CHAPTER 32
SURGICAL RECONSTRUCTION OF THE
TETRAPLEGIC HAND
The greatly increased life span of traumatic tetraplegics has no doubt widened the scope
of reconstructive surgery of the lower motor neuron paralysis of muscle groups of hands
and fingers which, hitherto, was confined to victims of polio and peripheral nerve lesions,
and several authors have described techniques of reconstructive surgical procedures in
tetraplegics (Thompson, 1942; Napier, 1956; Wilson, 1956; Street, 1958; Riordan, 1959;
Fowler, 1959; Nickel
et
a/., 1963; Lamb, 1963, 1972; Zancolli, 1965; Lipscomb
et al.,
1965; Freehafer, 1967, 1969; Sarrafian, 1969; and others).
From all experience certain conclusions have been drawn:
There is no single solution to surgical reconstruction and each case should be con
sidered individually.
The careful study of the patient's personality and the degree of readjustment to his
muscular deficit by mobilization of natural forces of adjustment is as essential as the
detailed analysis of the actual neurological defect. From my personal experience on a
very large number of traumatic tetraplegics below C6/7 there is no doubt that these
patients can readjust the function of their arms and hands with or without aids to a con
siderable degree, enabling them to carry out daily activities, such as self-dressing to some
extent, combing the hair, cleaning the teeth, shaving with an electric shaver, feeding,
typing, writing, using the telephone and taking part in certain sports, etc., provided the
extensor carpi radialis longus and brevis and the brachioradialis are of good strength.
Naturally, in these cases we have already in the early stages of their paralysis encouraged
them: 'If you can't use one hand, use both hands' (Guttmann, 1969).
It must also be remembered that only a very small percentage of tetraplegics are
suitable for reconstructive surgery to improve the muscular function of their hands and
fingers for certain daily activities. According to McSweeney (1969) and Bedbrook (1969)
in only 5 per cent of the clinical material is constructive surgery applicable. On the other
hand, Lamb in a recent paper (1972) reported about 113 cases which he treated in a
period between 1958-69 of whom 25 patients had reconstructive surgery (22-16 per cent).
Another important point to be considered before contemplating reconstructive
surgery is the time, which has elapsed since the spinal cord injury. It is a well-known fact,
that in incomplete cord lesions, muscle groups which initially show complete paralysis
may recover to more or less considerable degrees; this applies, in particular, to brachio
radialis, triceps, pronator teres, extensor carpi radialis longus and brevis and flexor carpi
radialis. Opinion varies amongst authors regarding the time when tendon transfers are
indicated. From my own personal observations no reconstructive surgery appears to be
indicated before 1^-2 years after cervical cord injury. This will give the tetraplegic
patient enough time to assess his own capabilities in compensating his neurological
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