it can be done. Eric has normal sensibility in the thumb and index fingers. His right hand is group six with a functioning extensor digitorum communis, but no extensor pollicis longus. His left hand is being classified as group eight because he has partial digital flexion but this is very weak so he is essentially a group seven patient as far as the surgical plan is concerned. A one stage grasp and pinch reconstruction was performed on the right hand. Thumb position and control was provided by an adduction of ponensplasty with transfer of the flexor carpi ulnaris by way of the flexor digitorum superficialis of the ring finger to a split thumb insertion. The brachioradialis was transferred to the flexor pollicis longus to provide thumb flexion. The extensor digiti quinti was transferred through the second dorsal compartment to the extensor pollicis longus for thumb extension. Finger flexion was provided by transfer of the extensor carpi radialis longus to the flexor profundus. Intrinsic balance was achieved by a lasso of the flexor superficialis around the A1 pulley of the four fingers. The left hand underwent surgery three months later with the thumb positioned by an adduction of ponensplasty also using the flexor carpi ulnaris as the motor by way of the flexor superficialis of the ring to a split thumb insertion into the abductor pollicis brevis and extensor pollicis longus. The brachioradialis was transferred to the flexor pollicis longus for thumb flexion. Finger flexion was provided by transfer of the extensor carpi radialis longus to the flexor digitorum profundus of the index middle ring and little fingers. One year ago yesterday I had tendon transfer surgery done on my right arm. Three months later I had tendon transfer surgery done on my left arm. Now we're going to illustrate the same things I did before surgery, but I want to say that these things are not really important to my life, what we're about to do right now. What's really been a change are things we're not going to demonstrate, things like just efficiency in the morning getting dressed, getting up, speed in my transferring in and out of the car, getting dressed. I've gotten a lot more active in sports from it. But what we're going to demonstrate to you now I'll just show you a little bit better how I can function with my hands. This is my grip strength. Before the surgery I think it was zero in both hands. Now it's right around 20 in that hand. And it's 20 in the other hand as well. My pinch strength might have been a little bit in this hand before the surgery, but now it goes up quite a bit higher. Cooking and eating have all been things that have become more enjoyable after the hand surgery. It's just easier to manipulate things obviously when you have a little more grip in your hands. I've got a cold so I'm going to leave this close by. Peeling an orange is still not something I like doing, but it is quite a bit easier now that I can tear away at it. Tears like this I've found are much easier to do. And here's something I haven't done since the last video tape. And that's something I'll spend a lot of time doing. This is something we can illustrate that has been really nice. This was the type of steering I used on my car before my hand surgery because I didn't have any grip in my right hand. This tri-pin some of you are probably familiar with. Now I just use a tractor knob which is farther out of the way when I drive and transfer. Four years after surgery, Eric received the George Williams Scholarship as an outstanding second year medical student at the University of Minnesota. His grip and pinch strengths are noted. The next patient will demonstrate the two stage grasp and pinch reconstruction used for group four and five. This patient from group five has preservation of functions of the C6 nerve root and in addition to good elbow flexion and fair extension, she has good function of the brachioradialis, extensor carpi radialis longus, extensor carpi radialis brevis, pronator teres, flexor carpi radialis. The functional hand needs dynamic control of many functional modalities to achieve effective grasp, pinch, and release. To achieve this she needs wrist extension, wrist flexion, finger flexion, thumb flexion, adduction opposition, finger extension, thumb extension, and intrinsic function. These functions are performed in the normal hand by over thirty separately innervated muscle tendon units. We will begin our discussion of reconstruction with the flexor phase which preserves wrist control and allows transfer of the remaining functional muscles to provide grasp and pinch. The extensor carpi radialis brevis is retained to provide wrist extension which is necessary to stabilize the wrist for strong finger flexion. The flexor carpi radialis is retained to provide wrist flexion which is important because it provides power for wheelchair propulsion and assists in transfers. Also, active wrist flexion augments finger extension through natural or surgical tenodesis. In the flexor phase of surgery, the extensor carpi radialis longus is transferred to the four tendons of the flexor digitorum profundus to provide finger flexion. The amplitude is sufficient and the muscle is strong. It is synergistic for finger flexion. The pronator teres or brachioradialis is transferred to the flexor pollicis longus to provide thumb flexion. The pronator teres is anatomically situated close to the flexor pollicis longus in the forearm. It can also retain a small pronating force following transfer. The brachioradialis or other motor is then transferred by way of the paralyzed flexor superficialis tendon as a graft to the abductor pollicis longus and extensor pollicis longus of the thumb to provide adduction opposition. The superficialis tendon is withdrawn from the ring finger into the palm where it is passed superficial to the palmar fascia and inserted into the abductor pollicis longus and extensor pollicis longus with a split insertion. The distal border of the transverse carpal ligament and the ulnar border of the palmar fascia act as the pulley. The brachioradialis is inserted into the tendon of the paralyzed superficialis muscle in the forearm to provide the strong motor and a good position for lateral pinch. This constitutes the active portion of reconstruction and preserves control of the wrist and provides grasp and pinch. Digital extension for release may be accomplished by natural tenodesis if this is satisfactory but it is usually mediated through surgical tenodesis because it provides better opening of the hand without requiring extreme wrist flexion. The tendons of the extensor digitorum communis are tenodes to the distal radius to provide finger extension at the metacarpophalangeal joints. The extensor pollicis longus and the abductor pollicis longus rerouted through the third dorsal compartment are tenodes to the distal radius to provide thumb extension. Tenodesis is accomplished by fixation of the tendon ends into a window in the radius. The abductor pollicis longus is rerouted through the first dorsal compartment to provide extension of the thumb metacarpal away from the index finger. A free graft is usually used to restore intrinsic function to the index and long fingers. It is passed down the lumbrical canal of the index finger, volar to the transverse intermetacarpal ligament through the neck of the second metacarpal and out the lumbrical canal of the long finger. After adjusting tension, it is sutured to the wing tendons and central slips of both fingers. This prevents joint, MP joint hyperextension and facilitates interphalangeal joint extension. Following the extensor phase, on wrist extension, the extrinsic tendons are slack and allow the fingers and thumb to flex. With wrist flexion, these tendons tighten and extend the thumb and metacarpophalangeal joints of the fingers. As the metacarpophalangeal joints extend, the intrinsic tenodesis pulls the extensor mechanism proximally and thereby extends the interphalangeal joints. As the wrist extends, the extensor tenodesis is relaxed so that digital flexion can occur. As the transfer to the flexor profundus contracts, flexion of the interphalangeal joints begins. This pulls the extensor hood distally and tension on the intrinsic tenodesis facilitates flexion of the metacarpophalangeal joints. After reconstruction, the hand is by no means able to produce all the intricate functions of the normal hand, but it does have active digital motion. Now it can produce a reading on the pinch tensiometer. We will now demonstrate some preoperative functional activities of daily living. Because she has no grasp, she must use her mouth and both hands to hold her toothbrush. A special strap is necessary to hold the toothbrush. She manipulates a pad of butter very poorly. She has to interweave her knife in her fingers to butter the bread. Following the two-stage reconstruction of grasp, pinch, and release, her control and efficiency have greatly improved. She is able to pass her toothbrush from one hand to another and her speed has increased. Control allows some fine manipulation. And with coordinated activity of her two hands, she's able to load her toothbrush. This was some gooey toothpaste and it had a little difficulty. Using bread has now become much easier. The use of two hands provides for greater efficiency. The splint used before surgery has been discarded. She's able to manipulate the eyelash curler more effectively. In applying eye makeup, her accuracy in application is good and her overall efficiency has greatly improved. The independent use of both hands has significantly facilitated her activities of daily living. Although functional improvement may seem modest compared with the normal hand, a patient with little or no function of the hand is happy with any functional benefits derived from surgery.

reconstructive surgery

tetraplegia

spinal cord injury

functional groups

muscles

hand function

surgical reconstruction