Different Thumb Positions in the Tetraplegic Hand.

OBJECTIVE: To analyze factors associated with malposition that affects function of the thumb in individuals with tetraplegia. DESIGN: Retrospective cross-sectional study. SETTING: Rehabilitation Center for Spinal Cord Injury. PARTICIPANTS: Anonymized data from 82 individuals (68 men), mean age 52.9±20.2 (SD) with acute/subacute cervical spinal cord injury C2-C8 AIS A-D recorded during 2018-2020. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Motor point (MP) mapping and manual muscle test (MRC) of 3 extrinsic thumb muscles (flexor pollicis longus (FPL), extensor pollicis longus (EPL), and abductor pollicis longus (APL)). RESULTS: 159 hands in 82 patients with tetraplegia C2-C8 AIS A-D were analyzed and assigned to "key pinch" (40.3%), "slack thumb" (26.4%), and "thumb-in-palm" (7.5%) positions. There was a significant (P<.0001) difference between the 3 thumb positions depicted in lower motor neuron (LMN) integrity tested by MP mapping and muscle strength of the 3 muscles examined. All studied muscles showed a significantly different expression of MP and the MRC values (P<.0001) between the "slack thumb" and "key pinch" position. MRC of FPL was significantly greater in the group "thumb-in-palm" compared with "key pinch" position (P<.0001). CONCLUSIONS: Malposition of the thumb due to tetraplegia seems to be related to the integrity of LMN and voluntary muscle activity of the extrinsic thumb muscles. Assessments such as MP mapping and MRC of the 3 thumb muscles enable the identification of potential risk factors for the development of thumb malposition in individuals with tetraplegia.

[Surgical reconstruction of arm and hand functions in tetraplegia : Current concepts]. / Chirurgische Rekonstruktion der Arm- und Handfunktion bei Tetraplegie : Aktuelle Konzepte.

The reconstruction of arm and hand functions is of enormous importance for tetraplegic patients as it enables at least some degree of independence. Depending on the level of the spinal cord injury, certain residual functions are present in the arms which can be used for surgical reconstruction of upper extremity functions. By utilizing tendon and nerve transfers missing functions can at least be partially reconstructed. Tendon transfers are a proven technique with reliable results that can be performed at any time regardless of the type of accident. Due to the frequent presence of lower motor neuron damage, it is essential to consider the optimal time window for nerve transfer interventions. From the multitude of surgical options, an individual reconstruction plan must be created for each patient, which considers multiple factors. The combination of nerve transfers and later completing the functional reconstruction by tendon transfers is the preferred concept of the authors of this article.

Implications of thumb position and trajectory in tetraplegia grip reconstruction - a cohort study.

STUDY DESIGN: This study represents a retrospective observational cohort study. OBJECTIVES: The objective of this study was to investigate the impact of thumb position on postoperative patient-rated and functional outcomes in grip reconstruction surgery. SETTING: All consecutive adult patients with tetraplegia undergoing grip reconstruction surgery at the Swiss Paraplegic Centre between 06/2008 and 11/2020 were assessed for eligibility. METHODS: Standardized photo or film documentation was used for individually recreating and categorizing thumb position and trajectory during key pinch. Outcome measurements included key pinch strength, Canadian Occupational Performance Measure (COPM) and Grasp Release Test (GRT). RESULTS: Fifty-six hands of 44 patients (mean age 42.2 years, range 18-70 years) with a mean follow-up of 14.8 months (range 6 months to 12 years) were included. There was a significant postoperative improvement of key pinch strength, COPM score and GRT. COPM improvement was more pronounced for hands with more palmar abducted trajectories of the thumb. CONCLUSIONS: Regardless of reconstruction type, pinch strength, patient satisfaction and grasp and release abilities improved significantly after surgery. Thumb position and trajectory are strong determining factors for the selected outcome measurements.

Improving hand function after spinal cord injury.

Nerve transfer surgery has expanded reconstructive options for restoring upper extremity function following spinal cord injury. By adding new motor donors to the pool already available through tendon transfers, the effectiveness of treatment should improve. Planning which procedures and in which order to perform, along with their details must be delineated. To meet these demands, refined diagnostics are needed, along with awareness of the remaining challenges to restore intrinsic muscle function and to address spasticity and its consequences. This article summaries recent advances in surgical reanimation of upper extremity motor control, together with an overview of the development of neuro-prosthetic and neuromodulation techniques to modify recovery or substitute for functional losses after spinal cord injuries.

Rebalancing the Spastic Wrist by Transposition of Antagonistic Muscle-Tendon Complex.

Upper limb spasticity and spasticity-induced deformities after upper motor neuron lesions because of traumatic brain injury, encephalitis or cerebral palsy inhibit activities of daily living, result in impaired self-care and often dependence on assistance of carers. A key element of the dysfunction is wrist hyper-flexion and ulnar deviation deformity. Traditionally, this deformity has been corrected by transfer of the spastic flexor carpi ulnaris to the extensor carpi radialis brevis. Instead, this study emphasizes the causative role of the palmar subluxation of extensor carpi ulnaris and describes a surgical correction strategy detailing transfer of extensor carpi ulnaris-to-extensor carpi radialis brevis. This surgery re-establishes and maintains a more favorable muscle-tendon-joint mechanics and hand position. Patient satisfaction is high, time and effort in daily care for patients and caregivers are less, and incidence of complications is low.

Surgical intervention for carpal tunnel syndrome in individuals with spinal cord injuries-patient characteristics, diagnostic considerations, and treatment outcomes.

STUDY DESIGN: A retrospective chart audit. OBJECTIVES: To characterize SCI patients with carpal tunnel syndrome (CTS) and evaluate the diagnostic rationale for surgical decision-making. SETTING: Swiss Paraplegic Centre, Nottwil, Switzerland. METHODS: Retrospective investigation of medical history, diagnostics, surgeries, and outcomes of surgical treatments of CTS in patients with para- and tetraplegia. RESULTS: We identified a total of 77 surgeries for CTS in 55 patients: 16 females (25 surgeries) and 39 males (52 surgeries) with spinal cord injury. The majority (47 persons, 68 surgeries) were paraplegic (level of lesion Th2 and below); 8 persons (9 surgeries) were tetraplegic (level of lesion Th1 and above). ASIA scores in the tetraplegic group were A: 0, B: 1, C: 4, D: 3 while complete lesions predominated in the paraplegic group (A: 32, B: 4, C: 5, D: 6). Sixty-six out of 77 patients reported total relief of symptoms. Neither nerve conduction velocity nor motor amplitude correlated well with the severity of CTS. Co-morbidity and specific risk factors were rare. CONCLUSIONS: SCI patients with CTS respond well to surgical decompression of median nerve regardless of level and type of spinal cord lesion and risk factors. Nerve conduction parameters and clinical findings can provide additional diagnostic support of CTS although nocturnal hand paresthesia, wrist pain at and after loading as well as failed conservative treatment are the main indications for surgical interventions. Based on symptomatology, clinical findings, and nerve conduction studies, we propose a decision-making tree for suggesting surgery or not.

[Simplified active motion protocol following Extensor indicis to Extensor pollicis longus tendon transfer using a side-to-side suture]. / Vereinfachte aktive Nachbehandlung nach Extensor-indicis auf Extensor-pollicis-longus-Sehnentransfer mit Seit-zu-Seit-Naht.

BACKGROUND: Ruptures of the Extensor pollicis longus tendon are commonly treated by Extensor indicis transfer using Pulvertaft suture technique. Current literature does not yet give evidence for a preferable post-operative therapy protocol. A side-to-side suture technique is significantly stronger than the Pulvertaft repair technique and therefore allows an immediate active postoperative treatment. We present a new postoperative protocol, which is simple, fast and safe, and should make treatment easier for patients and therapists. PATIENTS AND METHODS: We treated 10 patients with a transfer of the extensor indicis tendon between 07/2016 and 08/2017 according to the new active protocol. Patients were seen for follow-up at 2, 4 and 8 weeks. Thumb range of motion, pinch and grip strength as well as subjective parameters like pain and general satisfaction were measured. RESULTS: All patients regained full function of their thumbs with retropulsion over the level of the palm at 4 weeks. Median pinch strength was 89 % and grip strength 74 % of the contralateral side at week 4. There was no secondary rupture of the reconstructed tendon over a one-year period. All patients were satisfied with the result of the operation and the protocol. CONCLUSION: Our new active postoperative protocol for extensor indicis transfer using a side-to-side suture has proven to be safe and less strenuous for patients and therapists and has been established as standard treatment in our clinic.