Surgical Rehabilitation of the Tetraplegic Upper Extremity

  • Andreas GohritzEmail author
  • Istvan Turcsányi
  • Jan Fridén


First priority for many individuals with cervical spinal cord injury (SCI) is to regain arm and hand function and thus more independence, mobility, and quality of life. This is a realistic goal in at least 70 % of patients with tetraplegia. However, a specialized treatment is only provided to few of possible candidates (less than 10 %) or not at all in many countries.

Main goals include restoration of elbow and wrist extension and hand grip against gravity which can be achieved by muscle or nerve transfer, joint stabilizations, and procedures reducing spasticity. One-stage combined procedures have proven considerable advantages over traditional multistage approaches. Immediate activation of transferred muscles reduces the risk of adhesions, facilitates relearning, avoids adverse effects of immobilization, and enhances functional recovery regarding strength, range of motion, and patient satisfaction.

Transfer of axillary, musculocutaneous, and radial nerve fascicles from above the SCI is effective and promising options to simplify aftertreatment and enhance motor outcome and sensory protection, especially in groups with limited resources. Functional recovery is yet less reliable and may take at least 6–9 months – ideally, nerve and muscle transfer should be combined to optimize results. Improved multidisciplinary cooperation of physiatrists, hand surgeons, and therapists should give more tetraplegic individuals the chance to profit from upper extremity surgery and get the chance to “take their life into their own hands” again.


Spinal Cord Injury Elbow Extension Tendon Transfer Wrist Extension Hand Opening 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.



Abductor pollicis brevis


Abductor pollicis longus






Distal interphalangeal


Extensor carpi ulnaris


Extensor digitorum communis


Extensor digiti minimi


Extensor carpi radialis brevis


Extensor carpi radialis longus


Extensor pollicis longus


Flexor digitorum profundus


Flexor digitorum superficialis


Flexor pollicis longus




Proximal interphalangeal


Peripheral nerve injury


Pronator teres


Spinal cord injury


Declaration of Conflicting Interests

The authors have no financial disclosures.


  1. 1.
    Bickenbach J, editor. International perspectives on spinal cord injury. Geneva: World Health Organization; 2013.Google Scholar
  2. 2.
    Anderson KD. Targeting recovery: priorities of the SCI population. J Neurotrauma. 2004;21:1371–83.CrossRefPubMedGoogle Scholar
  3. 3.
    Fridén J, Gohritz A. Novel concepts integrated in neuromuscular assessments for surgical restoration of arm and hand function in tetraplegia. Phys Med Rehabil Clin N Am. 2012;23:33–50.CrossRefPubMedGoogle Scholar
  4. 4.
    Fridén J, Reinholdt C, Wangdell J, Gohritz A. Upper extremity reconstruction in non-traumatic spinal cord injuries: an under-recognized opportunity. J Rehabil Med. 2014;46:33–8.CrossRefPubMedGoogle Scholar
  5. 5.
    Snoek GJ, Ijzerman MJ, Hermens HJ, Maxwell D, Biering-Sorensen F. Survey of the needs of patients with spinal cord injury: impact and priority for improvement in hand function in tetraplegics. Spinal Cord. 2004;42:526–32.Google Scholar
  6. 6.
    Fridén J, Gohritz A. Tetraplegia management update. J Hand Surg Am. 2015;40:2489–500.CrossRefPubMedGoogle Scholar
  7. 7.
    Moberg E. The upper limb in tetraplegia. A new approach to surgical rehabilitation. Stuttgart: Thieme; 1978.Google Scholar
  8. 8.
    Hentz V, Leclercq C. Surgical rehabilitation of the upper limb in tetraplegia. New York: WB Saunders; 2002.Google Scholar
  9. 9.
    Curtin CM, Gater DR, Chung KC. Upper extremity reconstruction in the tetraplegic population, a national epidemiologic study. J Hand Surg Am. 2005;30:94–9.CrossRefPubMedGoogle Scholar
  10. 10.
    Kozin SH, Zlotolow DA, Abzug JM. Upper limb reconstruction in persons with tetraplegia. In: Abzug JM et al., editors. The pediatric upper extremity. New York: Springer; 2015.Google Scholar
  11. 11.
    Fridén J, Gohritz A, Turcsanyi I, Ejeskar A. Restoration of active palmar abduction of the thumb in tetraplegia by tendon transfer of the extensor digiti minimi to abductor pollicis brevis. J Hand Surg Eur Vol. 2012;37:665–72.CrossRefPubMedGoogle Scholar
  12. 12.
    Fridén J, Reinholdt C. Current concepts in reconstruction of hand function in tetraplegia. Scand J Surg. 2008;97:341–6.Google Scholar
  13. 13.
    Wangdell J, Carlsson G, Fridén J. Enhanced independence: experiences after regaining grip function in people with tetraplegia. Disabil Rehabil. 2013;35:1968–74.CrossRefPubMedGoogle Scholar
  14. 14.
    Wangdell J, Fridén J. Activity gains after reconstructions of elbow extension in patients with tetraplegia. J Hand Surg Am. 2012;37:1003–10.CrossRefPubMedGoogle Scholar
  15. 15.
    Van Zyl N, Hahn JB, Cooper CA, et al. Upper limb reinnervation in C6 tetraplegia using a triple nerve transfer. J Hand Surg Am. 2014;39:1779–183.CrossRefPubMedGoogle Scholar
  16. 16.
    Bertelli JA, Ghizoni MF. Nerve transfers for elbow and finger extension reconstruction in midcervical spinal cord injuries. J Neurosurg. 2014;24:1–7.Google Scholar
  17. 17.
    Zancolli E. Structural and dynamic bases of hand surgery. 2nd ed. Philadelphia: Lippincott; 1979.Google Scholar
  18. 18.
    Coulet B, Boretto JG, Allieu Y, Fattal C, Laffont I, Chammas M. Pronating osteotomy of the radius for forearm supination contracture in high-level tetraplegic patients: technique and results. J Bone Joint Surg Br. 2010;92:828–34.CrossRefPubMedGoogle Scholar
  19. 19.
    Fridén J, Gohritz A. Brachialis-to-extensor carpi radialis longus selective nerve transfer to restore wrist extension in tetraplegia: case report. J Hand Surg Am. 2012;37:1606–8.CrossRefPubMedGoogle Scholar
  20. 20.
    Fridén J, Reinholdt C, Gohritz A. The extensor pollicis longus-loop-knot (ELK) procedure for dynamic balance of the paralyzed thumb interphalangeal joint. Tech Hand Up Extrem Surg. 2013;17:184–6.CrossRefPubMedGoogle Scholar
  21. 21.
    Muzykewicz DA, Arnet U, Lieber RL, Fridén J. Intrinsic hand muscle function, part 2: kinematic comparison of 2 reconstructive procedures. J Hand Surg Am. 2013;38:2100–5.CrossRefPubMedGoogle Scholar
  22. 22.
    McCarthy CK, House JH, Van Heest A, et al. Intrinsic balancing in reconstruction of the tetraplegic hand. J Hand Surg Am. 1997;22:596–604.CrossRefPubMedGoogle Scholar
  23. 23.
    Fridén J, Reinholdt C, Turcsanyí I, Gohritz A. A single-stage operation for reconstruction of hand flexion, extension, and intrinsic function in tetraplegia: the Alphabet procedure. Tech Hand Up Extrem Surg. 2011;15:230–5.CrossRefPubMedGoogle Scholar
  24. 24.
    Reinholdt C, Fridén J. Outcomes of single-stage grip-release reconstruction in tetraplegia. J Hand Surg Am. 2013;38:1137–44.CrossRefPubMedGoogle Scholar
  25. 25.
    Bertelli JA, Ghizoni MF. Single-stage surgery combining nerve and tendon transfers for bilateral upper limb reconstruction in a tetraplegic patient: case report. J Hand Surg Am. 2013;38:1366–9.CrossRefPubMedGoogle Scholar
  26. 26.
    Brown SH, Hentzen ER, Kwan A, Ward SR, Fridén J, Lieber RL. Mechanical strength of the side-to-side versus Pulvertaft weave tendon repair. J Hand Surg Am. 2010;35:540–5.CrossRefPubMedPubMedCentralGoogle Scholar
  27. 27.
    Hamou C, et al. Pinch and elbow extension restoration in people with tetraplegia: a systematic review of the literature. J Hand Surg Am. 2009;34:692–9.CrossRefPubMedPubMedCentralGoogle Scholar
  28. 28.
    Mohammed KD, Rothwell AG, Sinclair SW, Willems SM, Bean AR. Upper-limb surgery for tetraplegia. J Bone Joint Surg Br. 1992;74:873–9.PubMedGoogle Scholar
  29. 29.
    Vastamäki M. Short-term versus long-term comparative results after reconstructive upper-limb surgery in tetraplegic patients. J Hand Surg Am. 2006;31:1490–4.CrossRefPubMedGoogle Scholar
  30. 30.
    Keith MW, Peljovich A. Surgical treatments to restore function control in spinal cord injury. Handb Clin Neurol. 2012;109:167–79.CrossRefPubMedGoogle Scholar
  31. 31.
    Krasuski M, Kiwerski J. An analysis of the results of transferring the musculocutaneous nerve onto the median nerve in tetraplegics. Arch Orthop Trauma Surg. 1991;111:32–3.CrossRefPubMedGoogle Scholar
  32. 32.
    Cain S, Gohritz A, Fridén J, van Zyl N. Review of upper extremity nerve transfer in cervical spinal cord injury. J Brach Plex Peripher Nerve Inj. 2015;10:e34–42.CrossRefGoogle Scholar

Copyright information

© Springer International Publishing Switzerland 2017

Authors and Affiliations

  • Andreas Gohritz
    • 1
    • 2
    Email author
  • Istvan Turcsányi
    • 3
  • Jan Fridén
    • 4
    • 1
  1. 1.Department of Hand SurgerySwiss Paraplegia CentreNottwilSwitzerland
  2. 2.Department of Plastic, Reconstructive and Aesthetic Surgery, Hand SurgeryUniversity HospitalBaselSwitzerland
  3. 3.Department of OrthopaedicsSzabolcs-Szatmár-Bereg County Hospitals and University HospitalNyíregyházaHungary
  4. 4.Centre of Advanced Reconstruction of Extremities (C.A.R.E.), and Department of Hand SurgeryInstitute of Clinical Sciences, Sahlgrenska University HospitalGöteborgSweden

Personalised recommendations