After cervical spinal cord injury, the loss of upper limb function is common. This affects an individual's ability to perform activities of daily living and participate in previous life roles. There are surgical procedures that can restore some of the upper limb function lost after cervical spinal cord injury. Tendon transfer surgery has been performed in the tetraplegic population since the early 1970s. The goals of surgery are to provide a person with tetraplegia with active elbow extension, wrist extension (if absent), and sufficient pinch and/or grip strength to perform activities of daily living without the need for adaptive equipment or orthoses. These procedures are suitable for a specific group, usually with spinal cord impairment of C4-8, with explicit components of motor and sensory loss. Comprehensive team assessments of current functioning, environment, and personal circumstances are important to ensure success of any procedure. Rehabilitation after tendon transfer surgery involves immobilization for tendon healing followed by specific, targeted therapy based on motor learning and goal-orientated training. Outcomes of tendon transfer surgery are not limited to the improvements in an individual's strength, function, and performance of activities but have much greater life affects, especially with regard to well-being, employment, and participation. This article will provide an overview of the aims of surgery, preoperative assessment, common procedures, postoperative rehabilitation strategies, and outcomes based on clinical experience and international published literature.

Copyright © 2016 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.

By understanding the biomechanical motions that allow the hand to function effectively and how patients used the hand before their injury, the surgeon can best determine which surgical method is most suited to prevent permanent loss of function and significant impairment. The objective of this article is to discuss the biomechanics of the hand and, particularly, to assess the range of biomechanical motions that account for most of the hand functions and to determine the value of each function and which specific surgical procedures best restore the optimum function of the hand.

Copyright © 2013 Elsevier Inc. All rights reserved.

OBJECTIVE

To explore the effectiveness of functional reconstruction of hand grasp and pinch by tendon transfers in patients with cervical spinal cord injury.

METHODS

Between July 2013 and January 2016, tendon transfer surgery were performed in 21 patients (41 hands) with cervical spinal injury that motion level was located at C 6 to reconstruct hand grasp and pinch function. There were 18 males and 3 females with a mean age of 42.3 years (range, 17-65 years). Nineteen patients were with complete spinal cord injury [American Spinal Injury Association (ASIA) grading A], 1 patient was with central cord syndrome whose bilateral hands were completely paralyzed and lower limbs were normal (ASIA grading D), and 1 patient was with cervical spondylotic myelopathy (AISA grading D). The time from injury to hospitalization was 12-22 months (mean, 16.8 months). According to the International classification of surgery of the hand in tetraplegia (ICSHT), there were 6 cases of grade O3, 10 of grade O4, 3 of grade OCu5, and 2 of grade O5. The surgery was divided into two stages with an interval of 6-11 months. At the first stage, grip function was reconstructed in all patients by transfering the extensor carpi radialis longus from radialis side to palmar side through subcutaneous tunnel, and braided and sutured with the flexor pollicis longus and flexor digitorum profundus. At the second stage, the lateral pinch function of the thumb and index finger was reconstructed by braiding and suturing the radial half of the extensor carpi ulnaris (the patients graded as ICSHT O3) or pronator tere (the patients graded above ICSHT O3) with extensor pollicis longus and abductor pollicis longus. The grasp force, the thumb and index finger lateral pinch force, and the maximum fingertips distance between the thumb and index finger were measured at preoperation and at different time points after operation. The modified Lamb and Chan questionnaire, based upon the activities of daily living, was used to evaluate the hand function of all patients at 6 months after sencond stage surgery.

RESULTS

There was 1 patient with elbow skin lesion, 1 patient with wrist stiffness; both of them recovered after corresponding treatment. All the 21 patients were followed up 15-32 months (mean, 19.6 months) without wound infection, tendon adhesion, tendon rupture, and other complications. The grasp forces of all patients were significantly improved at 4 weeks, 3 months, 6 months, and 1 year after the first stage surgery when compared with preoperative value ( P<0.05); and no significant difference was found between different time points after operation ( P>0.05). The thumb and index finger lateral pinch force and the maximum fingertips distance between the thumb and index finger of all patients were also significantly improved at 4 weeks, 3 months, 6 months, and 1 year after the second stage surgery when compared with preoperative values ( P<0.05); and no significant difference was found between different time points after operation ( P>0.05). And there was no significant difference of above indexes between the patients graded as ICSHT O3 and above ICSHT O3 ( P>0.05). The functional outcome was good in 19 cases, fair in 1 case, and poor in 1 case according to modified Lamb and Chan questionnaire at 6 months after second stage surgery.

CONCLUSION

Tendon transfer can significantly improve the hand function and the quality of life of the patients with complete cervical spinal cord injury.

ObjectiveThis case report presents a comprehensive rehabilitation protocol and outcomes for zone 5 forearm injuries involving tendons and neurovascular structures. Phase-specific rehabilitation strategies were used to maximize functional recovery. The findings provide clinical guidance for managing this rare injury, offering insights into rehabilitation approaches and expected outcomes.DesignCase Report.ParticipationA 46-year-old right-handed male sustained a severe glass-induced open forearm injury during badminton. Emergency surgery revealed complete ruptures of: vascular structures (radial artery, ulnar artery and vein), nerves (ulnar, median, and little finger digital nerves), and tendons (flexor pollicis longus, flexor digitorum profundus and superficialis of digits 2-5, flexor carpi radialis, flexor carpi ulnaris, and palmaris longus)Rehabilitation ProgramA 7-month progressive rehabilitation protocol was implemented for zone 5 flexor tendon injuries with ulnar/median nerve damage, with adjustments based on recovery progress.Outcome MeasuresPostoperative rehabilitation progress was assessed through clinical and functional measures.ConclusionEarly surgery combined with a structured rehabilitation protocol achieved excellent functional recovery, with 70-90% wrist and digit range of motion restoration, improved grip strength and activities of daily living by 12 weeks, progressive sensorimotor recovery between 20-28 weeks, and successful work return by 10 weeks, demonstrating this protocol's efficacy for complex neurotendinous injuries.