1082 3131/02 $15.00 + .

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TENDON TRANSFERS

Tendon Transfers for Lateral

Pinch
Albert A. Weiss, MD, and Scott H. Kozin, MD

The paralyzed hand that could benet from transfers to restore lateral pinch is
seen in an impaired individual who is nearly always tetraplegic, although such
paralysis can conceivably be caused by a combination of peripheral nerve lesions or
incomplete brachial plexus palsy. The additional independence gained from this
transfer affords a monumental leap in functional capabilities, often providing the
ability to self-feed, independently catheterize, and seek employment.1,4 The restoration of lateral pinch also allows activities of daily living without brace encumbrance,
which blocks sensory feedback.

HISTORY
Early writings on the restoration of prehensile function in the paralyzed hand
focused on peripheral nerve injuries or brachial plexus palsies. Survival rates for
cervical spinal cord injury were low, owing largely to the challenges in nursing
care, dysautonomia, and genitourinary system complications. The Symposium on
Reconstructive Surgery of the Paralyzed Upper Limb of the Royal Society of Medicine in 1949 made no mention of the treatment of paralysis secondary to spinal cord
injury.3 A exor hinge splint to restore grasp in patients with intact wrist extensors
was introduced, although this device found little acceptance until the general care of
quadriplegics improved in the early 1960s.10 Bunnell2 described a exor tenodesis in
1948, and Lipscomb and coworkers6 published a series in 1958 in which transfers
were used for what was termed thumb opposition, which was actually lateral
pinch. In many early reports, the terms thumb opposition or adduction opposition were used to refer to what is currently dened as lateral pinch, key pinch,
or lateral grasp.

From the Department of Orthopaedic Surgery, MCP Hahnemann University (AAW); Temple University;
and Shriners Hospital for Children (SHK), Philadelphia, Pennsylvania

ATLAS OF THE HAND CLINICS Volume 7 Number 1 March 2002

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WEISS & KOZIN

PATIENT SELECTION
Tetraplegia secondary to spinal cord injury is dened according to the American Spinal Injury Association or the International Classication of Surgery of the
Hand in Tetraplegia (ICSHT).7 The ICSHT is designed to guide surgical reconstruction of the upper limb in tetraplegia (Table 1).
Table 1. INTERNATIONAL CLASSIFICATION OF SURGERY OF THE HAND

IN TETRAPLEGIA
Sensibility
O on Cu* Group
0
1
2
3
4
5
6
7
8
9
X

Motor Characteristics

Description of Function

No muscle below elbow suitable for transfer

Brachioradialis
Extensor carpi radialis longus
Extensor carpi radialis brevis
Pronator teres
Flexor carpi radialis
Finger extensors
Thumb extensor
Partial digital exors
Lacks only intrinsics
Exceptions

Flexion of elbow
Extension of the wrist (weak or strong)
Extension of the wrist
Pronation of the wrist
Flexion of the wrist
Extrinsic extension of the ngers
Extrinsic extension of the thumb
Extrinsic exion of the ngers (weak)
Extrinsic exion of the ngers

*O occular (visual) sensibility only; Cu cutaneous sensibility -visual.

Persons with high-level tetraplegia (ICSHT groups 0) have insufcient available

innervated motors for restoration of lateral pinch using tendon transfer without
supplemental electrical stimulation. Persons with lower-level tetraplegia (ICSHT 2
and greater) have enough available motors to reconstruct lateral pinch and other
grasp patterns (e.g., palmar grasp). In activities of daily living, more tasks are
performed with lateral pinch compared with palmar grasp, which underscores the
importance of pinch reconstruction. Utensils such as a toothbrush, pen, fork, oppy
disk, and compact disc are acquired and manipulated with lateral pinch, unless a
more sophisticated precision pinch (opposition or pulp-to-pulp) is available. Opposition pinch requires an opposable thumb with good control and sensibility, which is
often beyond the scope of conventional transfer restorability.
Candidates for a tendon transfer to restore lateral pinch must have an absence
of contracture, control of spasticity, and the capability of undergoing postoperative
rehabilitation (i.e., without chronic pain or psychiatric disorders).

CATEGORIES OF PINCH RECONSTRUCTION

Passive
Effective lateral pinch can be restored by tenodesis of the exor pollicis longus,
as long as a grade 3 or better volitional wrist extension is present. Active wrist
extension produces tension in the exor pollicis longus tendon and positions the
thumb against the index nger. The preferred point of contact is the index proximal
interphalangeal joint. The magnitude of wrist extension and the tautness of the
exor pollicis longus directly affect pinch strength. In patients in ICSHT group 1,
active wrist extension can be achieved by transfer of the brachioradialis to the
extensor carpi radialis brevis (Fig. 1A). The brachioradialis must be freed from its

TENDON TRANSFERS FOR LATERAL PINCH

insertion into the radial styloid and forearm fascia to maximize available excursion.
Because the need to mobilize proximally is critical, the passive amplitude of excursion should be measured repeatedly until 2.0 to 2.5 cm of excursion is evident (Fig.
1B).

Figure 1. A, Brachioradialis tendon harvested and transferred to extensor carpi radialis brevis. B,
Brachioradialis excursion can be increased by proximal dissection of muscle belly.

Mobilization proximal to the musculotendinous junction is required, which ensures

adequate excursion to provide sufcient amplitude for wrist extension and concomitant tension within the tenodesis.

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Technique
Preoperatively, the overall thumb posture must be evaluated when planning
lateral pinch reconstruction. The rst ray must be positioned sufciently to allow
the thumb to contact the index proximal interphalangeal joint. This requires some
thumb carpometacarpal joint stability and mild pronation. An unstable thumb carpometacarpal joint or supinated posture will result in malpositioning during attempted lateral pinch. A thumb carpometacarpal joint capsulodesis or arthrodesis
may be required to rectify this problem.
Through a longitudinal volar incision just radial to the exor carpi radialis
tendon, the exor pollicis longus tendon is exposed and divided from its muscle as
far proximally in the forearm as possible (Fig. 2A). Two holes are drilled in the
metaphysis of the palmar radius, separated by a bony bridge (Fig. 2B).

Figure 2. A, Longitudinal incision and exposure of exor pollicis longus tendon. B, Drill holes in distal
radius for passage of exor pollicis longus tendon.

TENDON TRANSFERS FOR LATERAL PINCH

The holes are enlarged to accept the exor pollicis longus tendon. The tendon is
passed into a hole, under the bony bridge, out the other hole, and then secured
back to itself around the bony bridge. This maneuver provides a stable anchor of
xation for the tenodesis that is secure enough to permit rapid postoperative use.
Tension is set such that lateral pinch is achieved with the wrist positioned in
extension, and thumb extension is attained with the wrist placed in exion. Tenodesis of the extensor pollicis longus may be necessary to enhance thumb extension and
facilitate release; however, the extensor pollicis longus has an unwanted adduction
vector and must be rerouted into the vicinity of the rst dorsal compartment before
tenodesis. Interphalangeal joint stabilization is routinely performed to maximize
effective contact between the thumb and index nger and is performed before
tensioning.
Criticisms of the exor pollicis longus tenodesis are related to stretching of the
tenodesis over time and ineffective pinch strength. Currently, passive pinch is reserved for ICSHT group 1, when functional electrical stimulation is not a viable
alternative.

Active
Patients with strong active wrist extension but absent thumb exion can regain
active lateral pinch using a tendon transfer. Depending on the patients motor
inventory, options for powering the exor pollicis longus include the brachioradialis
or the pronator teres (elongated with radial periosteum).
Technique
The skin incision varies slightly according to the chosen motor and concomitant
tendon transfers. A longitudinal radial incision allows access to the exor pollicis
longus tendon and the brachioradialis and pronator teres (Fig. 3A). The harvested
tendon is woven into the exor pollicis longus using a three-pass Pulvertaft weave
technique. This method provides enough integral strength to allow early active use
of the transfer without fear of transfer dehiscence. Similar to passive pinch, proper
tension of the transfer is determined by placing the wrist in exion and extension
and gauging tenodesis lateral pinch position and thumb release, respectively.

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As is true in passive tenodesis, the interphalangeal joint of the thumb is stabilized before tensioning the transfer. A split exor pollicis longus transfer is performed, which preserves some interphalangeal joint mobility. This joint stabilization
maximizes the lever arm for pinch strength and avoids unwanted interphalangeal
exion, which would compromise the lateral pinch pattern (Fig. 3B).

Figure 3. A, Longitudinal radial incision to expose brachioradialis, extensor carpi radialis brevis,
exor pollicis longus, and pronator teres tendons. B, Inefcient pinch pattern following tendon transfer
to restore lateral pinch without concomitant interphalangeal joint stabilization.

TENDON TRANSFERS FOR LATERAL PINCH

Functional Electrical Stimulation

Specic selection criteria for functional electrical stimulation are beyond the
scope of this article. The general selection criterion for functional electrical stimulation (FES) is high-level tetraplegia (ICSHT groups 0 and 1) without considerable
denervation (i.e., lower motor neuron injury).5 Functional electrical stimulation
controlled lateral pinch can be superb, with better strength than many active transfers; however, FES often limits applicability and requires caregiver support.
Ideal conditions for functional electrical stimulation restored lateral pinch allow implantation of electrodes into the exor pollicis longus and the adductor
pollicis muscles. Interphalangeal joint stabilization with or without carpometacarpal
joint capsulodesis or arthrodesis is also required. Denervation of the exor pollicis
longus or the adductor pollicis muscles precludes a usable response to stimulation
and requires transfer of other paralyzed but not denervated muscles to provide an
electrically controllable lateral pinch. Determination of a viable motor for transfer
requires an inventory of all paralyzed muscles that can be stimulated. The ability to
stimulate indicates an intact reex arc (upper motor neuron injury) without injury
to the anterior horn cells (lower motor neuron injury). General principles of tendon
transfer surgery apply, except that synergy of action (desirable in volitional transfers) is irrelevant with computer-controlled transfers. The exor carpi radialis normally would not be an ideal substitute motor for the exor pollicis longus because
wrist exion and thumb exion are not synergistic acts. Nevertheless, the paralyzed
but not denervated exor carpi radialis would work well by transfer to the exor
pollicis longus with electrical control.
Surgical approaches for these procedures are dependent on the total number
and location of motor points to be supplied with electrodes, along with consideration for any necessary tendon transfers. Typically, a longitudinal incision is needed
on the volar and dorsal forearm, as well as incisions for hand electrodes (thumb
abductor and adductor muscles).

Interphalangeal Joint Stabilization

Moberg3 recognized the need to block interphalangeal joint exion during
exor pollicis longus tenodesis to achieve an effective pinch against the index nger
(Fig. 3B). He further recognized the potential dissatisfaction with stiff joints in
persons with tetraplegia. Provisional Kirschner wire xation across the interphalangeal joint provided immediate stability for lateral pinch and offered reversibility. If
the patient sensed that the loss of exibility outweighed the gain in pinch strength,
simple wire removal could be performed; however, these pins often migrated,
broke, or caused pain, which necessitated a second procedure for their removal and
overall dissatisfaction with an unstable interphalangeal joint.

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The split exor pollicis longus transfer described by Mohammed and colleagues9
offered a solution to retain a supple joint and still provide an improved lateral
pinch pattern (Fig. 4).

Figure 4. Split exor pollicis longus tendon transfer to provide

stability to lateral pinch.

Technique
A radial midaxial incision is developed on the thumb. The neurovascular bundle is retracted in a palmar direction and the exor sheath incised to expose the
exor pollicis longus tendon (Fig. 5A). The tendon is divided in its midline and in a
longitudinal direction. The radial half of the tendon is incised at its insertion point
on the distal phalanx and pulled into the midaxial region of the thumb (Fig. 5B). A
dorsal ap is elevated to expose the extensor hood and terminal tendon. The cut
half of the exor pollicis longus tendon is passed through a slit in the midportion of
the extensor hood and sutured back to itself (Fig. 5C). The proximal end of the slit
in the extensor hood is reinforced with a suture to prevent proximal propagation of
the slit and the transfer further secured to the extensor tendon directly. A longitudinal Kirschner wire is passed retrograde across the interphalangeal joint to provide
temporary stabilization and protection of the transfer and to allow early motion
(Fig. 5D). This pin is removed 4 to 5 weeks after surgery.

TENDON TRANSFERS FOR LATERAL PINCH

Figure 5. A, Radial mid-axial incision to expose exor pollicis longus tendon. B, Radial half of exor
pollicis longus incised at distal phalanx insertion.
Illustration continued on following page

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Figure 5 (Continued). C, Radial half of exor pollicis longus routed in a dorsal direction and passed
through extensor hood. D, Longitudinal Kirschner wire passed across interphalangeal joint to protect
split exor pollicis longus transfer.

TENDON TRANSFERS FOR LATERAL PINCH

Carpometacarpal Joint Stabilization

The thumb position can adversely affect transfers for lateral pinch. In the
absence of an opponens muscle, supination of the thumb ray often develops, which
places the thumb pulp poorly on the index nger. This malrotation is further
compromised when combined with a thumb adduction contracture. The thumb ray
can be repositioned by osteotomy, capsulodesis, or arthrodesis. A soft-tissue procedure (i.e., capsulorrhaphy) tends to stretch over time, and an osteotomy does not
prevent continued supination; therefore, arthrodesis of the rst carpometacarpal
joint is preferred to provide a stable platform for the rst ray and simultaneous
correction of any rst web space malposition. A dorsal approach between the rst
and third compartments is used to expose the carpometacarpal joint. The articular
surface is removed with a saw and rigid xation accomplished with plate and
screws (e.g., minicondylar plate). Interphalangeal joint stabilization is still necessary
to prevent unwanted interphalangeal joint exion, which leaves only the metacarpophalangeal joint for motion.

References
1. Allieu Y, Coulet B, Chammas M: Functional
surgery of the upper limb in high-level tetraplegia. Techniques in Hand and Upper Extremity Surgery 4:50 68, 2000
2. Bunnell S: Bunnells Surgery of the Hand. Philadelphia, JB Lippincott, 1948
3. DAubigne RM: Treatment of residual paralysis
after injuries of the main nerves (superior extremity). (Symposium on Reconstructive Surgery of the Paralyzed Upper Limb): Proceedings of the Royal Society of Medicine XLII:
831 844, 1949
4. House J, Gwathmey FW, Lundsgaard DK: Restoration of strong grasp and lateral pinch in
tetraplegia due to cervical spinal cord injury. J
Hand Surg 1:152 159, 1976
5. Kilgore KL, Peckman PH, Keith MW, et al: An
implanted upper-extremity neuroprosthesis:
Follow-up of ve patients. J Bone Joint Surg
79A:533 541, 1997

6. Lipscomb PP, Elkins EC, Henderson ED: Tendon transfers to restore function of hands in
tetraplegia, especially after fracture-dislocation
of the sixth cervical vertebra on the seventh. J
Bone Joint Surg 40A:10 58, 1958
7. McDowell CL, Moberg EA, House JH: The second international conference on surgical rehabilitation of the upper limb in tetraplegia
(quadriplegia). J Hand Surg 11A:604 608, 1986
8. Moberg E: The Upper Limb in Tetraplegia.
Stuttgart, Georg Thieme Publishers, 1978
9. Mohammed KD, Rothwell AG, Sinclair SW, et
al: Upper limb surgery for tetraplegia. J Bone
Joint Surg 74B:873 882, 1992
10. Nickel VL, Perry J, Garrett AL: Development
of useful function in the severely paralyzed
hand. J Bone Joint Surg 45A:933, 1963

Address reprint requests to

Albert A. Weiss, MD
MCP Hahnemann University
230 N. Broad Street
Philadelphia, PA 19102
e-mail: bertieweiss@hotmail.com

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