Current Concepts in Elbow Extension Reconstruction for the Tetraplegic Patient

Abstract

Individuals with C5 or C6 spinal cord injury (SCI) have paralysis of the triceps brachii, and the subsequent loss of elbow extension makes it impossible to reliably use their hands above shoulder level because of the inability to hold the elbow extended against gravity. For persons with cervical SCI, elbow extension can be restored with both tendon and nerve transfers. Elbow extension is necessary for dressing, eating, wheelchair locomotion, pressure relief maneuvers, independent transfers, and reaching objects above shoulder level. Deltoid-to-triceps and biceps-to-triceps tendon transfers have established efficacy and a longer history of use. Transfer of motor branches from the axillary nerve to triceps motor branches is new with no current published prospective studies but shows early promise. This review aims to highlight the amazing potential these procedures can have on the independence and quality of life for people with quadriplegia. Despite the immense benefit possible, fewer than 14% of eligible people with cervical SCI in the United States receive upper limb reconstructive surgery. Surgical timing is critical. A broader understanding and raised awareness of reconstructive options for elbow extension in people with quadriplegia will increase recognition of eligible patients and speed referral time to the appropriate practitioner. Patients with spinal cord injuries present a complex challenge to the orthopaedic surgeon. There are many factors that need to be addressed to improve patients' physical and mental health. Spinal cord injury (SCI) results in complete or incomplete loss of function below the level of the lesion. As investigated by Chang et al, 1 SCI "has a broad impact on medical, social, psychological, and economic conditions for those directly affected, their paid and unpaid caregivers, and the community." Per the National SCI Statistical Center, the incidence of SCI is approximately 40 cases per million population. 2 There are 100,000 people living with quadriplegia in the United States today. 3 Most patients are aged between 16 and 30 years at the time of injury, with the overwhelming majority (80%) being male. 2 The most common mechanism of injury is motor vehicle accident followed by falls from height.