Upper limb reconstruction in quadriplegia: functional assessment and proposed treatment modifications

The functional results following reconstruction of key grip (40 limbs in 30 patients) and active elbow extension (14 limbs in 9 patients) in higher spinal level quadriplegic patients were reviewed and results were classified as follows: Good result (55% of operated limbs)--Patients were very pleased with the greater ease and capabilities in performing functional activities. Fair result (30%)--Patients were moderately satisfied; thumb instability and poor finger position during pinch were the two greatest sources of dissatisfaction. Poor result (15%)--Patients were disappointed, usually because of progressive contracture, spasticity, or pain. On preoperative assessment, these were the weakest patients or those who had the longest interval between injury and surgery. In 10 of 14 limbs functionally active elbow extension was obtained, although the long convalescent time was a deterrent. Based on these results, the modifications in the following areas of treatment protocol were made: (1) Patient selection--Of those patients with only minimum levels of functional resources, only the most highly motivated should have elective reconstructive surgery. (2) Surgical technique--Procedures to better stabilize the thumb metacarpophalangeal joint and to assist in positioning the other digits during pinch include a stronger tenodesis of the thumb extensor tendons to the metacarpal and tenodesis of the superficialis tendons of the index and long fingers to the proximal phalanx. Other procedures include modification of the methods of attachment of tendon transfers to shorten convalescence following reconstruction of active elbow extension. (3) Postoperative care--postoperative problems develop insidiously. Frequent reassessment is mandatory.