Tendon Transfer Surgery to Restore Hand Function
Tendon Transfer to Restore Hand Function in Persons with Tetraplegia
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.
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. 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. Depending upon the number of functional muscles, patients may require one or two surgeries. For the first surgery, 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. When the second operation is done, it is usually an outpatient procedure with patients beginning hand use within the first week.
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
Loyola Rehabilitation Institute of Chicago Shiners’ Hospital
Michael Bednar, M.D. David Chen, M.D. Lawrence Vogel, M.D.
2160 S 1st Ave 345 E Superior St 2211 N Oak Park Ave
Maywood, IL 60153 Chicago, IL 60611 Chicago, IL 60707
630-725-0037 312-238-0764 773-385-5528
Stanford University Hospital
Vincent R. Hentz, M.D.
N345 Hoover Pavilion
Stanford, CA 94305
Hand Surgery Association
850 East Harvard #405
Denver, CO 80210
University of Minnesota
Health Sciences Center
James H. House, M.D.
420 SE Delaware, Box 190
Minneapolis, MN 55455
MetroHealth Medical Center
Department of Orthopaedics
Michael Warren Keith, M.D.
2500 MetroHealth Drive
Cleveland, OH 44109
Moberg, E. Surgical treatment for absent single-hand grip and elbow extension in quadriplegia. Journal of Bone and Joint Surgery 1975; 57A;196.
Reiser, TV, Walters, RL. Long-term follow-up of the Moberg key grip procedure. Journal of Hand Surgery 1986; 11A; 724-728.
Walters, RL, Moore, KR, Graboff, SR, Parks, K. Brachioradials to flexor pollicis longus tendon transfer for active lateral pinch in the tetraplegic. Journal of Hand Surgery 1985.10-A; (3); 385-391.
Hentz, V, Brown, M. Keoshian, L. Upper limb reconstruction in quadriplegia, functional assessment and proposed treatment modifications. Journal of Hand Surgery 1983; 8(2); 119-131.
Smith, AG. Early complications of key grip hand surgery for tetraplegia. Paraplegia 1981; 19(2); 123.
Hiersche, DL, Waters, RL. Interphalangeal fixation of the thumb in Moberg’s key grip procedure. Journal of Hand Surgery 1985; 10A; 30-32.
Zancoli, E. Surgery for the quadriplegic hand with active strong wrist extension preserved – A study of 97 cases. Clinical Orthopedics 1975; 112; 10.
House, JH, Gwathmey, FW, Lundsgaard, DK. Restoration of strong grasp and lateral pinch in tetraplegia due to cervical spinal cord injury. Journal of Hand Surgery 1976; 1(2); 152-159.
House, JH, Shannon, MA. Restoration of strong grasp and lateral pinch in tetraplegia: A comparison of two methods of thumb control in each patient. Journal of Hand Surgery 1985; 10; 21-29.
McDowell, CL, Moberg, EA, House, JH. The Second International Conference of Surgical Rehabilitation of the Upper Limb in Tetraplegia (Quadriplegia). Journal of Hand Surgery 11A(4); 604-608.
Ainsley, J, Voorhees, C, Drake, E. Reconstructive hand surgery for quadriplegic persons. American Journal of Occupation Therapy 985; 39(11) 715-721.
Kelly, C, Freehafer, A. Peckham, P, Stroh, K. Postoperative results of opponen’s plasty and flexor tendon transfer in patients with spinal cord injuries. Journal of Hand Surgery 1983; 10A; 890-894.
Ejeskar, A, Dahllof, A. Results of reconstructive surgery in the upper limb in tetraplegic patients. Paraplegia 1988; 26; 204-208.
The National Spinal Cord Injury Association would like to thank James H. House, M.D., and Ann L. Dahl, OTR, for contributing their time and expertise in the preparation of this fact sheet. This fact sheet is offered as an information service and is not intended to cover all treatments or research in the field, nor is it an endorsement of the methods mentioned herein. NSCIA, 8/95