F • CLINICAL ASPECTS OF SPINAL CORD INJURIES
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Furthermore, in this type of lesion pronation contracture of the forearm may develop,
if the forearm is left lying continuously or for long periods in pronation.
In complete lesions below C6 the hand should not be left lying flat on the bed, as this
invariably leads to extension contractures of the wrist and fingers. Palm rolls or palmar
pads are usually employed to avoid contractures of the metacarpophalangeal joint, but
these are only effective if they allow flexion of that joint well beyond 45°. Our Occupational
Therapy Department has constructed a type of 'Boxing Glove' splint which has proved
most effective in producing maximum flexion of the metacarpophalangeal and inter-
phalangeal joints. This can be combined with a wrist 'cock-up' splint, as advocated by
Cheshire & Rowe (1970). If contractures of these joints are prevented, the prehensive
effects of the wrist extension by strong action of the extensor carpi radialis longus and
brevis on the paralysed long finger flexors can be considerable in helping the tetraplegic
to grasp objects with some power. If the wrist extensors are weak artificial splints as
developed by Nickel and his colleagues (1963) and Freehafer (1969) have proved of
value in specific cases.
Hand in hand with proper positioning and regular frequent passive movements of all
joints, not just twice or three times a day as is usually done, but every half an hour by the
patient himself, goes the education of the patient to utilize the remaining function of
muscles and joints to mobilize and develop re-adaptive movement patterns (trick move
ments), which will enable him to become relatively independent in some of his daily
activities. This re-education of the patient is, of course, intensified as soon as he is up in
his wheelchair by the combined operation of the physiotherapist and occupational
therapist. Reconstructive surgical procedures can be of value at a later date in selected
cases to improve the function of hand and fingers (see Chapter on Surgical Reconstruc
tion of the Tetraplegic Hand).
Contractures in upper motor neuron lesions
Permanent fixation of paralysed limbs in any position must also be avoided in transverse
lesions of the cord above the thoraco-lumbar junction as they are serious complications
to spasticity.
In spastic lesions involving the upper limbs, as a result of cervical injuries above
C5, contractures usually develop in adduction of the arm and pronation of the forearm.
These can be avoided by proper positioning of the arm in abduction and of the paralysed
forearms in supination, in the initial stages. Once developed, they are difficult to over
come, but auto-assisted movements, using a simple device, have proved to be most
helpful in hemiplegia or tetraplegia as a result of cerebral injury. This is demonstrated
in a case of traumatic triplegia, following gunshot injury of the head, resulting in
profound adduction and pronation contractures of the left arm (Fig. 222). A splint is
fixed to the dorsal surface of the hand, fingers and forearm, by a bandage, thus keeping
the hand and fingers in extension. Metal rings, which are soldered to the radial border
of the splint, are connected to a rope passing over a pulley fixed over the patient's head.
According to the position of the pulley, a pull on the free end of the rope by the patient
with his normal arm, or by his attendant, will either abduct the paralysed arm or supinate
