JBJS | Article

The Journal of Bone & Joint Surgery, Volume 78, Issue 7

Articles | July 01, 1996

Brachioradialis Transfer for Wrist Extension in Tetraplegic Patients Who Have Fifth-Cervical-Level Neurological Function*

DARREN L. JOHNSON, M.D.†; HARRIS GELLMAN, M.D.‡; ROBERT L. WATERS, M.D.§; MONICA TOGNELIA, O.T.R.§, DOWNEY, CALIFORNIA

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Investigation performed at Rancho Los Amigos Medical Center, Downey.

The Journal of Bone & Joint Surgery. 1996; 78:1063-7

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Abstract

The brachioradialis tendon was transferred to the extensor carpi radialis longus and brevis tendons to restore active extension of the wrist in nine patients who had traumatic tetraplegia. The classification of neurological function was the fifth cervical level for all patients. The average time from the injury to the operation was six years (range, one to twenty years), and the average duration of follow-up was ten years (range, two to fifteen years).The evaluation of the patient included a determination of the preoperative and postoperative ranges of motion of the wrist, manual muscle-testing of the strength of the brachioradialis and the wrist extensors, a functional assessment of the ability to perform activities of daily living (eating, grooming, dressing, personal hygiene, and desktop activities [writing, typing, using a telephone, and so on]), and an assessment of functional independence. In addition, the result of the operation was evaluated subjectively by the patient.No patient had active extension of the wrist against gravity preoperatively. The strength of the wrist extensors improved postoperatively to a grade of good in six patients and to a grade of fair-plus in three. Function of the hand improved markedly in seven patients, and no patient had a loss of function. The patients had improvement in the ability to pick up objects, to feed and groom themselves, to tend to personal hygiene, to write and type, and to use a telephone.

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Introduction

Introduction | Materials and Methods | Results | Discussion | References

Restoration of the function of the hand is one of the greatest challenges in the rehabilitation of a patient who has traumatic tetraplegia following a spinal cord injury^8,17,18. Impaired function of the hand prevents such patients from achieving independence in activities of daily living such as feeding and grooming themselves, personal hygiene, and writing and typing.

Classification of neurological function at the fifth cervical level⁶ (international class OCu-1^14,19) indicates functional use of the deltoid, biceps brachii, and brachioradialis muscles but no function of the wrist or the hand. Sensation is present over the deltoid area of the arm and the radial aspect of the thumb only. Prehension pinch is possible only with use of either an electrical hand-splint or a passive ratchet hand-splint that is operated by the contralateral extremity or by means of a mouth strap. Moreover, the low endurance of the shoulder muscles may necessitate the use of mobile arm-supports for positioning and support of the upper extremities.

Transfer of the brachioradialis to the extensor carpi radialis longus and brevis as a means of augmenting extension of the wrist in patients who have high-level tetraplegia has been described previously^1,6. This procedure also may improve grasp and pinch indirectly because active dorsiflexion of the wrist may bring about passive flexion of the fingers and the thumb³. The purpose of the present report is to describe the results of this procedure in patients who had traumatic tetraplegia with the classification of neurological function at the fifth cervical level.

*No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. No funds were received in support of this study.

†University of Kentucky Sports Medicine Center, Kentucky Clinic, K401, Lexington, Kentucky 40536-0284.

‡Department of Orthopaedic Surgery, University of Arkansas for Medical Sciences Medical Center, Slot 531, 4301 West Markham Street, Little Rock, Arkansas 72205.

§Rancho Los Amigos Medical Center, 7601 East Imperial Highway, Downey, California 90242.

*No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. No funds were received in support of this study.

†University of Kentucky Sports Medicine Center, Kentucky Clinic, K401, Lexington, Kentucky 40536-0284.

‡Department of Orthopaedic Surgery, University of Arkansas for Medical Sciences Medical Center, Slot 531, 4301 West Markham Street, Little Rock, Arkansas 72205.

§Rancho Los Amigos Medical Center, 7601 East Imperial Highway, Downey, California 90242.

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TABLE I DATA ON THE PATIENTS

*Strength was graded, according to the system described by Lovett and Martin, as absent (no strength and no evidence of muscular contraction), trace (10 per cent strength and slight muscular contraction without motion of the joint), poor (25 per cent strength and complete motion with gravity eliminated), fair (50 per cent strength and barely complete motion against gravity), good (75 per cent strength and complete motion against gravity with some resistance), or normal (100 per cent strength and normal motion against resistance). Fair (+) meant that there was complete motion against gravity with slight resistance.†The wrist extensors included the extensor carpi radialis longus and brevis.

Case	Gender, Age (Yrs)	Time from Injury to Op. (Mos.)	Durat. of Follow-up (Yrs)	Range of Motion (Degrees)				Muscle Strength*			Additional Procedures
Preop.		Postop.		Preop.		Preop. Wrist Extensors†
Ext.	Flex.	Ext.	Flex.	Brachio- radialis	Wrist Extensors†
1	M,15	243	15	60	60	60	45	Normal	Poor	Good	Moberg key-grip¹⁷
2	M,26	125	15	48	38	45	20	Normal	Poor	Good	Moberg key-grip¹⁷
3	M,41	21	15	45	49	40	30	Normal	Trace	Good	Moberg key-grip¹⁷
4	M,22	28	15	35	50	35	37	Good	Poor	Fair (+)	Moberg key-grip¹⁷
5	M,17	44	15	33	50	30	35	Good	Absent	Fair (+)
6	M,19	81	10	47	55	45	45	Good	Poor	Good
7	M,32	22	3	42	40	38	35	Good	Poor	Good	Arthrodesis of interphalangeal joint of thumb
8	F,22	15	5	34	38	30	20	Good	Poor	Fair (+)	Rerouting of biceps brachii
9	M,21	72	2	38	55	30	40	Normal	Poor	Good	Moberg key-grip¹⁷

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TABLE I DATA ON THE PATIENTS

Case	Gender, Age (Yrs)	Time from Injury to Op. (Mos.)	Durat. of Follow-up (Yrs)	Range of Motion (Degrees)				Muscle Strength*			Additional Procedures
Preop.		Postop.		Preop.		Preop. Wrist Extensors†
Ext.	Flex.	Ext.	Flex.	Brachio- radialis	Wrist Extensors†
1	M,15	243	15	60	60	60	45	Normal	Poor	Good	Moberg key-grip¹⁷
2	M,26	125	15	48	38	45	20	Normal	Poor	Good	Moberg key-grip¹⁷
3	M,41	21	15	45	49	40	30	Normal	Trace	Good	Moberg key-grip¹⁷
4	M,22	28	15	35	50	35	37	Good	Poor	Fair (+)	Moberg key-grip¹⁷
5	M,17	44	15	33	50	30	35	Good	Absent	Fair (+)
6	M,19	81	10	47	55	45	45	Good	Poor	Good
7	M,32	22	3	42	40	38	35	Good	Poor	Good	Arthrodesis of interphalangeal joint of thumb
8	F,22	15	5	34	38	30	20	Good	Poor	Fair (+)	Rerouting of biceps brachii
9	M,21	72	2	38	55	30	40	Normal	Poor	Good	Moberg key-grip¹⁷

Materials and Methods

Introduction | Materials and Methods | Results | Discussion | References

Sixteen patients who had traumatic tetraplegia were managed with a transfer of the brachioradialis tendon to the extensor carpi radialis longus and brevis tendons at Rancho Los Amigos Medical Center beginning in 1975. The records of nine patients who had been followed for more than two years were reviewed retrospectively. The other seven patients were excluded because they had had the procedure within two years before the beginning of the study (five patients) or because they had been lost to follow-up less than two years after the transfer (two patients).

For all patients, neurological function was classified at the fifth cervical level according to the system used by the American Spinal Injury Association and at Rancho Los Amigos Medical Center⁶; this system is based on the most caudad nerve root functioning as indicated by a fair-plus result on a manual muscle test. Muscle strength was classified, according to the system described by Lovett and Martin, as absent (no strength and no evidence of muscular contraction), trace (10 per cent strength and slight muscular contraction without motion of the joint), poor (25 per cent strength and complete motion with gravity eliminated), fair (50 per cent strength and barely complete motion against gravity), good (75 per cent strength and complete motion against gravity with some resistance), or normal (100 per cent strength and normal motion against resistance). Fair-plus meant that there was complete motion against gravity with slight resistance.

The average age at the time of the injury was twenty-five years (range, fifteen to forty-one years), and the average time from the injury to the operation was six years (range, one to twenty years). The mechanism of injury was a diving or motor-vehicle accident for three patients each and a gunshot wound, a downhill skiing accident, or a professional football accident for one patient each.

The results of manual muscle tests as well as of active and passive range-of-motion examinations were recorded both preoperatively and postoperatively (Table I). The strength of the wrist extensors was measured with the elbow stabilized in 90 degrees of flexion. To test the strength of the brachioradialis, the examiner placed the elbow in 90 degrees of flexion and neutral rotation and then assessed the muscle tension of the brachioradialis by palpation while the patient flexed the elbow against resistance. Preoperatively, the average passive extension and flexion of the wrist measured 42 degrees (range, 33 to 60 degrees) and 48 degrees (range, 38 to 60 degrees), respectively. The strength of the brachioradialis was good in five patients and normal in four. The strength of the wrist extensors was poor in all but two patients, in whom it was trace (Case 3) or absent (Case 5).

Functional changes were evaluated with respect to activities of daily living, including the ability of the patients to pick up objects; to feed, groom, and dress themselves; to tend to personal hygiene; and to perform desktop activities (writing, typing, using a telephone, and so on). The ability of the patient to perform each activity was graded as improved, unchanged, or decreased.

The patients' subjective assessment of the procedure was ascertained from their answers to a questionnaire, as well as to direct questions by the physician or therapist, during an occupational therapy session.

Candidates for the operation included tetraplegic patients in whom impairment of the function of the dominant hand limited the performance of activities of daily living or in whom involvement of the non-dominant hand limited the performance of bimanual tasks. A patient was selected for the procedure only if the injury had occurred at least one year previously; the strength of the brachioradialis was at least good according to the system of Lovett and Martin; the strength of the wrist extensors¹³ was absent or was trace or poor with very limited endurance; the wrist, the metacarpophalangeal joints, and the thumb had a full passive range of motion and there was good passive tenodesis positioning of the thumb and the fingers when the wrist was extended and flexed; and there was no spasticity of the muscles of the wrist and the hand.

Operative Procedure

The procedure is performed with the patient under general anesthesia and with the limb positioned on an arm-board after the placement of a pneumatic tourniquet on the arm. Two incisions are made over the dorsoradial aspect of the forearm⁶. The brachioradialis is exposed through the proximal incision; care must be taken to preserve the radial sensory nerve as this structure often contains the only remaining sensory fibers innervating the hand. The brachioradialis tendon is released distally from the radius and is dissected proximally until at least three centimeters of excursion from the resting position of the muscle is obtained⁴. To achieve this excursion, it usually is necessary to mobilize the brachioradialis tendon and muscle proximally to the level of the elbow joint. The brachioradialis tendon is inserted into the extensor carpi radialis longus and brevis tendons with use of the side-weave technique described by Pulvertaft. The tendons are sutured together with 3-0 non-absorbable Ethibond suture (Ethicon, Somerville, New Jersey) with the elbow in 90 degrees of flexion, the forearm in neutral rotation, and the wrist in 45 degrees of extension. The tension of the brachioradialis tendon should be sufficient to hold the wrist in neutral flexion-extension but still permit complete passive flexion. After closure of the wound, the limb is immobilized in an above-the-elbow cast for three weeks with the elbow in 90 degrees of flexion, the forearm in neutral rotation, and the wrist in 45 degrees of extension.

Seven patients had an additional procedure. Five had the key-grip procedure of Moberg¹⁷, which consists of tenodesis of the flexor pollicis longus tendon to the radius, release of the proximal annular pulley of the thumb, and percutaneous pinning of the interphalangeal joint of the thumb to improve lateral pinch^17,23. Another patient had rerouting of the biceps brachii because of an associated paralytic supination contracture of the forearm⁷, and the seventh patient had an arthrodesis of the interphalangeal joint of the thumb to improve lateral pinch.

Postoperative Management

The cast is changed weekly and is removed three weeks postoperatively. The patient then is admitted to the hospital for an intensive three-week program of occupational therapy that emphasizes passive range-of-motion exercises and retraining of the brachioradialis. Various therapeutic methods, including biofeedback and therapeutic electrostimulation, are used to train the patient to contract the brachioradialis without flexing the elbow. There are two therapy sessions each day. When the patient is not receiving therapy, the limb is kept in a dorsal above-the-elbow splint that holds the wrist in 45 degrees of extension.

Active range-of-motion exercises as well as training of the patient in the use of a wrist-driven wrist-hand orthosis are begun six weeks postoperatively. When the strength of the wrist extensors reaches a level of fair or fair-plus, use of the splint is discontinued and functional activities are initiated to encourage the development of an ability to grasp with use of the tenodesis effect of active extension of the wrist on the flexor tendons. Resistive exercises, unlimited activities, and independent transfers are permitted after twelve weeks.

Results

Introduction | Materials and Methods | Results | Discussion | References

At the time of follow-up (average duration, ten years; range, two to fifteen years), the strength of the wrist extensors had improved to a grade of good in six patients and to a grade of fair-plus in three. This improvement enabled each patient to use a wrist-driven wrist-hand orthosis for manual tasks. The average active extension of the wrist measured 39 degrees (range, 30 to 60 degrees), and the average passive flexion measured 34 degrees (range, 20 to 45 degrees).

The preoperative flexion strength of the elbow was retained in eight patients (Cases 1 through 7 and Case 9), in whom the postoperative arc of motion of the elbow ranged from an average extension of 5 degrees (range, 0 to 10 degrees) to an average flexion of more than 120 degrees. An 80-degree flexion contracture of the elbow developed in the remaining patient (Case 8), in whom concomitant rerouting of the biceps had been performed because of a supination contracture of the forearm. This patient had met all of the goals of the rehabilitation program by three months after the operation and had not returned for follow-up until five years postoperatively.

Functional independence improved in seven patients (Cases 3 through 9), all of whom could name at least five activities of daily living that they now were able to perform or were able to perform more efficiently. The patients were better able to pick up objects, to feed and groom themselves, to tend to personal hygiene, to write and type, and to use a telephone. The ability of the patients to perform these manual tasks improved with the increased strength of the wrist extensors. The ability to drive an automobile improved in only two patients. These seven patients stated that the improvement in the level of functional independence also contributed to an improvement in their mental attitude.

Two patients (Cases 1 and 2) had minimum functional improvement despite an increase in the strength of the wrist extensors. In both patients, the key-grip procedure of Moberg¹⁷ had been performed concurrently with the transfer of the brachioradialis tendon. In one (Case 1), a flexion contracture of the interphalangeal joints of each of the fingers and a 55-degree flexion deformity of the metacarpophalangeal joint of the thumb developed. In the other patient (Case 2), a flexion deformity of 30 and 50 degrees developed in the interphalangeal and metacarpophalangeal joints of the thumb, respectively, thereby positioning the thumb into the palm and limiting lateral pinch between the thumb and the index finger as well as grasp. Both of these patients had had the operation early in the study period, at which time the key-grip procedure had involved release of the proximal annular pulley of the thumb. We subsequently stopped performing this release in the hope of avoiding the complication of flexion contracture. Both patients stated that they did not regret having had the operation and that function had not deteriorated compared with the preoperative status.

All patients considered the operation to have been successful and none had a decline in function.

Discussion

Introduction | Materials and Methods | Results | Discussion | References

Perhaps the greatest problem for the tetraplegic patient is the loss of independence. Among the physical improvements most desired by these patients is the restoration of the function of the hand¹⁶.

The functional independence of tetraplegic patients who have fifth-cervical-level neurological function is determined by the remaining extension of the wrist. Active extension of the wrist brings about passive flexion of the fingers and thereby permits grasp, which assists with eating, grooming, holding reading material, and light desktop activities. Patients in whom the strength of the wrist extensors is graded as less than fair can perform such activities only with use of a specially designed orthotic device such as an electrical hand-splint or a passive ratchet hand-splint that is operated by the contralateral extremity or by means of a mouth strap^22,24,25. While these devices are useful, previous studies have shown that they are cumbersome and inefficient and that they are discarded by more than 50 per cent of patients within one year after the injury⁵. If the strength of the wrist extensors can be improved to a grade of fair-plus or better, function of the hand—particularly lateral pinch between the thumb and the index finger and grasp—may be improved^2,4,25. Such an increase in strength also enables the patient to operate a wrist-driven wrist-hand orthosis. This orthotic device permits active palmar prehension by transferring power from the wrist extensors to the fingers; subsequent release is achieved by relaxation of the wrist extensors²⁰.

The operative restoration of extension of the wrist is limited by the number of suitable donor muscles available for transfer^{2,3,9-12,22,23}. In patients in whom neurological function is at the fifth cervical level, the only muscles available for transfer are the deltoid and the brachioradialis. Freehafer and Mast¹ recommended transfer of the brachioradialis into the extensor carpi radialis brevis or longus, or both, to provide extension of the wrist that is strong enough for useful function of the hand. While transfer to the extensor carpi radialis brevis alone gives the most direct extension to the wrist, the extensor carpi radialis longus usually is stronger because it is innervated more cephalad in the spinal cord. However, transfer to the extensor carpi radialis longus alone causes more radial deviation than extension^4,26. In order to maximize function, therefore, we think that it is beneficial to incorporate both extensors in the transfer.

In the current study, the strength of the wrist extensors improved in all patients after the transfer of the brachioradialis tendon to the extensor carpi radialis longus and brevis. It is important to evaluate the strength of the brachioradialis carefully preoperatively¹⁵. Patients in whom function of the radial wrist extensors is completely absent may have partial denervation of the brachioradialis^4,26.

A comparison of the preoperative and postoperative levels of activity is important in the evaluation of the outcome of an operation that was performed to improve function in a tetraplegic patient; writing, inserting a catheter, dressing, feeding oneself, washing, lifting objects, buttoning, and turning dials are only some of the skills that may become possible after such a procedure. Seven of the nine patients in the present study stated that the operation had greatly enhanced their functional independence by improving their ability to pick up objects, to feed and groom themselves, to tend to personal hygiene, to write and type, and to use a telephone. Moreover, the ability to eat without the assistance of special equipment not only results in a measurable functional gain but also improves the self-image and mental attitude of the patient. Although two patients had minimum improvement in function, both had improved strength of the wrist extensors. No patient in the present study had a loss of function.

Restoration of the strength of the wrist extensors to fair-plus or better is a prerequisite of procedures that are intended to restore lateral pinch²³. The key-grip procedure described by Moberg¹⁷ will not be successful if active extension of the wrist is absent. If the transfer of the brachioradialis is unsuccessful, therefore, the key-grip procedure will not improve function. Optimum positioning after the transfer of the brachioradialis is with the wrist in full extension, while optimum positioning after the key-grip procedure is with the wrist in flexion. The need to sacrifice optimum positioning of the wrist after either procedure may result in an unsatisfactory outcome. If the transfer of the brachioradialis and the key-grip procedure had been staged, a better outcome may have resulted. We no longer recommend concomitant procedures at the time of the transfer.

References

Introduction | Materials and Methods | Results | Discussion | References

Freehafer, A. A., and |and |Mast, W. A.: Transfer of the brachioradialis to improve wrist extension in high spinal-cord injury. J. Bone and Joint Surg.,49-A: 648-652, June 1967.49-A648 1967

Freehafer, A. A.; Kelly, C. M.; and |and |Peckham, P. H.: Tendon transfer for the restoration of upper limb function after a cervical spinal cord injury. J. Hand Surg.,9A: 887-893, 1984.9A887 1984

Freehafer, A. A.; Vonhaam, E.; and |and |Allen, V.: Tendon transfers to improve grasp after injuries of the cervical spinal cord. J. Bone and Joint Surg.,56-A: 951-959, July 1974.56-A951 1974

Freehafer, A. A.; Peckham, P. H.; Keith, M. W.; and |and |Mendelson, L. S.: The brachioradialis: anatomy, properties, and value for tendon transfer in the tetraplegic. J. Hand Surg.,13A: 99-104, 1988.13A99 1988

Garber, S. L., and |and |Gregorio, T. L.: Upper extremity assistive devices: assessment of use by spinal cord-injured patients with quadriplegia. Am. J. Occup. Ther.,44: 126-131, 1990.44126 1990 [PubMed]

Gellman, H., and Waters, R. L.: Spinal cord injury/tetraplegia. In Operative Nerve Repair and Reconstruction, edited by R. H. Gelberman. Vol. 2, pp. 1387-1411. Philadelphia, J. B. Lippincott, 1991.

Gellman, H.; Kan, D.; Waters, R. L.; and |and |Nicosa, A.: Rerouting of the biceps brachii for paralytic supination contracture of the forearm in tetraplegia due to trauma. J. Bone and Joint Surg.,76-A: 398-402, March 1994.76-A398 1994

Hanson, R. W., and |and |Franklin, M. R.: Sexual loss in relation to other functional losses for spinal cord injured males. Arch. Phys. Med. and Rehab.,57: 291-293, 1976.57291 1976

Hentz, V. R.; Brown, M.; and |and |Keoshian, L. A.: Upper limb reconstruction in quadriplegia: functional assessment and proposed treatment modifications. J. Hand Surg.,8: 119-131, 1983.8119 1983

House, J. H.; Gwathmey, F. W.; and |and |Lundsgaard, D. K.: Restoration of strong grasp and lateral pinch in tetraplegia due to cervical spinal cord injury. J. Hand Surg.,1: 152-159, 1976.1152 1976

Lamb, D. W., and |and |Chan, K. M.: Surgical reconstruction of the upper limb in traumatic tetraplegia. A review of 41 patients. J. Bone and Joint Surg.,65-B(3): 291-298, 1983.65-B(3)291 1983

Lamb, D. W., and |and |Landry, R. M.: The hand in quadriplegia. Paraplegia,9: 204-212, 1972.9204 1972 [PubMed][CrossRef]

Lovett, R. W., and |and |Martin, E. G.: Certain aspects of infantile paralysis with a description of a method of muscle testing. J. Am. Med. Assn.,66: 729-733, 1916.66729 1916

McDowell, C. L.; Moberg, E. A.; and |and |House, J. H.: The second international conference on surgical rehabilitation of the upper limb in tetraplegia (quadriplegia). J. Hand Surg.,11A: 604-608, 1986.11A604 1986

McDowell, C. L.; Moberg, E. A.; and |and |Smith, A. G.: International conference on surgical rehabilitation of the upper limb in tetraplegia. J. Hand Surg.,4: 387-390, 1979.4387 1979

McKenzie, M. W.: The ratchet handsplint. Am. J. Occup. Ther.,27: 477-479, 1973.27477 1973 [PubMed]

Moberg, E.: Surgical treatment for absent single-hand grip and elbow extension in quadriplegia. Principles and preliminary experience. J. Bone and Joint Surg.,57-A: 196-206, March 1975.57-A196 1975

Moberg, E.: The Upper Limb in Tetraplegia: a New Approach to Surgical Rehabilitation. Stuttgart, Georg Thieme, 1978.

Moberg, E.; Freehafer, A. A.; Lamb, D. W.; Leffert, R. D.; Nigst, H.; and |and | Zancolli, E. A.: International federation of societies for surgery of the hand. A report from the committee of spinal cord injuries 1980. Scandinavian J. Rehab. Med.,14: 3-5, 1982.143 1982

Nickel, V. L.; Perry, J.; and |and |Garrett, A. L.: Development of useful function in the severely paralyzed hand. J. Bone and Joint Surg.,45-A: 933-952, July 1963.45-A933 1963

Pulvertaft, R. G.: Tendon grafts for flexor tendon injuries in the fingers and thumb. J. Bone and Joint Surg.,38-B(1): 175-194, 1956.38-B(1)175 1956

Raczka, R.; Braun, R.; and |and |Waters, R. L.: Posterior deltoid-to-triceps transfers in quadriplegia. Clin. Orthop.,187: 163-167, 1984.187163 1984 [PubMed]

Rieser, T. V., and |and |Waters, R. L.: Long-term follow-up of the Moberg key grip procedure. J. Hand Surg.,11A: 724-728, 1986.11A724 1986

Stauffer, E. S.: Orthotics for spinal cord injuries. Clin. Orthop.,102: 92-99, 1974.10292 1974 [PubMed][CrossRef]

Waters, R.; Moore, K. R.; Graboff, S. R.; and |and |Paris, K.: Brachioradialis to flexor pollicis longus tendon transfer for active lateral pinch in the tetraplegic. J. Hand Surg.,10A: 385-391, 1985.10A385 1985

Zancolli, E.: Functional restoration of the upper limb in traumatic quadriplegia. In Structural and Dynamic Bases of Hand Surgery. Ed. 2, pp. 229-262. Philadelphia, J. B. Lippincott, 1979.

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TABLE I DATA ON THE PATIENTS

Case	Gender, Age (Yrs)	Time from Injury to Op. (Mos.)	Durat. of Follow-up (Yrs)	Range of Motion (Degrees)				Muscle Strength*			Additional Procedures
Preop.		Postop.		Preop.		Preop. Wrist Extensors†
Ext.	Flex.	Ext.	Flex.	Brachio- radialis	Wrist Extensors†
1	M,15	243	15	60	60	60	45	Normal	Poor	Good	Moberg key-grip¹⁷
2	M,26	125	15	48	38	45	20	Normal	Poor	Good	Moberg key-grip¹⁷
3	M,41	21	15	45	49	40	30	Normal	Trace	Good	Moberg key-grip¹⁷
4	M,22	28	15	35	50	35	37	Good	Poor	Fair (+)	Moberg key-grip¹⁷
5	M,17	44	15	33	50	30	35	Good	Absent	Fair (+)
6	M,19	81	10	47	55	45	45	Good	Poor	Good
7	M,32	22	3	42	40	38	35	Good	Poor	Good	Arthrodesis of interphalangeal joint of thumb
8	F,22	15	5	34	38	30	20	Good	Poor	Fair (+)	Rerouting of biceps brachii
9	M,21	72	2	38	55	30	40	Normal	Poor	Good	Moberg key-grip¹⁷

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TABLE I DATA ON THE PATIENTS

Case	Gender, Age (Yrs)	Time from Injury to Op. (Mos.)	Durat. of Follow-up (Yrs)	Range of Motion (Degrees)				Muscle Strength*			Additional Procedures
Preop.		Postop.		Preop.		Preop. Wrist Extensors†
Ext.	Flex.	Ext.	Flex.	Brachio- radialis	Wrist Extensors†
1	M,15	243	15	60	60	60	45	Normal	Poor	Good	Moberg key-grip¹⁷
2	M,26	125	15	48	38	45	20	Normal	Poor	Good	Moberg key-grip¹⁷
3	M,41	21	15	45	49	40	30	Normal	Trace	Good	Moberg key-grip¹⁷
4	M,22	28	15	35	50	35	37	Good	Poor	Fair (+)	Moberg key-grip¹⁷
5	M,17	44	15	33	50	30	35	Good	Absent	Fair (+)
6	M,19	81	10	47	55	45	45	Good	Poor	Good
7	M,32	22	3	42	40	38	35	Good	Poor	Good	Arthrodesis of interphalangeal joint of thumb
8	F,22	15	5	34	38	30	20	Good	Poor	Fair (+)	Rerouting of biceps brachii
9	M,21	72	2	38	55	30	40	Normal	Poor	Good	Moberg key-grip¹⁷