STRATEGY and INDICATIONS

STRATEGY and INDICATIONS

Groups 3, 4, and 5

When extension of the wrist is strong, ECRL and ECRB are active, then ECRL can be used as a motor along with BR.

Because harvesting ECRL when ECRB is paralysed would be a functionnal disaster in tetraplegic patient, it is of paramount importance to make sure that ECRB is active, and to not confuse group 2 and group 3. Many tricks have been proposed for this purpose, including intra-operative testing under local anesthesia. In our experience, the most efficient and the simplest ways to make sure that both ECR muscles are active are :

when PT or FCR are active (group 4 and group 5), ECRB is certainly active. Nevertheless, if wrist extension seems to be weak in this case, strength of ECR must be reinforced before any surgery.
when PT or FCR are paralysed, repeated functionnal testing of wrist extension is the only way to distinguish group 2 from group 3. Repeat the test 5 to 10 times during examination. Patient must resist at each time to the strong pression of your hand against the dorsal aspect of his actively extended wrist. If you are not absolutely sure that wrist extension is strong , repeat the test another day, or another week, or another month. If you have any slight doubt, always consider the upper limb is in group 2, and do not use ECRL as a motor.

OK! Wrist extension is strong. So you have 2 motors : BR and ECRL. What for ?

There are two options :

either to use one motor (ECRL the best) for flexor phase (pinch AND grasp = FPL and FDP), and the other one (BR) for extensor phase. According to Caroline Leclercq, BR to EDC transfer only works when flexion of the wrist is active, that is to say in group 5.
or to use one motor for FDP (ECRL), the other one for FPL (BR), and to restore passively the extensor phase (EDC and EPL tenodesis). This option is also interesting in group 5, where active flexion of the wrist improves the tenodesis effect.


SITUATION (see table)	Remaining functions	active flexion of the elbow active and strong extension of the wrist PT active in group 4, FCR active in group 5
	Paralysed functions	active extension of the elbow (remains sometimes in group 5 or 4) active flexion of the wrist (groups 4 and 5) all extrinsic and intrinsic functions of the fingers and thumb
	Muscles available for transfers	BR ECRL (ECRI) PT (groups 4 and 5)




SUGGESTED SURGICAL PROGRAM for groups 3, 4, and 5 (3 stages)	1st surgical stage	Restoration of elbow extension when paralysed (biceps-to-triceps or deltoid-to-triceps)
	2nd surgical stage	intrinsic palliative of the fingers (4 lassos) thumb stabilisation (NZ tenodesis, or IP arthrodesis, or TM arthrodesis) (sometimes APL crossed dynamic tenodesis) restoration of fingers MP extension (EDC tenodesis in groups 3 or 4, BR-to-EDC transfer in group 5)	Postoperative immobilization : 4 weeks (elbow in flexion at 90°, wrist in extension, fingers MP joints in flexion)
	3rd surgical stage	restoration of fingers flexion (ECRL to FDP transfer) restoration of pinch closure : ECRI- (if exists), BR- (groups 3 or 4) , PT- (group 4 or 5), or ECRL-(in any group 3 to 5) to-FPL transfer)	Postoperative immobilization : 4 weeks (elbow in flexion at 90°, wrist in flexion, fingers MP joints in flexion)

GROUP 3	1st surgical stage	Restoration of elbow extension when paralysed (biceps-to-triceps or deltoid-to-triceps)
	2nd surgical stage	intrinsic palliative of the fingers (4 lassos) thumb stabilisation (NZ tenodesis, or IP arthrodesis, or TM arthrodesis) (sometimes APL crossed dynamic tenodesis) restoration of fingers MP extension (EDC tenodesis)	Postoperative immobilization : 4 weeks (elbow in flexion at 90°, wrist in extension, fingers MP joints in flexion)
	3rd surgical stage	restoration of fingers flexion (ECRL to FDP transfer) restoration of pinch closure : ECRI- (if exists), BR- , or ECRL- to-FPL transfer)	Postoperative immobilization : 4 weeks (elbow in flexion at 90°, wrist in flexion, fingers MP joints in flexion)

GROUP 4	1st surgical stage	Restoration of elbow extension when paralysed (biceps-to-triceps or deltoid-to-triceps)
	2nd surgical stage	intrinsic palliative of the fingers (4 lassos) thumb stabilisation (NZ tenodesis, or IP arthrodesis, or TM arthrodesis) (sometimes APL crossed dynamic tenodesis) restoration of fingers MP extension (EDC tenodesis)	Postoperative immobilization : 4 weeks (elbow in flexion at 90°, wrist in extension, fingers MP joints in flexion)
	3rd surgical stage	restoration of fingers flexion (ECRL to FDP transfer) restoration of pinch closure : ECRI- (if exists), BR- , PT- , or ECRL-to-FPL transfer)	Postoperative immobilization : 4 weeks (elbow in flexion at 90°, wrist in flexion, fingers MP joints in flexion)

GROUP 5	1st surgical stage	Restoration of elbow extension when paralysed (biceps-to-triceps or deltoid-to-triceps)
	2nd surgical stage	intrinsic palliative of the fingers (4 lassos) thumb stabilisation (NZ tenodesis, or IP arthrodesis, or TM arthrodesis) (sometimes APL crossed dynamic tenodesis) restoration of fingers MP extension (EDC tenodesis, or BR-to-EDC transfer)	Postoperative immobilization : 4 weeks (elbow in flexion at 90°, wrist in extension, fingers MP joints in flexion)
	3rd surgical stage	restoration of fingers flexion (ECRL to FDP transfer) restoration of pinch closure : ECRI- (if exists), PT- , or ECRL- to-FPL transfer)	Postoperative immobilization : 4 weeks (elbow in flexion at 90°, wrist in flexion, fingers MP joints in flexion)