Tendon Surgery

Hand surgery can play a very important role in the rehabilitation of selected individuals with paralysis following spinal cord injury. When the spinal cord is injured as a result of a fracture or dislocation in the neck, or as a result of direct injury to the spinal cord from a bullet, knife, tumor or other disorder, there is a profound disturbance of function at the level of injury and a loss of voluntary control of all muscles and sensory function that occur below the level of injury. Individuals with these injuries are often referred to as persons with quadriplegia or tetraplegia because all four limbs have at least some degree of paralysis.

Basic Hand Anatomy

Nerves originating in the spinal cord from the fifth cervical vertebra to the first thoracic vertebra (designated as C5, C6, C7, C8, and T1) supply the upper limbs. There are over 35 muscles involved in controlling voluntary movements in the forearm, wrist and hand, which receive their nerve supply from C6, C7, C8, and T1. Since the most common area of injury to the cervical spinal cord results in paralysis below C6, these persons usually have only two to five of their arm muscles that are not paralyzed.

Tendon Transfer Surgery

Tendons are strong cords that connect muscles to bones and transmit muscle action into movement of the joints where they cross. The important muscles that move the wrist and fingers are located in the forearm and their tendons are attached to the bones in the hand. In tendon transfer surgery, the tendon of muscle that is not paralyzed is transferred to the tendon or tendons of paralyzed muscles so that the transferred muscle will be able to replace the important action that was lost. When a tendon is transferred, its former action will be weakened so it is essential to select the proper muscles for transfer. It is of greatest importance to maintain wrist extension so one strong muscle must be retained for that purpose. Many individuals at the C6 level will be able to maintain wrist control and have one or more other muscles that can be transferred to provide other actions, such as pinching with the thumb.

The hand is also a highly sensitive organ possessing millions of sensory nerve endings that allow us to feel objects we are touching, sense the position of the hand, and protect us from being cut or burned. The C6 level of the spinal cord supplies sensation to the region of the thumb and index finger. The potential for functional improvements through hand surgery depends upon the level of injury to the spinal cord, the number of muscles that retain function, as well as the quality of sensation that remains.

The details of the surgical concepts and functional results of surgery to restore grasp and pinch to the hands of individuals with strong C6 and C7 level of function (International Groups IV through VII) have been reported from the University of Minnesota and published in the Journal of Hand Surgery, in 1976 and 1985 as listed in the suggested readings.

Candidate Selection

Selection of persons for surgery must consider many aspects of their entire rehabilitation process in order to regain a maximum level of independent function consistent with the level of the spinal cord injury. Eligible candidates for reconstructive hand surgery must be one year post-injury, have minimal to no spasticity or fixed contracture in the hand and upper extremity, and be free of infection and skin sores. Individual motivation and commitment to the team process plays a key role in making functional outcome successful.

The Education Process

The education process begins when inquiry is made so that the individual may learn what his/her role is and how surgery will affect his/her life. A series of videotapes, evaluations and decision-making takes place prior to surgery and can usually be completed in half a day. During this time, the individual will be introduced to the members of the Hand Surgery and Rehabilitation team. Evaluation includes assessing the muscle system, quality of sensation, present level of ADL function, use of adaptive equipment and orthotics, and individual goals of the potential surgical candidate. From this information, a surgical rehabilitation plan is then outlined.

The Surgery and Rehabilitation

Surgery usually requires general anesthesia and takes from two to four hours. The usual hospital stay is one to three days. Patients usually remain in a long arm cast for approximately three weeks and then return as an outpatient to begin their intensive hand rehabilitation. This is started with removal of the arm cast and stitches, fabrication of a custom orthotic to protect the hand and transferred tendons, whirlpool, active range of motion, muscle re-education using biofeedback, and further education in how to care for the new tendon transfers. During this early post-operative rehabilitation, the hand is gently moved, trained and protected. Active strengthening and "normal" unrestricted hand use are not available until eight to twelve weeks after surgery. Because of the necessary time required to allow the tendons to heal, the level of dependence felt by the individual can sometimes be frustrating. Realizing this in advance, appropriate plans can be made to allow the person to establish a support system at home (including attendant assistance) or the use of a motorized wheelchair during the early phase following surgery. The initial phase of rehabilitation is usually completed at the facility with the patient carrying-out the remainder of the program in his/her home, with the assistance of local therapists to assure that appropriate progress is being made.

Most individuals will select one hand to start with, and then, six to twelve months later, complete the other hand. The timetable is optional, but at least three to six months is required between hands.

Although it may seem difficult to understand all of the details of anatomy, muscle terminology and surgical procedures, many individuals with spinal cord injury have learned during their rehabilitation process to understand something about hand function. It is hoped that through this fact sheet you will also understand the concepts involved in the International Classification of Tetraplegia and, most importantly, become aware of the option to improve hand function through reconstructive surgery.

Hand Surgery Centers
(click on highlighted text for website information)

Hand Surgery Association
850 East Harvard #405
Denver, CO 80210
(303) 744-7078 Stanford University Hospital
Vincent R. Hentz, M.D.
Hand Clinic
N345 Hoover Pavilion
Stanford, CA 94305
(413) 723-5256

MetroHealth Medical Center
Department of Orthopaedics
Michael Warren Keith,M.D.
2500 MetroHealth Drive
Cleveland, OH 44109
(216) 459-4339 University of Minnesota
Health Sciences Center
James H. House, M.D.
Orthopaedic Surgery
420 SE Delaware, Box 190
Minneapolis, MN 55455
(612) 625-7951

Spinal Cord Injury Association
______________________________

of Illinois

Basic Hand Anatomy

Candidate Selection

The Education Process

The Surgery and Rehabilitation

Hand Surgery Centers
(click on highlighted text for website information)

Suggested Readings

Spinal Cord Injury Association ______________________________

of Illinois

Basic Hand Anatomy

Candidate Selection

The Education Process

The Surgery and Rehabilitation

Hand Surgery Centers (click on highlighted text for website information)

Suggested Readings

Spinal Cord Injury Association
______________________________

Hand Surgery Centers
(click on highlighted text for website information)