Volume 19, Issue 4, Pages 545-716 (November 2003)

The Upper Limb in Cerebral Palsy

Edited by Michael A. Tonkin
articles 1 - 20
1 fmv-viii: TOC
Pages v-viii

2 fmix: forthcoming issues

Page ix

3 The upper limb in cerebral palsy

Page xi
Michael A. Tonkin

4 Introduction
Page 545
Michael A. Tonkin

5 Etiology of cerebral palsy

Pages 547-556
Richard D. Lawson and Nadia Badawi

6 General assessment of the upper limb

Pages 557-564
Caroline Leclercq

7 Functional assessment aided by motion laboratory studies

Pages 565-571
Ann E. Van Heest

8 Casting, splinting, and physical and occupational therapy of hand deformity and
dysfunction in cerebral palsy
Pages 573-584
Judith Wilton

9 Pharmacologic management of the spastic and dystonic upper limb in children

with cerebral palsy
Pages 585-589
Stephen O'Flaherty and Mary-Clare Waugh

10 Botulinum toxin A in the management of upper limb spasticity in cerebral palsy

Pages 591-600
Terence Y. P. Chin and H. Kerr Graham

11 Electrical stimulation in the management of spastic deformity

Pages 601-606
Luis R. Scheker and Kagan Ozer
12 Introduction: Part 2: surgical management
Page 607
Michael A. Tonkin

13 Surgical management of the hand in infantile spastic hemiplegia

Pages 609-629
Eduardo A. Zancolli

14 The upper limb in cerebral palsy: surgical management of shoulder and elbow
deformities
Pages 631-648
A. Landi, S. Cavazza, G. Caserta, A. Leti Acciaro, S. Sartini, M. C. Gagliano
and M. Manca

15 Surgical management of forearm pronation

Pages 649-655
Claudia R. Gschwind

16 Surgical management of wrist and finger deformity

Pages 657-665
Ann E. Van Heest

17 Surgical management of the thumb in cerebral palsy

Pages 667-677
Richard D. Lawson and Michael A. Tonkin

18 Functional and cosmetic outcome of surgery for cerebral palsy in the upper limb
Pages 679-686
Bruce R. Johnstone, Philip W. F. Richardson, Christopher J. Coombs and Josie
A. Duncan

19 Brachial plexus dorsal rhizotomy in hemiplegic cerebral palsy

Pages 687-699
Jayme Augusto Bertelli, Marcos Flávio Ghizoni, Thatiana Rodrigues Frasson
and Karla Samara Fernandes Borges

20 Cumulative Index
Pages 701-716
 THE UPPER LIMB IN CEREBRAL PALSY

CONTENTS

Preface xi
Michael A. Tonkin

Part 1: Assessment and Nonsurgical Management

Introduction 545
Michael A. Tonkin

Etiology of Cerebral Palsy 547

Richard D. Lawson and Nadia Badawi
Cerebral palsy has a complex and multifactorial etiology, with perinatal ischemic
hypoxia responsible for only approximately 10% of cases. Preconceptional, antenatal, peri-
natal, and postneonatal influences can interact to result in permanent damage to the de-
veloping central nervous system. This article examines the epidemiology of the condition
and discusses the risk factors and causal pathways that have been defined for cerebral
palsy. It goes on to describe preventative measures and potential areas of intervention.

General Assessment of the Upper Limb 557

Caroline Leclercq
Cerebral palsy is a general term that includes all the sequellae of infantile encephalopa-
thies. This article discusses only infantile cerebral hemiplegia because it is the only one in
which surgery can regularly improve function of the upper limb. Clinical examination of
a spastic patient is lengthy and somewhat difficult, and is best performed together with
all the practitioners involved in the child’s care. Surgery should be aimed at correcting
spasticity, muscle contracture and motor deficit, therefore all these elements must be
specifically assessed during clinical examination.

Functional Assessment Aided by Motion Laboratory Studies 565

Ann E. Van Heest
Preoperative assessment of the patient with cerebral palsy includes assessment of their
static deformity (contractures), dynamic deformity (spasticity versus motor control),
and their sensibility, in order to integrate a treatment plan based on their age, motiva-
tion, and use of the upper limb. Motion laboratory analysis is discussed as a tool that
can assist the surgeon in assessment of patterns of spasticity or control in muscles
considered for tendon transfer or lengthening.

VOLUME 19 Æ NUMBER 4 Æ NOVEMBER 2003 v

Casting, Splinting, and Physical and Occupational Therapy of Hand
Deformity and Dysfunction in Cerebral Palsy 573
Judith Wilton
Facilitation of hand function is a major focus of physical and occupational therapy for
persons with cerebral palsy. A model for analysis of deformities of the hypertonic hand
is presented. It encompasses analysis of movement patterns and associated contracture,
impact of deformity on functional pinch and grip, and discussion of appropriate treat-
ment, including splinting and casting.

Pharmacologic Management of the Spastic and Dystonic Upper Limb in

Children with Cerebral Palsy 585
Stephen O’Flaherty and Mary-Clare Waugh
Pharmacologic management in cerebral palsy may be directed to spasticity, dystonia, or
a combination of these after an assessment of treatment goals. The most common phar-
macologic agents are botulinum toxin (discussed elsewhere) for spasticity and dystonia,
baclofen, diazepam, dantrolene sodium, and tizanidine for spasticity, and L-Dopa and
benzhexol for dystonia. Medications are introduced slowly to monitor efficacy and side
effects and are performed largely on an open trial basis, as evidence of specific treatment
programs is lacking.

Botulinum Toxin A in the Management of Upper Limb Spasticity in

Cerebral Palsy 591
Terence Y.P. Chin and H. Kerr Graham
Botulinum Toxin A has been used in the management of focal dystonia for more than 20
years and in that of focal spasticity for more than 10 years. There have been many open
label studies and randomized clinical trials demonstrating efficacy and safety in the
management of lower limb spasticity in children with cerebral palsy, especially dynamic
equinus (toe walking). In children with juvenile cerebral palsy (JCP), there are good
grounds to suggest that Botulinum Toxin A may be more beneficial in the upper limb
than in the lower limb and further clinical trials are warranted. Botulinum Toxin A
has not been approved for management of upper limb spasticity in children in any coun-
try. All such use is ‘‘off label’’ and should be undertaken only in the context of clinical
trials. Botulinum Toxin A therapy has several upper limb indications and should be con-
sidered complementary to such interventions as occupational therapy, splinting, casting,
and muscle-tendon surgery.

Electrical Stimulation in the Management of Spastic Deformity 601

Luis R. Scheker and Kagan Ozer
This article outlines a nonsurgical approach that includes neuromuscular electrical stim-
ulation and dynamic bracing for the management of spastic deformity in cerebral palsy.
Neuromuscular electrical stimulation is used commonly for lower extremity spasticity.
Its clinical application in upper extremity spasticity, together with dynamic bracing,
is a new entity providing predictable and quick short-term results with significant
improvement in quality of life.

Part 2: Surgical Management

Introduction 607
Michael A. Tonkin

vi CONTENTS
Surgical Management of the Hand in Infantile Spastic Hemiplegia 609
Eduardo A. Zancolli
Upper limb surgery in cerebral palsy is efficacious for patients with a spastic or predom-
inantly spastic pattern of deformity. The deformity can be classified into groups I, IIA,
IIB, and III, according to the ability to extend the fingers with altered wrist position
and the presence or absence of active wrist extension. This scenario allows surgical plan-
ning, following clinical assessment, with selection of appropriate muscle releases, tendon
transfers, and joint stabilizations that are directed to specific clinical presentations. In 47
patients, outcomes were satisfactory in more than 90% of patients in groups I and II, but
were less successful in group III patients.

The Upper Limb in Cerebral Palsy: Surgical Management of Shoulder and

Elbow Deformities 631
A. Landi, S. Cavazza, G. Caserta, A. Leti Acciaro, S. Sartini,
M.C. Gagliano, and M. Manca
The authors report a simple chart that offers a comprehensive picture of spasticity of the
upper limb and provides a more objective method of recording data. Distinction is made
between fixed postures and the residual active range of motion at the shoulder and el-
bow. The presence and function of the muscles can be identified easily on dynamic EMG
studies, which are essential for understanding the degree of spasticity and dyssynergy
related to a single muscle. When spasticity of the upper arm is managed with a global
approach and objectives are defined clearly in advance with the patient and caregivers,
treatment of shoulder and elbow deformities can achieve important results for personal
hygiene or functional targets.

Surgical Management of Forearm Pronation 649

Claudia R. Gschwind
Pronation deformity is part of the common deformity pattern in cerebral palsy. A clas-
sification and treatment plan is proposed. Specific assessment of forearm rotation in con-
junction with assessment of elbow, wrist, and finger deformity is recommended to
optimize surgical planning and to avoid over or under correction of the pronation
deformity.

Surgical Management of Wrist and Finger Deformity 657

Ann E. Van Heest
Children with cerebral palsy can improve their motor function and perhaps also their
sensibility function with appropriately planned and executed tendon release and transfer
surgery. Balance of the wrist and fingers is the key element in improvement of upper
limb function.

Surgical Management of the Thumb in Cerebral Palsy 667

Richard D. Lawson and Michael A. Tonkin
The typical thumb deformities in cerebral palsy are adduction contracture and adduc-
tion-flexion contracture (thumb-in-palm deformity). Surgical treatment of thumb defor-
mity involves a rebalance of forces acting across the thumb joints by release of spastic
muscles and augmentation of paretic muscles. Unstable joints may need stabilization
or arthrodesis.

CONTENTS vii
Functional and Cosmetic Outcome of Surgery for Cerebral Palsy in
the Upper Limb 679
Bruce R. Johnstone, Philip W.F. Richardson, Christopher J. Coombs, and
Josie A. Duncan
Surgical treatment of the upper limb in cerebral palsy aims to improve function and
cosmesis in many patients and ease of dressing and hygiene in severely disabled pa-
tients. This has been achieved through multiple simultaneous procedures. These proce-
dures include the release, lengthening, or paralysis of deforming spastic muscles, tendon
transfers, and joint stabilizations. The authors present an approach to the surgical man-
agement of upper limb cerebral palsy and a patient/caregiver-based outcomes assess-
ment. In addition to the functional scale developed by House, cosmesis, dressing,
hygiene, and overall satisfaction have been assessed and found to be significantly
improved.

Brachial Plexus Dorsal Rhizotomy in Hemiplegic Cerebral Palsy 687

Jayme Augusto Bertelli, Marcos Flávio Ghizoni,
Thatiana Rodrigues Frasson, and Karla Samara Fernandes Borges
Brachial plexus dorsal rhizotomy interrupts pathologic afferents, leading to high resolu-
tion of spasticity and general upper limb functional improvement. The authors present
a cohort clinical study with 20 patients and discuss the indications, hand sensibility
preservation, and motor control after dorsal rhizotomy.

Cumulative Index 2003 701

viii CONTENTS
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 Hand Clin 19 (2003) xi
Preface
The upper limb in cerebral palsy
Michael A. Tonkin, MD, FRACS
Guest Editor
This issue of the Hand Clinics is devoted to the
upper limb in cerebral palsy. Surgery undoubtedly
has a role to play—more so for disorders in which
spasticity is dominant—and perhaps, as far as
function is concerned, is ideally directed toward
the child with spastic hemiplegia who has good
sensibility and pre-existing function in the affected
upper limb. Surgery for severe deformity, with or
without pain, is beneficial in improving both
appearance and ease of management for carers.
In severely affected cases, function is unlikely to
be improved.
Surgery is not suitable for all and should only
be undertaken after careful and frequent consid-
eration. Therefore, Part 1 of this issue is devoted
to assessment and nonsurgical management so
that the surgeon to whom this text is directed
has the benefit of the assessment and management
methods provided by nonsurgical physicians and
therapists, who play such an important role in
the care of those afflicted by cerebral palsy.
The authors are not only of disparate medical
background but also reflect international knowl-
edge and experience in this field, with European,
North American, South American, and Australian
contributors. If there is a preponderance of Austra-
lian authors, this is because the guest editor was
able to exert greater editorial control over his own
countrymen and -women. However, one of the joys
1042-3680/03/$ - see front matter Ó 2003 Elsevier Inc. All rights reserved.
doi:10.1016/S0749-0712(03)00097-0
of acting as a guest editor is to appreciate the charm
of the English language as written by those for
whom English is not the first language. I have tried
to retain the flavor of nationality in English expres-
sion, because I believe it enriches us all.
The faults of any multi-authored book are
repetition and lack of continuity. I have attempted
to minimize repetition while allowing each article
to stand on its own as a reference for its particular
topic.
Finally, this issue would never have been pub-
lished were it not for the invaluable assistance of
Susan Filan, research assistant in the Department
of Hand Surgery at the Royal North Shore Hospi-
tal in Sydney, in whose hands I placed most of the
onerous tasks associated with preparing these 14
articles for publication. I have no doubt that the
invited authors are aware of her efforts.
My gratitude also goes to Deb Dellapena at
Elsevier, who provided invaluable advice and sup-
port to the guest editor and the authors.
Michael A. Tonkin, MD, FRACS
Department of Hand Surgery
Royal North Shore Hospital
Pacific Highway
St. Leonards, NSW 2065, Australia
E-mail address: mtonkin@surgery.usyd.edu.au
 Hand Clin 19 (2003) 545

Part 1: assessment and nonsurgical management

Introduction
Michael A. Tonkin, MD, FRACS
Department of Hand and Peripheral Nerve Surgery, Royal North Shore Hospital,
St. Leonards, NSW 2065, Australia

This section provides the reader with an
understanding of the causes of cerebral palsy,
how to assess the overall conditions affecting the
afflicted individual, and the nonsurgical manage-
ment protocols, which include physical therapy
and splinting, pharmacological management, the
administration of botulinum toxin, and the use of
electrical stimulation.
The article by Lawson and Badawi provides an
insight into the multiplicity of pathways that may
lead to a diagnosis of cerebral palsy, dispelling the
previously commonly held theory of anoxia at
birth as the culprit in causation. The assessment
articles by Leclerq and Van Heest give an
indication of the complex reviews undertaken
before surgery is considered. These rely very much
on the expertise of general physicians, neuro-
logists, therapists, caregivers and parents. Wilton
provides the reader with a detailed account of the
therapist’s classification methods and management
protocols. O’Flaherty and Waugh summarize the
medications available to control both spasticity
and dystonia. Graham’s unit is at the forefront of
investigations into the efficacy of botulinum toxin
administration. Finally, the Louisville group have
described their experience with a combination of
electrical stimulation and splinting.
As a unit, these articles provide great insight
for the surgeon who must not undertake treat-
ment in isolation.

E-mail address: mtonkin@surgery.usyd.edu.au

0749-0712/03/$ - see front matter Ó 2003 Elsevier Inc. All rights reserved.
doi:10.1016/S0749-0712(03)00095-7
 Hand Clin 19 (2003) 547–556

Etiology of cerebral palsy

Richard D. Lawson, MB, BS, FRACSa,1,
Nadia Badawi, PhD, FRACPb,c,*
a
Department of Orthopaedic Surgery, The Children’s Hospital at Westmead, New South Wales, Australia
b
Department of Neonatology, The Children’s Hospital at Westmead, Locked Bag 4001, Parramatta,
New South Wales, NSW 2145, Australia
c
University of Sydney, New South Wales, Australia

Cerebral palsy refers to a group of disorders approximately 1 in 20 survivors, or 50 times as high.

of the central nervous system characterized by
aberrant control of movement or posture, present
since early in life and not the result of recognized
progressive disease. The motor abnormalities that
define cerebral palsy often are accompanied by
other neurologic problems, including cognitive
impairment, seizure disorders, and impairments in
vision, hearing, or speech [1–5].
Little first attributed cerebral palsy to a difficult
birth in 1843 and this view remained current for
nearly 150 years [6]. Current thinking implicates
perinatal asphyxia in less than 5%–10% of cases.
The alternative view proposed by Freud, that
cerebral palsy could be a manifestation of ab-
normal fetal development [7], now is given more
emphasis. Most children with cerebral palsy are
born following uncomplicated pregnancies and
normal deliveries, with no evidence of fetal dis-
tress or immediate neurologic impairment [8].
The prevalence of cerebral palsy is approxi-
mately 1.0–2.5 per 1000 live births and is strongly
influenced by gestational age and birthweight.
Although cerebral palsy occurs in less than 1 per
1000 survivors for whom the birthweight was
>2500 g, in early preterm children this rate is
1
Present address: Discipline of Pediatrics and Child
Health, University of Sydney, New South Wales, NSW
2145, Australia.
* Corresponding author. Department of Neonato-
logy, The Children’s Hospital at Westmead, Locked Bag
4001, Parramatta, New South Wales, NSW 2145,
Australia.
E-mail address: nadiab@chw.edu.au (N. Badawi).
0749-0712/03/$ - see front matter Ó 2003 Elsevier Inc. All rights reserved.
doi:10.1016/S0749-0712(03)00040-4
Although they carry a much lower individual risk,
infants born at or near term account for at least half
of all cases of cerebral palsy [9]. Continuing
improvements in obstetric and neonatal care, which
have resulted in significant reductions in intra-
partum hypoxia-related perinatal death, have not
been associated with any consistent decrease in the
rate of cerebral palsy in term infants [10].
Etiology of cerebral palsy
Many risk factors for cerebral palsy have been
described in the preconceptional, antepartum,
intrapartum, and postneonatal periods. Because
the final presentation may be the same regardless of
when the damage occurred, however, the etiology
in any given case is often difficult to ascertain [11].
Preconception risk factors
Some maternal conditions are associated with
a significantly greater risk for cerebral palsy in the
offspring.
Neurologic disorders
Women with seizure disorders are at increased
risk for cerebral palsy, stillbirth, microcephaly,
intellectual disability, and seizures in their off-
spring. Maternal intellectual disability and neu-
rologic and neuromuscular disorders also are
associated with neurologic abnormality in the
offspring, including cerebral palsy [9,12–14].
Infertility treatment
There is evidence to suggest an increased risk
for cerebral palsy associated with in vitro
548 R.D. Lawson, N. Badawi / Hand Clin 19 (2003) 547–556

fertilization (IVF) [15]. Stromberg et al per- Antepartum risk factors

formed a population-based retrospective cohort
Other antepartum maternal medical conditions
study in which the investigators compared
that are associated strongly with cerebral palsy
neurologic problems in 5680 children born after
include severe pre-eclampsia and bleeding in
IVF, with 11,360 matched controls. The most
pregnancy (particularly placental abruption and
common neurologic diagnosis was cerebral palsy,
placenta previa) [30,31]. The mechanism of injury
for which children born after IVF had an overall
of these conditions is uncertain but may be
increased relative risk of 3.7 (2.0–6.6). These risks
mediated in some situations through antepartum
were mostly because of the high frequency of
fetal hypoxia. Placental pathology and polyhy-
twin pregnancies, low birthweight, and prematu-
dramnios also are associated with an increased
rity in this group. Even IVF singletons have
risk for cerebral palsy [32].
a relative risk for cerebral palsy of 2.8 (1.3–5.8),
however, compared with non-IVF singletons [16].
Antepartum infection
To limit these risks, the authors recommend that
There is increasing interest in the role of
only one embryo should be transferred during
infection in the etiology of fetal brain pathology
IVF.
[33]. Damaging systemic infections, including
It is of interest in this context that a positive
toxoplasmosis, rubella, cytomegalovirus, and lis-
association also has been noted between cerebral
teriosis [9] are well recognized and attention is being
palsy and abnormally long or short menstrual
focused now on the role of ascending genitourinary
cycles, intervals of more than 3 years or less than 3
infection. In term or near-term infants, markers of
months between pregnancies, and previous spon-
infection are associated with an estimated nine-fold
taneous abortion and still birth [17].
increase in the risk for spastic cerebral palsy [34].
Intrauterine infection is also an important
cause of preterm birth. Many studies in preterm
Thyroid disease
infants have found markers of infection to be
Thyroid disease in the mother has been
associated with cerebral palsy. Evidence of in-
associated consistently with an increased risk for
fection or inflammation is so common in preterm
cerebral palsy in the infant. Other adverse
birth that it is hard to separate its contribution
neurologic outcomes including schizophrenia
from the effect of prematurity itself [35–38].
and suboptimal neuropsychologic development
[18–20] also have been described. Follow-up data
Pre-eclampsia
from the Australian Collaborative Trial of Ante-
Maternal pre-eclampsia is a consistent risk
natal Thyrotropin Releasing Hormone have
factor for cerebral palsy in term infants. Severe
suggested a link between the administration of
pre-eclampsia was associated strongly with term
antenatal thyrotropin-releasing hormone and de-
newborn encephalopathy in a population-based
velopmental delay at 1 year of age [21].
study [27]. There has been recent controversy
This link is biologically plausible. Thyroid
about the role of pre-eclampsia in preterm births,
hormones and iodine play an essential role in
however. In these infants, cerebral palsy was less
the development of the nervous system, including
common in births following pre-eclampsia than in
cerebral neurogenesis and migration and myelo-
other causes of preterm birth. There are several
genesis [22,23]. Because the fetal thyroid does not
possible reasons for this, including the planned
produce substantial amounts of thyroxine until
nature of most preterm births complicated by pre-
mid gestation [24], it is possible that relative
eclampsia, which allows time for steroids and
under-replacement in hypothyroid women may
appropriate in utero transfer, and the potentially
compromise the amount of thyroid hormone
more damaging nature of many other precursors
reaching the fetus at crucial stages of early
of preterm birth, such as abruption, chorioam-
neurologic development. Severe iodine deficiency
nionitis, and cord complications [39,40].
resulted in a cluster of spastic diplegia and deaf
mutism in Papua New Guinea [25].
Infant characteristics associated with
Thyroid disease in pregnancy is one of the
cerebral palsy
strongest independent risk factors for newborn
encephalopathy with an odds ratio of 9.7 (95%CI, Gestational age
1.97–47.91) [26–28]. Newborn encephalopathy Animal studies have shown that the post-term
often precedes cerebral palsy [29]. fetus is more vulnerable to asphyxia, a finding of
 R.D. Lawson, N. Badawi / Hand Clin 19 (2003) 547–556
particular significance in the context of the recent
debate about the merits of induction at 41 weeks’
gestation [41,42]. The capacity of the fetus to
recover from an insult also is believed to be
strongly associated with gestational age, with
post-term infants having a lesser capacity for
recovery [42].
The prevalence of cerebral palsy among pre-
mature infants increased during the 1970s and
1980s, although it has stabilized in recent years in
developed countries. The initial increase may have
been related to increasing survival among pre-
mature infants with postnatal damage, whereas
ongoing improvements in perinatal and neonatal
intensive care probably have contributed to the
recent stabilization in rates [9].
Cerebral palsy in premature infants currently is
believed related to cerebral ischemia and inflam-
mation. Premature infants are more likely to be
exposed to events that predispose to systemic
hypotension and also are less able to compensate
for these episodes of hypotension because of
impaired autoregulation. Many investigators have
noted a strong association between cerebral palsy
in premature infants and chorioamnionitis, ante-
natal infection, and neonatal sepsis [43].
Cytokines produced in response to maternal
and fetal infection/inflammation can exert direct
toxic effects on cell function, differentiation,
interaction, and indirect effects by way of the
induction of fetal hypotension and disseminated
intravascular coagulation. Periventricular leuko-
malacia is a common finding in patients with
cerebral palsy and is associated strongly with fetal
sepsis and elevated levels of inflammatory cyto-
kines (IL-6 and TNF-a) in the blood and amniotic
fluid of preterm infants [44,45]. These inflamma-
tory mediators may be a final common pathway
to neurologic injury for a variety of pathogenic
disorders.
Antenatal steroids are used in women who are
anticipated to go into premature labor to accel-
erate fetal lung maturity. Another benefit of this
therapy is a reduced risk for cerebral palsy, with
a 50% reduction in white matter damage and
a 30% reduction in the risk for cerebral palsy [46].
Conversely, there is accumulating evidence that
multiple doses of antenatal steroids and lengthy
postnatal exposure to steroids may be harmful to
neurologic development [47,48].
Multifetal gestation
Twins are more likely to be born prematurely
than singletons and to have lower birth weights.
549
When one twin dies in utero, the risk for cerebral
palsy is increased markedly in the surviving twin.
Multiple gestation seems to be an independent risk
factor for cerebral palsy, with the rate of cerebral
palsy increasing with the number of fetuses.
Triplets have a cerebral palsy rate of 28/1000
survivors, compared with 7.3/1000 in twins and 1.6/
1000 in singletons. This is becoming increasingly
important with advancing maternal age and in vitro
fertilization, which are associated with multiple
gestation [49–51].
Growth restriction
In all animal species, survival correlates with
percentile birth weight, with neonatal survival
greatest among infants whose birth weight is
slightly greater than the population average [52–
55]. Many investigators have described an associ-
ation between intrauterine growth restriction
(IUGR) and cerebral palsy and newborn seizures
[56–59]. Intrauterine growth restriction may in-
crease the susceptibility of the fetus to asphyxia
during labor, and these fetuses are also at higher
risk for intrauterine death [57,60]. There can be
little doubt that for many growth-restricted infants,
however, cerebral injury has occurred before the
onset of labor. An insult severe enough to have an
adverse impact on growth also is capable of
affecting intrauterine cerebral development.
Growth restriction thus may have a direct effect
on cerebral development, be an indicator of
a separate damaging event that also affected
growth, or be part of a syndrome that affects
growth and cerebral function.
IUGR also is predictive of other subsequent
neurodevelopmental disability, such as global
developmental delay, learning disability, and
psychiatric disorders. These sequelae are more
frequent in the presence of other associated
antepartum complications [61,62].
Gender
Many studies have noted the preponderance of
males affected by cerebral palsy and intellectual
disability [63]. These findings warrant further
genetic and biologic investigation, as they may give
clues to causation. Investigation along this line
already has yielded results, with identification of
sex-linked conditions such as the Fragile X
syndrome. In addition, it has become apparent
that there are differences in myelination rates
between male and female fetuses. The significance
of this in the etiology of neuropathology has yet to
be determined.
550 R.D. Lawson, N. Badawi / Hand Clin 19 (2003) 547–556
Placental pathology
Because the placenta is the direct link between
mother and fetus, the idea that it may yield
important etiologic and prognostic information
for the management of the sick newborn is an
appealing one [64].
Small placental size has been linked with
subsequent cerebral palsy, whereas placental
infarcts have been shown to correlate with
prenatal cerebral ischemic lesions in stillborn
infants [65]. In any particular patient, placental
pathology also may give a clue to the etiology of
cerebral palsy or encephalopathy by revealing
such clues as evidence of sepsis, retroplacental
bleeding, vasculitis in autoimmune diseases, or
placental vascular malformations [64,66]. Other
significant findings include evidence of extensive
infarction in conditions such as pre-eclampsia,
systemic lupus erythematosus, maternal or fetal
thrombophilias, and cord abnormalities such as
true knots.
Birth defects and genetic factors
There is a high rate of birth defects among
children with cerebral palsy and newborn enceph-
alopathy [67], and abnormalities of the central
nervous system are particularly common. A recent
study of Californian infants found that birth
defects occurred in 19.2% of children with cerebral
palsy and 4.3% of control children [68]. The high
rate of birth defects in children with cerebral palsy
has prompted some pediatric neurologists to
recommend that patients with neonatal encepha-
lopathy should have perinatal MRI of the brain,
which may reveal neurodevelopmental lesions
such as cerebral dysgenesis [69]. Non-neurologic
birth defects are more common in infants with
cerebral palsy. This raises the possibility that an
insult that occurs at a time during which a partic-
ular organ system is vulnerable, causing maldevel-
opment of that system, also may be sufficient to
affect cerebral development or function. This may
occur with or without a recognizable structural
lesion in the central nervous system.
Genetic causes
McHale found that approximately 2% of
cerebral palsy cases in Swedish and English
populations were attributable directly to genetic
factors. Athetoid and ataxic variants of cerebral
palsy are particularly likely to have a genetic basis.
Inheritance is typically autosomal recessive, but
autosomal dominant and sex-linked syndromes
have been noted. A gene for symmetric spastic
cerebral palsy has been mapped to chromosome
2q24-25 [70].
The thrombophilias
A recent study of children with cerebral palsy
demonstrated significant differences in the levels of
cytokines and autoimmune or coagulation factors
in the cord blood of these infants compared with
control subjects [71]. These findings raise the
possibility that abnormalities of coagulation in
the fetus may result in antepartum or perinatal
brain damage. The most common of these disor-
ders is the factor V Leiden mutation, found in
approximately 6% of Caucasian populations.
Alone, the Leiden mutation is associated with
a low level of risk, but with the addition of other
genetic or acquired risk factors, the risk increases
markedly. Other coagulation disorders may coexist
in affected individuals, suggesting that several risk
factors may need to be present to cause neurologic
damage. In this study, children with cerebral palsy
who also carried a coagulation disorder were more
likely to have additional pregnancy complications
than other children with cerebral palsy. These
included pre-eclampsia, fetal growth restriction,
low Apgar scores, neonatal seizures, and a diag-
nosis of asphyxia during birth [71,72].
The link between thrombophilias and cerebral
palsy may result directly from central nervous
system infarction [73] or indirectly through pla-
cental infarction with the consequent release of
vasoactive compounds into the fetal circulation.
These findings are particularly exciting because
these conditions are potentially open to therapeu-
tic intervention and may represent an avoidable
pathway to neurologic injury.
The intrapartum period
Labor is the period of most intensive scrutiny
during pregnancy. There is, however, a wide range
of ‘‘expert opinion’’ as to what constitutes the
normal range of labor events. There is now an
expectation by the community that pregnancy will
result in a normal outcome. If the course of labor
deviates from a perceived norm, there is often an
assumption that events observed during this time
were causally related to the outcome. This perva-
sive belief, accurate in only a minority of cases, has
had a profound effect on medical practice.
Factors in the intrapartum period that have
been studied for association with cerebral palsy
include intrapartum fever, acute intrapartum
events, fetal malposition, the mode of delivery,
meconium-stained liquor, and hypoxia.
 R.D. Lawson, N. Badawi / Hand Clin 19 (2003) 547–556
Intrapartum fever
Maternal pyrexia in labor is associated with
a significantly increased risk for cerebral palsy in
infants with a birthweight >2500g (adjusted OR
3.3; 95% CI, 1.4, 8.1) [34]. Fever may represent
infection of mother or infant, but can occur in the
absence of an obvious source or identified organ-
ism. The association with cerebral palsy may be
mediated directly by fetal infection or indirectly
through inflammatory cytokines that cause the
fever. In animal studies, fever per se, without
underlying infection, has been associated with the
development of metabolic acidosis and hypoxia
[74].
Acute intrapartum events
Labor is an inherently unstable condition, with
the fetus called on to survive substantial periods
of hypoxia and ischemia as part of the normal
course of labor. The fetus has many mechanisms
to protect itself in these circumstances, such as the
capacity to extract oxygen from maternal blood
at low partial pressures, redundancies in placental
surface area for diffusion, and the capacity to
redirect cardiac output to the cerebral circulation
to protect the brain. The result is that the fetal
central nervous system is able to tolerate low
partial pressures of oxygen for extended periods
of time [75]. There are occasions, however, in
which catastrophic events can overwhelm the
fetus’ protections. These include placental abrup-
tion, cord complications (eg, prolapse or tighten-
ing of true knots), uterine rupture, or hypertonic
uterine contractions. In these circumstances even
a well nourished fetus may sustain damage. In
a fetus with an underlying compromise, the
reserve to cope with normal labor or its compli-
cations may be diminished greatly. It seems clear
that some fetuses, because of good reserve,
tolerate even severe complications and emerge
unscathed, whereas in others even normal labor
may cause or exacerbate damage. Though this
subgroup of cerebral palsy may be fairly small, it
is of vital importance because it is potentially
avoidable.
Malposition
Malposition is a common complication of
pregnancy and labor. Although it is known that
nonvertex fetal presentations are associated with
cerebral palsy, it remains uncertain whether this
relationship is causal, as the abnormal lie may
itself be a manifestation of pre-existent fetal
hypotonia [17,76].
551
Mode of delivery
Caesarean section does not seem to decrease
the prevalence of cerebral palsy in fetuses judged
to be at risk from abnormalities in fetal heart rate
monitoring [76]. Cerebral palsy rates are consis-
tent across countries with westernized medical
systems despite marked disparities in the rate of
caesarean section.
The contribution of possible intrapartum hypoxia
Fetal hypoxia of some degree is common, and
perhaps even normal in labor, yet most asphyxi-
ated infants do not develop cerebral palsy [77]. It is
not known what represents excessive exposure to
hypoxia. Long-term follow-up studies linking
oxygen saturations and neurologic outcomes are
not available, and at present we have no means of
adequately assessing individual susceptibility [78].
With currently used methods of monitoring, it is
difficult to meaningfully define clinically significant
intrapartum hypoxia except in severe cases [79].
In practice the situation is further complicated.
The traditional markers of intrapartum hypoxia
that include low Apgar scores, the passage of
meconium, and abnormalities of fetal heart rate
have poor specificity. Moreover, none of the
current indicators of asphyxia give reliable in-
formation about the timing or duration of an
asphyxial insult, which can occur before labor and
be acute or chronic. The mere presence of
intrapartum hypoxia is insufficient to demonstrate
a causal link between that hypoxia and the
observed outcome. For many infants who later
show signs of injury, this hypoxia may be ‘‘an
innocent bystander’’ unrelated to outcome. It also
may contribute proportionally in the context of
prior compromise, with pre-existent vulnerability
sensitizing the fetus to what otherwise may have
been a nondamaging event [78,80].
Fetal intrapartum hypoxia currently is believed
to be causally involved in up to 10% of cases of
cerebral palsy, and its significance lies in that it
may be potentially avoidable. It is important to
remember, however, that even when intrapartum
hypoxia plays a primary role, it is not always
avoidable, nor necessarily evidence of incorrect
management. In an attempt to identify those cases
in which intrapartum hypoxia may have had a role
in causation, International Consensus Guidelines
were published in 1999 to define the criteria
necessary to attribute a neurologic deficit to acute
perinatal hypoxia [75]. The guidelines suggest that
three factors are essential if a perinatal hypoxic
event is to be considered as potentially causative:
552 R.D. Lawson, N. Badawi / Hand Clin 19 (2003) 547–556
metabolic acidosis, the presence of neonatal
encephalopathy, and cerebral palsy of the spastic
quadriplegic or dyskinetic type. Further guidelines
on factors that supported an intrapartum hypoxic
origin and those that made it less likely also were
included.
Kernicterus
In the past, Rhesus isoimmunization was
a major cause of hemolytic disease of the newborn,
which can result in significant deposits of bilirubin
in the developing brain, a potent cause of cerebral
damage and subsequent kernicterus. The advent of
anti D has reduced markedly the burden of Rhesus
disease, although there have been several reports
of kernicterus in the United States, possibly related
to early discharge programs [81].
Postneonatally-acquired cerebral palsy
Postneonatal factors, such as meningoenceph-
alitis, head injury, cerebrovascular accidents, near
drowning, and nonaccidental injury now are
believed to account for 15% of cases of cerebral
palsy, a proportion that seems to be increasing in
recent years [9].
Prevention
Medical management
Infection, autoimmunity, coagulation, and
thyroid disorders are problems for which modern
medicine has therapeutic tools; however, screen-
ing and management strategies that optimize
neurologic development of the fetus or neonate
in these circumstances remain to be identified. The
potential benefits of any intervention must be
balanced carefully against potential risks in any
new public health policy [82].
There may be novel targets for therapy. For
example, if certain cytokines are neurotoxic, then
anticytokine therapies may be possible if at-risk
infants can be identified reliably. Use of anti-
cytokines requires great caution, however, because
of the important roles some of the cytokines play
in normal brain development, in limiting injury to
cerebral tissue and in immunologic defense [83].
Magnesium sulfate
Some studies have demonstrated a decrease in
the incidence of cerebral palsy in the children of
mothers treated for pre-eclampsia, and this has
stimulated research into possible protective effects
of magnesium sulfate, an agent commonly used in
the treatment of pre-eclampsia in many countries
[39]. Several international multicenter trials cur-
rently are examining this possibility.
Dexamethasone
Though there is evidence that the antenatal use
of fluorinated corticosteroids such as Celestone
and dexamethasone may be protective against
cerebral palsy, prolonged neonatal use may be
associated with an increased risk for cerebral palsy.
The timing and duration of treatment is yet to be
determined but is crucial, for what may be
protective in one period may well be harmful in
another.
Fetal intrapartum monitoring
It was hoped that the introduction of cardio-
tocograms would lead to a decrease in the rate of
cerebral palsy, but this has not occurred. In-
terpretation of fetal heart rates is difficult, with
a wide interobserver variability. The clinical
response to various patterns also has been shown
to be inconsistent [76]. Cardiotocographs lack
specificity, with up to 79% of tracings having
nonreassuring patterns [75]. The features that are
believed to indicate possible fetal compromise,
such as late decelerations in the fetal heart rate
after the onset of contractions and diminished
beat-to-beat variability, have a false positive rate
of 99.7%. Intervention in the form of caesarean
section on the basis of a nonreassuring fetal heart
rate pattern does not seem to reduce the risk for
cerebral palsy [84].
In a randomized, controlled trial of electronic
fetal monitoring in labor by MacDonald and
colleagues, infants who had been monitored
electronically in labor were less likely to have
neonatal seizures than those who had intermittent
auscultation [85], but there was no increased risk
for cerebral palsy in the intermittent auscultation
group at follow-up. New methods of monitoring
are being developed, including continuous fetal
oxygen monitoring and computerized cardiotoco-
graph interpretation systems. It is vital that these
systems are validated in their predictive power for
an abnormal outcome before being accepted into
clinical practice.
Summary
Cerebral palsy has a complex and multifacto-
rial etiology. Approximately 5%–10% of cases can
be ascribed to perinatal hypoxia, but the vast
majority of cases are caused by the interplay of
several risk factors and antenatal, perinatal, and
 R.D. Lawson, N. Badawi / Hand Clin 19 (2003) 547–556
neonatal events. The strongest risk factors include
prematurity and low birth weight. The prevalence
of cerebral palsy has remained constant despite
improvements in obstetric and neonatal care. For
a long time, the only causal factors explored to
account for risk for cerebral palsy were complica-
tions of labor and delivery. As other periods have
been investigated, new associations have come to
light. The current understanding of contributors to
the risk for cerebral palsy is still incomplete.
Multiple causes may interact by way of excito-
toxic, oxidative, or other converging pathophysi-
ologic pathways. A single factor, unless present to
an overwhelming degree, often may be insufficient
to produce cerebral damage, whereas two or three
interacting pathogenic assaults may overwhelm
natural defenses and produce irreversible brain
injury. The low prevalence of cerebral palsy makes
the formal testing of preventative strategies
difficult. There is a need for such strategies to be
carefully assessed in well designed, multicenter,
randomized, controlled trials before becoming
part of clinical practice, however, so that the
balance between harm and benefit is known in
advance [85,86].
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[81] Anonymous. Kernicterus in full-term infants—
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 Hand Clin 19 (2003) 557–564

General assessment of the upper limb

Caroline Leclercq, MD
Institut de la Main, 6 Square Jouvenet, Paris 75016, France
Institut de la Main, Neurological Rehabilitation Centre, Coubert 75016, France

Clinical examination procedures (eg, injections) are necessary, they

Clinical examination is the key to successful
treatment. Unlike many other conditions, there is
no standard clinical picture for spastic upper
limbs, whatever their cause, as the condition
primarily depends on the extent of the brain
damage, which can vary greatly. A careful
assessment of all parameters is therefore manda-
tory to get an accurate clinical picture of the
deficits and potentials in each patient and to treat
them accordingly.
This examination is performed with a fourfold
goal:
 Evaluate spasticity
 Evaluate the motor and sensory deficit in the
upper limb
 Evaluate the existing function and functional
needs of the upper limb
 Perform a complete general examination to
seek associated neurologic disorders and seek
contraindications to surgery
This examination is lengthy and requires
detailed knowledge of neurology, pediatrics, and
physiatry. It is best performed with all the
specialists involved in the child’s care (physiatrist,
physical therapist, occupational therapist, pedia-
trician, and surgeon). It should be done in a warm,
quiet, and friendly environment (eg, toys, adapted
furniture). Trust must be established by the
examiner at the beginning of the evaluation; this
is essential because the child’s cooperation is
mandatory for the sensorimotor evaluation and
because spasticity may increase considerably if
the child is frightened or recalcitrant. If painful
E-mail address: caroline.leclercq@free.fr
0749-0712/03/$ - see front matter Ó 2003 Elsevier Inc. All rights reserved.
doi:10.1016/S0749-0712(03)00059-3
must be left for last.
Symptoms may vary with the child’s emotional
state and fatigue level; even the weather can mod-
ify the clinical picture. Moreover, many children,
especially younger ones, cannot cooperate
throughout the entire examination and require
that this examination be fragmented. It is there-
fore not wise to decide on surgery after a single
examination, and at least a second session is
recommended to have a more accurate view of the
clinical picture. Video recording of this examina-
tion is most helpful in the decision making and in
evaluation of surgical outcome.
Resting posture of the upper limb
Inspecting the limb at rest before examination
provides information on the amount of spasticity.
It is done while the child is sitting or lying down
motionless, with his or her attention distracted
elsewhere (eg, TV, movie). If predominant,
spasticity usually leads to a resting posture in
shoulder adduction and internal rotation, elbow
flexion, forearm pronation, and wrist flexion. If it
is moderate, however, the resting posture may be
normal.
The fingers may assume varied positions when
spasticity is predominant. Most often they are
curled in a clenched fist, but they also can display
a swan neck deformity or a claw type deformity.
A boutonniere type of deformity is less common.
The thumb can assume either an adducted
posture or an adducted and flexed posture.
The adducted thumb is often in a slight retropo-
sition with the metacarpophalangeal (MP) and
interphalangeal (IP) joints extended. The flexus-
adductus thumb, often referred to as ‘‘thumb-
in-palm,’’ is embedded in the palm with full
558 C. Leclercq / Hand Clin 19 (2003) 557–564
opposition and full flexion of MP and IP joints.
Often the clenched fist is curled around the
thumb.
Any factor that aggravates spasticity increases
these deformities.
Evaluation of spasticity
Spasticity is a muscle hypertonicity defined by
five classic characteristics.
1. It is selective, predominant in flexor and
adductor muscles, and is responsible for the
characteristic flexion-pronation deformity of
the upper limb. It is usually less evident in the
shoulder and elbow and more severe in the
distal part of the upper limb.
In the shoulder it involves the adductor and
internal rotator muscles and in the elbow the
flexor muscles, predominantly the biceps
brachii and the brachialis, but possibly also
the brachioradialis [1]. The medial epicondy-
lar muscles, often spastic, are responsible for
the pronation deformity and also contribute
to the elbow flexion deformity.
The wrist flexors, especially the flexor carpi
ulnaris (FCU), are frequently the muscles
most involved by spasticity in the upper limb,
leading to a characteristic hyperflexion and
ulnar deviation of the wrist. If the finger
flexors are also spastic, they contribute to this
deformity. Spasticity of the finger extrinsic
muscles is tested by tapping briefly on the
pulps (flexors) or the nails (extensors), which
produces an exaggerated response of the
tested muscles.
In such cases, spasticity of the intrinsic
muscles of the hand is extremely difficult to
evaluate because of associated deformities.
An intrinsic-plus deformity (MP joint flexion
and IP joint extension) results from spasticity
of the interossei. A swan neck deformity
(proximal interphalangeal [PIP] joint hyper-
extension and distal interphalangeal [DIP]
joint flexion) may be the result of either
excessive traction on the extensor tendons
caused by excessive wrist flexion (extrinsic
swan neck) or to spasticity of the interossei
muscles (intrinsic swan neck), in which case it
is often associated with MP joint flexion.
Passively flexing the wrist usually reduces the
intrinsic swan neck, whereas it increases the
extrinsic swan neck. A claw-type deformity
with the MP joints hyperextended and the
PIP joints flexed usually is caused by
a combination of excessive traction on the
extensor tendons and paralysis of the intrinsic
muscles.
Thumb spasticity involves mainly the ad-
ductor pollicis, resulting in an adducted posi-
tion. When the flexor pollicis longus (FPL)
also is involved, a thumb-in-palm deformity
develops.
2. It is elastic. Attempts at stretching the
involved muscles meet with resistance, which
increases with the amount of strength applied
and which correlates with the degree of spas-
ticity. Unlike plastic contractures, the joint
returns to its initial position as soon as the
opposing force is stopped. If the opposing
force is maintained long enough, however, the
muscles usually yield, sometimes abruptly
(this is referred to as the ‘‘penknife blade’’
phenomenon). The degree of resistance to
stretching can be quantified by Ashworth’s
scale, modified by Bohannon [2].
3. It is present at rest and exaggerated with
voluntary movement, emotion, fatigue, and
pain.
4. Osteotendinous reflexes are exaggerated,
brisk, diffuse, and polykinetic. Clonus is
infrequent in the upper limb.
5. Synkineses may be associated. Synkinesis is
the phenomenon wherein paralyzed muscles,
incapable of a certain voluntary movement,
attempt to execute this movement in associ-
ation with contraction of accompanying in-
tact muscles. For example, in Souques
synkinesis, the hand displays ‘‘active’’ exten-
sion and abduction of the fingers with
voluntary shoulder abduction.
Motor assessment
Motor examination of the upper limb is not
easy in children, especially in children younger
than 5 years of age. The child should be provided
with toys of different forms and colors and should
be observed at play [3]. Each muscle or group of
muscles is evaluated for (1) voluntary motor
control, (2) fibrous contracture, and (3) joint
range of motion.
Voluntary motor control
The palsy usually predominates in the extensor
and supinator muscles and in the distal part of the
upper limb. Rather than a true paralysis, it is
a deficit in voluntary control linked with the
pyramidal tract involvement (‘‘pseudo palsy’’).
 C. Leclercq / Hand Clin 19 (2003) 557–564
Voluntary motion is often slow and may be better
in a limited range of motion.
This examination may become difficult when
the antagonist muscles are severely spastic.
Weakness generally predominates in the distal
muscles spared from spasticity (wrist and finger
extensors, abductor, and extensor pollicis longus,
and supinator muscles). The proximal muscles
(shoulder external rotators and abductors and
elbow extensors) are involved to a lesser degree.
The lack of control varies with limb position.
For instance, voluntary movement of the thenar
muscles often is facilitated by elbow extension.
In some cases, these pseudo-paralyzed muscles
may be present but made ineffective by the spastic
antagonist or by elongation caused by a severe
deformity. Such is often the case for the wrist
extensors in severe flexion deformities of the
wrist. Careful palpation of the muscle belly
during attempted active motion may confirm that
the muscle is not paralyzed but cannot give
information of its actual strength. In such cases,
an accurate evaluation of individual muscles can
be performed only after spasticity of the antag-
onists has been suppressed (see ‘‘Motor blocks’’
below).
The spastic muscles (flexor, adductor, and
pronator muscles) are also usually active, but
their voluntary movements often are impaired by
co-contractions of other muscle groups. Co-
contractions are frequent in the hand, especially
of the wrist flexors during attempted finger
flexion. They may render clinical examination
difficult. In difficult cases, motor blocks and
electromyographic studies are helpful.
Fibrous contracture
Fibrous contracture involves only spastic
muscles. Unlike spasticity, fibrous contracture is
permanent and cannot be overcome. It can be
alleviated by shortening the involved articular
segment. For example, posturing the wrist in
maximal flexion relieves fibrous contracture of the
finger flexors.
In cases of severe spasticity, however, clinical
distinction between contracture and spasticity
may be extremely difficult to establish. In such
cases, motor blocks may be helpful [4].
Motor blocks. These blocks require a percutane-
ous injection. It is recommended that they be per-
formed at the very end of the clinical examination
so the child remains confident and cooperative
throughout the whole session.
559
Motor blocks provide several types of in-
formation:
They differentiate spasticity from fibrous con-
tracture in flexor, adductor, and pronator
muscle groups
They allow assessment of individual muscles
after removing spasticity of the antagonists or
co-contractions of adjacent muscles
Within a spastic muscle group they help
determine which muscles are spastic and which
are not
Several pharmacologic agents have been used
percutaneously: anesthetics (lidocaine), diluted
alcohol [5], and phenol [6]. As the last is toxic to
surrounding soft tissues and sensory nerve fas-
cicles, it is better to approach the nerve surgically
for phenol blocks [7].
Whichever substance is used, it may be injected
either around the nerve trunk or in the motor
endplates of the involved muscles. Nerve trunks are
fairly easy to locate. Injection at this site diffuses to
other motor nerves, however, with an overlapping
response. The motor endplates of individual
muscles are much more difficult to locate and
clinicians previously relied on chart drawings [5].
This has been facilitated greatly with the use of
nerve stimulators. For intrinsic muscles in the
hand, it is practically impossible to find the motor
endplates of each individual muscle. One usually
chooses to inject the motor branch of the ulnar
nerve and, if required, the thenar motor branch.
The effect of a motor block with lidocaine
starts 15 minutes after injection and usually lasts
for half an hour. The duration of efficacy is longer
for alcohol and much longer for phenol. Spasticity
yields completely, whereas contracture persists [7].
One then can assess muscle contracture in each
muscle or muscle group. The most frequent
example in the upper limb is severe spasticity of
the wrist flexors. Following paralysis, muscles can
be tested for contracture and the finger flexors can
be assessed. Injection of a spastic pronator teres
informs of a possible contracture of the inter-
osseous membrane.
One also can test the nonspastic muscles then,
now relieved of their spastic antagonists, for
voluntary motor control. In specific cases (eg,
extensor carpi radiales muscles) the muscles are
present and do contract, but are ineffective
because of progressive lengthening over time,
secondary to a severe wrist flexion deformity.
Within a spastic group, one can perform
a selective block of the predominant spastic
560 C. Leclercq / Hand Clin 19 (2003) 557–564
muscle to evaluate voluntary control and spastic-
ity of the other muscles. For example, after
injecting the FCU, one can test flexor carpi
radialis (FCR). In the same way, after injecting
the biceps brachii, one can test the brachialis and
the brachioradialis.
Recently, botulinum toxin has partially sup-
planted motor blocks. It produces the same effects
but with a much easier technique of injection,
a lack of side effects, and a long lasting effect [8].
Injection of botulinum A within the body of
a muscle induces a paralysis that starts 10–15 days
after the injection and lasts 3–6 months [9,10].
Another article in this volume is dedicated to
botulinum toxin and describes its indications in
cerebral palsy (See article by Chin and Graham).
Whether used as a diagnostic tool for preoperative
assessment or as part of the therapeutic plan,
botulinum effectively replaces motor blocks.
Joint range of motion
Passive range of motion rarely is affected in
isolated cerebral palsy in children. It is impaired
more frequently in adults [11] and, when severe,
associated neurologic lesions coexist.
The precise range of motion of many joints
may be difficult to assess, not so much because
of spasticity, but because of muscle fibrous
contractures.
Each individual joint is tested with the in-
volved muscles fully relaxed. This is performed as
gently as possible so as not to trigger spasticity. If
fibrous contracture is present, motor blocks do
not assist in assessment of the passive range of
joint motion. Sometimes it is so difficult that
preoperative examination under anesthesia is
necessary to define the range of motion precisely.
Some joints of the fingers and thumb may have
excessive passive motion, resulting in joint in-
stability. This occurs mainly at the thumb MP
joint (hyperextension and lateral instability) and
at the finger MP and PIP joints (hyperextension).
Finally, a general motor assessment of the
upper limb is performed to evaluate global motor
control. Some standard tests are helpful, such as
the head-to-knee test, in which the patient is asked
to place his hand on his head and then move it to
the contralateral knee. The speed and precision of
the movement are recorded. These nonspecific
tests involve many of the elements susceptible to
perturbation (hypertonia and muscle contracture,
ataxia, apraxia, and extrapyramidal lesions) and
give information of the potential use of the limb
should a surgical treatment be decided on.
Primitive reflexes also are sought. They are
caused by an abnormal sensory motor develop-
ment and impair greatly the functional capacity of
the limb. One classic example of these primitive
reflexes is the asymmetric neck reflex: when the
head is turned actively or passively to one side, it
produces abduction of the shoulder and extension
of the elbow, wrist, and fingers of the ipsilateral
upper limb, whereas the contralateral limb flexes
in all joints.
Once the motor examination has been com-
pleted, an attempt at classification can be made.
Zancolli’s classification [12] is probably the most
popular one:
 Type I includes the spastic intrinsic-plus
hands, in which spasticity of the interossei
and lumbrical muscles causes flexion of the
MP joints and extension of the IP joints,
sometimes associated with a swan neck
deformity. In this type a wrist flexion de-
formity is rare.
 Type II includes the spastic flexion-pronation
hands with (hyper)flexion of the wrist and
pronation of the forearm. Three groups are
individualized depending on the degree of
active finger extension. In the first group, with
the wrist in neutral or near neutral, there is
full active extension of the fingers. In the
second group there is nearly complete active
extension of the fingers, but only with some
degree of wrist flexion. This group is sub-
divided further based on the presence (sub-
group A) or absence (subgroup B) of active
wrist extension. In the third group there is no
active finger extension, even with maximum
wrist flexion.
Goldner [4] has produced another classifica-
tion:
 In group I the wrist and MP joint can be
extended at least to neutral. There is active
grasp and release. The main deficiencies are
delayed speed, slow coordination, and mini-
mal dexterity.
 In group II there is weakness of wrist and
finger extension with mild contracture of the
wrist, finger, and thumb flexors. The thumb
remains in the palm during hand extension.
The hand is used only as an assist and
a stabilizer.
 In group III the wrist and finger flexors are
contracted severely. The primary goal of
surgery is cosmetic improvement.
 C. Leclercq / Hand Clin 19 (2003) 557–564
 In group IV the hands are spastic and
athetoid.
House [13] has classified thumb deformities in
four types:
 Type I is an isolated adduction of the first
metacarpal.
 Type II is adduction of the first metacarpal
with flexion of the MP joint.
 Type III is adduction of the first metacarpal
with MP joint hyperextension.
 Type IV is adduction of the first metacarpal
with flexion of MP and IP joints.
Aside from the thumb classification of House,
which is purely descriptive, the author does not
find any of the available classifications particularly
helpful, as the clinical picture always varies from
one child to another, depending on the amount
and extent of spasticity and paralysis. There are no
two identical cases and often they do not fit
accurately in any of the described categories.
Sensory examination
Sensory examination requires, besides the
child’s cooperation, a certain level of intellectual
capacity and language ability. It is practically
impossible in the small child; it becomes feasible
at age 4–5 years, and more complicated tests such
as two-point discrimination become reliable only
at age 6–7 years.
The basic sensory functions (light touch, pain,
temperature) are essentially intact in cerebral
palsy, whereas complex sensations (epicritic sen-
sibility, proprioception, gnosis) are affected more
severely.
Light touch is explored with a smooth point or
a finger, pain with a needle, and temperature with
tubes of hot (40 C) and cold (melting ice) water.
Epicritic sensibility is explored with discrimina-
tory tests such as two-point discrimination.
Proprioception is tested by vibration (tuning
fork) and by the sense of position of the limb: the
patient is blindfolded, has the unaffected limb
placed in one position and is asked to reproduce
the position with the affected limb. Proprioception
is usually more disturbed in the distal part of the
limb.
Gnosis is most affected. Placing an object in
the child’s hand and asking him or her to identify
it tests stereognosis. Graphesthesia is tested by
drawing figures or forms in the patient’s palm.
Sensation is considered satisfactory when the
child identifies at least three out of five objects,
561
can recognize large figures drawn in the palm,
and has a two-point discrimination test of no
greater than 5-10 mm (according to the child’s
age) [14].
Pain may be present but is difficult to evaluate,
especially in children who may not report it and
may not know how to describe it. It may be linked
to severe contractures or to a deformed joint.
Other causes of pain should be considered. For
example, the author has treated a young adult
with CP with wrist pain caused by Kienböck
disease, perhaps related to the severe flexion
deformity of his wrist [15].
Functional examination
This part of the examination tests the actual
use of the upper limb. It is done with standard
reproducible tests using a pre-established scenario
and simple objects.
It should be video recorded. This usually
proves to be a great assessment tool, as it can be
visualized as many times as necessary without
necessitating the child’s presence and cooperation.
The same tests and video recording are repeated
after surgery and serve as a comparison for
evaluation of the results of surgery.
Grasping tests
Handing objects to the child tests prehension.
Thumb-finger pinch often is limited to a lateral
(key) pinch because of the lack of fine voluntary
control and because of the adducted posture of
the thumb. Grasp generally is preserved, although
not always functional because of finger flexor
contractures, extensor weakness, and wrist flexor
co-contractions. Release often proves difficult
because of weakness of active finger extension.
The pick up and release test is done with
several objects of different size and shape dis-
played on a table in front of the child, asking him
or her to pick up each of them and displace it to
a different spot. This test evaluates not only the
prehensile capacity of the hand but also the
contribution of the whole limb to that function.
Quantitative measurements can be made if one
introduces the time factor.
Many different tests have been described for
this assessment. In the ‘‘Box and Block Test,’’ the
patient moves as many wooden blocks as possible
from one compartment to another in 1 minute
[16]. Enjalbert’s test [17], designed for stroke
patients, involves grabbing a pen presented 40 cm
away from the involved upper limb and handing it
back to the examiner.
562 C. Leclercq / Hand Clin 19 (2003) 557–564
Instrumented objects have been used more
recently in an attempt to quantify hand grasp.
Computerized systems of movement analysis now
allow analysis of the different sequences of motor
events and captors integrated in gloves can
measure the forces generated by grasp [18,19].
Bimanual activities
These give accurate information of the spastic
upper limb’s actual functional ability. Several tests
can be used, such as carrying a container with two
handles, holding one object into which another
one should be placed (eg, envelope and letter, nest
of dolls) or holding a ruler while drawing a line
with the other hand.
Questionnaire
The child and family are asked to describe
precisely how the hand is used in activities of daily
living, such as dressing, self-care, and eating. This
can be done in the form of a questionnaire that
must be adapted to the child’s age. The question-
naire can be completed during the session or given
to the child and family to be completed at home
(self-questionnaire). In many cases the upper
extremity is neglected by the child despite
functional capacity. In these cases it is possible,
if not probable, that the child persists in ignoring
the limb even if functional ability can be improved
by surgery.
There are several validated nonspecific ques-
tionnaires evaluating hand function (Michigan
Hand Outcome Questionnaire [20]. To the best of
the author’s knowledge, however, there is no
validated questionnaire adapted to the cerebral
palsied child.
Tests
Many tests have been designed to assess the
functional value of the upper limb. Among the
nonspecific tests, only those testing the simplest
functions can be used in patients with CP
(Frenchay Arm Test, with only five items [21],
Jebsen test, with seven items [22]).
There are few tests specifically designed for the
spastic upper limb [4]. The ‘‘400 points’’ test [23],
which analyzes mobility, grip strength, pick up
and release, and bimanual function, can be used in
children starting from 7 years of age. In children
younger than 7 years, Rumeau et al [24] use
a bimanual test adapted to each age group.
The author’s group has chosen to use that
described by Hoffer [14], which tests dressing,
personal hygiene, feeding, bimanual activities,
grasp and release, and lateral pinch.
General preoperative examination
The aim of this general examination is to
evaluate the real benefit the child will get from
surgery, taking into account other neurologic
impairments, the patient’s age, intelligence, moti-
vation, and environment.
Other neurologic impairments
As these children are hemiplegic, the lower
limb deficit also must be assessed. It is especially
important to know about the child’s walking
ability and the possible need for walking aids (eg,
crutch, wheelchair). If operations are necessary
for improvement of the lower limb, they usually
are planned before upper extremity surgery.
Associated extrapyramidal signs also should be
detected. These include the following:
 Athetosis, which consists of unexpected,
nonvoluntary movements causing a slow os-
cillation of the limbs. It is reduced at rest,
abolished at sleep, and increased by noise,
fatigue, and emotions.
 Chorea consists of brisk, rapid, and anarchic
nonvoluntary movements of variable ampli-
tude that can involve all territories. In the
upper limb these contortions of the forearm,
hand, and fingers make activities of daily
living impossible.
 Parkinson syndrome is characterized by the
classic triad: resting tremor, plastic hyperto-
nia (predominant in the proximal muscles)
with the cogwheel sign, and akinesia.
If these extrapyramidal signs are predominant,
they preclude surgical treatment, because the child
is unable to use the hand because of these
nonvoluntary movements. When they are mild,
surgery may be performed when indicated.
The capacity of the child to communicate must
be evaluated, seeking visual, hearing, and lan-
guage deficits. Behavioral problems, such as
irritability, inability to concentrate, and emotional
instability, also may constitute contraindications
to surgical treatment if they predominate. In-
telligence is evaluated through the intelligence
quotient (IQ). It usually is stated that rehabilita-
tion surgery is not indicated when the IQ is lower
than 70, but this is not absolute. Surgical
procedures, aimed at improving comfort, cosme-
sis, and personal hygiene, still are indicated [25].
Age
Because the neurologic deficit in cerebral palsy
is not progressive, early surgery can be planned.
 C. Leclercq / Hand Clin 19 (2003) 557–564
Sometimes it is necessary to operate very early
because of an increasing deformity. In most cases,
however, one can wait until the child is old
enough that motor and sensory capacities can be
evaluated accurately and he or she can cooperate
with surgery and the postoperative rehabilitation.
Sequelae of cerebral palsy in adults should be
evaluated cautiously before surgical planning,
because usually the patients have adapted already,
functionally and socially, to the handicap, and
surgery may be more disturbing than beneficial
[26].
Motivation and environment
Evaluation of motivation should take into
account the patient’s ability to understand the
modalities and benefits of the proposed treatment
and to participate actively in the postoperative
regimen. Understanding and motivation on the
part of the parents are also mandatory. Environ-
mental factors during the surgical period are also
important, such as a rehabilitation center with an
integrated school system and physiotherapists
experienced in the management of children with
CP. All are necessary components of the pre-
operative evaluation.
According to Tonkin [27], ‘‘the ideal candidate
is a cooperative 6-year-old child, with stable
family support, who has a predominantly spastic
upper limb deformity, with satisfactory hand
sensibility, hemiplegic or monoplegic and without
significant neurological deficits.’’
Electromyography
EMG studies are often helpful. Static and
dynamic studies are necessary, but they require
cooperation on the child’s part [28]. This may be
difficult to achieve in children younger than 5
years of age.
In spastic muscles, EMG studies give informa-
tion on the voluntary control, the possibility of
relaxation, and possible co-contractions with
another active movement. This is of the utmost
importance when planning a tendon transfer, as
a spastic muscle may be considered for potential
transfer only if it displays satisfactory relaxation
at rest and no co-contraction with other voluntary
movements [28].
In other muscles, EMG studies are able to
identify voluntary control that is not clinically
detectable, for example, when spastic or retracted
antagonists, joint deformity, or stiffness prevent
functional contraction. EMG studies can help in
563
determining the most appropriate muscles for
transfer.
Radiography
Radiographs are part of the preoperative
evaluation. They are aimed at assessing any
growth disturbance and joint deformity linked to
the spasticity. Satisfactory assessment, however,
may not be easy when there is a severe deformity
such as wrist hyperflexion. Contralateral views in
the same position may be helpful then. In such
cases, standard radiographs may reveal growth
disturbances of the distal radius and ulna and the
carpus. They also may reveal avascularity of the
lunate (Kienböck disease) [15]. In the elbow there
may be a rare dislocation of the radial head
[29,30].
Summary
Clinical examination of the upper limb of
a spastic patient is a lengthy and somewhat
complicated procedure that is best performed
together with all the practitioners involved in the
child’s care. It should be repeated before any
decision is made regarding treatment.
Standard procedures in surgery of the upper
limb in cerebral palsy are not appropriate, as the
clinical picture is different for each individual
patient. Surgery should be aimed at correcting
spasticity, muscle/joint contracture, and motor
deficit as required. All these elements there-
fore must have been assessed carefully before
treatment.
Finally, clinical examination detects all local
and general contraindications to surgery and
selects the appropriate candidates.
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[11] Sherk HH. Treatment of severe rigid contractures
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of hand surgery. 2nd edition. Philadelphia: JB
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approach to the thumb-in-palm deformity in
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AAOS Instructional Course Lecture. St Louis:
Mosby; 1979. p. 133–7.
[15] Leclercq C, Xarchas C. Kienböck’s disease in
cerebral palsy. J Hand Surg 1998;23B:746–8.
[16] Mathiowetz V, Volland G, Kashman N, Weber K.
Adult norms for the Box and Block Test of manual
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[21] Heller A, Wade DT, Wood VA, Sunderland A,
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[22] Jebsen RH, Taylor N, Trieschmann RB, Trotter
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[23] Gable C, Chau N, Xenard J, Andre JM. Accords
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[24] Rumeau F, Moras F, Jelezkoff C, Ehret I.
Appareillage du membre supérieur opéré et non
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[25] Mital MA, Sakellarides HT. Surgery of the upper
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Tubiana R, editor. The hand. Vol IV. Philadelphia:
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[29] Pletcher DF, Hoffer MM, Koffman DM. Non-
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 Hand Clin 19 (2003) 565–571

Functional assessment aided by motion

laboratory studies
Ann E. Van Heest, MD*
Department of Orthopedic Surgery, University of Minnesota, 2450 Riverside Avenue South R200,
Minneapolis, MN 55454, USA
Hand Surgery Section, Gillette Children’s Specialtycare Hospital, Shriner’s Hospital–Twin Cities Unit,
Minneapolis, MN 55414, USA

Cerebral palsy is a primary central nervous
system (CNS) dysfunction that can lead to
significant functional impairment because of its
secondary peripheral manifestations in the upper
extremity. Depending on the size and location of
the central nervous system insult, the peripheral
manifestations can vary and need individual
assessment. This article deals with the assessment
protocol necessary for formulation of appropriate
treatment plans.
In summation of the evaluative process, the
physician needs to assess mentation, motivation,
sensibility testing, and static and dynamic de-
formities with their resultant functional impair-
ments, to synthesize an overall treatment plan,
taking into account the child’s capabilities, dis-
abilities, and potential in the context of the child’s
age. Discussion with the parents and the child
is imperative in formulating the individualized
treatment plan and its expected outcome.
Purpose of evaluation
If a child first presents to the hand surgeon with
complaints of delayed development of normal
pinch and grasp function and does not yet carry
a diagnosis of cerebral palsy, this occurs most
commonly at approximately 1–2 years of age. In
this scenario, a complete neurologic evaluation is
necessary, including evaluation of their lower
* Department of Orthopedic Surgery, University of
Minnesota, 2450 Riverside Avenue South R200, Min-
neapolis, MN 55454, USA.
E-mail address: vanhe003@tc.umn.edu
0749-0712/03/$ - see front matter Ó 2003 Elsevier Inc. All rights reserved.
doi:10.1016/S0749-0712(03)00058-1
extremities; the purpose of the evaluation is to
confirm a diagnosis of cerebral palsy.
In most other scenarios, the purpose of the
hand surgeon consultation is for management of
upper extremity deformity after the diagnosis of
cerebral palsy has been made. The hand surgeon
must continue to work with the other members of
the patient’s care team (eg, rehabilitation physi-
cians, neurologists, neurosurgeons, orthopedic
surgeons managing the lower extremity care, and
physical and occupational therapists) to maintain
a multispecialty approach that coordinates ser-
vices for the patient appropriately. Associated
issues can include mental retardation, seizures,
speech disorders, lower extremity involvement
that affects mobility issues, and timing/coordina-
tion with lower extremity surgeries.
The hand surgeon most commonly is asked to
evaluate the patient for appropriate treatment
interventions to improve the child’s use and
appearance of the arm. Initial evaluation may be
more comprehensive to include all aspects of the
evaluation (as described later) or may be more
limited in the very young child or the child with
very limited function. For example, a noncommu-
nicative quadriplegic spastic teenager with totally
dependent care would have a more limited ex-
amination consisting mostly of history with the
caregivers and physical examination documenting
passive range of motion only (if little active motion
exists). In a highly functioning spastic hemiplegic
9-year-old patient with wrist flexion deformity,
however, a fairly comprehensive examination
should be performed to evaluate whether the pa-
tient would be a good candidate for surgical in-
tervention and for surgical management planning.
566 A.E. Van Heest / Hand Clin 19 (2003) 565–571
The purpose of subsequent yearly or biyearly
monitoring visits with the hand surgeon is to assess
for development of contractures and overall de-
velopmental progress regarding age-appropriate
use of the arm. For example, infants are assessed
for their ability to bear weight on the arm for sitting
and crawling; young children are assessed for
bimanual gross motor skills such as dressing and
ball catching; school age children are assessed for
fine motor skills such as buttoning and shoe tying;
all children are assessed for development of
contractures with growth. If failure to meet de-
velopmental milestones is encountered, a specific
therapy protocol is instituted to help keep the child
as close to ‘‘on target’’ as their physical disabilities
allow. Therapists are in a unique position to
develop a relationship with the family and child
in patient education regarding use patterns and
adaptive patterns; therapists are a key source of
information as to whether the child is making
appropriate developmental progress.
General classification
Cerebral palsy commonly is classified by topo-
graphic involvement. Topographic involvement
means the number of limbs involved: monoplegia
(one limb), hemiplegia (one arm, one leg), diplegia
(both legs), triplegia (three limbs), quadriplegia
(both arms and both legs), and total body in-
volvement (quadriplegia with mental retardation).
The type of muscle tone disorder clinically
manifested further classifies the disorder; mani-
festations of central nervous system dysfunction
can include spasticity, dystonia (athetosis), flac-
cidity, or mixed. The amount of central nervous
system control of the peripheral muscles is vari-
able and needs to be assessed specifically as part of
the patient evaluation.
Patient evaluation
History
Because cerebral palsy is associated with low
birth weight and prematurity, associated medical
problems should be noted, particularly seizures
and mental retardation, as indicators of more
global CNS involvement. Developmental motor
delays should be assessed. Past history should
include birth history, medical problems, past
surgical history, medications, and social history,
including the child’s educational situation.
Functional use of the limb needs to be assessed
next. The parent and child (if old enough) should
be interviewed regarding use of the affected limb.
Most commonly children with spastic hemiplegia
show premature hand dominance favoring the
unaffected side even as young as 6 months of age;
this may be the presenting complaint leading to
the diagnosis. Generalized patterns of upper
extremity use for activities of daily living, com-
mensurate with the child’s age, are discussed
with the parents and child, specifically inquir-
ing about necessary bimanual skills such as cut-
ting meat, tying shoes, zippering, buttoning, and
sports. Often parents complain that the child
never uses the hand at all, but this needs to be
verified by observation and assessment.
Physical examination
Physical examination begins with evaluation for
static deformity by examining the limb for passive
range of motion of the shoulder, elbow, forearm,
wrist, and hand, evaluating for joint contractures
and shortening of the muscle-tendon units. Passive
range of motion needs to be done slowly to
overcome muscle tone. If there is full passive
mobility of the joints and muscle, no contracture
exists. If there is loss of passive range of motion,
then a joint or muscle contractures exists. Most
commonly muscle and joint contractures coexist as
shown in Fig. 1, but may occur separately as shown
in Fig. 2. The finger flexor muscles are biarticular
muscles, meaning they cross over more than one
joint (the wrist joint and the finger joints).
Positioning of the wrist joint in flexion thus allows
full finger extension if there is no finger joint
contractures; however, positioning of the wrist
joint in extension does not allow full finger
extension if there is finger flexor muscle contrac-
ture. This is analogous to the intrinsic tightness test.
Active range of motion is assessed next,
including specific muscle testing for voluntary
motor control of antagonist muscles. This is
particularly important for muscles that are
considered for tendon transfer, such as the pro-
nator teres (for pronator teres rerouting), the
flexor carpi ulnaris, extensor carpi ulnaris, or the
brachioradialis (for wrist extension), the extensor
pollicis longus (EPL) (for EPL rerouting), and the
extensor pollicis brevis and abductor pollicis
longus for control of antagonists to the thumb-
in-palm deformity. In some cases the spasticity in
the agonist muscles (eg, pronator teres, flexor
carpi ulnaris, adductor pollicis) is significant; in
these cases strength or control of the antagonist
can be difficult to assess. In these instances,
 A.E. Van Heest / Hand Clin 19 (2003) 565–571 567

Fig. 1. (A) Wrist joint contracture and finger/thumb flexors (muscle) contractures coexist in this patient. (B) With wrist
extension, the finger flexors and thumb flexor tighten. Passive finger extension with concomitant wrist extension does not
exist, indicating myostatic contracture of the finger/thumb flexors.

further assessment of antagonist control can be
assessed after botulinum toxin injection into the
spastic agonist or by motion laboratory analysis.
Dynamic deformity is assessed during active
range of motion activities. The dynamic position-
ing of the shoulder, elbow, forearm, wrist, fingers,
and thumb is noted, particularly for grasp,
release, and pinch function. Age-appropriate tasks
or toys that require two-handed use are helpful in
this assessment. Identification of the specific
spastic muscle can be determined by the joint
position; for example, excessive dynamic wrist
flexion with ulnar deviation identifies the flexor
carpi ulnaris as the spastic deforming force.
Palpation of specific spastic muscles also localizes
the source of the dynamic imbalance.
Functional testing
The child’s functional use of the hand can
quantified using House’s [1] Classification
Upper Extremity Functional Use (Table 1).
this nine-level classification, functional use
assessed as: does not use, passive assist (poor,
fair, good), active assist (poor, fair, good), and
spontaneous use (partial, complete). Direct ob-
servation of the child during bimanual activities
and use of videotape review of bimanual skills
help with appropriate functional use assessment.
Videotaping allows assessment of the spasticity
encountered during routine ADLs and bimanual
skills; further, it eliminates the stress of perfor-
mance on demand in the physician’s office.
Classification of the Functional Use of the upper
extremity provides a baseline that can be used
to help the physician communicate the func-
tional goals of the surgery with the parents.
The functional use can be reassessed postopera-
tively using this scale to assess for functional
improvement.
In the higher functioning child, the Pediatric
be Jebsen Taylor [2] standardized test can be used as
of a baseline from which to measure the effect of sub-
In sequent treatment and also as a screen of which
is subtest functions have the greatest impairment

Fig. 2. (A) Wrist joint contracture with full finger mobility, ie, no myostatic contractures of finger flexors. (B) With
maximum wrist extension there is full digital mobility.
568 A.E. Van Heest / Hand Clin 19 (2003) 565–571

Table 1
House’s classification of upper extremity functional use
Class Designation
0 Does not use
1 Poor passive assist
2 Fair passive assist
3 Good passive assist
4 Poor active assist
5 Fair active assist
6 Good active assist
7 Partial spontaneous use
8 Full spontaneous use
Activity level
Does not use
Uses as stabilizing weight only
Can hold an object placed in hand
Can hold onto object placed in hand and stabilize it for use by other hand
Can actively grasp object and hold it weakly
Can actively grasp object and stabilize it well
Can actively grasp object and then manipulate it against other hand
Can perform bimanual skills easily and occasionally uses the hand spontaneously
Uses hand completely independently without reference to the other hand

(eg, pinching small objects versus grasping large
cans). Identification of the specific spastic muscle
can be determined by the joint position; for
example, excessive dynamic thumb adduction
without other thumb deformity identifies the
adductor pollicis as the spastic deforming force.
Motion laboratory assessment
Dynamic EMG testing is another diagnostic
tool that has been used to help assess motor tone
and phasic control of specific muscles [3,4]. In
major centers, motion laboratories for gait
analysis have been used extensively for lower
extremity tendon transfer surgery [5–7], and the
same technology can be used for upper extremity
assessment. The specific role of the use of the
motion laboratory in the upper extremity, how-
ever, continues to be under investigation as
a promising tool for more objective assessment
of muscle control for planning appropriate tendon
transfer surgery [3,4,8–11].
One use of the motion laboratory has been for
assessment of correction of elbow flexion de-
formity. Kozin et al [12] have shown that biceps or
brachialis spasticity can lead to elbow flexion
deformity; preoperative dynamic electromyogra-
phy (EMG) can assess spastic tone and phase
control of each muscle to direct treatment to the
specific offending muscles.
Hoffer et al [8] has focused their use of
dynamic EMGs to assess differences in phasic
control of muscles. Hoffer described using dy-
namic EMG assessment to characterize preoper-
atively the extensor digitorum communis (EDC),
the flexor carpi ulnaris (FCU), the flexor digito-
rum superficialis (FDS), the flexor digitorum
profundus (FDP), the extensor carpi radialis and
brachioradialis, and the pronator quadratus
muscles. Each muscle was described as firing in
grasp or in release. He described the results of
tendon transfers in 17 patients with cerebral palsy.
Only muscles with isolated activity in grasp were
used to transfer in hands with weak grasp; only
muscles with isolated activity in release were used
to transfer in hands with poor release. The two
most common procedures were FCU to EDC
transfer (nine procedures) and FCU to extensor
carpi radialis brevis (ECRB) (three procedures).
This approach assumes that no change in phasic
activity occurs. These investigators assumed that
all muscles in cerebral palsy are phase-dependent;
only when the FCU fired in release was it
transferred to the EDC or ECRB for release.
Mowery et al [9] evaluated 16 transferred
tendons in eight patients with pre- and post-
operative dynamic EMG testing. Four of the 16
muscles showed changes in their electrical activity
postoperatively: three muscles that fired continu-
ously became phasic and one muscle changed
phase to match its recipient. Phasic versus con-
tinuous spastic activation can be assessed, as can
determination of central control of muscles as
children are observed carrying out functional
tasks. This study brings forth the concept that
muscles may be able to change phase with trans-
fer, even in cerebral palsy.
In the author’s laboratory, we have used the
motion laboratory for planning tendon transfers
for forearm rotation and wrist extension, as
shown in Fig. 3. The two video frames show
a front and side view of the child performing the
Pediatric Jebsen hand test. Looking at the two
angles simultaneously allows assessment of the
deformity in the sagittal and coronal planes. For
example, this child can be seen to demonstrate
a wrist flexion and ulnar deviation deformity. The
EMG data on the right show 3 seconds of
electrical-myographic activity of four muscles:
the biceps, the pronator teres, the flexor carpi
ulnaris, and the extensor carpi radialis longus/
brevis. Needle electrodes are used for the pronator
 A.E. Van Heest / Hand Clin 19 (2003) 565–571 569

Fig. 3. Motion laboratory assessment with dynamic Fig. 4. Motion laboratory assessment with dynamic
EMG. The two video frames on the left show a front and EMG. This motion laboratory assessment demonstrates
side view of the child performing the Pediatric Jebsen spastic continuous activity of the flexor carpi ulnaris, yet
hand test. Looking at the two angles simultaneously there is phasic control of wrist extension. The flexor
allows assessment of the deformity in the sagittal and carpi ulnaris fires continuously during grasp and release,
coronal planes. For example, this child can be seen to indicating significant spasticity that masks this patient’s
demonstrate a wrist flexion and ulnar deviation de- ability to extend the wrist actively. Electrical activity in
formity. The EMG data on the right shows 3 seconds of the extensor carpi radialis brevis and longus seems to be
electrical myographic activity of four muscles: the biceps, firing appropriately during grasp and relaxing during
the pronator teres, the flexor carpi ulnaris, and the release, but is not seen clinically as it is overpowered by
extensor carpi radialis longus/brevis. Needle electrodes the flexor carpi ulnaris spasticity.
are used for the pronator teres and the flexor carpi
ulnaris. Surface electrodes are used for the biceps and the In Figs. 3 and 4, the two patterns of wrist
radial wrist extensor muscles. The box encompassing the flexion deformity are demonstrated. In Fig. 3, the
central one third of the EMG data highlights the one flexor carpi ulnaris is seen to fire phasically, ie, it
second of activity that is shown simultaneously on the
turns off and on according to the function
video frames on the left. This motion laboratory study
performed and the position of the limb. In Fig.
demonstrates continuous firing of the flexor carpi
ulnaris. Lack of normal firing during grasp and re- 4, the flexor carpi ulnaris does not show selective
laxation during release indicates lack of phasic activity control, but rather fires continuously in a spastic
and poor cortical control of this muscle. pattern. This can be appreciated best by watching
the continuous video with simultaneous EMG
over time and through activities.
teres and the flexor carpi ulnaris. Surface elec-
Decision making for tendon transfer surgery is
trodes are used for the biceps and the radial wrist
based then on the pattern of muscle spasticity and
extensor muscles. The box encompassing the
central one third of the EMG data highlights the
one second of activity that is shown simulta-
neously on the video frames. This motion analysis
study allows for assessment of the spasticity pat-
terns of the muscles and helps determine whether
the child is able to control actively the muscles for
functional use.
The motion laboratory has shown several
patterns of EMG activity in the muscles tested. In
Fig. 5, the wrist extensors show good phasic
control. The patient is able to fire the wrist
extensors actively. The FCU and FCR leads show
continuous spastic activity with no phasic control.
In such a pattern (wrist extensors in phasic control Fig. 5. Motion laboratory assessment with dynamic
and wrist flexors in spastic activity), the patient is EMG. This motion laboratory assessment demonstrates
treated with a flexor pronator slide. The patient was phasic control of flexor carpi ulnaris. Appropriate firing
skeletally mature, and with reduction of the flexion during grasp and relaxation during release is seen cor-
forces, the extensor control could be unmasked. responding to functional grasp and release of the cans.
570 A.E. Van Heest / Hand Clin 19 (2003) 565–571
voluntary control. For muscles with good volun-
tary control, tendon transfer is recommended. In
Fig. 3, the flexor carpi ulnaris has phasic control
and would be transferred to the extensor carpi
radialis brevis. In Fig. 4 the FCU has uncon-
trolled spasticity and would be lengthened with
use of another muscle for transfer, such as
brachioradialis or extensor carpi ulnaris. In Fig.
5, a flexor pronator slide was done to decrease
flexion forces and unmask a phasic, well con-
trolled wrist extensor.
Sensibility
Sensation can be evaluated by stereognosis,
two-point discrimination, and proprioception. In
the author’s review of 40 children with spastic
hemiplegia [13], the author has found that stereog-
nosis is the most sensitive discriminator of degree of
sensibility impairment as shown in Table 2. In this
study, 97% of children with spastic hemiplegia had
a stereognosis impairment using the 12 objects
shown in Box 1. The first six objects discriminate
fine motor function and the second six objects
discriminate gross motor function. All children
demonstrated 12/12 object recognition on the
unaffected side, verifying understanding of the test.
Furthermore, this study found that those children
with severe sensibility impairment had a significant
size discrepancy when compared with the un-
affected side. The shortened limb can be a useful
clue to underlying sensibility deficiency, particu-
larly in the child too young or too retarded to
perform a sensibility assessment reliably. Children
with sensibility deficiencies need to be coached to
use the eyes rather than their touch for afferent
feedback. Several studies have indicated that poor
sensation is not a contraindication for surgery
[14,15]. In fact, one study has reported an
improvement in sensibility function after surgical
intervention [14], presumably associated with in-
creased postoperative functional use.
Table 2
Sensibility deficiencies
Type of sensibility testing Percentage of
patients impaired
Stereognosis 97%
2-point discrimination 90%
Proprioception 46%
From Van Heest AE, House JH, Putnam M.
Sensibility deficiencies in the hands of children with
spastic hemiplegia. J Hand Surg [AM] 1993;18:278–81;
with permission.
Box 1. Objects for assessment
of stereognosis function
12 common objects
Pill
Penny
Button
Key
Paper clip
Safety pin
Spoon
Cube
Marble
Rubber band
String
Pencil
The first six objects require fine discrimination
between similar sized small objects, and the
second six objects require gross discrimination
between larger objects and different materials.
Summary
The physician needs to integrate the results of
the assessment of overall patterns of functional
use (Table 1), static contractures, dynamic defor-
mities of motor imbalance for multiple levels of
involvement (shoulder, elbow, wrist, and hand),
and sensory deficiencies. This information is
combined with a general assessment of the child’s
mentation, motivation, and generalized medical
condition.
Certain patients benefit most from surgical
intervention in cerebral palsy. Patients with
spastic deformities or flaccid control of specific
movements can be helped significantly. In patients
with flaccid control of certain movements, such as
absent ability to extend the wrist or abduct the
thumb, surgery is centered on tendon transfers to
augment the patient’s ability to perform that
movement. In patients with excessive spasticity or
musculotendinous contracture, surgery is centered
on muscle lengthening. In general, patients with
athetosis are not treated surgically; the only
surgical treatment considered for the athetotic
patient is fusion, as this helps preposition the limb
in a desired position and ‘‘simplifies’’ the system
for the patient to control.
Sensibility deficiencies do not preclude effective
tendon transfer but do limit the overall use of the
limb; patients with sensibility deficiencies need to
 A.E. Van Heest / Hand Clin 19 (2003) 565–571
be coached to use visual input as their afferent
information.
Motor deficiencies can be assessed by observa-
tion, examination, functional testing, and motion
laboratory analysis. Combining an assessment of
shoulder, elbow, forearm, wrist, thumb, and finger
abilities and disabilities helps provide the physician
with an overall plan of upper limb reconstruction
using soft tissue releases, tendon transfers, and joint
stabilization procedures to address the upper limb
functional deficiencies. The ideal candidate for
tendon transfer surgery is 7 years of age or older so
they can be cooperative with postoperative re-
habilitation and motivated to improve the use of
their limb. Children with passive use of their limb
(Functional Use Classification levels 1–3) can be
improved most, on average 2.7 levels to active use
of their limb (Functional Use Classification levels
4–6) [16].
An overall treatment plan is synthesized, tak-
ing into account the child’s capabilities, disabil-
ities, and potential, in the context of the child’s
age and expectations. The assessment techniques
discussed in this article are the first step to ap-
propriate treatment.
References
[1] House JH, Gwathmey F, Fidler M. A dynamic ap-
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[2] Taylor N, Sand PL, Jebsen RH. Evaluation of hand
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[3] Hoffer MM. The use of the pathokinesiology
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[4] Hoffer MM, Perry J, Melkonian G. Postoperative
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[5] Perry J. The use of gait analysis for surgical
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[6] Sutherland DH, Santi M, Abel MF. Treatment of
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[7] Water RL, Frazier J, Garland DE. Electromyo-
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[8] Hoffer MM, Perry J, Melkonian G. Dynamic
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[9] Mowery CA, Gelberman RH, Rhoads CE. Upper
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[10] Pinzur MD. Dynamic electromyography in func-
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[11] Thepaut-Mathieu C, Maton B. The flexor function
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[12] Kozin SH, Keenan MH. Using dynamic electromy-
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[13] Van Heest AE, House JH, Putnam M. Sensibility
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[14] Dahlin LB, Komoto-Tufvesson Y, Salgeback S.
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[15] Van Heest AE, House JH, Eliasson AC. Hand
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 Hand Clin 19 (2003) 573–584
Casting, splinting, and physical and occupational
therapy of hand deformity and dysfunction
in cerebral palsy
Judith Wilton, MS, GradDipHthSc, BAppSC, OT
Hand Rehabilitation Specialists, 10 Altona Street, West Perth, WA 6005, Australia
Significant occupational and physical therapy
time and resources are directed to the manage-
ment of the upper limb in cerebral palsy (CP). The
evidence to support therapy interventions for the
upper limb is not strong [1]. This in part reflects
the difficulties of research [2] rather than a lack of
critical review of practice. Experience and
logic underpin many therapeutic applications.
This presentation details the available options,
the rationale for their use, and the results of
treatment.
Prerequisites for hand function
Efficient performance of the upper limb
depends on proximal control and dynamic stabil-
ity of the trunk and shoulder girdle. From a stable
base, distal mobility of the limb enables partici-
pation in age-appropriate occupational tasks.
Improvement in scapulohumeral and trunk con-
trol is a major focus of neurodevelopmental
therapy (NDT), one of the most commonly used
approaches for treatment of children with CP.
NDT techniques attempt to alter muscle tone
during movement to facilitate normal movement
patterns and postural reactions under the premise
that improved postural control improves func-
tional skills [3]. Investigations into this premise in
relation to the upper limb determined the effects
of NDT on quality of upper limb movements [4]
and reaching [5,6]. Although improvements were
evident, they were not greater than reach training
using principles of motor learning or occupational
therapy directed toward functional skills.
E-mail address: turnwil@ozemail.com.au
0749-0712/03/$ - see front matter Ó 2003 Elsevier Inc. All rights reserved.
doi:10.1016/S0749-0712(03)00044-1
For children with more severe motor dysfunc-
tion in whom head and trunk control are affected
by spasticity and persistent postural reflexes,
postural control for effective upper limb function
is achieved only through adaptive seating. As
children get older, the requirements for schooling
demand longer periods of time seated. Therapists
thus should consider how restrictions imposed by
the chair and table in upper limb movement may
potentiate deformity and what strategies are
needed to address it.
Altered sensibility commonly is identified as
a contributing factor to impaired hand function in
children with CP. Much of the literature has
focused on the measurement of sensory deficits,
with two-point discrimination and stereognosis
identified as the most common tests [7–9]. Recent
studies of children with hemiplegia have estab-
lished a strong relationship between tactile sensi-
bility and dexterity [10] and fingertip force
regulation during object manipulation [9,11].
The relationship between sensibility and hemi-
plegic hand performance in functional bimanual
activities, however, was not as strong [10]. The
potential to improve hand sensation by systematic
sensory education programs, shown to be effective
following stroke [12–14], has yet to be determined
in children with CP.
Principles of intervention options
Therapeutic modalities specific to hand func-
tion essentially fall into two categories—those
that have an impact on hypertonicity and
associated contracture and those that facilitate
functional use of the hand related to active motion
and dexterity. In the absence of extensive evidence
574 J. Wilton / Hand Clin 19 (2003) 573–584
under-pinning the therapeutic modalities as ap-
plied to typical patterns of deformity of the hand
and wrist.
Hypertonicity and contracture
When addressing the increased muscle tone in
children with CP, it is useful to distinguish
between the neural or reflexive components—the
tonic muscle contractions—from the non-neural
or mechanical components, the viscoelastic prop-
erties of muscle and connective tissue associated
with contraction and stretch [15,16]. Spasticity,
a somewhat imprecise term in clinical practice,
refers to the neural component of hypertonicity,
that is, the velocity-dependent increase in stretch
reflex activity [17]. The altered mechanical prop-
erties of the muscle and associated tissues occur in
response to the abnormal conditions imposed on
the muscle by the spasticity. In turn, muscle
shortening may participate in the generation and
maintenance of spasticity [16,18].
Strategies that address muscle contracture
affect the neural and mechanical components of
the hypertonicity present. Studies by Nash,
Neilson, and O’Dwyer [19,20] suggest that neural
and non-neural components of hypertonicity
should be considered as reducing spasticity alone
and not altering muscle contracture. Following
electromyographic biofeedback training over 10
weeks, subjects were able to reduce spasticity by
50%, but no associated change in muscle con-
tracture was measured, nor improvement in
voluntary movement evident. To address contrac-
ture and hypertonicity effectively, it is recommen-
ded therapists use modalities that prevent or
reverse contracture in target muscles for sufficient
duration each day to promote muscle growth [19].
During growth and in response to changes in
posture, the functional length of the muscle is
adjusted by altering the number of sarcomeres in
series for optimum force generation and power
output [21]. When movement does not put the
joint through a full range of motion and daily
passive range of movement or posturing does not
adequately maintain range, adaptation of the
muscle results in contracture. This adaptation,
a combination of shortening of muscle fibers and
remodeling of muscle connective tissue [19,22,23],
is accompanied by changes in the skin and
periarticular tissues [24–26].
When safe forces are applied to tissues
statically or cyclically, they demonstrate a tran-
sient lengthening depending on the viscoelastic
properties of the tissues. This elongation reverses
once the force is relaxed. This elastic response is
associated with unfolding of tissue and temporary
realignment of collagen fibers within the connec-
tive tissues. The resolution of contracture through
the application of low-load prolonged stress to the
contracted tissues at the end of their available
range ultimately depends on the ability of the cells
to sense and transduce the mechanical force into
biologic action and to grow [20,23,27].
The response of shortened muscles to stretch,
using plaster cast immobilization, has been
explored in numerous animal studies. Adult
muscle responds to stretching by adding new
sarcomeres in series, thereby returning the sarco-
meres to their optimum tension-generating length
with no change in tendon length. In growing
muscles, however, the initial increase in number of
sarcomeres up to day five is followed by a decrease
in sarcomere number, thereby decreasing muscle
fiber length. Muscle tendon length is maintained
by lengthening of the tendon [23,28,29]. These
findings suggest that extended casting protocols
for young children should consider potential to
increase tendon length rather than to influence
muscle fiber length. It is stressed also that cast
lengthening of muscle contracture should be
gradual, because decrease in sarcomere number
is greater than decrease in length of muscle
connective tissue [23]. Potential exists for
muscle fiber breakdown from too fast or forceful
stretching.
Although stretch is essential to muscle growth
and in maintenance of functional length once
growth has stopped [30], the effectiveness of
passive range of motion exercises depends on
their frequency. Long-term stretch, applied con-
tinuously for periods greater than 6 hours, has
been shown to be most effective [31,32]. Casting
and splinting are best in applying low-load
prolonged stretch to contracted tissues. Experi-
ence suggests that, in muscles with hypertonicity,
shortening of muscle and connective tissues recur
unless stretch is maintained [20,33].
Splinting and casting
Published studies in the last 50 years that have
addressed the issue of hand splinting in the
presence of spasticity have tended to reflect the
theoretic basis of therapy at the time [34–40].
Although direct comparison between studies is not
possible, the vast majority identified improvement
 J. Wilton / Hand Clin 19 (2003) 573–584
in range of motion associated with splint wearing
[41–43].
Static splints and casts maintain the joint in
one position with the goal of stabilizing it for
efficient transfer of muscular forces to distal
joints. Serial static splints and casts are designed
to lengthen tissues and correct deformity through
application of gentle forces sustained for extended
periods of time [44]. Splints are remolded and
casts replaced at intervals that allowed for tissue
response to the lengthened position. Casting has
biomechanic and neurophysiologic effects. Bio-
mechanic effects relate to changes in the length of
muscle and connective tissues reversing the
histologic changes that occur in tissues main-
tained in a shortened position. The exact neuro-
physiologic effects of casting on spasticity are
undefined. It is proposed that inhibition results
from decreased sensory input from cutaneous
and muscle receptors during the period of immo-
bilization. The effects of neutral warmth and
circumferential contact also are believed to
contribute to modification of spasticity.
Much of the research on upper limb casting in
the presence of spasticity is undertaken in a single
case study design. Two groups of studies are
seen—those using mobilizing principles with
a series of circumferential casts worn for 24 hours
per day for periods up to 4 weeks [45–50] and
those in which a single cast is bivalved and worn
for periods of 3–5 hours per day for many months
[33,44,51,52]. In the first group, serial casts
applied to elbow and wrist flexion contractures
for 24 hours per day over several weeks resulted in
significant gains in range of motion. Intermittent
static casting of the wrist also demonstrated
improvements in range of motion, quality of
movements, and functional use of the hand.
Biomechanically, bivalved casts achieve wrist
immobilization as effectively as a thermoplastic
splint. The studies that used static bivalved casts
to immobilize the wrist joint for function for
extended periods provided no explanation re-
garding choice of material. Choice may relate to
the skills of the therapist in splinting or casting,
ease of fabrication, cost, comfort, and aesthetics.
Splints to facilitate functional use of the hand
include the wrist splints with reflex inhibiting
components [53,41], a neoprene splint to position
the thumb in abduction and the forearm in
supination [54], and splints to position the thumb
in abduction [55,56]. Studies that investigated
splints worn by children with CP reveal trends
toward more normal movement patterns and
575
greater grasp skills [57,58]. No significant rela-
tionship was found between splint type and
changes in hand function. Functional gains were
associated with splint wear. In practice, splints are
designed to meet specific objectives identified by
the patient or their caregiver. In many instances
splints compensate for functional deficits in hand
grasping or pointing to secure toys, eating
utensils, and writing and computing devices.
When a variety of postures of the upper
limb are required in the performance of func-
tional tasks, rigid correction of deformity is not
always compatible with function. It is probably
one of the key issues for noncompliance with
rigid splinting and the preference for use of
custom made or commercial neoprene and Lycra
splints. These splints use a wraparound design
with inserts to position the thumb and reinforce-
ment achieved by way of splinting material or
metal inserts.
Dynamic Lycra splints use the inherent prop-
erties of the fabric and design features of the
garment to create a low force to resist the spastic
muscle action while also facilitating the antagonist
action. The mechanical properties of dynamic
Lycra arm and hand splints have been established
in studies involving normal and hemiplegic sub-
jects [18,59]. More extensive Lycra body splinting
in children with CP [60] also showed improved
dynamic upper limb function, with reduction in
involuntary movement and improved patterns of
movement associated with a reduction in muscle
tone. Thirteen of fourteen subjects experienced an
immediate reduction in involuntary movement,
with six maintaining some improvement after
removal of the body splint. Although preliminary
research suggests Lycra splints have potential to
influence involuntary movement and apply low
stretching force to the limb in people with CP
without compromising comfort or functional use
of the limb, further controlled clinical trials are
needed.
Functional strength
Current understanding is that spasticity is not
the primary cause of voluntary movement impair-
ment [20]. The perception of greater strength in
the hypertonic muscle, with weakness in its
antagonist, is in part caused by the techniques
used to determine strength. As skeletal muscle is
highly adaptable, its structural characteristics are
determined by its conditions of use. Shortened
muscles may seem strong at normal length
576 J. Wilton / Hand Clin 19 (2003) 573–584
because they are tested in their optimal position.
Associated changes in passive tension through
shortening of the connective tissue elements also
may contribute to perceived strength. Weakness
in lengthened muscles is the result of remaining in
an elongated position beyond the neutral physi-
ologic rest position but not beyond the normal
range. Muscles seem weaker because they are not
tested at their optimal length. Constant contrac-
tion of the muscle when allowed to shorten also
may exaggerate the rate and quantity of sarco-
mere loss, thus weakening the muscle [21]. The
hypertonic muscle may be constrained during
voluntary movement by the passive mechanical
properties of the muscle itself.
Lengthening the shortened connective tissue
elements in the muscle, together with modifica-
tion of the functional length with adaptation of
sarcomere number, has potential to modify
‘‘strength’’ of the muscle. Improvement in
strength of wrist extensor musculature described
following serial progressive casting [50] is in part
the consequence of muscle length adaptation.
Following the period of immobilization, therapy
is required to assist weaker muscles to work
against gravity and to perform functional grasp.
Splints that offer support to the joint but allow
active motion are preferable to rigid immobiliza-
tion.
It is observed that repetitive use of the hand in
functional tasks has the potential to further
increase strength and endurance. Further investi-
gation is required, however, to validate grip and
pinch strength exercise protocols.
Manipulation and dexterity
Improvement in manipulation and dexterity
are aims for children with CP with milder motor
difficulties [61,62]. Hand intrinsic muscular con-
trol is essential to achieve fine motor coordina-
tion. Therapy aims to facilitate isolated thumb
and finger stability and mobility, accurate pat-
terns of pinch and grip of objects of varying sizes,
shapes, and textures, translation and rotation of
objects within the hand, bilateral manipulation,
and strength and endurance to meet functional
demands.
The efficacy of occupational therapy programs
to address development of fine motor skills in
preschool children has been established in several
studies by Case Smith [61,63,64]. Although the
number of children in these studies with a di-
agnosis of CP was small, the therapist’s use of
play and peer interaction influenced fine motor
skills, improving function. Therapists therefore
are encouraged to use activities of daily living
(ADL), play, and recreational and vocational
activities as an integral part of therapy [33,63].
Analysis and treatment of hand dysfunction
The wrist and hand present a complex in-
teraction of intrinsic and extrinsic musculature in
which hypertonicity dictates the predominant
pattern of deformity. Performance of an isolated
movement may elicit a different pattern from that
evident when attempting to use the hand in
a functional task. Analysis of patterns of function
of the wrist and digits during movement and
during function provide the basis for treatment
decisions. In addition to the usual tests of passive
and active range of motion, information from
parents or caregivers about the posture of the limb
during sleep often can assist in determining
whether contracture is present.
In 1981, Zancolli and Zancolli [65] described
a surgical classification of spastic hand deformities
in the wrist and fingers, whereas House, Gwath-
mey, and Fidler [66] identified four patterns of
deformity in the thumb. Building on these
classifications, the following model was developed
to facilitate analysis of the anatomic and bio-
mechanic components of deformity and dysfunc-
tion. Patterns of deformity may evolve over time.
Pattern 1: minimal wrist flexion in function,
thumb adduction
Children with this deformity have mild spas-
ticity in flexor carpi ulnaris (FCU), which means
that reach to grasp, occurs with slight wrist flexion
and ulnar deviation. The wrist extensor muscles
can extend against the resistance of hypertonicity
in FCU and there is no evidence of hypertonia in
the finger musculature. In a large number of
patients, no deficit is seen in the thumb, but when
present the deformity pattern is adduction at the
carpometacarpal (CMC) joint from a combination
of contraction and contracture in the adductor
pollicis (AP) and first dorsal interosseous (DI)
muscles. Some CMC joint extension and abduc-
tion are restricted but with no limitations in
motion of the metacarpophalangeal (MCP) and
interphalangeal (IP) joints.
Full passive range of motion (ROM) is avail-
able at all joints of the wrist and fingers with the
possibility of reduced ROM of the thumb–index
 J. Wilton / Hand Clin 19 (2003) 573–584
finger web space. Imbalance of muscles acting
across the joints can contribute to instability.
Hyperextension seen at the proximal interphalan-
geal (PIP) joints results from wrist flexion in-
creasing the distance the extensor digitorum
communis (EDC) tendons traverse before insert-
ing at the base of the middle phalanx. Great
variability exists in the population as to ‘‘normal’’
mobility of these joints, and unless instability
impedes function it need not be addressed.
Therapeutic intervention
Maintenance of full extensibility of tissues is
a primary goal. Function and play activities
that incorporate weightbearing are used to
provide regular stretch to FCU. In the presence
of contracture of the thumb web space, a serial
splint worn during nonfunctional times ad-
dresses the contracture without compromising
function.
Designing functional splints to stabilize the
thumb in a position for opposition is a significant
challenge. To control the thumb joints, splint
components must control the thumb metacarpal
against the forces of spasticity. When the web
space is shortened by skin contracture, the
difficulty in directing the abducting force to the
metacarpal is increased. Although neoprene or
Lycra are more acceptable splinting materials for
young children, their elasticity and lack of
contour require careful design to ensure appro-
priate application of forces to the thumb. Com-
binations of low temperature thermoplastic
materials and Lycra or neoprene may better
achieve this objective, particularly in older chil-
dren in whom the tissue forces are greater. It is
important to ensure that functional thumb splint-
ing does not impede use of the thumb; no single
Fig. 1. Pattern 2 with and without dynamic Lycra splint. (A) Approach to grasp is associated with significant wrist in
flexion with hyperextension of the MCP joint. (B) Dynamic Lycra splint facilitates a balance between wrist and finger
musculature when approaching objects for grasp.
577
splint design has been found that resolves this
problem effectively.
People with this pattern of deformity have
good grasp and release and pinch; however, fine
manipulation is impeded by thumb dysfunction.
Therapy is focused on activities requiring grasp
and pinch of objects of a wide variety of sizes and
shapes to encourage thumb opposition and hand
manipulation. Placement of objects for manipu-
lation should use a variety of wrist postures, with
vertical play one of the ways to promote wrist
extension.
Pattern 2: moderate wrist flexion in function,
active wrist extension
People with this deformity use a tenodesis-type
action, approaching objects with significant wrist
flexion with extension of the MCP and PIP joints
of the fingers (Fig. 1A). Active flexion of the
fingers is associated with extension of the wrist.
Control of the speed and force of finger flexion is
a common problem. The hypertonicity is located
predominantly in flexor digitorum profundus
(FDP) and flexor digitorum superficialis (FDS),
with mild hypertonicity located in FCU and flexor
carpi radialis (FCR). Strength in the wrist
extensor muscles can overcome the resistance in
the wrist flexors, but EDC cannot extend the
fingers with the wrist approaching neutral. EDC is
a critical player in this pattern, as it is compro-
mised by its incapacity to generate tension when
constantly working in a lengthened position, and
by its size and overall smaller capacity to generate
tension as compared with FDS and FDP [67]. The
thumb metacarpal generally is held in an adducted
position by hypertonicity in the AP and first DI
muscles. Extensor pollicis longus (EPL) and
extensor pollicis brevis (EPB) act across the
578 J. Wilton / Hand Clin 19 (2003) 573–584
MCP joint, creating a hyperextension deformity
on reach, while not impairing thumb flexion.
No deficits are evident in the passive range of
motion of the wrist. Shortening may be demon-
strated in FDP and FDS, however, with combined
finger and wrist extension. Daily stretching pro-
tocols in association with weightbearing on the
hand with extension of the wrist and fingers may
maintain length without need for splinting or
casting. Contracture of the index thumb web
space is generally present. Persistent extension of
the MCP in combination with adduction of the
CMC joint can lead to instability of the MCP
joint capsule and ineffective force transmission
through the thumb during pinch.
In people with this deformity, grasping is
impaired by reduced thumb web span, limiting
the area of the palm of the hand available for
object contact. In addition, diminished control of
wrist extension in conjunction with flexion of the
fingers often results in failure to secure the object
between the fingers and thumb or the fingers and
palm. Successful grip depends on the size and
shape of objects in relation to the size of the hand.
Transverse volar grip is the most effective because
of the tenodesis action in grasping, with effective-
ness of lateral and two-point pinch dependent on
the size and shape of the object.
Therapeutic intervention
The objective of intervention is to gain better
coordination between wrist and finger muscular
action. Treatment is designed to combine re-
education of movement patterns in functional tasks
that require wrist extensors to work in their mid
range of motion, maximize action of EDC for finger
extension, and gain control over speed and force of
contraction of finger flexors during grip. Dynamic
Lycra splints (Fig. 1B) can assist in achieving this
objective, but rigid splints are incompatible with
functional use of the hand. The Lycra fabric allows
movement but desires to return to its predeter-
mined resting length. Looking like a glove with
inclusion of fingers to prevent migration, the
multiple components across the dorsal and volar
aspects are designed to provide directional pull and
so facilitate movement. The thumb is included with
addition of small thermoplastic components if
additional stability or positioning is required.
Initial splint application should be incorporated
into a therapy program directed toward mastery of
movement patterns required in specific occupa-
tional tasks. Repetition in ADL provides opportu-
nities to use newly acquired movement patterns and
consolidate gains.
The thumb presents a two-fold challenge.
First, the presence of contracture of the thumb–
index web space, and second, diminished active
motion to position the thumb for effective
opposition. Resolution of contracture requires
serial progressive splinting, preferably at night so
as not to impede performance of functional
activities. Although thumb mobility is desirable,
thumb stability in a position for opposition to the
fingers is more important. Achieving this stability
is not easy in a situation in which spastic muscles
have good moment arms, and splinting levers are
small. Splinting materials must have sufficient
strength to resist the force of AP and extrinsic
extensors to stabilize the CMC and MCP joints.
Correction of the wrist position and thus
reduction of the distance over which the EDC
tendons traverse at the wrist resolves much of the
hyperextension deformity at the MCP and PIP
joints of the fingers. Splinting for the PIP joints is
required only if joint instability compromises
function, particularly for switching devices or
computer access. Small splints that restrict PIP
joint extension beyond neutral can be fabricated
and worn for specific functional tasks, but
compliance with long-term wear is problematic.
Pattern 3: wrist flexion >20 in function,
no active wrist extension
In people with this pattern, moderate spasticity
is located in FCU and FCR and the FDP, FDS,
and palmaris longus. Wrist extensor muscles are
weak, constantly working in a position of sig-
nificant wrist flexion. Mid range flexion of the
fingers is possible, but active insufficiency in FDS
and FDP impairs strength of grip. Hyperexten-
sion of the PIP joints is present (Fig. 2). This
pattern is more common in older children and
adults and reflects the impact of growth and tissue
shortening over time.
The significant feature of this pattern is the
deficit in extensibility in the wrist flexor and
extrinsic finger flexor musculature, resulting in
loss of extension ROM. Shortening also may be
present in EDC, limiting full passive finger flexion.
The predominant posture of the thumb is
adduction at the CMC joint and hyperextension
of the MCP joint as described in the previous
classification.
People with this deformity grasp objects
between the finger and thumb pads, as it is not
 J. Wilton / Hand Clin 19 (2003) 573–584 579

Fig. 2. Examples of pattern 3 deformities. (A) In association with significant wrist flexion tension on EDC contributes to
hyperextension in the PIP joints, while AP and contracture influence the thumb CMC joint and EPL extends the IP joint
of the thumb. (B) The right hand illustrates the resting position of the wrist reinforced by gravity and wrist and finger
hypertonicity. Greater degrees of extension in the resting position of the left wrist and fingers are the outcome following
18 days of serial casting.

possible to orientate the palm toward the object use as an assist/stabilizer to the dominant hand.
because of significant wrist flexion. For patients in whom bilateral involvement exists,
intervention often is directed at achieving the
hand function requirements for a specific task,
Therapeutic intervention
such as wheelchair control or activating commu-
The objective of intervention is to improve
nication devices (Fig. 5). Generally, splinting is
hand function, prevent further wrist contracture
for ease of management, or address pain in the
wrist. As the fingers cannot be flexed tightly, there
is rarely a risk for breakdown of skin in the palm
of the hand.
Rigid splinting or casting are directed to
decreasing hypertonicity and increasing length in
wrist and finger flexors. These are best undertaken
for extended periods or over night. For patients in
whom the contracture of the wrist exceeds
a position of 45 of flexion, a series of two or
three casts over several weeks (Fig. 3) is recom-
mended. With this severe deformity, casting,
maintaining the joint for maximum time at end
range, has advantages over rigid splints that may
be uncomfortable.
A dorsal volar splint (Fig. 4) is used when there
is less contracture of the wrist and shortening of
FDS and FDP. This design is superior to other
splint designs because it uses an effective lever
system to apply an extension force to the wrist
and fingers [68]. Dorsal forearm and volar hand
components are remolded as lengthening occurs in
shortened tissues.
For people with this deformity, functional
goals often are determined by the competence of Fig. 3. Three plaster casts illustrate progressive increase
the other hand. For children with hemiplegia, the in range of passive wrist and finger extension with
goal may be to achieve an efficient gross grasp to successive applications.
580 J. Wilton / Hand Clin 19 (2003) 573–584
Fig. 4. The dorsal volar splint has components for
dorsal hand and forearm, volar hand and fingers, and the
thumb. Each component is molded separately to position
joints to address hypertonicity in wrist and finger
musculature.
required to assist the wrist in achieving a more
neutral position to resolve the biomechanic
disadvantage for FDS and FDP in grasp, while
not compromising EDC. Functional activities
requiring controlled finger opening and closing
complement the splinting program.
Functional splinting of the wrist may use rigid
thermoplastic materials to immobilize the wrist in
a position that does not compromise the ability to
extend the fingers during reach. Alternatively,
materials such as Lycra or neoprene may be used
to make circumferential soft splints, reinforced by
splinting material or flexible boning that restricts
wrist motion and opposes the wrist flexor spasticity.
Lycra or neoprene alone has insufficient strength
to oppose the strong flexion pattern and have no
effect on extension deficits in the wrist or fingers.
Splinting options for the wrist also should in-
corporate components to address the thumb de-
formity as described in the previous classification.
Fig. 5. (A) In the absence of active wrist extension in pattern 3 deformity, the wrist flexion deformity is reinforced by use
of the wheelchair control. (B) A rigid functional thermoplastic splint immobilizes the wrist to achieve a better
biomechanic position for finger and thumb musculature. A lining sock is worn under the splint.
Pattern 4: wrist extension with intrinsic
hypertonicity
Spasticity in this pattern is located primarily in
the wrist extensor muscles, extensor carpi radialis
longus (ECRL) and extensor carpi radialis brevis
(ECRB), and hand intrinsic muscles, with adduc-
tion flexion at the thumb CMC and MCP, flexion
and adduction of finger MCP joints, and hyper-
extension deformities of the finger PIP joints.
With flexion of the MCP joints the intrinsic pull
on the lateral bands of the finger extensor
mechanism is facilitated across the dorsal aspect
of PIP joint often restricting flexion motion at this
joint. The thumb metacarpal is held in an ad-
ducted position by contraction in the AP and first
DI muscles, with spasticity in the flexor pollicis
brevis (FPB) contributing to MCP flexion and IP
extension.
Contracture can develop in the ECRL and
ECRB musculature, restricting wrist flexion. In-
trinsic muscle contracture is compounded by
decreased extensibility of palmar fascia and skin,
and by the fact EDC function is compromised in
extremes of wrist extension (Fig. 6A). Failure to
manage contracture in the intrinsic muscles and
palmar tissues presents problems for skin care and
hygiene.
The major obstacle to functional use of the
hand is the inability to open the hand spontane-
ously. These patients need to disassociate elbow
extension from attempts to grasp, with opening of
the hand requiring a neutral wrist position and
extension of finger MCP joints. In addition, the
thumb must be extended out of the palm of the
hand if any grasp is to be effective. In small
children with this pattern, the thumb MCP flexion
contracture often presents the most significant
problem, as the thumb is trapped constantly
under the flexed fingers.
 J. Wilton / Hand Clin 19 (2003) 573–584
Fig. 6. (A) Pattern 4 deformity results in a posture of the hand with significant wrist extension and finger flexion, with
the thumb adducted and flexed across the palm. (B,C) A two-piece splint is required to control wrist and thumb positions
to allow active finger motion.
Therapeutic intervention
Without intervention that has a long-term
perspective, this pattern of deformity can lead to
significant contractures of the thumb and finger
MCP joints. Treatment is directed toward pre-
vention of intrinsic muscle contracture with main-
tenance of tissue extensibility and restoration of
the biomechanic balance to the wrist.
In young children who are highly motivated to
use their hand, who can control their elbow
position, and who have no contractures, dynamic
Lycra splints with design components to facilitate
wrist flexion and finger MCP extension can assist
re-education of extrinsic–intrinsic muscle func-
tion. Repetitive functional use of the hand is
essential for improved muscle strength. Gross
voluntary opening and closing of the fingers
around objects appropriate to the hand size and
simple thumb–index finger pinch are appropriate
functional goals. Stretching protocols to prevent
contracture must address joint capsular structures,
particularly at the MCP joints and muscle tendon
unit length of the extrinsic finger musculature.
In persons/people for whom tonal patterns are
high and contracture is present, however, a greater
degree of wrist control is required, necessitating
more rigid functional splinting. Materials of choice
depend on whether the person can control wrist
movement to neutral or slight flexion. Designs must
incorporate volar and dorsal components (Fig.
581
6B,C). The volar component is used to position the
thumb in abduction and extension for opposition
to the fingers and to provide counterforce at the
wrist. With appropriate splinting, finger extension
to activate switching or computer devices is
possible, together with a simple gross grip.
Night splinting to address contracture in
shortened musculature and soft tissues requires
the wrist to be positioned in some degrees of
flexion, the MCP joints in extension and abduc-
tion, the IP joints in some flexion, with main-
tenance of the thumb web space and MCP joint
extension. Experience suggests that a reduction in
hypertonicity of the wrist and finger musculature
also improves elbow function.
Pattern 5: fisted hand with wrist flexion or wrist
extension
This is the most severe deformity and reflects
the hypertonicity and secondary contracture of
muscles and associated connective tissues. The
fingers and thumb are maintained in a fisted
position with minimal active motion evident. Skin
maceration and nail care are problems.
Therapeutic intervention
The aim is to maintain sufficient motion so the
hand can be opened to prevent maceration,
582 J. Wilton / Hand Clin 19 (2003) 573–584
infection, and breakdown of the skin of the palm
and thumb. If opening of the fingers and
positioning of the thumb are possible, casting is
the preferred option. The gains are maintained by
bivalving the final cast or applying a splint. If
casting is not an option, prefabricated palmar
protectors and custom made soft rolls can create
an interface between tissue layers; however, they
do little to resolve contracture. This can be
achieved by gradually adding firm components
made of splinting material to the soft rolls to hold
joints more extended, with the circumference
determined by the degree of contracture in the
fingers and web space of the thumb.
Summary
The treatment of hand deformity and associ-
ated dysfunction is a major focus of physical and
occupational therapy for people with CP, as poor
grasp and manipulation has potential to impact
on many aspects of daily life. To assist therapists
in analyzing patterns of movement of the wrist,
finger, and thumb musculature at rest and during
functional activities, five patterns of deformity
commonly seen in the hypertonic hand are
described. Interventions that impact on hyperto-
nicity and associated contracture and that facili-
tate functional use of the hand in the presence of
these deformities are discussed. The paucity of
evidence from clinical trials on intervention
strategies reflects in part the diversity of people
with CP and the highly individual functional
problems they encounter. While further research
is needed on the many possible interventions and
how they contribute to maximizing hand function,
there is increasing evidence of the value of therapy
that is directed to functional outcomes relevant to
the individual.
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 Hand Clin 19 (2003) 585–589
Pharmacologic management of the spastic and
dystonic upper limb in children with cerebral palsy
Stephen O’Flaherty, FRACP, FAFRM*, Mary-Clare Waugh,
FRACP, FAFRM
Department of Rehabilitation, Children’s Hospital at Westmead, Locked Bag 4001, Westmead,
Sydney NSW 2145, Australia
Cerebral palsy (CP) is a disorder of movement
and posture that has its onset in the developing
years. Spasticity is present in more than 80% of
individuals with CP. By definition, CP is a non-
progressive, central nervous system deficit; how-
ever, the musculoskeletal effects do change with
time.
Spasticity or dystonia of the upper limb in
children with CP commonly is seen as part of
a more involved clinical picture. Interventions for
managing spasticity/dystonia need to be consid-
ered in this context and also in the context of each
child’s goals, underlying motor function, degree
of muscle contracture, ability to participate in
therapy, and developmental level. The nonphar-
macologic interventions used most frequently to
assist in management include therapy (stretching,
splinting, strengthening, positioning, and training
movement patterns [1]) and selective surgery,
including tendon/muscle releases and transfers
and dorsal rhizotomy. Thalamotomy, pallidot-
omy, and deep brain stimulation [2,3] may be
considered in patients with severe, disabling
dystonia whose symptoms of pain and discomfort
are not improved despite a full exposure to
pharmacologic (and other) interventions.
The recent addition of botulinum toxin A
(BTX-A) to the pharmacologic options in the
management of spasticity and dystonia makes it
possible to target specific muscles in the upper limb
[4]. BTX-A has a rapid onset of action and has
* Corresponding author.
E-mail address: stepheno@chw.edu.au
(S. O’Flaherty).
0749-0712/03/$ - see front matter Ó 2003 Elsevier Inc. All rights reserved.
doi:10.1016/S0749-0712(03)00061-1
been shown to decrease consistently but tempo-
rarily spasticity in targeted muscles [5,6]. Whether
the child can use the relaxed state to improve their
functional ability is still to be established. The
authors’ experience with this product in the upper
limb has been positive and has reinforced the
importance of patient selection, the setting of goals
that are relevant to the child, the careful verifica-
tion of the needle location in the shoulder, arm,
forearm, and hand muscles before injection, and
the need for taking care of such details as pain-free
administration to ensure that the child’s cooper-
ation with and confidence in the team is main-
tained [7]. The use of BTX-A in the upper limb is
described elsewhere in this edition. Alcohol and
phenol injections to manage spasticity in specific
muscles are mentioned to highlight the number of
practical problems and side effects that may occur
when used in children [8,9]. The focus of this article
is on the use of systemic medication to assist in
managing the upper limb of children with severe
spasticity or dystonia.
The three major subgroups of CP are diplegia,
hemiplegia, and quadriplegia. Depending on the
presence of spasticity or dystonia, affected chil-
dren are classified as spastic (dystonic) di-, hemi-,
and quadriplegic CP [10–12]. Most of the children
with severe generalized problems from spasticity
and dystonia fall within the quadriplegic classifi-
cation group. This group is the most likely to
require systemic medication to help manage their
spasticity and dystonia. Children with spastic
diplegia now make up most of those newly
diagnosed with CP and, despite the implication
in the name, diplegic children always have some
586 S. O’Flaherty, M-C. Waugh / Hand Clin 19 (2003) 585–589
involvement of their upper limbs that can be
relatively mild. The presence of a pseudobulbar
palsy manifesting as dysphagia, drooling, and
speech impairment would place children in the
more severely affected (quadriplegic) group.
Spasticity
Spasticity is a velocity-dependent increase in
muscle resistance to stretch that contributes to
the impairment of function and reduced muscle
growth [13]. It is a major cause of disability in
the juvenile CP population.
Dystonia
Children with dyskinetic CP may have this
in isolation or in combination with spasticity.
Dyskinetic CP often manifests as athetosis or
uncoordinated writhing movements in the young
child and then may evolve into a dystonic picture.
Dystonia associated with cerebral palsy is
classified as secondary or symptomatic dystonia
and often is associated with abnormalities of the
basal ganglia [14]. Dystonia is a movement dis-
order in which involuntary sustained or inter-
mittent muscle contractions result in twisting and
repetitive movements, abnormal postures, or both.
Despite its name children with dystonia may not
have abnormal muscle tone at rest [15].
Dystonia has been described as the production
of one pattern of muscle activity when a different
pattern was intended [13]. Dystonia can be difficult
to recognize. The high variability of the speed of
contractions and co-contractions result in a con-
tinual movement of affected muscle groups. The
dystonia disappears in certain positions (null
position) and in sleep, which distinguishes it from
tremor, myoclonus, and chorea [15].
Pharmacologic management of spasticity
and dystonia
The aim of systemic pharmacologic manage-
ment is to reduce the muscle overactivity seen with
spasticity and dystonia. Medication may be de-
livered orally or through a feeding tube (enterally)
or directly to the cerebrospinal fluid (intrathecally).
There are four mainstream antispasticity enteral
medications: baclofen, diazepam, dantrolene so-
dium, and tizanidine [16–21]. There are many other
medications such as clonazepam and gabapentin
[17,18] that may have a role. The major antidysto-
nia medications are L-Dopa and benzhexol (also
known as trihexyphenidyl). Baclofen and diazepam
also are used to manage dystonia [18,22,23]. Mech-
anisms of action vary, but the result is either
a suppression of muscle excitation or an enhance-
ment of neural inhibition. Response to medications
is variable and not predictable before embarking
upon a clinical trial of the drug. As a result,
treatment recommendations are not standardized
in the order that medication should be used and
how medication combinations are prescribed.
The principles of successful systemic pharma-
cologic management are to determine [24]:
 whether a decrease in muscle hyperactivity
will cause any problems with function (eg,
standing, reaching).
 whether it is the spasticity +/ÿ dystonia that
requires treatment.
 whether the goal is to improve function (eg,
reach to a cup, use of a switch) or to assist
with care (eg, pain relief, hand hygiene, ability
to get the hyperflexed spastic elbow and wrist
through a sleeve). Use of medications such as
BTX-A for management of the elbow-flexed
posture during effort are considered a func-
tional (as distinct from a cosmetic) goal.
 the goal the family should use to indicate
a successful intervention such that appropri-
ate dose rates can be ascertained (eg, im-
provement in transferring, improvement in
chair posture, reduction in spasm, sleeping
longer).
 the results of side effects such as sedation and
seizure exacerbation in the child.
No one medication has been found to meet all
the above principles. Clinically we use medica-
tions on an open trial basis. The medications are
introduced slowly with printed guidelines to aid
the family. At times there can be dramatic positive
and negative effects. The listed medications (see
Tables 1 and 2) can have significant side effects
and this is often the limiting factor in their use.
When embarking on a trial of medication,
careful documentation of efficacy and tolerance of
the medication is necessary. Side effects need to be
balanced against what the family and child see as
positive responses.
When children have a mixed pattern of move-
ment, treatment choices depend on the dominant
pattern of movement problem as a guide to which
medication to trial first. Often multiple medica-
tions are trialed serially or in combination, partic-
ularly for dystonias [25].
Listed in Table 1 are the medications used in the
authors’ unit for significant generalized spasticity
 S. O’Flaherty, M-C. Waugh / Hand Clin 19 (2003) 585–589 587

Table 1
Antispasticity and antidystonia medications and numeric ranking order of use
Antispasticity Order of use Antidystonia Order of use
Medication benefit for spasticity benefit for dystonia
Levodopa–Carbidopa — — 3 1
Benzhexol (trihexyphenidyl) — — 3 2
Baclofen 3 1 3 3
Diazepam 3 2 3 4
Tizanidine 3 3 — —
Dantrolene 3 4 — —
Intrathecal baclofen 3 After failure of 3 —
other measures
Carbemazepine — — 3 —
Clonazepam 3 — 3 —
Clonidine 3 — — —
Cyproheptadine 3 — — —
Gabapentin 3 — — —
Haloperidol — — 3 —
Tetrabenazine — — 3 —
3 Indicates that the medication has been used for this motor disorder.

and dystonia and a ranking of how these are
introduced. The questions posed in the principles
of management need to be considered at the outset
and when making changes to the child’s regimen.
Dosage and a summary of mechanism of action
and major side effects are listed in Table 2.
Increased sedation, deterioration in seizure con-
trol, and liver toxicity are the most significant side
effects that need to be considered. A full description
of each of the medications is beyond the scope of
this article and is covered extensively in Gracies
et al 1997 [18] and Pranzatelli 1996 [26].
Continuous infusion of baclofen by way of
a catheter placed intrathecally and driven by an
implanted programmable pump has been shown
to be effective in managing severe spasticity and
dystonia [27,28]. It also has several potential
complications [29]. A test dose is given as a bolus
or infusion to see if there is a significant, im-
mediate improvement in spasticity or dystonia.
This approach is more likely to allow assessment
of effect in children with severe dystonia and
should be considered if other systemic agents are
ineffective (Table 2).
Treatment of dystonia is mostly on a symp-
tomatic basis. Focal dystonia in adults responds
best to BTX-A injections [30]. In children with CP
there are no reports of BTX-A treatment in
dystonia. The authors’ experience is that BTX-A
can be beneficial particularly for painful muscle
spasm from dystonia.
Generalized dystonia can be managed with
enteral or intrathecal medications. A wide variety
of drugs have been used. The most common
medications are levodopa-carbidopa, anticholi-
nergics (benzhexol [trihexyphenidyl], benztro-
pine), baclofen, benzodiazepines (clonazepam,
diazepam), dopamine depletors (tetrabenazine),
dopamine antagonists (haloperidol), and mexile-
tine [15,22,31–35].
Response rates to medications vary widely.
Some children respond favorably to low-dose
benzhexol (4–6 mg/day) and others require high
doses (80 mg/day) before benefit is seen. In
general children seem to tolerate higher doses of
medications in comparison with adults who report
more intolerable side effects [36–39].
Dopa-responsive dystonia (DRD) may cause
a variety of motor symptoms that mimic other
disorders. It is recommended now that any child
with unexplained dystonia should receive a trial of
levodopa therapy [40,41]. If the child does have
DRD, the response is often dramatic and further
testing should be arranged. Most children with CP
and dystonia, however, are not dopa-responsive
and this group is difficult to treat. Multiple medi-
cation trials including combinations of medica-
tions are often required [25,32].
Summary
Spasticity or dystonia of the upper limb in
children with CP commonly is seen as part of
a more involved clinical picture. Each can cause
functional problems in and can interfere with the
quality of life of children with CP. Pharmacologic
588 S. O’Flaherty, M-C. Waugh / Hand Clin 19 (2003) 585–589

Table 2
Medication, mechanism of action, initial and maximum dosages, and side effects
Drug Action Dosage: initial Dosage: maximum Side effects
Baclofen Stimulates GABA-b 5 mg/day for 1 80 mg/day total Drowsiness
receptor and suppresses week then Reduced seizure
excitatory neuro- increase by 5 mg threshold
transmitter release each week Gastro intestinal
TDS or QID track upset
Intrathecal As above 25 to 50 mcgm/day 1,000 mcg/day Pump and catheter
baclofen (constant infusion) problems
Diazepam Binds to GABA-a 2 mg/day 0.3–1 mg/kg/day Drowsiness Tolerance
receptors and increases Nocte BD or TDS
presynaptic inhibition
Dantrolene Inhibits calcium release 2 mg/kg/day 12 mg/kg/day Weakness Gastro
sodium from sarcoplasmic TDS or QID 100 mg QID intestinal tract upset
reticulum Sedation
Hepatotoxicity
Tizanidine Alpha 2 agonist decreases Adult dose 2–4 36 mg/day total Sedation
presynaptic activity in mg/day TDS Dizziness
excitatory neurons Hypotension
Dry mouth
Liver dysfunction
BTX-A Blocks release of — Varies according Weakness
acetylcholine at to preparation
neuromuscular junction
Benzhexol Anticholinergic 2 mg/day 80 mg/day total Dry mouth
(trihexyphenidyl) Nocte TDS or QID Blurred vision
Urinary retention
Levodopa- Dopaminergic 1 mg/kg/day 10 mg/kg/day Gastro intestinal
Carbidopa TDS or QID track upset
Insomnia
Clonazepam Enhances polysynaptic 0.5 mg 3 mg BD Sedation
inhibitory processes Nocte Drooling
Gabapentin GABA-ergic Anticonvulsant — Depression
dosages Sedation
Fatigue
Ataxia

manipulation of the spasticity and dystonia
requires a patient and ordered approach. Treat-
ment often is performed using an open trial
method, with medications introduced slowly but
often being limited in their usefulness by signifi-
cant side effects. Despite multiple medications
being available for spasticity and dystonia man-
agement, few of the oral treatments have been
assessed systematically in children with CP.
Specific evaluation of the use of enteral medica-
tions in upper limb management is even rarer.
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 Hand Clin 19 (2003) 591–600

Botulinum Toxin A in the management of upper

limb spasticity in cerebral palsy
Terence Y.P. Chin, MBBSa,
H. Kerr Graham, MD, FRCS (Ed), FRACSa,b,*
a
Department of Orthopaedic Surgery, Royal Children’s Hospital, Melbourne, Flemington Road,
Parkville 3052, Victoria, Australia
b
University of Melbourne, Hugh Williamson Gait Analysis Laboratory, Royal Children’s Hospital, Melbourne,
Flemington Road, Parkville 3052, Victoria, Australia

Juvenile cerebral palsy (JCP) is the most
common cause of the upper motor neurone
syndrome (UMNS) in children and is associated
with positive and negative features [1–3]. The
positive features are movement disorders, such as
spasticity, dystonia, athetosis, and co-contraction.
The negative features are weakness, dyspraxia,
impaired selective motor control, and sensory
impairment. Physicians and therapists tend to
focus on the positive features of UMNS (spastic-
ity and contractures) because these are influenced
more easily by intervention than are the negative
features. The negative features, however, largely
determine the long-term functional prognosis.
There is no satisfactory solution to weakness
and lack of sensibility.
Associated comorbidities include cognitive
impairment, learning difficulties, epilepsy, respi-
ratory disease, and gastrointestinal problems.
These problems are more common in children
with severe cerebral palsy, especially children with
spastic quadriplegia.
Neuromusculoskeletal pathology
At birth the child with JCP does not have fixed
deformities. These are acquired during growth
[4,5]. The key feature of the musculoskeletal
pathology is a failure of longitudinal growth of
* Corresponding author.
E-mail address: kerr.graham@rch.org.au
(H.K. Graham).
0749-0712/03/$ - see front matter Ó 2003 Elsevier Inc. All rights reserved.
doi:10.1016/S0749-0712(03)00060-X
skeletal muscle. An apt orthopaedic synonym for
cerebral palsy is short muscle disease [6].
In spastic hemiplegia, the upper limb deform-
ities typically include internal rotation and adduc-
tion at the shoulder, and this may progress in
a small minority of patients to anterior migration
of the humeral head. The pectoralis major and the
subscapularis are usually the main deforming
forces. At the elbow, flexion deformity is common,
initially dynamic, progressing to a fixed deformity
with variable degrees of joint contracture. In the
forearm, pronation deformities are ubiquitous and
are the result of muscle imbalance between spastic
pronators (pronator teres and pronator quadra-
tus) and weak supinators. Loss of active supina-
tion results in a contracture in the interosseous
membrane and may predispose to subluxation or
dislocation of the radial head. Flexion deformities
of the wrist and fingers are the most common
deformities in the upper limb, because the spastic
flexors overpower the weaker extensors. Wrist
flexion deformity usually is accompanied by ulnar
deviation, because the ulnar deviators are more
powerful than the radial deviators. The ‘‘thumb-
in-palm’’ deformity is common and is associated
with significant functional impairment [5,6].
As with all deformities, there is a postural-
dynamic phase with gradual development of fixed
contracture of the muscle–tendon units caused
by muscle imbalance. Eventually this leads to the
phase of decompensation, which may include fixed
joint contractures and joint subluxation. Different
muscles develop fixed contractures at different
592 T.Y.P. Chin, H.K. Graham / Hand Clin 19 (2003) 591–600
speeds. The pronator teres is invariably the first
muscle in the hemiplegic upper limb to develop
a contracture. This is not because it is more spastic
than other muscles but because it is never stretched
by antagonist action [5,7]. Loss of active supina-
tion is present to some degree in all children with
hemiplegia. Prevention of pronation contracture is
simple in principle but difficult in practice. The
pronator teres must be stretched out fully to its
maximum length by parent or therapist, because
the child is unable to do this for himself.
Spasticity management in juvenile cerebral palsy
Spasticity management has become increas-
ingly sophisticated and effective in recent years and
is best managed by a multidisciplinary team. The
spasticity team ideally should have representation
from developmental pediatrics, neurology, phys-
iotherapy, occupational therapy, neurosurgery,
plastic surgery, and orthopaedic surgery.
Spasticity interventions can be classified as
temporary or permanent and as focal or general-
ized [7,8]. The choice of appropriate spasticity
management often is dictated by the topographic
distribution of cerebral palsy and associated
comorbidities. In spastic monoplegia and hemi-
plegia, focal or regional spasticity management
with injections of Botulinum Toxin A (BoNT-A)
to the appropriate target muscles is a widely used
intervention. In spastic diplegia, selective dorsal
rhizotomy may be indicated for lower limb
spasticity. There may be incidental improvements
in upper limb function after rhizotomy in the
lumbosacral area [9]. In spastic quadriplegia,
continuous intrathecal administration of baclofen
by implantable pump may be appropriate. Signif-
icant reduction in upper limb spasticity and
improvements in function can be achieved in some
children by placing the tip of the intrathecal
catheter high enough to achieve a significant
concentration of baclofen in the cerebrospinal fluid
(CSF) at the level of the cervical roots [10].
Interventions for the management of spasticity
can be combined when appropriate. In teenagers
with spastic quadriplegia, global spasticity man-
agement may require intrathecal baclofen. Re-
sidual elbow flexor spasticity can be managed by
focal injection of BoNT-A.
Intramuscular botulinum toxin A
BoNT-A is a potent neurotoxin produced by
the bacterium Clostridium botulinum under anaer-
obic conditions. It binds to cholinergic nerve
endings and inhibits release of the neurotransmit-
ter acetylcholine by blocking the binding of
acetylcholine vesicles to the interior of the motor
end-plate plasma membrane. The sprouting of
new nerve endings restores neurotransmission. It
takes approximately 3 months for the original
nerve endings to be restored while the ‘‘new’’
nerve endings are being eliminated concurrently
[11]. The effect of BoNT-A thus is pharmacolog-
ically completely reversible.
Of the six serotypes, only types A and B have
become commercially available. Type B has
a shorter duration of action than type A and offers
no advantages in the management of chronic
spasticity associated with JCP. There are two
commercially available type A preparations, Dys-
portÒ (Ipsen; UK) and BotoxÒ (Allergan; USA).
Although they are both type A neurotoxins, the
preparations differ significantly in preparation,
potency, and antigenicity [12]. The units are not
interchangeable and clinicians must be vigilant in
calculating the appropriate dosage [8]. The ap-
proval and licensing of the commercially available
neurotoxins vary from country to country. BotoxÒ
and DysportÒ are approved in Australia and most
European countries for the management of spastic
equinus in children with cerebral palsy, but the
approval does not extend to the injection of spastic
upper limb muscles. In the United States, the
Federal Drug Administration (FDA) has ap-
proved neither preparation for use in children
with cerebral palsy. Upper limb injections in
spastic cerebral palsy are therefore an ‘‘off label’’
indication. The authors believe that all ‘‘off label’’
use of BoNT-A should be in the context of ethically
approved and properly regulated clinical trials.
When injected into skeletal muscle, BoNT-A
causes a dose-dependent, reversible chemodener-
vation of muscle [13]. The treatment converts
paresis with muscular hyperactivity to paresis with
muscular hypoactivity [14]. In general BoNT-A
should be considered a focal/regional intervention
[8,10].
Koman et al in the United States, Wall et al in
South Africa, and Graham et al in the United
Kingdom reported the first clinical trials of in-
tramuscular BoNT-A in cerebral palsy in 1993 and
1994 [13,15,16]. The authors first investigated the
effects of BoNT-A injections in an animal model of
JCP, the hereditary spastic mouse. The authors
found that injections of BoNT-A to the gastrocso-
leus muscle in juvenile mice improved growth of
the muscle–tendon unit and reduced contracture
 T.Y.P. Chin, H.K. Graham / Hand Clin 19 (2003) 591–600 593

[4]. In an open label clinical study, the authors
found that injections of spastic lower limb muscles
in JCP resulted in reduced spasticity, improved
joint range of motion, and improved gait and
function [16]. Improvements in equinus gait were
confirmed in a subsequent randomized clinical
trial by the authors’ group and replicated in other
centers [17,18]. The authors then designed a ran-
domized, placebo-controlled clinical trial to in-
vestigate the effects of intramuscular BoNT-A in
the upper limb of children with cerebral palsy [19].
The authors’ study was placebo controlled and
double blind. Children were assigned randomly to
receive multiple injections of BoNT-A or normal
saline to selected muscle groups in the upper limb.
The child, parents, therapists, and investigators
were blind to the treatment group until the code
was broken 12 weeks later. Extensive testing of
muscle stiffness, joint range of motion, and
function was performed at baseline and at 2 and
12 weeks after injection. The main results were that
intramuscular injection of BoNT-A resulted in
consistent reduction in spasticity and muscle
stiffness as measured by a torque motor (Fig. 1).
The torque motor was used to measure the
resonant frequency of the wrist as an objective
and quantifiable measure of forearm muscle
stiffness [6,20]. A reduction in spastic posturing,
improved active and passive joint range of motion,
and some improvements in function followed
reduced muscle stiffness. The strengths of the
authors’ study were that it was double blind and
placebo controlled and that an objective measure
of muscle stiffness was included. The weaknesses
were that the study cohort was small and hetero-
geneous, the amount of occupational therapy was
not controlled or recorded, and the study lacked
a good functional outcome measure. Most of these
shortcomings have been addressed in a more recent
study by Fehlings et al [21]. They randomized 30
children with hemiplegic JCP to receive occupa-
tional therapy (control group) or occupational
therapy combined with intramuscular injections of
BoNT-A. In this larger randomized clinical trial
they demonstrated significant functional gains
using the Quality of Upper Extremity Skills Test
(QUEST), a validated tool measuring upper limb
function [22]. This study has been critical to the
development of good study design for upper limb
trials in JCP. The need for a control group is made
clear by the demonstration of progressive improve-
ment in function in the control group, probably
because of natural improvement with time and the
acquisition of functional skills. Validated measures
such as QUEST and the Melbourne upper limb
assessment scale should be used to quantify
functional outcomes of spasticity management
objectively [22,23].

Fig. 1. Change in forearm muscle stiffness as measured by wrist resonant frequency (Hz2) following injection of BoNT-A
into forearm flexors in a child with spastic hemiplegia. A dramatic decline in forearm muscle stiffness from 20.7 Hz2 to an
almost normal value of 5.6 Hz2 is seen at 1 week after BoNT-A injection into wrist flexors. Subsequent measurements
show a gradual increase in muscle stiffness approaching (but still lower than) baseline levels at 1 year. Repeat BoNT-A
injection produces a second fall in muscle stiffness, albeit to a lesser degree compared with the first injection. Note that
although the pharmacologic effect of BoNT-A lasts for 3–6 months, the biomechanical benefits may persist up to 1 year.
(From Corry IS, Cosgrove AP, Walsh EG, McClean D, Graham HK. Botulinum toxin A in the hemiplegic upper limb:
a double blind trial. Dev Med Child Neurol 1997;39:185–93; with permission.)
594 T.Y.P. Chin, H.K. Graham / Hand Clin 19 (2003) 591–600

Treatment goals sponse to weakening of the elbow flexors, wrist

flexors, and finger flexors, particularly in the
Intramuscular injections of BoNT-A can be
presence of dynamic contractures alone [24]. The
used for a variety of indications in the upper limbs
presence and efficacy of extensor and supinator
of children with cerebral palsy. The most common
function, previously masked, can be assessed.
indication is for the correction of spastic posturing
Severe postoperative pain and spasm may
that interferes with function in the absence of fixed
complicate muscle–tendon surgery in many chil-
deformity [16,19]. Dynamic deformities are caused
dren with spastic cerebral palsy. BoNT-A has been
by dystonia or spasticity and are absent under
found to provide effective pain relief in a double
anesthesia. Fixed deformities are found in the
blind, placebo-controlled trial [26]. Reduction in
older child and require muscle–tendon surgery for
spasm also protects lengthened tendons and
correction. Determining the effect of dynamic
tendon transfers from postoperative disruptions.
deformities on function can be difficult, but it
is a vital step in predicting whether functional
benefits can be obtained. The transition from Selection of target muscles for BoNT-A injection
dynamic to fixed deformity in many children is
The selection of target muscles for BoNT-A
gradual. Dynamic and fixed deformities coexist in
injection is individualized after a careful analysis of
many children. It requires considerable judgment
the functional deficits, the postural deformities, the
to decide when to use BoNT-A alone and when to
treatment goals of the child and family, and the
use combinations of BoNT-A followed by serial
clinician’s analysis of the muscular hypertonia and
casting for residual contracture. In general, BoNT-
how it relates to the individual’s abilities and
A is more appropriate in the younger child with
disabilities [19,21]. This is a complex process re-
dynamic deformities and muscle–tendon surgery
quiring experience and time. A systematic ap-
is reserved for the older child with fixed deform-
proach is important, starting with patient/family
ities. Those children with mild spasticity and the
identified limitations, problems, and goals. This is
inability to initiate voluntary finger movements are
followed by objective assessment of the movement
also less likely to benefit. Patients need to be able
disorder and characteristic posturing at rest and
to activate and strengthen antagonist muscles to
during functional activities. Selective motor con-
take advantage of BoNT-A weakened agonists.
trol and active and passive joint range of motion
Those with a good baseline grip strength are more
should be assessed by standardized examination
likely to benefit, as muscle strength and spasticity
techniques and should be recorded. Functional
are reduced after injection [24]. Other favorable
testing using assessments such as the Melbourne
factors are: young age, good capacity for motor
Upper Limb Assessment is strongly recommended,
learning, and high levels of motivation [25].
together with video recording of specific postural
The correction of spastic posturing has a sig-
and functional tasks. Upper limb kinematics and
nificant impact on deformity and self esteem.
dynamic electromyography require specialized
When the authors investigated the functional
equipment, expertise, and time. They are valuable
outcomes of BoNT-A injections in the hemiplegic
in a research setting but are not yet widely available.
upper limb, the outcome that was rated most
Spastic postures should be identified and the
highly was reduction in elbow flexor posturing
degree of spastic and fixed shortening of all the
when running, a cosmetic rather than a functional
major muscle tendon units should be documented.
outcome [19]. In severely affected patients for
The retained function must be identified and
whom functional improvements are not achiev-
documented, that is, the voluntary control of
able, BoNT-A still may be used to improve spastic
individual muscle–tendon units and muscle
posturing, enabling easier management of hy-
strength. In the authors’ practice the most common
giene, dressing, and other aspects of general care.
target muscles, in descending order of frequency,
Additional indications for BoNT-A therapy
have been:
include preoperative planning and perioperative
pain and spasm control. Preoperative BoNT-A  Pronator teres (93%) and pronator quadratus
chemodenervation can be used to simulate sur- (2.9%)
gery. In the presence of fixed contracture, a  Wrist flexors: flexor carpi ulnaris (86%) and
complete surgical simulation is not possible. It flexor carpi radialis (82%)
can be useful, however, for the child, the family,  Elbow flexors: biceps (78%), brachialis
and the therapists to determine the child’s re- (72%), and brachioradialis (6%)
 T.Y.P. Chin, H.K. Graham / Hand Clin 19 (2003) 591–600
 Adductor pollicis and flexor pollicis brevis
(76%)
 Long finger flexors (31%) and flexor pollicis
longus (43%)
 Pectoralis major (16%) and subscapularis
(12%)
When the aim is to decrease typical spastic
posturing and to improve function, the usual
combination is biceps and brachialis, pronator
teres, flexor carpi ulnaris, flexor carpi radialis, and
adductor pollicis. The long finger flexors should be
avoided carefully to prevent weakening grip
strength. When the aim is improved palmar
hygiene, injection of the finger flexors (flexor
digitorum superficialis and profundus) is always
required.
Location of the target muscles and dose levels
Target muscles are identified by simple means
such as palpation and the use of anatomic land-
marks (Fig. 2). This may be adequate for large
subcutaneous muscles such as the biceps but is
not reliable for smaller, deeper muscles. BoNT-A
diffuses readily across fascial barriers and the
effects of injection of neurotoxin into one muscle
may be complicated by diffusion into another
muscle or even into another compartment. It is not
known how the location and number of injection
sites and the dose of toxin and its dilution influence
the diffusion characteristics. Intuitively it makes
sense, however, to locate target muscles as
accurately as possible. A good understanding of
longitudinal and cross-sectional anatomy is re-
Fig. 2. Typical pattern of spastic flexion deformity of the upper limb in a patient with CP. Sites for injection of BoNT-A
are illustrated: biceps brachii for elbow flexion, flexor carpi radialis and flexor carpi ulnaris for wrist flexion, pronator
teres for forearm pronation, and adductor pollicis for thumb-in-palm posturing.
595
quired for this (Fig. 3). Other frequently used
methods to locate muscles accurately include
electromyography (EMG) and muscle stimulation.
EMG works well in cooperative adult patients, but
direct stimulation is the authors’ preferred tech-
nique for children [27]. Stimulation is achieved by
using an insulated needle for stimulation of the
muscle and injection of the toxin into the target
muscle belly (Figs. 4–6) [27]. For most children this
requires mask anesthesia [19].
In children, BoNT-A doses are usually on a unit/
muscle/Kg of body weight basis. The two com-
mercially available preparations of type A toxin,
BotoxÒ and DysportÒ, have different potencies
and the units are not interchangeable. The type B
toxin has a shorter duration of action, greater
systemic spread, and more side effects than the
type A toxins [12]. The only logical indication for
type B toxin is when antibody-mediated resistance
to type A toxin develops following repeated
BoNT-A administration.
Current dose guidelines have been established
empirically by consensus of experienced injectors
and have been described fully elsewhere (Table 1)
[25,28,29]. The dose required is based on the
number of selected target muscles, the degree of
hypertonia, and the desired effect.
Injection aftercare
The first episode of upper limb injections is
a clinical experiment and close follow-up is
required to describe the response. The first post-
injection assessment should be at 2–3 weeks after
596 T.Y.P. Chin, H.K. Graham / Hand Clin 19 (2003) 591–600

Fig. 3. Longitudinal and cross-sectional anatomy of the upper limb with common target muscles shaded in cross-
section. A good knowledge of this anatomy is essential for accurate needle placement for BoNT-A injections.

injection, which is the time of peak pharmaco-
logic effect. The active and passive joint range of
motion benefits, unintended effects, and adverse
events are documented. Need for splintage and
casting can be determined at this stage. Physical
and occupational therapy should be instituted
when appropriate to improve range of motion,
strengthen antagonist muscles, and improve pat-
terns of functional movements (eg, grasp and
release, pincer grip). Functional gains may take

Fig. 4. Equipment for BoNT-A injection. Shown are a vial of BotoxÒ (Allergan, USA), normal saline for reconstitution,
insulated injection needle, and a portable electrical stimulator.
 T.Y.P. Chin, H.K. Graham / Hand Clin 19 (2003) 591–600 597

Fig. 5. BTX-A injection into pronator teres. The patient’s forearm is placed initially in full supination. Following needle
placement, electrical stimulation produces pronation of the forearm, confirming needle placement into the muscle belly
of pronator teres. Injection sites for biceps brachii, FCR, and FCU also are marked.

longer to become evident and a repeat assessment
of function should be deferred until approxi-
mately 3 months after injection.
Results and complications
Between 1994 and 2002, the authors injected the
upper limbs in 103 children with spastic or mixed
dystonic/spastic cerebral palsy. Most children had
spastic hemiplegia, but there were 12 children with
spastic quadriplegia who had bilateral upper limb
involvement and bilateral injections of BoNT-A.
In more than one third of children with hemiplegia,
upper limb injections were combined with lower
limb injections for spastic equinus deformity. The
most common indication for BoNT-A in the upper

Fig. 6. BoNT-A injection into adductor pollicis. An assistant holds the first web space fully abducted as the needle is
placed into the muscle belly of adductor pollicis. Needle placement is confirmed with electrical stimulation.
598 T.Y.P. Chin, H.K. Graham / Hand Clin 19 (2003) 591–600

Table 1
Botulinum toxin A: upper limb sites and dose guidelines (Botox only) for children with spastic hemiplegia
Number of
Clinical pattern Muscles involved Botox dose U/Kg injection sites
Pronated forearm Pronator teres 1 1
Pronator quadratus 1 1
Flexed elbow Biceps 2–3 4
Brachialis 2 2
Brachioradialis 1 1
Flexed wrist Flexor carpi ulnaris 1–2 1
Flexor carpi radialis 1–2 1
Thumb-in-palm Adductor pollicis/flexor 5–10 Ua 1
pollicis brevis
Flexor pollicis longus 10–20 Ua 1
Clenched fist Flexor digitorum profundus 1–2 4
Flexor digitorum superficialis 1–2 4
Adducted/internally Pectoralis major 2 2–3
rotated shoulder
Subscapularis 1 1–2
a
Total dose per muscle.
References: [25,28,29].

limb was improvement in function (Table 2). The is evidence of a systemic spread of toxin and we
most common adverse event was weakness of have reported previously three cases of inconti-
grasp, which was noted in 12 children (11.7%) nence after lower limb injections [30].
(Table 3). This resolved fully in all children by The outcome of BoNT-A injections to the
3-month follow-up. Bruising and pain at the upper limb in children with cerebral palsy can be
injection site was found in 14 children (13.6%). classified according to the scheme the authors
Three children experienced a ‘‘dropped index devised for lower limb injections [30]. In approx-
finger.’’ This lasted 2–6 weeks before resolution imately 3%–5% of children a dramatic improve-
occurred. One child had urinary and fecal in- ment in posture and function is evident and the
continence after combined upper and lower limb results are long-lasting, in some cases permanent.
injections at a total dose of 12 U/Kg BotoxÒ. The authors have referred to this group as ‘‘golden
Incontinence developed within 2 days of injection responders.’’ The authors are unsure as to the
and resolved after 3 weeks. The authors believe this mechanism of the response. Peripheral biome-
chanic factors and central mechanisms may be
responsible. The authors currently are investigat-
Table 2
ing central and peripheral effects after injections
Indications for upper limb BoNT-A and percent re-
sponse rate in 103 children with cerebral palsy
of BoNT-A in a randomized clinical trial. Most
children (approximately 70%) demonstrate a clin-
Number and percent ical or symptomatic response that is unfortunately
Total of golden or
number clinical respondersa
Dynamic upper 62 41 (66%) Table 3
limb function Adverse events in 103 children who received botox
Presurgical trial 14 12 (86%) injections to the upper limb for the management of
Combined with upper 12 — spasticity
limb surgery
Number Percent
Hygiene/splinting 12 11 (92%)
Painful arm spasms 3 3 (100%) Weakness of grasp 12 11.7
Total 103 67 of 91b (74%) Bruising 10 9.7
a Pain 4 3.9
See text for classification of responders after BTX-
Dropped index finger 3 2.9
A injection.
b Incontinence 1 1.0
Total of 91 patients after exclusion of 12 who had
Total 30 29
combined BoNT-A and upper limb surgery.
 T.Y.P. Chin, H.K. Graham / Hand Clin 19 (2003) 591–600
relatively short lived (6–9 months) (Table 2). The
authors refer to this group as ‘‘clinical respond-
ers.’’ A reduction in muscle tone is observed,
accompanied by improved joint range of motion
and some small gains in function. The decision
whether to reinject and to continue with a combi-
nation of six monthly injections combined with
occupational therapy or to proceed with definitive
surgery can be difficult. Parents and therapists
often favor continuing with conservative meas-
ures, but repeated injections are expensive and
the long-term outcome has not been studied or
reported. In other children, the reduction in
muscle tone is not accompanied by any change in
joint range of motion or function and the authors
classify these patients as ‘‘minimal responders.’’
Finally, some children are ‘‘non-responders,’’
having no detectable or observable response to
injection. The most common reason for failure to
respond to BoNT-A injection is the presence of
fixed contractures, absence of selective motor
control in antagonist muscles, sensory impair-
ment, and learned non-use. In this large cohort,
some of the children were participants in pro-
spective studies with objective functional outcome
measures and others were followed less rigorously.
Although it is difficult to give meaningful figures,
the authors’ preliminary results show 74% of our
cohort achieved their treatment goals (Table 2).
Summary
Clinical experience thus far has shown BoNT-A
to be a safe and efficacious method in the short
to medium term management of spasticity of the
upper limb in cerebral palsy. The relaxation of
hypertonic musculature allows for improvement in
function and posture, reduction of pain, and in
some patients, improvement in cosmesis. It is also
a valuable tool in predicting response to and
guiding contemplated muscle–tendon surgery.
Careful patient selection, detailed clinical assess-
ment of deformity and disability, and a clear
outline of treatment goals are essential to good
outcomes. Further work needs to be done to
determine optimum doses of BoNT-A for in-
dividual muscles and to evaluate the long-term
outcome of repeated injections.
Acknowledgments
The authors wish to thank the staff of the
Educational Resource Centre of the Royal Child-
ren’s Hospital, Melbourne, for their help with
599
photography and illustrations. We also thank
Mary Sheedy for assistance with the preparation
of this manuscript.
References
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[2] Stanley F, Blair E, Alberman E. Classification of
cerebral palsies. In: Cerebral palsies: epidemiology
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[3] Pirpiris M, Graham HK. Management of spasticity
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cal management and neurophysiology. Cambridge:
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[4] Cosgrove AP, Graham HK. Botulinum toxin A
prevents the development of contractures in the
hereditary spastic mouse. Dev Med Child Neurol
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[6] Brown JK, Walsh EG. Neurology of the upper limb.
In: Neville B, Goodman R, editors. Congenital
hemiplegia (Clinics in developmental medicine, No.
150). London: Mac Keith Press; 2000. p. 113–49.
[7] Boyd RN, Graham HK. Botulinum toxin A in the
management of children with cerebral palsy: indica-
tions and outcome. Eur J Neurol 1994;1(Suppl 2):
S15–22.
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Delgado MR, Gaebler-Spira DJ, Gormley ME,
Guyer BM, Heinen F, Holton AF, Matthews D,
Molenaers G, Motta F, Garcia Ruiz PJ, Wissel J.
Recommendations for the use of Botulinum toxin
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Posture 2000;11:67–79.
[9] Loewen P, Steinbok P, Holsti L, MacKay M.
Upper extremity performance and self-care skill
changes in children with spastic cerebral palsy
following selective posterior rhizotomy. Pediatr
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[10] Gormley ME Jr, Krach LE, Piccini L. Spasticity
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JO. Functional repair of motor endplates after
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[12] Aoki KR, Guyer B. Botulinum toxin type A and
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[13] Wall SA, Chait LA, Temlett JA, Perkins B, Hillen
G, Becker P. Botulinum A chemodenervation: a new
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[15] Koman LA, Mooney JF III, Smith BP, Goodman
A. Management of cerebral palsy with Botulinum
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[18] Flett PJ, Stern LM, Waddy H, Connell TM, Seeger
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[20] Walsh EG. Muscle masses and motion: the physi-
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[25] Autti-Rämö I, Larsen A, Taimo A, von Wendt L.
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[27] O’Brien CF. Injection techniques for Botulinum
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[28] Russman BS, Tilton A, Gormley ME Jr. Cerebral
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[30] Boyd RN, Graham JEA, Natrass GR, Graham
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 Hand Clin 19 (2003) 601–606

Electrical stimulation in the management

of spastic deformity
Luis R. Scheker, MDa,*, Kagan Ozer, MDb
a
Division of Plastic and Reconstructive Surgery, University of Louisville School of Medicine,
225 Abraham Flexner Way, Suite 800, Louisville, KY 40202, USA
b
C.M. Kleinert Institute for Hand and Microsurgery, 225 Abraham Flexner Way,
Suite 850, Louisville, KY 40202, USA

Cerebral palsy (CP) in children continues to be
a severe problem, with an incidence of 2–5 per
1000 people in developed countries [1–4]. Half
have upper extremity involvement [5]. Traditional
treatment methods consist of surgery, physio-
therapy, orthoses, and medication. Evidence for
the efficacy of these treatment modalities in the
literature is scarce and often confounded by the
problems of extensive variability in the clinical
presentation and types of management offered
and difficulty in objective assessment of outcomes.
Surgery is performed to rebalance the muscles in
the limb to improve function, to decrease hygiene
problems, and to improve cosmesis [6]. Some
patients with CP, however, have contraindications
for upper extremity surgery [4], and even when
appropriate, surgery may fail to improve function.
The amount of conclusive research supporting
the use of physical therapy to improve function
is limited [7]. The application of orthoses in
the upper extremity is common but results have
seldom been reported [8–11]. Medications to
paralyze the spastic muscle group have major side
effects of sedation and weakness [12–15]. Recent
studies on Botulinum toxin A showed encourag-
ing results in relieving spasticity and increasing
range of motion (ROM), with no improvement in
fine motor skills and no carryover effect after
3 months [16–18]. Investigators therefore con-
tinue to look for alternative treatment modalities
* Corresponding author.
E-mail address: lscheker@kkahand.com
(L.R. Scheker).
0749-0712/03/$ - see front matter Ó 2003 Elsevier Inc. All rights reserved.
doi:10.1016/S0749-0712(03)00037-4
in the management of patients with CP. One
such treatment is functional electrical stimulation
(FES).
Levine in 1952 first introduced the concept of
electrical stimulation in the management of CP
[19]. Treatment consisted of stimulation of the
antagonist muscles to oppose a spastic muscle
group, followed by vigorous ROM exercises,
which led to a dramatic decrease in the muscle
tone. Alfieri also demonstrated a long-term re-
duction of muscle tone by administering multiple
treatment sessions of FES to the antagonist of
spastic muscles [20]. Later the technique found
a more common application in the lower extrem-
ities [21]. There have been few studies on its use on
the upper limb affected by CP. In 1991, the first
report of FES being used for the upper limbs of
children with CP was published [22]. The study
involved two children who received FES to their
wrist extensors and demonstrated the feasibility of
application without a significant improvement in
function. Later, Carmick reported three patients
with improved grasp and release activities and
locomotor efficiency after applying FES to vari-
ous spastic and nonspastic muscle groups [23,24].
The success of this treatment was attributed to
strengthening of spastic and nonspastic muscle
groups, increased awareness, and spontaneous use
of the upper limb. Following these anecdotal
reports, the authors published our experience with
neuromuscular electrical stimulation (NMES)
together with dynamic bracing in 1999 [25]. This
preliminary report included 19 patients, some with
more than 5 years of follow-up, this being the
largest series with longest follow-up in the
602 L.R. Scheker, K. Ozer / Hand Clin 19 (2003) 601–606

literature. The authors’ preliminary results Patient selection criteria

showed remarkable improvement in hand func-
Between 1992 and 1997, children visiting The
tion, ROM, and cosmesis. Finally, Wright, in his
Kentucky Commission for Children with Special
report of eight cases, used FES and demonstrated
Health Care Needs with a diagnosis of spastic
significant improvements in hand function and
hemiplegic CP who met the following additional
wrist extension until the end of follow-up (6
criteria were considered eligible for the study:
weeks) [26].
(1) patients who were 3 years of age and older
Children with CP have motor, sensory, and
(3–21 years), (2) patients with mild to moderate
intellectual problems that should be evaluated
spasticity of the shoulder and elbow that allowed
together. In children with a spastic-type upper
the patient to place the hand in a desired position
extremity involvement, the elbow is usually in
in space, (3) patients with protective sensation, (4)
flexion and the forearm in pronation; the wrist is
patients with cognitive abilities that enabled them
in ulnar deviation and flexion, with variable
to follow doctors’ directions, and (5) patients with
extension ability; the thumb is adducted and
moderate to severe spasticity of the wrist and
flexed into the palm [4]. Excessive wrist and elbow
hand without any static contracture.
flexion and forearm pronation do not allow
The Zancolli classification was used to grade
manipulation of objects. Release is typically slow,
the patients before and after the application of the
with excessive wrist flexion instead of extension,
protocol (Table 1) [32]. Nineteen patients were
caused by the inability to extend the fingers and
evaluated before the treatment: 11 were classified
wrist at the same time. Wrist flexion mechanically
at type III, 7 as type IIb, 1 as type IIa. No one was
assists finger extension using the tenodesis effect
classified as type I.
of the extensor digitorum communis (EDC) muscle
as the wrist is flexed. Motion is limited because of
decreased strength of the extensors, contractures, Electrical stimulation
and the increased muscle tone of the flexors
[6,27,28]. The disease is associated with positive The electrical stimulation system is comprised
and negative features. Spasticity and hyperactive of three elements: the stimulator unit (EMS 400
reflexes are considered positive features. Muscle Skylark Device Co., Louisville, Kentucky), elec-
weakness and loss of motor control are considered trodes, and connecting wires (Medi-Stim Inc.,
negative features. In the past, spasticity was Delaware, Ohio). The reusable, self-adhering,
considered the most disabling factor. Currently, carbonized rubber electrodes are connected to
many researchers consider the negative symptoms the stimulator by leads that are snapped to the
(muscle weakness, loss of control) more disabling button of the electrode. The adhesive electrodes
[29,30]. Function seems to correlate with strength,
not with muscle tone [31].
Table 1
The authors’ approach in the management of
Zancolli classification of wrist and finger deformity
CP consists of the combined use of NMES of
nonspastic extensors of the wrist together with the Before the
use of dynamic (daytime) and static (nighttime) Zancolli classification protocol Follow-up
bracing. Using NMES, the authors stimulate the Type 1: Complete extension None 10
nonspastic extensor compartment muscles, help- of the fingers with wrist
ing them to regain their strength and possibly to in neutral position or with
stimulate a retrograde reflex arc inhibiting the less than 20 flexion
Type 2a: Active extension 1 9
spastic contracture of the flexors. The dynamic
of the fingers with
brace used in the authors’ protocol only allows
wrist flexion of greater
active metacarpophalangeal (MP) joint flexion than 20 , active wrist
and fixes the wrist joint in 10 dorsiflexion. This extension present
type of bracing helps the effective stretching of Type 2b: Active extension of 7 None
the spastic flexors without stimulating spastic the fingers with wrist flexion
contraction and assists in shortening of the of greater than 20 , active
extensor musculature while strengthening intrin- wrist extension absent
sic muscles. The following text includes a detailed Type 3: No active extension 11 None
description and the results of the authors’ new of the fingers even with
maximal wrist flexion
approach.
 L.R. Scheker, K. Ozer / Hand Clin 19 (2003) 601–606
are placed on the dorsum of the forearm over the
bellies of the wrist and finger extensor muscles at
distal and proximal positions (Fig. 1).
The battery operated electrical stimulator
consists of a dual-channel with a current output
that can be set between 0 and 100 mA. The
stimulus waveform consists of biphasic symmetric
rectangular pulses with a 200-lsec duration. The
pulse rate ranges from 40–60 pulses per second to
produce tetanic muscle contraction. The stimulus
amplitude is adjusted from 30–40 mA to produce
tolerable muscle contractions. During the training
sessions with the parents, electrical stimulation is
applied first on the clinician’s arm, then on the
arm of the parents, and finally on the patient’s
arm. A 2-second ON ramp, 2-second OFF ramp,
10-second ON duty, and 7-second OFF duty cycle
commonly is selected to produce rhythmic muscle
contraction. The stimulus amplitude threshold is
determined by increasing the amplitude of the
stimulus until muscles start to contract. The am-
plitude then is reduced gradually until no con-
tractions are apparent. This amplitude threshold
then is doubled and used routinely. If necessary,
the amplitude is decreased to make contractions
tolerable.
Dynamic orthotic traction
The orthotic device has two parts: a wrist/hand
unit and an elbow unit. The wrist/hand unit
consists of a thermoplastic rigid support that
positions the wrist in extension (Fig. 1). This unit
also has an adjustable finger platform that locks the
proximal interphalangeal (PIP) and distal inter-
Fig. 1. Placement of electrodes to the extensor surface
of the forearm together with application of the dynamic
brace.
603
phalangeal (DIP) joints in the extended position,
allowing finger movement only at the MP joints.
To resist the spastic muscles but not facilitate
a spastic response (that is, a stretch reflex), the wrist
unit is positioned 10 short of maximum extension
stretch with the finger platform immobilizing the
IP joints, allowing MPJ motion. The elbow unit
has a dynamic dual hinge with adjustable tension
(0–7.2 kg) and an adjustable lock.
This stretching technique resists tight spastic
flexors while stretching intrinsic musculature and
gives the antagonist musculature the chance to
shorten. The custom-fitted orthosis (Ultraflex;
Malvern, Pennsylvania) is used to alter the elbow
flexion contracture and pronation deformity by
placing the forearm in maximum supination and
then applying the elbow extension unit. Velcro is
used to prevent slippage of the orthosis during
pronation. With this technique, the authors
achieve maximum mechanical leverage on the
pronator teres muscle and strengthen the ability of
biceps to supinate the forearm.
Neuromuscular electrical stimulation
and dynamic bracing protocol
The home-based program consists of approx-
imately 1 hour per day of electrical stimulation
preceded by dynamic bracing. Treatment time can
be divided into two 30-minute sessions or three
20-minute sessions, depending on the working
schedules of the parents and availability of care-
givers. After the parents and caregivers are
instructed, children are fitted with the wrist and
elbow unit. Adhesive, reusable electrodes then are
placed on the bellies of the wrist and finger
extensor muscles. Once the amplitude is deter-
mined, the extensor muscles are stimulated for
10 seconds to obtain a tetanic contraction, fol-
lowed by 7 seconds with no electrical stimulation.
During the period with no stimulation, the patient
is told to flex the fingers repeatedly so that they
learn which muscles to contract to flex the fingers
and prevent co-contraction. At the beginning of
the treatment, the rubber bands in the outrigger
part of the dynamic brace are strong enough to
extend the fingers, and then, as the extensor
tendons become stronger, the strength of the
rubber bands is decreased gradually. After each
session, children are allowed to continue with
their daily activities. The orthotic devices and the
electrode positioning are reviewed every time the
patient is seen in the clinic, initially 2 weeks after
starting treatment and then every month, to
604 L.R. Scheker, K. Ozer / Hand Clin 19 (2003) 601–606
assure that the orthosis and the stimulation are
being applied correctly. At night, the finger plat-
form is connected to a dorsal outrigger using a
static Velcro strap to resist the contracted extrin-
sic flexors and maintain the ROM gained during
the day.
The children are assessed using the Zancolli
classification at the start of treatment and every
month thereafter (Table 1) [32]. Patients who
comply with the program show a significant
improvement in quality of movement of the upper
extremity. They are able to extend the wrist and
fingers leading to better control and use of the
hand. Fourteen out of 19 patients moved two
grades in Zancolli’s classification (Figs. 2 and 3).
None of the patients have reported any pain or
injury related to the stimulation. Eight patients
reported some discomfort while wearing the splint
because it did not fit perfectly. Reforming the
thermoplastic arm support relieved this discom-
fort. In all patients co-contractions were reduced.
One patient, in whom treatment was discontin-
Fig. 2. At the beginning of the combined protocol of
NMES and dynamic bracing, the patient is unable to
extend the right wrist without the help of the contralat-
eral side.
Fig. 3. Four months’ follow-up of the same patient
reveals well controlled wrist and finger motion.
ued, showed signs of regression of spasticity and
had to begin the program again.
The results of the current protocol showed
that the use of NMES with dynamic orthotic trac-
tion during the day and static orthosis at night
is a quick and dramatically effective method to
improve function in children with spasticity of the
upper extremity caused by cerebral palsy. The
efficacy of this treatment was confirmed by the
improvement observed in the Zancolli classifica-
tion scoring. All patients improved at least one
grade during the treatment period, with progress
noted as early as 4–6 weeks following the
application of the protocol.
Previous reports on the use of electrical stim-
ulation for the management of spastic upper ex-
tremities have reported conflicting results [22,24,
26]. Atwater first reported two patients, aged 11
and 12 years, who received stimulation of their
wrist extensors [22]. The protocol consisted of
three 20-minute treatment sessions each day for 8
weeks. Those investigators reported no improve-
ment at the end of the treatment period. Later,
Carmick used a similar protocol using 15 minutes
of stimulation with a fixed 300-microsecond pulse
width and a static wrist extension splint [23,24].
The electrodes were applied to the nonspastic
wrist extensors and the spastic flexors at the same
time. Electrical stimulation, although applied to
the spastic flexors, did not increase the spasticity,
and improved overall function. Finally, Wright
and Granat reported the results of eight patients
receiving FES to wrist extensors [26]. The pro-
tocol consisted of 30-minute daily sessions of
cyclic FES (300 microsecond) for 6 weeks.
Significant improvement of hand function was
observed at the end of the study. These studies
 L.R. Scheker, K. Ozer / Hand Clin 19 (2003) 601–606
support the usefulness of electrical stimulation.
The protocol used in the current study differs
from these reports in several ways. First, the use
of NMES is aimed at nonspastic but weak
extensor compartment muscles. This approach
provides effective stretching and elongation of the
spastic flexors while strengthening the weak
extensor muscles. Furthermore, the use of the
dynamic orthotic device simply reinforces the
intrinsic muscles, providing better fine motor
movement and control.
Certain elements of the current protocol need
further investigation. The authors noted that the
effects of therapy decrease after discontinuation
of therapy. The duration of effectiveness of the
protocol varied between patients. The authors
therefore recommend a lifelong application of the
protocol, but after the first 12 months it is possible
to reduce the frequency of the NMES and the
period of use of dynamic bracing. Patients who
were classified as Zancolli I after treatment
continued a maintenance program consisting of
NMES and dynamic traction once a week for
30 minutes. They also were instructed to wear the
brace at night. These patients were monitored
periodically by their local therapist and reviewed
every 6 months. Many of the authors’ patients
who have been on the maintenance program for
more than 2 years use the electrical stimulator on
alternate days, often using the brace only at night.
The first patient treated has been on the mainte-
nance program for 5 years, 5 months and has not
shown any signs of regression of spasticity. With
this protocol, the authors have noted a decrease in
spasticity of the flexor pronator muscles and an
increase in strength of the extensor supinator
muscles with time.
The mechanism of action of NMES and
dynamic traction is not yet known. One may
speculate that by stimulating the muscles through
NMES and dynamic bracing, we stimulate a nat-
ural muscle contraction that, through the reflex
arch, inhibits the antagonist spastic muscle. The
current protocol is quick and provides an effective
alternative for the management of spasticity.
More research is needed to determine whether
the improvement demonstrated in this report is
caused by NMES, the dynamic traction, or the
combination of both.
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 Hand Clin 19 (2003) 607

Part 2: surgical management

Introduction
Michael A. Tonkin, MD, FRACS
Department of Hand and Peripheral Nerve Surgery, Royal North Shore Hospital,
St. Leonards, NSW 2065, Australia

This section is appropriately introduced by
Eduardo Zancolli, for the principles he has
espoused have guided all those who have fol-
lowed. The repetition of these principles by other
authors is a testament to his influence.
Little is written about the management of
elbow deformity in cerebral palsy, and even less
has been directed toward the shoulder. It is for
this reason that Landi’s contribution has been
included in this section, although much of the
work is devoted to spasticity as a consequence of
head injury and stroke. However, many of the
principles remain the same. Gschwind and Van
Heest discuss the management ‘of pronation
deformity and wrist and finger deformity, and
the section on thumb deformity comes from my
own experience.
The outcome paper of Johnstone and col-
leagues is a welcome summary of methods of
assessment of surgical results in cerebral palsy,
sometimes a most difficult objective exercise.
Finally, the work of Bertelli and colleagues de-
scribes encouraging results from neurosurgical
intervention, procedures that may be less familiar
than the more common orthopedic procedures
of muscle releases, tendon transfers, and joint
fusions. The result is a comprehensive compilation
of surgical indications, techniques, and results in
the management of cerebral palsy in the upper
limb.

E-mail address: mtonkin@surgery.usyd.edu.au

0749-0712/03/$ - see front matter Ó 2003 Elsevier Inc. All rights reserved.
doi:10.1016/S0749-0712(03)00096-9
 Hand Clin 19 (2003) 609–629
Surgical management of the hand in infantile
spastic hemiplegia
Eduardo A. Zancolli, MD*
National Academy of Medicine, Orthopaedics and Traumatology,
3092 Las Heras Avenue, Buenos Aires, Argentina
The spastic hand in cerebral palsy represents
one of the most complex problems in upper limb
reconstructive surgery. The pathology depends on
lesions of the central nervous system, resulting in
severe motor imbalance and sensory impairment
of the hand. Despite these difficulties, upper
extremity reconstructive surgery has become an
excellent aid in the management of selected cases
of the spastic hand when properly indicated and
performed, as shown by Goldner 1955 [1], 1975
[2], Swanson 1968 [3], Zancolli 1968 [4], 1975 [5],
and 1979 [6].
Cerebral palsy may be defined as any disorder
of neuromotor functions secondary to cerebral
damage occurring prenatally, at birth, or early in
the postnatal period.
The purpose of this article is to describe the
surgical rehabilitation of the spastic upper limb in
infantile hemiplegia, in which peripheral recon-
structive surgery gives the best results. The
author’s experience is based on a series of 113
upper limb spastic cases operated on over a period
of 33 years. The final results refer to 47 patients
evaluated from a group of 91 patients (23% were
hemiplegics). Of these cases, 84% were treated in
the Rehabilitation Center of Buenos Aires (Ar-
gentina). Satisfactory results were obtained in
92% of the most favorable cases, groups I and II
of the author’s classification.
Careful examination, testing, and evaluation
by the neurologist, the surgeon, and the occupa-
tional therapist are of major importance in the
selection of patients for surgical rehabilitation.
* Correspondence. Avenida Alvear 1535, 1014 Bue-
nos Aires, Argentina.
E-mail address: adriananegri@hotmail.com
0749-0712/03/$ - see front matter Ó 2003 Elsevier Inc. All rights reserved.
doi:10.1016/S0749-0712(03)00034-9
General preoperative evaluations in cerebral palsy
The principal evaluations for selecting cerebral
palsy patients suitable for hand surgery refer to
etiology, general neurologic condition, type of
neuromuscular disorder, extent of limb involve-
ment (hemiplegia, tetraplegia, diplegia, triplegia, or
monoplegia), age, sensory impairment, and upper
limb deformity (wrist and finger classification).
Etiology
Lesions of the intercranial central nervous
system may have their origins in pre-, peri-, and
postnatal periods. In the author’s experience,
patients with perinatal brain damage are best
suited to peripheral reconstructive surgery when
the patient is a spastic young hemiplegic.
Perinatal injuries have two main causes,
trauma and anoxia during the time of birth.
Blumel et al [7] found the most frequent lesions
were caused by trauma at birth (13%), anoxia
(24%), prematurity (32%), congenital defects
(11%), and postnatal damage (7%).
Neurologic lesions
Severe neurologic disorders are usually absent
in the typical infantile spastic hemiplegia, the
condition most adapted to peripheral reconstruc-
tive surgery of the upper limb. Reconstructive
surgery is contraindicated in severe neurologic
alterations, such as defects in speech, vision, and
hearing, and mental retardation, which are
generally present in spastic tetraplegia and extra-
pyramidal neuromuscular disorders. Mild alter-
ation of the mental condition in hemiplegic cases
is not a surgical contraindication.
610 E.A. Zancolli / Hand Clin 19 (2003) 609–629

Type of neuromuscular disorder 2. Hypertonicity increases when the affected

muscles are gradually stretched passively.
Patients with neuromuscular disorders can be
3. Hypertonicity is constant except during sleep
classified into three types: spastic or pyramidal,
or under anesthesia and it does not diminish
extrapyramidal, and mixed. Determining the type
with orthoses or manipulations.
of neurologic disorder is of paramount impor-
4. Hypertonicity produces what has been named
tance in selection of candidates for reconstructive
synchronous activity or co-contraction [8]. Its
surgery (Fig. 1).
clinical manifestation is represented by an
abnormal reaction of the spastic muscles
Pyramidal type (hypertonicity)
during rest or when the muscles are acting
In this type of neuromuscular disorder, the
as antagonists. Antagonist spastic muscles
most frequent type of neuromuscular disorder in
remain electrically active on flexion and
cerebral palsy (70%), the classic deformity of the
extension of the involved part of the limb. A
upper limb is characterized by a combination of
typical finding of this phenomenon is the
spastic and paretic or flaccid paralysis. It depends
persistent activity of the flexor muscles of the
on the damage of the corticospinal tracts. The
wrist when complete finger and wrist exten-
principal clinical characteristics of spasticity in the
sion are attempted, especially at the level of
infantile hemiplegic patient are:
the flexor carpi ulnaris (FCU). Synchronous
1. Flexor–pronator deformity of the upper limb activity alters the normal grasping and release
(Fig. 1A). This deformity depends on the patterns of the hand. Co-contraction can be
spasticity of the extrinsic muscles of the a favorable situation in some tendinous
forearm and hand represented by the flexor– reconstructive procedures [3]. Co-contraction
pronator muscular mass. Flaccid paralysis or thus favors active extension of the wrist after
paresis of the opposite muscles (extensor– the transfer of a spastic FCU tendon to the
supinator mass) is present. extensors of the wrist. Under this condition,

Fig. 1. Most frequent types of neuromuscular disorders. (A) Spastic. (B,C) Athetosis. In athetosis, the fingers show
opposite postures in the same hand, which is a typical clinical manifestation of extrapyramidal disorders (see Fig. 17).
 E.A. Zancolli / Hand Clin 19 (2003) 609–629
the co-contraction of the FCU produces
wrist extension caused by its synchronous
activity (Green’s procedure [9]).
5. Overactive stretch reflex is one of the most
typical manifestations in the diagnosis of
hypertonicity. It is produced by failure of the
normal muscle lengthening reaction to elon-
gation by sudden passive stretching. Owing to
the hyperactive stretch reflex, the spastic
muscle contracts at the same point in the arc
of motion each time a passive elongation
maneuver is produced. The overactive stretch
flex is absent in extrapyramidal neuromuscu-
lar disorders but present in most of the mixed
group, in which spasticity is predominant over
athetosis. The stretch reflex should be in-
vestigated for each muscle or group of
muscles. Spasticity and overactive reflexes
can be decreased by certain surgical proce-
dures, such as lengthening of distal tendons or
release of proximal muscle insertions.
6. Myostatic contracture. This represents a sec-
ondary muscular fibrosis after a long-standing
hypertonicity. This fibrosis is seen frequently
in the flexor muscles of the wrist and digits. It
persists with the patient under general anes-
thesia or peripheral nerve blocking. Muscular
fibrotic retraction is not a contraindication to
surgical reconstruction of the hand. It is ob-
served frequently after infancy and during or
after adolescence. It can be reduced preoper-
atively by physical methods of stretching with
casts or braces. During surgery it can be corrected
by tenotomy preserving muscular continuity.
7. Hypertonicity increases with emotional stim-
uli. If this reaction is a predominant clinical
finding it is difficult to obtain a reasonable sur-
gical result even if the hand deformity is mild.
In these cases the patient is incapable of col-
laboration in the postoperative reeducation [6].
Extrapyramidal type
The extrapyramidal type of neuromuscular
disorder is represented by athetosis, ataxia,
tremor, or rigidity. The most frequent extrapyra-
midal disorder is athetosis—approximately 25%,
usually produced by neonatal anoxia and eryth-
roblastosis fetalis. Athetosis is the result of
dysfunction of the basal ganglia. It is character-
ized by the following clinical findings:
1. Abnormal, involuntary, and poorly coordi-
nated movements with varying degrees of
tension. The deformity decreases at rest and
disappears during sleep, but it is accentuated
611
by efforts to move or by any emotional or
environmental stimuli. Typically the patient
may show different asymmetric finger deform-
ities in the same hand (Fig. 1B and C). Abn-
ormal hand movements and deformities
usually decrease if the patient is distracted.
2. Delayed postural development. The disorder
is usually generalized, but unilateral involve-
ment also occurs.
3. Hypotonus in infancy. This condition may
change with growth to increased tonus in
stress situations.
4. Decreased reflexes in infancy that may
become hyperactive later.
5. No tendency to muscular contracture.
6. Absence of Hoffman reflex and stretch reflex.
7. Frequently tactile gnosis of the hand is
preserved.
Soft tissue procedures performed in the pure
athetoid patient are contraindicated because they
may produce a new undesirable opposing de-
formity that may be totally uncontrollable by the
patient. In this situation a transference of the
initial distorted position to other muscle groups is
usually produced. Soft tissue procedures also are
contraindicated in other extrapyramidal muscular
disorders, such as chorea, ataxia, tremor, and
rigidity. Clonus is a poor prognostic sign for the
success of tendon transfers. In athetosis it is
possible to consider surgical procedures of bones
(osteotomy) or joints (fusion).
Soft tissue procedures also are absolutely
contraindicated in a young child with extrapyr-
amidal hypotonus, which may change with growth
to abnormal athetoid involuntary movements and
increased tonus under emotional stimuli. [6].
Mixed type
The mixed type of neuromuscular disorder is
a common form. Most frequently spasticity is
associated with athetosis and is characterized by
a combination of hypertonus and reduced abnor-
mal movements (Fig. 1). Reconstructive surgery
through soft tissue techniques may be indicated in
the mixed type of neuromuscular disorder if
hypertonicity and, consequently, overactive stretch
reflexes are present and dominant.
Age
Surgical correction of spastic upper limb
deformities usually is indicated after 6–7 years of
age. Maturation of the central nervous system has
occurred by this age, and the child is usually
612 E.A. Zancolli / Hand Clin 19 (2003) 609–629

cooperative during postoperative rehabilitation. wrist and finger flexion contracture (occasionally
After adolescence and adulthood, patients are accompanied by flexible swan-neck deformity)
not generally good candidates for reconstructive and thumb deformity. The flexed wrist usually
surgery, because they usually have accepted their tends to deviate ulnarly. Two types of thumb
cosmetic and functional problems. deformities may be present: (1) adduction con-
tracture (adduction of the first metacarpal) and
Hand sensory impairment (2) flexion–adduction contracture (thumb-in-palm
deformity) (Fig. 2). All these deformities are
Based on the author’s experience [10], all
variable in severity and reducibility by external
patients with a pure spastic neuromuscular
passive maneuvers of thumb extension combined
disorder have some deficit of sensibility in pro-
with wrist flexion.
prioception (conscious control of position, mo-
tion, and power) and stereognosis (ability to
Hand deformity classification: based in voluntary
recognize objects by touch only). In the classic
grasp and release patterns between the wrist
infantile hemiplegia with a pure spastic neuro-
and fingers
muscular disorder, the affected hand preserves the
ability to recognize the physical characteristics of Since the author’s publications in 1968 [4],
objects (shape, size, texture) or protective sensa- 1979 [6], 1981 [12], and 1987 [10], the spastic
tions (hot, cold, pain, pressure), but the patient is infantile hand has been classified into three
unable to name the objects because of the cortical groups, based on the voluntary possibility of the
involvement. This is the typical condition in patient to produce release of the fingers through
spastic patients. Defects in stereognosis are not active wrist flexion (Fig. 3). The surgical program
a contraindication for attempting to improve
hand motor function and appearance by surgery
[11]. Only in patients in whom spasticity is
combined with some athetoid component may
hand sensibility be preserved completely.
Sensibility tests used in these patients are: (1)
pinprick test (protective sensation), (2) recogni-
tion of size and shape of objects (differentiation of
cubes from marbles in small children), (3)
Seddon’s coin test (tactile gnosis), which is the
author’s preferred investigation for sensibility
evaluation, (4) two-point discrimination (Mo-
berg’s paper clip test, tactile gnosis), and (5)
position sense (proprioception or body position
movement recognition).
It is characteristic that the spastic hemiplegic
child with stereognosis defects prefers to use the
normal hand. He or she uses the affected hand
only when necessary for bimanual activities and
always as an assistant limb. When sensibility is
not affected, as exceptionally may occur in mixed
groups, better function can be obtained and
independent function of the affected hand can be
expected after reconstructive surgery.

Upper limb deformity (pronator–flexor spastic

contracture)
The typical flexion–pronation deformity of the
spastic upper limb in cerebral palsy is character-
ized by the following components: (1) elbow
flexion contracture, (2) forearm pronation con- Fig. 2. Typical spastic deformities of the thumb. (A)
tracture, and (3) hand deformity, characterized by Adduction. (B) Thumb-in-palm (flexor–adduction).
 E.A. Zancolli / Hand Clin 19 (2003) 609–629
of the wrist and finger deformities is closely
related to this classification.
Group I
In this group of patients, flexion spasticity is
minimal. The patient can extend completely the
fingers in a neutral position of the wrist or with less
than approximately 20 –30 of active wrist flexion.
Here the principal spasticity is localized at the
FCU muscle. The principal deficits in this group of
patients are the lack of complete active wrist
dorsiflexion when the fingers are totally extended
and the presence of thumb deformity [11] (Figs. 3I
and 4). The general appearance of the upper limb is
satisfactory and the emotional influence on spas-
ticity is usually mild or almost absent. Pronation
spasticity of the forearm may be present.
Group II
In these patients, the fingers also can be
actively extended, as in group 1, but only with
more than 20 –30 of active wrist flexion (see Fig.
3II). Principal spasticity is localized at the wrist
and finger flexors and thumb. In severe cases in
group II, the wrist needs to flex completely to
permit complete or partial finger extension.
Group II has two subgroups according to the
functional condition of the extensor muscles of
the wrist (IIA and IIB). In subgroup IIA the
patient can actively extend, partially or totally, the
wrist, when the fingers are flexed (Figs. 5 and 17).
This means that the extensor muscles of the wrist
and fingers are active and voluntarily controlled
and that the main spasticity is localized in the
flexor muscles of the wrist and fingers. In these
cases, obviously, it is unnecessary to perform
tendon transfers to extend the wrist. In subgroup
IIB the patient cannot actively extend the wrist
with the fingers flexed because of the flaccid
paralysis of the wrist extensor muscles or because
the wrist flexor muscles are severely contracted
(Figs. 6 and 16). Tendon transfers to extend the
wrist are necessary in cases of subgroup IIB when
the wrist extensor are paralyzed. Occasionally the
wrist flexors are not affected by spasticity or
myostatic contracture (Fig. 7).
Group III
Here the spasticity of the hand is severe and
localized at the flexor–pronator mass, as in the
other groups. The extensor muscles of the wrist
and fingers are totally paralyzed. The patient
cannot actively extend the fingers, even with
maximal active or passive flexion of the wrist
613
(see Fig. 3III, Fig. 8). Synergism between the wrist
muscles and finger muscles is completely lost. This
condition is the most complex to improve by
reconstructive surgery. Partial release of all the
spastic muscles of the upper limb is the author’s
choice in this group of patients.
All groups usually are associated with thumb
deformity—either in adduction or flexion-in-palm
(see Fig. 2)—elbow flexion contracture, and pro-
nation contracture of the forearm of variable
severity. The degree of sensory impairment varies
between groups.
Swan-neck deformity may be present in all
groups but particularly in group II. This de-
formity reduces substantially after the flexion
contracture of the wrist is surgically corrected
(Fig. 9).
Surgical goals
The principal goals in surgical reconstruction
of the spastic hand are directed at improving
grasp and release patterns between the wrist and
digits, hand appearance, function of the affected
hand, and the psychologic status of the patient
and the family.
Prognosis
According to the classification previously de-
scribed, basic grasp and release functions of the
hand can be significantly improved in groups I
and II. In these cases it is possible to obtain
improved finger release with decreased flexion of
the wrist, decreased flexion contracture of the
elbow, wrist, and fingers, decreased forearm
pronation contracture, and correction of thumb
deformity to improve gripping and lateral pinch.
The main concept in surgical reconstruction of
the spastic hand is that an improvement in the
existing pattern of function can be achieved by
improving the balance between the spastic pro-
nator–flexor muscles and the normal or paretic
extensor–supinator muscles. Attempts to modify
radically the preoperative existing patterns of
hand activity or overcorrection usually lead to
poor results. Only in mild spasticity (group I) is it
possible to obtain normal complete and simulta-
neous extension of the wrist and fingers through
release of the FCU.
In group II, reconstructive surgery is related
to the condition of the flexor–pronator and
extensor–supinator muscles.
614 E.A. Zancolli / Hand Clin 19 (2003) 609–629

Fig. 3. Grouping of wrist-fingers deformities in the spastic infantile hand. Group I, group II with subgroup A and B, and
group III.
 E.A. Zancolli / Hand Clin 19 (2003) 609–629 615

Fig. 3 (continued )

Fig. 4. Group I of spastic hand. The fingers can only

In group III, surgery is indicated exclusively to extend completely with a wrist flexion spasticity of 30 .
improve appearance, hygiene, and comfort. This
can be achieved by reducing the spasticity of the
flexor–pronator muscles without pretending to
obtain voluntary hand grasp and release.

Fig. 5. (A) Group IIA of an infantile spastic hemiplegic hand. The fingers can voluntary flex with the wrist in 65 of
flexion. (B) The fingers extend with the wrist in 45 of flexion. (C) With the fingers flexed, the wrist extends voluntary up
to 25 of flexion. Spastic contracture of the wrist flexors prevents complete wrist extension.
616 E.A. Zancolli / Hand Clin 19 (2003) 609–629

Fig. 6. (A) Group IIB in an infantile hemiplegic patient. The wrist cannot voluntary extend with the fingers flexed. The
wrist extensor muscles are paralyzed. (B) The fingers can only extend with the wrist in 90 of wrist flexion.

Surgical indications 6. Basic sensibility present, even with some

impairment of proprioception and tactile
According to the preoperative conditions, the
gnosis.
best candidates for peripheral reconstructive
7. Voluntary control of the spastic muscles and
surgery are:
voluntary ability to open the fingers in flexion
1. Spastic type of neuromuscular disorder. (preserved synergism) (groups I and II).
Surgical reconstruction of the upper limb
It is important for the patient to have some
through soft tissues procedures, such as
voluntary control of the spastic muscles and some
tenotomies and tendon transfers, is indicated
voluntary ability to release and close the fingers
in pure spastic hands but also in mixed cases
for satisfactory results to be achieved through
in which mild athetosis is combined (mixed
reconstructive surgery. Experience has shown the
group).
author that the most favorable cases for surgery
2. Sufficient mental condition and emotional
are those in which it is possible to open the fingers
stability (usually present in spastic hemi-
by active flexion of the wrist. For this reason wrist
plegia).
arthrodesis should not be a primary option in
3. Low emotional influence on spasticity.
typical spastic infantile hemiplegia if the patient
4. Infantile hemiplegia (especially perinatal).
has the ability to extend the fingers through wrist
5. Young patients (infantile or adolescent),
flexion. Synergism between wrist and fingers
ideally after 6–7 years of age. Training is
should be preserved whenever possible.
more effective after this age.

Fig. 7. A severe case of infantile spastic hand. (A) The fingers open with only 110 of voluntary wrist flexion. (B) The
wrist only extends passively. This means that the wrist extensor muscles are paralyzed and its flexor muscles are not
spastic or with myostatic contracture. Spasticity is only present in the long flexor muscles of the fingers.
 E.A. Zancolli / Hand Clin 19 (2003) 609–629
Fig. 8. An infantile hemiplegic spastic patient with
a group III of wrist-fingers deformity. The patient
cannot voluntarily open the hand. Typical flexor–
pronator deformity.
The author only considers wrist fusion in
atypical spastic cases, such as the residual
deformities of failed previous operations in which
tendon transfers or other soft tissue procedures
are impossible to perform or are contraindicated,
and in some extrapyramidal neuromuscular dis-
orders [4].
8. Capacity to concentrate and cooperate during
the postoperative period.
9. Good motivation of the patient and family
support.
10. Adequate behavioral patterns.
11. Good general neurologic condition, which is
generally present in infantile spastic hemi-
plegia.
12. Spastic flexion–pronation deformity of the
upper limb. This is the most suitable condi-
Fig. 9. Group IIB of spastic hand deformity with
pronounced swan-neck deformities of the fingers when
the wrist flexes. Recurvatum of the proximal interpha-
langeal joints reduces if the wrist is extended passively.
617
tion for peripheral surgical reconstructive
procedures. The surgical program depends
on the severity and type of deformity at the
different levels of the upper limb. The most
common deformities corrected by reconstruc-
tive surgery are: thumb deformities, flexion
contracture of the wrist and fingers, flexion
contracture of the elbow, and pronation
contracture of the forearm. Seldom, swan-
neck deformities of the fingers need to be
corrected. Surgery of the thumb is indicated
to hold the digit out of the palm during grasp.
The surgical procedures indicated depend on
the type of deformity present: adduction or
adduction–flexion contractures (thumb-in-
palm deformity) (see Fig. 2).
Flexion contracture of the elbow is common
in the spastic upper limb and frequently is in-
fluenced by emotional stimuli. Correction of
marked flexion contracture of the elbow improves
significantly the appearance and function of the
hand.
Pronation contracture of the forearm is cor-
rected when severe and when the patient has
difficulty carrying out activities of daily living
because of lack of supination. A mildly pronated
forearm is a useful position for hand function and
its correction is not essential.
Flexion contracture of the wrist and fingers is
corrected through surgical techniques based on
the classification presented (groups I, II, and III).
This indicates that during the preoperative
examination it is of great importance to note
the degree of wrist flexion needed to enable the
patient to extend the fingers completely or
partially. It is also important to determine if the
wrist can be extended with the fingers flexed
(subgroups IIA or IIB). This test demonstrates
the degree of spasticity of the flexor muscles of
the wrist and fingers, the functional condition of
the wrist extensors, and the degree of voluntary
control. This information is needed to determine
the most appropriate surgical program for each
patient.
It is of paramount importance that all the
existing deformities of the upper limb (elbow,
forearm, and hand) should be corrected at the
same surgical procedure. A contracted thumb
thus must be simultaneously corrected with the
rest of the hand to allow better active extension of
the fingers and lateral pinch grip.
Severe swan-neck deformities are usually cor-
rected in a secondary surgical stage. Severe spastic
618 E.A. Zancolli / Hand Clin 19 (2003) 609–629

equinus foot preferably should be corrected

before hand surgery with the aim to eliminate
foot hypertonicity that helps with postoperative
rehabilitation of the hand.

Surgical procedures
Surgical procedures most frequently indicated
are: muscle release, tenotomy, fasciotomy, tendon
lengthening, tendon transfer, capsuloplasty, te-
nodesis, arthrodesis, osteotomy, and neurotomies.
The selection of the procedure basically depends
on the type and severity of the deformity, the type
of neuromuscular disorder, the functional defi-
ciencies, the age of the patient, and the surgeon’s
preferences.
The operative techniques are described in
relation to the different deformities.

1-Flexion contracture of the wrist and fingers

This deformity basically results from the
spasticity and occasional myostatic contracture
of the flexor muscles of the wrist and fingers. The
goal of surgery is to improve the active release of
the hand without affecting the voluntary closure
of the digits and grasping functions. This is
achieved by preserving the balance between
the flexor and extensor muscles of the wrist and
digits.
According to the grouping of hand deform-
ities, the author’s surgical program to obtain the
desirable balance between the wrist and finger
muscles is as follows.
Group I
The principal muscular co-contraction in these
cases basically is located in the FCU. Our aim is
to lengthen the FCU through a simple tenotomy,
preserving muscle continuity. In this type of
tenotomy, the tendinous part is sectioned, pre-
serving the muscular fibers. After the release
a passive stretching maneuver permits lengthening
of the muscular unit. Tenotomy is located
proximal to the distal end of the muscular belly
(Fig. 10).
If the wrist and finger flexor muscles and the
pronator teres are spastic, an aponeurotic release
of the medial epicondyle muscles is added. This
release is located 5 cm distally to the medial
epicondyle. This technique is sufficient to release
flexion contractures of the wrist and fingers in this
group of patients. It is described in group II of the
spastic flexion–pronation deformity.
Fig. 10. Most frequent indication in the wrist in mild
cases of spastic hand group I. The FCU muscle is
lengthened with tenotomy preserving the muscular
fibers. This procedure improves simultaneous wrist and
finger extension.
The treatment of the thumb deformity and
occasional elbow flexion spasticity is described in
subgroup IIB.
Group II
Surgical technique in group II of flexion
contracture of the fingers and wrist depends on
severity of spasticity and functional condition of
the wrist extensor muscles (subgroups IIA and IIB).
Incisions used in these cases are shown in Fig. 11.
The desired correction of wrist and fingers
spasticity of this group of patients is obtained by
the author’s technique, described in 1968 [4] and
1979 [6], of medial epicondyle aponeurotic release,
tenotomies, and tendon transfers.
Aponeurotic release of the medial epicondyle
muscles. This is an effective technique in patients
with mild and median spasticity of wrist and
finger flexor muscles. In this procedure spasticity
is reduced because all the deep attachments of the
medial epicondyle muscles are released at the
proximal third of the forearm. The muscular
fibers are left intact. Mild and median spastic
patients are those in whom preoperative voluntary
 E.A. Zancolli / Hand Clin 19 (2003) 609–629 619

Fig. 11. (A) Incisions in cases of group IIB. 1, biceps release; 2, medial epicondyle aponeurotomy; 3, pronator teres
approach to release or transfer of the pronator teres; 4, FCU approach (transference to extensor carpi radialis brevis
through the interosseous membrane); 5, adductor pollicis release; 6, radial approach for metacarpal-sesamoid synostosis
(see Fig. 14). (B) Dorsal approach in the wrist to reach the extensor tendons of the fingers and thumb.

finger extension is obtained with less than
approximately 70 of active wrist flexion.
In the aponeurotic release of the medial
epicondyle muscles, a transverse excision of the
superficial fascia is made around the whole
muscular mass. This is followed by a complete
excision of the septa that separate the muscles.
Each septum is released deeply where one can see
the median and ulnar nerves covered by the
muscles. The muscular bellies are left intact,
particularly the FCU if this muscle is to be
transferred to the extensor tendons of the wrist
(subgroup IIB) (Figs. 12A, 13A).
In cases of severe spasticity or myostatic
contracture of the wrist and fingers muscles, in
which finger extension is only possible with
greater than 70 of wrist flexion, one adds tendon
releases through selective tenotomies (preserving
muscle continuity) of some retracted muscles
(flexor digitorum superficialis and profundus and
flexor carpi radialis). This complementary release
is located distal to the proximal aponeurotic
release, at approximately the level of the muscu-
lotendinous junction in the middle of the forearm
[12]. Myostatic contracture is recognized under
anesthesia in which a passive extension maneuver
is unable to obtain complete and simultaneous
extension of the wrist and fingers.
The author does not indicate the classic
muscular slide technique as described by Page
[13]; see also Inglis and Cooper [14] and White
[15]. Using this technique it is difficult to calculate
the necessary degree of muscular release and
consequently overcorrection could be the result,
causing the fingers to lose flexion and grasp
abilities or to produce an intrinsic plus deformity.
620 E.A. Zancolli / Hand Clin 19 (2003) 609–629

Fig. 12. (A) Most frequent surgical program indicated in subgroup IIB of a spastic hemiplegic hand with a thumb-in-
palm deformity, mild flexion contracture of the elbow, and pronation contracture of the forearm. 1, Biceps lengthening
with its muscle fibers in continuity; 2 and 3, excision of part of the superficial fascia and all septae of the medial
epicondyle muscles; 4, pronator teres release (pronator quadratus remains active); 5, transference of the FCU through an
ample window in the interosseous membrane to the extensor carpi radialis brevis tendon; 6, lengthening in continuity of
the flexor pollicis longus tendon. It is necessary to avoid too much relaxation; 7, release of the abductor pollicis longus at
its proximal end. When the metacarpophalangeal joint of the thumb is lax and deforms in hyperextension, a sesamoid-
metacarpal fusion is indicated during the same surgical stage (see Fig. 14). (B) 1, Transference of FCU to extensor carpi
radialis brevis with partial excision of the extensor retinaculum; 2, transference of brachioradialis to abductor pollicis
longus; 3, transference of palmaris longus to extensor pollicis longus through the interosseous membrane (too much
tension should be avoided). Balance of tension needs to be maintained between the lengthened flexor pollicis longus and
the transferred extensor pollicis longus. In cases with a single adduction contracture of the thumb, the flexor pollicis
longus is left unreleased and the extensor pollicis longus is translocated radially. (C) Transference of the pronator teres
through the interosseous membrane to produce forearm supination. The tendon is fixed to the radius.

Another possible complication of an excessive flexors—flexor carpi radialis and palmaris

muscular slide procedure is the loss of vascular-
ization of the medial epicondyle muscular mass.
Tendon transfer of the FCU to the extensor carpi
radialis brevis. This technique is indicated only
when active wrist extensors are weak or completely
paralyzed (subgroup IIB) (see Figs. 12A,B). It is
not indicated, obviously, in subgroup IIA, in
which active wrist extension is present (see Fig.
5). In the classic Green’s procedure [9,16], the FCU
tendon is passed around the ulnar border of the
wrist and is fixed to the extensor carpi radialis
brevis tendon, because it is the major dorsiflexor of
the hand. The goal is to obtain wrist extension and
supination of the forearm. The other wrist
longus—must remain in place to avoid an un-
desirable permanent wrist hyperextension post-
operatively. The author prefers to pass the FCU
through an ample window in the interosseous
membrane—proximal to the pronator quad-
ratus—and suture it to the extensor carpi radialis
brevis tendon (see Figs. 12A,B, 13B,C). The
tension of the transfer is calculated during surgery.
It is considered correct when the wrist maintains
20 of extension under the effect of gravity.
Group III
In this group there is a permanent and severe
flexion contracture of the wrist and fingers,
particularly under emotional stimuli, and it is
 E.A. Zancolli / Hand Clin 19 (2003) 609–629 621

Fig. 13. (A) Excision of part of the superficialis fascia and all the septae of the medial epicondyle muscles. This gives
a partial release of spasticity of the muscles inserted in the medial epicondyle tuberosity. (B) Transference of the FCU
tendon (1) through an ample window opened in the interosseous membrane (2) proximally to the pronator quadratus (3).
(C) FCU (1) and the brachioradialis (2) tendons to activate the extensor carpi radialis brevis and abductor pollicis longus
(3), respectively.

impossible to voluntarily open the hand. The
extensor muscles of the wrist and fingers are
paralyzed (see Figs. 3III, 8).
These patients do not have any kind of hand
release and grasp pattern. Sensory function is
usually seriously affected. Myostatic contracture
is frequent with time because of the severity of the
spasticity and permanent flexed position of the
wrist and digits.
The best treatment for these patients is to
release all the upper limb contractures at the
elbow, forearm, wrist, fingers, and thumb. This is
accomplished by multiple tenotomies—with mus-
cular continuity—of all the contracted muscles.
If the tenotomies are insufficient because of the
great severity of spasticity or myostatic contracture
of the finger flexor muscles, the author indicates
a special technique described in 1957 [17] to release
severe contracture of the long flexor tendons of the
fingers. The procedure consists of sectioning the
flexor superficialis tendons distally, near the wrist,
and the flexor digitorum profundus tendons
proximally at the mid-forearm level. The fingers
are then extended to a median flexed position, and
while maintained in this position, the proximal end
of the flexor superficialis tendons is sutured to the
distal end of the flexor digitorum profundus
tendons with latero–lateral tenorrhaphies. The
pronator teres is released and the flexor tendons
of the wrist are ‘‘Z’’ lengthened. This procedure
was indicated initially by the author to correct
pronounced flexion contractures of the wrist and
fingers in severe segmentary arthrogryposis, but
the technique also can be indicated in severe group
III cases of spastic hand in cerebral palsy. Braun et
al described in 1974 [18] a similar procedure in
cases after cerebrovascular lesions of the brain.
2-Release of flexion contracture of the elbow
Flexion contracture of the elbow is a common
finding in the spastic hemiplegic upper limb and
frequently is influenced by emotional stimuli.
Correction of marked flexion contracture of
the elbow is an excellent indication, because it
improves the appearance and function of the
622 E.A. Zancolli / Hand Clin 19 (2003) 609–629
upper limb. Aponeurotic release of the medial
epicondyle muscles contributes to correction of
the elbow contracture. Additional correction is
obtained by tenotomy in continuity or ‘‘Z’’
lengthening of the biceps tendon (see Fig. 12A).
Occasionally the lacertus fibrosus may be
sectioned.
3-Release of pronation contracture of the forearm
Mild cases of forearm pronation spasticity that
reduce passively preoperatively are improved by
simple division of the distal tendon of the pronator
teres (see Fig. 12A). In severe contractures the
distal tendon of the pronator teres is rerouted
around the radius through the interosseous
membrane (procedure of Tubby [19]) (see Fig.
12C).
In three adolescent patients of the author’s
series, affected by severe and fixed pronation
contracture, the distal end of the ulna was
dislocated dorsally. In these cases it was necessary
to perform a complete release of the contracted
interosseous membrane, excision of the ulnar
head, and a distal radioulnar fusion proximal to
the growing cartilage of the distal radius. This
technique fixes the forearm in 10 of pronation,
which is a useful functional position for the hand.
4-Correction of thumb deformity
Surgery is indicated to hold the thumb out of
palm during grasp and to permit lateral pinch.
The surgical technique indicated depends on the
type of deformity adduction, or adduction–flexion
contracture (see Fig. 2).
Adduction contracture depends on the spas-
ticity of the adductor pollicis muscle. There is an
adduction contracture of the first metacarpal. The
metacarpophalangeal and interphalangeal joints
are not flexed. Correction is obtained by a prox-
imal release of the adductor pollicis muscle and
reinforcement of the abductor pollicis longus.
Release of the adductor pollicis is obtained by
sectioning its origin from the third metacarpal
through a palmar incision, parallel to the proxi-
mal palmar crease (Mateu’s technique) [20] (see
Fig. 12A).
In this type of thumb deformity (the same as in
the thumb-in-palm deformity), release of the origin
of the lateral thenar muscles is not indicated,
because there is not hypertonicity of the lateral
thenar muscles in the classic spastic deformity.
Reinforcement of the abductor pollicis longus
usually is accomplished by transfer of the
brachioradialis [21] (see Fig. 12B), by tendon
plication [20], or by tenodesis of the abductor
pollicis longus. In the latter, the proximal end of
the abductor pollicis longus is fixed around the
distal tendon of the brachioradialis [6]. The best
results are obtained by tendon transfers.
Adduction–flexion contracture (thumb-in-palm de-
formity). This contracture depends on the spas-
ticity of the adductor pollicis and flexor pollicis
longus muscles [22]. The most frequently used
reconstructive procedures for this deformity are:
(1) release of the origin of the adductor pollicis
from the third metacarpal, (2) lengthening of the
flexor pollicis longus at its musculotendinous
junction in the forearm, preserving the muscular
continuity, (3) translocation of the extensor
pollicis longus toward the radial aspect of the
wrist, and (4) reinforcement of the abductor
pollicis longus and extensor pollicis longus by
tendon transfers (eg, motors: brachioradialis,
palmaris longus). It is important to maintain
function of the flexor pollicis longus. Overcorrec-
tion should be avoided. When reinforcement of
the extensor pollicis longus is indicated but
spasticity of the flexor pollicis longus is mild, this
tendon is not lengthened.
Stabilization of the metacarpophalangeal joint of
the thumb. This stabilization is indicated in both
types of thumb deformities when the joint is
hypermobile in hyperextension (more than 20 ).
The most frequently indicated procedures are
joint fusion or capsulodesis through sesamoid-
metacarpal synostosis.
In metacarpophalangeal fusion in children,
damage to the epiphyseal line can be avoided by
the use of transitory thin fixation pins. Meta-
carpophalangeal joint fusion alone, without prop-
er release of flexion and adduction spasticity and
without reinforcement of the extensor muscles,
does not in itself eliminate the thumb-in-palm
deformity.
Metacarpophalangeal capsulodesis was de-
scribed by the author in 1968 (see Fig. 102B
caption) [4]; 1979 [6], and by Filler et al [23]. In
this technique, the radial sesamoid is fixed to the
neck of the first metacarpal in 10 of flexion
(sesamoid-metacarpal synostosis) (Fig. 14). The
joint is immobilized for 6 weeks.
Swan-neck deformity
Swan-neck deformity can be present in the
hands of patients with spastic cerebral palsy
 E.A. Zancolli / Hand Clin 19 (2003) 609–629 623

Fig. 14. Sesamoid-metacarpal synostosis. (A) Radial side incision in the thumb over the MP joint. (B) The radial
sesamoid without its cartilage (1) is fixed to the neck of the first metacarpal with a thick suture. Cortical bone of the
metacarpal is partially excised (2). The volar plate is preserved. (C) The metacarpophalangeal joint is maintained in a few
degrees of flexion through the tension given to the volar plate (capsulodesis).

[24,25]. This deformity depends on the effect of
a permanent and pronounced flexed position of
the wrist and the pull of the long extensor tendons
during the patient’s efforts to open the hand (see
Fig. 9). These conditions are present particularly
in group II of spastic flexion–pronation deform-
ity. Under these functional conditions, a progres-
sive stretching of the finger’s PIP joint volar plate
is produced, associated with a flexion deformity of
the distal interphalangeal joint as the consequence
of the dysfunction of the extensor apparatus. The
proximal interphalangeal joint frequently locks in
extension and the ability and force of pinch and
grasp are impaired.
When the fingers show a permanent and severe
swan-neck deformity after the release of the
flexion spasticity of the wrist and fingers after
the first surgical procedure, a surgical correction
of the finger deformity is indicated in a second
surgical stage. This is an uncommon indication in
624 E.A. Zancolli / Hand Clin 19 (2003) 609–629

spastic cerebral palsy patients [3]. It is a frequent
observation that swan-neck deformities improve
spontaneously with correction of flexion contrac-
ture of the wrist because this decreases the
traction of the long digital extensor tendons over
the middle phalanx. If surgery is indicated, the
author prefers his procedure described (since
1975) as the ‘‘sling’’ operation [5,26–28].
The procedure consists of the translocation of
the radial side lateral band of the extensor
apparatus into the flexor tendon sheath. This
technique is shown in Fig. 15. The first step of the
operation consists of freeing the extrinsic lateral
extensor band of the affected fingers (radial side)
between the middle third of the proximal phalanx
and the middle third of the middle phalanx.
The distal end of this tendinous sling remains
attached to the extensor apparatus, and the
proximal end is continuous with the central
extrinsic extensor tendon and with the intrinsic

Fig. 15. Correction of severe swan-neck deformity (technique). (A) Mid-lateral longitudinal incision on the radial side of
the finger. (B) The lateral band (1) is released between the middle of the proximal phalanx and the middle of the middle
phalanx. The proximal end of the released band remains in continuity with the lateral slip of the extensor tendon and the
lateral band of the intrinsic tendons. The flexor tendon sheath is opened at the proximal PIP joint level (2). (C) The
released lateral band (3) is translocated to the volar part of the finger and placed between the volar plate (5) and the
flexor superficialis tendon (6). Two strong stitches (4) join the volar plate and the chiasma of Camper, distal to the PIP
joint level. These sutures maintain the lateral band volarly to the joint. (D) After the procedure, the finger must extend
passively up to almost neutral extension. The suture of the volar plate to the flexor superficialis represents a pulley for the
transferred lateral band (7). During active finger extension, the transferred band produces a simultaneous stabilization of
the PIP joint and an extension of the distal interphalangeal joint. The lateral band in its new position is shortened. The
normal use of the finger produces with time the relocation of the opposite lateral band to its normal position.
 E.A. Zancolli / Hand Clin 19 (2003) 609–629
lateral band (radial interosseous and lumbrical).
The second step consists of opening the flexor
tendon sheath and exposing the flexor tendons at
the PIP joint level. In a third step, the lateral band
is rerouted palmar to the joint and introduced
between the palmar plate and the flexor superficialis
tendon (Camper’s chiasma). The lateral band is
maintained in this position by two strong separate
sutures (with the finger in 5 of PIP flexion) that
unite the lateral borders of the tendinous chiasma
and the palmar plate. The transposed lateral band
should not be included in the suture. These sutures
are located distally to the PIP joint level at the base
of the middle phalanx. The tendon sheath is closed.
If the tension of the tendinous sling is correct, the
finger extends passively to 5 of PIP flexion. If PIP
flexion is greater than 5 , the freeing of the lateral
band is extended at its proximal or distal ends to
reach the desired PIP position. If there is some
tendency to PIP joint recurvatum, stitches are
applied at either end to tighten the sling. Flexion
greater than 5 of the PIP joint may produce
a boutonniere deformity.
This technique represents the reconstruction
of an active retinacular ligament. The activation
of the tendinous sling by the action of the
extensor tendons and the intrinsic muscles
produces complete finger extension and corrects
the hyperextension of the PIP joint. The finger
is immobilized in slight flexion for 1 week
before active exercises begin. The results of this
procedure have been encouraging. The pro-
cedure is contra-indicated in cases with intrinsic
paralysis (claw-hand).
Assessment of hand motor function
Grouping of patients for results of surgery is
obtained by the evaluation of different upper limb
functions [10]. These evaluations include:
1. Ability to open the hand. This is evaluated by
using wood discs of different sizes (6, 8, 10,
12, 14, 16, and 18 cm); determining hand
placement over the table; and measuring the
degrees of wrist flexion that enable the patient
to extend the fingers.
2. Grasp and pinch patterns. The ability to
grasp is evaluated through the use of spher-
ical balls (5, 8, 10, and 12 cm) and cylinders
(3, 5, 8, 10, and 12 cm). Tip, pulp, lateral
pinches, and chuck three-digit pinch are
evaluated during manipulation of different
objects.
625
3. Speed, skill, voluntary control, and coordi-
nation for prehension are functions examined
by the pick-up test and by manipulating
objects. Manipulation of toys by children can
help the surgeon make decisions as to
indication for reconstructive procedures in
an attempt to improve function and cosm-
esis. Function between both hands is studied.
4. Grasp and pinch strength. The grip strength
is measured with a dynamometer. A sphyg-
momanometer may be used to record grip
strength in weak hands. A pinch meter is used
to evaluate pinch strength.
5. Activities of daily living. These activities in-
volve hygiene, dressing, writing, and feeding.
6. Active and passive range of motion of all the
upper limb joints (shoulder, elbow, forearm,
wrist, fingers, and thumb) are examined. The
range of motion should be recorded on the
principle that the neutral position equals 0 .
The patient is asked to straighten the fingers
and to make a fist to obtain a global idea of
motion of all digits and to note limited
motions or abnormal postures.
Results
Results after surgery can be grouped as good,
fair, and poor in relation to the assessment of
hand function.
Good
Complete digital extension with less than 20
wrist flexion. In the best of cases the wrist
dorsiflexes with complete digital extension.
Complete elbow extension and almost com-
plete active forearm supination.
Good lateral pinch and grasping (thumb-in-
palm deformity corrected).
Good voluntary control of muscles.
The affected limb is predominantly used as an
assistant of the normal side.
Fair
Complete digital extension with more than 20
of wrist flexion (reduced with respect to the
preoperative value).
Partial elbow extension and forearm supi-
nation.
Weak and partial lateral pinch and grasping.
The limb is used only as an assistant.
Poor
Hand function and deformities not improved
with respect to the preoperative condition
(passive hand).
626 E.A. Zancolli / Hand Clin 19 (2003) 609–629

Fig. 16. (A) A group IIB of infantile spastic hemiplegic hand in a 17-year-old boy. Voluntary finger flexion was possible.
The right hand was dominant. (B) Fingers extend actively with a flexion spasticity of the wrist of 70 . Surgical program
shown in Fig. 12 was indicated. (C) Postoperative; shows that the fingers extend now with only 25 of wrist flexion. The
thumb extends actively. (D) Complete active closure of the hand. Thumb-in-palm deformity has been corrected. (E)
Excellent lateral pinch was obtained. (F) Hand posture and function obtained during eating.
 E.A. Zancolli / Hand Clin 19 (2003) 609–629 627

The author considers that good and fair results
represent a satisfactory improvement for these
patients.
In the author’s surgical series of 91 spastic
patients, 47 cases were evaluated for their final
result. Twenty-nine were females. The age at
operation was after 7 years in most cases.
According to the classification presented before,
the number of patients was: group I, 8 cases,
group II, 31 cases, and group III, 8 cases.
The results were: group I, 7 good and 1 poor;
group II, 19 good, 10 fair, and 2 poor; group III, 1
fair and 7 poor. In most cases of group I and II, the
patient or the family believed there was substantial
postoperative improvement in function and cosm-
esis of the hand (Figs. 16, 17).
Three pure athetoid patients who had soft
tissue procedures had a poor result. The initial
deformities were replaced with other deformities.
Summary
Selected spastic patients with cerebral palsy
can be helped by peripheral reconstructive surgery
of the upper limb.

Fig. 17. Spastic infantile hemiplegia (group IIA) combined with athetosis in a 15-year-old girl. (A) Hand deformity when
attempting hand release. (B) Hand closure preoperatively. Active wrist extension was possible. (C,D,E) Postoperative
result after muscle rebalance. Good digit extension, hand closure, and lateral pinch was obtained. The thumb-in-palm
deformity was corrected. The FCU was not transferred to the wrist extensor because it was a group IIA.
628 E.A. Zancolli / Hand Clin 19 (2003) 609–629
Fig. 17 (continued )
Although surgery cannot make a limb that was
functionally poor into a perfect one, it can greatly
improve the preoperative condition. Most poor
surgical results are caused by incorrect selection of
patients or poor execution of surgical procedures.
The worst mistake is to perform soft tissue
procedures—tendinous release or tendinous trans-
fers—on a patient with pure athetosis. The results
in these cases are unpredictable and often fail. The
same concept is applied to rigidity, hypotonia,
dystonia, and ataxia.
The surgical program is organized according to
the type and severity of the deformity (clinical
groups).
The goals are to correct the deformities and to
improve the muscular balance of the hand in one
surgical stage. It must be remembered that spastic
muscle cannot be used for tendon transfer with
the same efficiency as in patients with a flaccid
paralysis. Results were satisfactory in 92% of
cases of groups I and II. If group III is included,
the percentage of satisfactory results reduces sig-
nificantly.
References
[1] Goldner JL. Reconstructive surgery of the hand in
cerebral palsy and spastic paralysis resulting from
injury to the spinal cord. J Bone Joint Surg
1955;37A:1141–54.
[2] Goldner JL. The upper extremity in cerebral palsy.
In: Samilson RL, editor. Orthopaedic aspects of
cerebral palsy. New York: Harper & Row; 1975.
p. 221–57.
[3] Swanson AB. Surgery of the hand in cerebral palsy
and muscle origin release procedures. Surg Clin N
Am 1968;48:1129–38.
[4] Zancolli EA. Structural and dynamic bases of hand
surgery. Philadelphia: JB Lippincott; 1968.
[5] Zancolli EA. La operación del ‘‘asa’’ en la
corrección de la deformidad en ‘‘cuello de cisne.’’
Primer Congresso Nacional de la Sociedad Espa-
ñola de cirugia de la mano. Octobre 17–19, 1975.
Bilbao, España (unpublished).
[6] Zancolli EA. Structural and dynamic bases of hand
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[7] Blumel I, Eggers GWN, Evans EB. Genetic
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patients. JAMA 1960;174:860–72.
[8] Samilsom SL, Morris JM. Surgical improvement of
the cerebral-palsied upper limb. J Bone Joint Surg
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[9] Green WT. Tendon transplantation of the flexor
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[10] Zancolli EA, Zancolli ER. Surgical rehabilitation of
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[11] Twitchell TE. Sensation and the motor deficit in
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[12] Zancolli EA, Zancolli ER. Surgical management of
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[13] Page CM. An operation for the relief of flexion
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[14] Inglis AE, Cooper W. Release of the flexor pronator
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[15] White WF. Flexor muscle slide in the spastic hand.
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[16] Green WT, Banks HH. Flexor carpi ulnaris trans-
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[17] Zancolli EA. Un nuevo método de corrección de las
contracturas congénitas de los músculos flexores
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Argentina 1957;44:279–81.
[18] Braun RM, Guy TV, Roper B. Preliminary
experience with superficialis-to-profundus tendon
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[19] Vulpius O, Stoffel A. Orthopädische Operations
Lehre. Stuttgart: Ferdinang Enke; 1920.
[20] Matev I. Surgical treatment of the spastic ‘‘thumb-
in-palm’’ deformity. J Bone Joint Surg 1963;
45B:703–8.
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[21] McCue FC, Honner R, Chapman WC. Transfer
of the brachioradialis for hands deformed by
cerebral palsy. J Bone Joint Surg 1970;52A:
1171–80.
[22] Keats S. Surgical treatment of the hand in cerebral
palsy: correction of thumb-in-palm and other
deformities. Report of nineteen cases. J Bone Joint
Surg 1964;47A:274–84.
[23] Filler BC, Stark HH, Boyes J. Capsulodesis of meta-
carpophalangeal joint of the thumb in children with
cerebral palsy. J Bone Joint Surg 1976;58A:667–70.
[24] Swanson AB. Surgery of the hand in cerebral palsy
and the swan-neck deformity. J Bone Joint Surg
1960;42A:951–64.
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[25] Swanson AB. Surgery of the hand in cerebral palsy.
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Baltimore: Williams & Wilkins; 1982. p. 476–88.
[26] Zancolli EA. Management of boutonniere and
swan-neck deformities. In: Program of the 25th
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[27] Zancolli EA. Panel on soft tissue reconstruction in
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 Hand Clin 19 (2003) 631–648

The upper limb in cerebral palsy: surgical management

of shoulder and elbow deformities
A. Landi, MDa,*, S. Cavazza, MDb, G. Caserta, MDa, A. Leti Acciaro,
MDa, S. Sartini, MDc, M.C. Gagliano, MDa, M. Manca, MDb
a
Unit of Hand Surgery and Microsurgery, Policlinico of Modena, Via del Pozzo, 71 41100, Modena, Italy
b
Unit of Rehabilitation, St. Giorgio Hospital, Ferrara, Italy
c
Unit of Rehabilitation, Policlinico of Modena, Via del Pozzo, 71 41100, Modena, Italy

The population of patients affected by ac-
quired spasticity is large. Apart from cerebral
palsy (CP), numerous different conditions ulti-
mately can lead to spasticity of the upper limbs:
cerebrovascular accidents (CVA), traumatic brain
injuries (TBI), brain tumors, and spinal cord
injuries (SCI) (Table 1).
Injury to the upper motor neuron following
supraspinal trauma may be defined as a disorder
of motor control attributable in part to the loss of
cortical control of the spinal cord, characterized
by weakness, impaired coordination (negative
signs), spasticity, increased tendon jerks, and
release of primitive cutaneous-muscular reflexes,
such as the Babinski response (positive signs) [1].
The primary lesion often is associated with
secondary lesions of the muscle and joint that act
in concert to alter the movements or posture of
the subject. Secondary lesions include muscle
retraction, bone deformities, and capsular re-
traction from disuse; these are elements that must
be considered when planning the therapeutic
program. It is now known that increased passive
muscle tension is generated by changes in
rheologic properties (viscoelastic and plastic
properties) [2].
Surgical attention for the upper limb in
cerebral palsy traditionally has been concentrated
on the distal upper limb segment. The universally
adopted classification of Zancolli [3] and its
subsequent modifications [4,5] usually are con-
* Corresponding author.
E-mail address: landi_antonio@virgilio.it (A. Landi).
0749-0712/03/$ - see front matter Ó 2003 Elsevier Inc. All rights reserved.
doi:10.1016/S0749-0712(03)00062-3
fined to the segments below the elbow. Scant
attention has been given in the past to the
classification and treatment of shoulder deformity
[6] and spastic deformities of the elbow [7,8].
The shoulder
Hypotonic and hypertonic phases follow cere-
bral lesions. Initially there is complete muscle
flaccidity with a total lack of voluntary control.
In this phase the risk for subluxation of the
scapulohumeral joint is high, and indeed is
observed in 66%–92% of hemiplegic patients [6].
There are three forms of subluxation of the
hemiplegic shoulder: anterior, superior, and in-
ferior. Inferior subluxation is the most frequent,
whereas anterior and superior subluxations are
observed in a smaller percentage of patients and
often in a later phase of recovery [6].
A few days or weeks following supraspinal
damage the patient progressively regains partial
control of the muscles of the scapular girdle.
Voluntary recruitment of the muscle is usually
slow, as is the capacity to relax the muscle at the
end of contraction. The subject has great difficulty
in activating simple movements selectively and
is able to reproduce only simple motor patterns.
The force generated is generally low and is not
sufficient to achieve antigravitational movement.
A light muscular activity or emotional stress can
trigger an ‘‘associated reaction’’ with activation of
muscle patterns at the shoulder girdle.
Some motor units are under voluntary control
and other units are flaccid or hypertonic to passive
 632

Table 1
Lindon Lindon Pinzur Pinzur
Target pre- post- pre- post-
Patient Age Sex Etiology Diagnosis Segment Site Procedures (group) operative operative operative operative
1. P. S 27 M T.B.I. Tetra S+ E L MDr,Bt,BCr,BRpr Hygienic 6 6 1 1
2. M. M 24 M T.B.I. Tetra E L Bt,BCt,BRpr,Er Hygienic 6 6 1 1
3. V 52 F C.V.A. Hemi S+ E R PMr,Bbr,CBr Hygienic 6 6 0 0
4. DE 27 M C.P. Tetra S+ E+F L PMr,Bbr,BRdr,FCUr,FCRr Hygienic 6 6 0 1
5. PT 24 M T.B.I. Hemi S+ E+F L PMr,LDr,TMr,Br,BRpr,FCRt, Hygienic 6 6 1 2
FCUt,STP
6. OM 30 F C.P. Hemi S + E R PMr,CBr,Bt,BRpr Hygienic 6 6 0 2
7. CL 73 F C.V.A. Hemi S + E L PMt,Bbr,BCr,LDt,TMt,BRpr,MEMbr Hygienic 6 6 0 1
8. BK 28 F C.V.A. Hemi S + E R PMr,SHBr,CBr,LDr,TMr,MEMbr,BRdr Hygienic 5 5 1 2
9. CE 25 M T.B.I. Hemi S + E L PMr,Bbr,MEMbr,BRpr Hygienic 6 6 0 0
10. CR 41 F T.B.I. Tetra S + E L PMr,LDr,TMr,SHBr,CBr,Bt,BCt, Hygienic 6 6 0 0
BRpr,FCUt
11. B. L 62 M TB.I. Hemi E+F R Bt,BCt,MEMbr Hygienic 6 6 0 0
12. C 33 F C.V.A. Hemi S L PMt,SHBr,CBr,ADr Hygienic 6 6 0 1
13. ME 37 M T.B.I. Hemi E L Bzlnt,BCr,MEMr Hygienic 6 6 0 0
14. MV 46 F C.V.A. Hemi S L PMt,LDt,TMt,SHBr,CBr Hygienic 6 6 2 3
15. BA 21 M T.B.I. Hemi E+F L Bzlnt,BRpr,MEMr,ECRLt, Hygienic 6 6 2 2
ECRBr,FCRt
16. FS 28 M T.B.I. Hemi E L Bzlnt,LEMr,PLt Hygienic 6 6 1 1
17. SF 23 M T.B.I. Tetra E L Bt,BRpr Hygienic 6 6 0 0
A. Landi et al / Hand Clin 19 (2003) 631–648

18. FR 50 M C.V.A. Hemi E+F L Bzlnt,BCt,BRpr Hygienic 6 6 0 1

19. MD 30 M T.B.I. Tetra S+E+F R PMr,LDr,TMr,Br,BRpr,FCRt, Hygienic 6 6 1 1
FCUt,STP
20. BN 37 M T.B.I. Tetra S+E L PMt,Bt,BCt,SHBr,CBr,TMt,MEMr Hygienic 6 6 0 0
21. CS 32 M T.B.I. Hemi S+E+ F L PMt,ADr,MEMbr Hygienic 6 6 0 0
22. BM 17 M T.B.I. Tetra S+E+ F L PMt,SHBr,CBr,Bt,BRpr,FRCr,FCUr Hygienic 6 6 1 1
23. FE 37 F T.B.I. Hemi S+E L PMt,Bt,MEMr Hygienic 6 6 1 1
24. G. S 27 M T.B.I. Tetra E+F L BRpr,FCUt, FCRt,PRC Functional 5 5 2 3
25. T.R 27 F T.B.I. Hemi E R Er,UNant Functional 5 3 1 1
26. L 26 M T.B.I. Hemi E+F R MEMr,UNant, Er, HOr Functional 5 4 2 3
27. PF 22 M T.B.I. Hemi E R Bfrltn,BCt,Er, HOr Functional 4 3 1 3
28. De D 26 M T.B.I. Hemi S+E+ F R PMr,SHBr,CBr,LDr,TMr, MEMbr Functional 6 5 0 2
29. VG 52 F C.V.A. Hemi S+E+ F L PMr,SHBr,CBr,MEMbr Functional 4 3 2 3
 30. MM 34 M T.B.I. Tetra E L Br,BRpr,Er Functional 4 4 2 2
31. PG 33 M T.B.I. Hemi S+F L PMr,FCUr,FCRr,PINd Functional 4 4 2 3
32. FL 56 M C.V.A. Hemi S R PMr,CBr,SHBr Functional 5 2 2 5
33. OG 25 F C.P. Tetra S+E+F L PMr,ADr,Bzlnt,FCRt Functional 5 4 2 3
34. RC 29 M T.B.I. Tetra E+F R MEMbr, AbPLtoECRB Functional 6 4 1 2
35. C.M 24 M C.V.A. Hemi E+F L MS,IMr,Grilli Functional 5 5 2 3
36. MA 22 M T.B.I. Hemi E L Bzlnt,BCt,Er,UNant,HOr Functional 5 4 3 4
37. TD 20 M Enc. Hemi E+F L Bzlnt,BCr,BRpr,MEMr,LEMr, Functional 6 5 3 3
FCRtoECRB, Caps
38. BA 18 M C.P. Hemi S+E+F L PMr,SHBr,CBr,BRdr,MEMr, PRC Functional 5 4 3 4
39. VF 37 M T.B.I. Hemi S+E R PMr,Er Functional 5 4 2 3
40. M. A 47 M C.V.A. Hemi E+F L Bt,MEMbr Mixed 5 5 2 2
41. C. D. 23 M T.B.I. Tetra S+E R PMt,Bdr,MEMr Mixed 6 6 0 1
42. MM 51 M C.V.A. Hemi S+E+F L PMt,Bbr,ADr,MEMr,BRdr Mixed 5 5 1 1
43. NV 52 F C.V.A. Hemi S+E L PMt,Bbr,ADr,BRpr Mixed 5 5 1 2
44. BM 30 F T.B.I. Hemi E+F L Bdr,BRdr,FCUt Mixed 6 5 2 2
45. Z. A 21 M T.B.I. Tetra E+F L Bbr,BRdr,FCUt,FCRt Mixed 6 4 2 2
46. VM 26 M T.B.I. Hemi E L Ancr,BRpr, MEMr Mixed 5 5 1 1
47. S .P 25 M C.V.A. Hemi E R Bt Mixed 6 6 1 1
48. FL 25 M T.B.I. Tetra E R Tlnt,Er Mixed 6 5 2 3
49. IM 43 F C.V.A. Hemi S+E L PMt,SHBr,CBr,MEMr Mixed 6 4 1 3
50. CB 18 M C.V.A. Hemi E+F R Bbr,MEMr Mixed 6 6 4 4
CP, cerebral palsy; CVA, cerebral vascular accident; TBI, traumatic brain injury; Enc, encephalitis; S, shoulder; E, elbow; F, forearm; Hemi, hemiplegia; Tetra, tetraplegia;
L, left; R, right.
See Table 3 for explanation of abbreviations of procedures.
A. Landi et al / Hand Clin 19 (2003) 631–648
633
634 A. Landi et al / Hand Clin 19 (2003) 631–648
stretching, with the capacity for voluntary con-
trol. These lead to different postures of the
shoulder.
Scapulohumeral internal rotation and slight
abduction
This posture generally is associated with
a subcontinual activation of the upper bundles
of the trapezius and supraspinatus muscles and of
the three heads of the deltoid, which the patient
often is not able to activate selectively. The subject
generally is able to produce movements of in-
complete abduction, with partial anteroposition
of the shoulder and a synergistic pattern with the
elbow in flexion. This pattern, in patients with
severe impairment, can be associated with anterior
or superior subluxation of the scapulohumeral
joint and of postures that are maintained over
a wide range of voluntary movements and gait,
assuming patterns of spastic dystonia. A limited
number of these patients, especially those with
deep cerebral lesions associated with cranioence-
phalic trauma, assume a posture with the shoulder
held in abduction and slight extension.
Scapulohumeral internal rotation and adduction
This posture is associated frequently with
a subcontinuous activation of the pectoralis
major, latissimus dorsi, and teres major muscles.
Activation frequently has features of associated
reaction of the superior bundles of the trapezius,
supraspinatus and anterior deltoid muscle. In
these cases, only modest anteroposition of the
shoulder is generally possible in combination with
elbow flexion and wrist and finger flexion. Closely
associated with shoulder adduction is limited
forward flexion, making it difficult to position
the hand appropriately for functional activities.
Dynamic EMG studies are extremely useful in
identifying dyssynergic extensor muscle activity
and in documenting appropriate firing of the
flexor muscles. The muscles contributing to
spastic extension deformities include the posterior
deltoid, long head of the triceps, teres major, and
latissimus dorsi [9].
The lowered posture of the shoulder is caused
by the need to maintain the plegic hemisoma in
relative contraction (the pelvic hiking effect) to
permit improved advancement of the plegic lower
limb.
In addition to this more severe condition
associated with a focal cortical–subcortical brain
lesion observed in vascular lesions of the middle
cerebral artery, there are also an appreciable
number of patients with a lesser degree of motor
damage who show a certain capacity for volun-
tary movements that go beyond the patterns
described. These patients have the capacity to
abduct and adduct or carry out flexion–extension
of the shoulder while maintaining the elbow
extended, to maintain the shoulder in abduc-
tion–anteropulsion against gravity and perform
flexion–extension of the elbow, and to produce
voluntary external rotation of the shoulder.
Consideration also should be directed to the
shoulder joint, as rotator cuff tears may occur
occasionally and should be recognized as a possi-
ble cause of non-neuropathic pain at this level.
Heterotopic ossifications (HO) may be associated
with head injuries and usually form inferomedially
to the joint but might locate posteriorly and
usually follow the teres muscles. When surgical
removal is considered, care must be exercised to
identify the axillary nerve. Furthermore, the
trauma concurrent with brain injury may have
caused complex fractures that might have been
missed in the initial resuscitation phase. Malunion
of the proximal humerus and of the greater
tuberosity are possible causes of underlying non-
neuropathic pain that also can lead to degenera-
tive arthritis [9].
The elbow
Many patients present with hypertonus of the
flexor muscles of the elbow. The extensor muscles
are inactive or weak, with disorders of phasic
contraction.
The posture most commonly assumed is
flexion of the elbow associated with pronation
or supination of the forearm. Usually flexor
muscle control is poor and may be associated
with spastic dystonia or muscular retraction.
At dynamic EMG evaluation, spastic contrac-
tion of the brachioradialis muscle often is seen,
whereas the biceps and brachialis muscles contract
as an associated reaction and are under volun-
tary control with prolonged and continuous
activation.
The study of the capacity to control the flexor
and extensor muscles of the elbow is useful for
evaluating the degree of voluntary motion and
compulsory postures in flexion of the elbow.
Occasionally posterior dislocation of the radial
head might develop in cerebral palsy, though
 A. Landi et al / Hand Clin 19 (2003) 631–648
rarely requiring treatment [8]. The incidence of
HO at the elbow is approximately 90% in
combined head and elbow injury (Fig. 1). HO
often involves the collateral ligament and might
contribute to ulnar palsy (Fig. 1). Surgical re-
moval usually has a positive effect on outcome [8]
(Fig. 1).
Elbow joint stiffness occasionally can be
observed in the absence of HO, and joint release
for functional and hygienic purpose should be
considered.
Indications for surgery and assessment methods
It is necessary to assess possible surgical
candidates on multiple occasions. It is unusual
to operate on patients with cerebral palsy younger
than age 5 years and is more common in
adolescents, but is not contraindicated in the
adult. Following CVA it is necessary to wait
a minimum of 1 year for clinical stabilization and
more than 2 years following spastic palsy as
a result of head injury.
Severe behavioral disorders, severe and wide-
spread dystonia, and presence of choreoathetotic
movements, myoclonus, or disorders of coordina-
tion are contraindications to surgery. Focal
dystonia is in itself not an absolute contrain-
dication, especially if it responds to local phar-
macologic treatment with botulinum toxin or
diagnostic nerve blockade. Severe sensory deficits
do not prevent surgery but gains in functional
outcome are limited.
Preoperative assessments and outcome meas-
ures include the following:
 Identification of the priority placed by the
patient or caregiver on posture by means of
a questionnaire derived from the Canadian
Occupational Performance Measure (COPM)
[10] in which the patient or caregiver defines
the most relevant problems of the upper limb
and the degree of satisfaction with motor
performance.
 Assessment of the level of global disability by
means of the FIM scale [11] and Disability
Rating Scale. Considering the low sensitivity
of the global rating scale for assessing
treatment for segmental spastic hypertonus,
the authors employed the scale proposed by
Bhakta [12] to evaluate the impact of spastic
hypertonus on disability.
 Evaluation of the functional level of the
upper limb by means of a qualitative scale
635
and a manual dexterity scale for single hand
(Jebsen test) and bimanual (De Renzi test for
ideomotor apraxia) tasks [13]. In particular,
global functioning was assessed using a qual-
itative scale such as the Lindon score [4,5].
The capacity to control the shoulder and
elbow voluntarily was evaluated using the
hand placement scale proposed by Pinzur,
modified by the authors’ group [4,5], whereas
the capacity for efficient handgrip was mea-
sured with the Sollerman test as modified by
Eliasson [4,5].
 Evaluation of cognitive functioning (Mini
Mental State Examination), attention, and
memory, in addition to clinical assessment of
severe neglect or apraxia.
 The tactile sensory, proprioceptive, and dis-
criminative level were evaluated by means of
the Fugl-Meyer [14] score for tactile discrim-
ination and proprioception and of the
Moberg test for two-point discrimination.
 Videotaping of standardized movements in-
volving reaching and grasping is beneficial.
 The passive range of motion of the elbow in
flexion and extension and of the shoulder
in abduction and external rotation is
documented.
 The modified Ashworth scale [15] is used for
assessment of the flexors of the elbow and for
abduction and external rotation of the
shoulder.
The surgeon must specifically evaluate the
following:
 Differential diagnosis between myostatic re-
traction and spastic hypertonus by means of
clinical tests, diagnostic nerve blocks, and
dynamic EMG during passive mobilization.
 Capacity for voluntary control of muscle
antagonist to those in myostatic retraction
by means of dynamic EMG performed during
simple voluntary movements.
 Clinical study of the movements associated
with pathologic synergisms with the contri-
bution of dynamic EMG studies recorded
during complex movements and minimum
force or during walking.
These evaluations allow assessment of, for
each muscle studied, the prevalence of retraction,
spastic hypertonus, and the level of coactivation
or dyssynergy among antagonistic muscles, in
addition to the degree of voluntary control of the
636 A. Landi et al / Hand Clin 19 (2003) 631–648

Fig. 1. (A,B) Right hemiplegia following a road traffic accident (RTA) with subsequent coma for 1 month. Elbow
ankylosed at 85 . (C) Radiograph showing the posterior location of HO at the elbow. (D) Corresponding CT scan. (E)
Intraoperative findings following HO removal, MEMr, and ulnar nerve transposition. Arrow points to ulnar nerve. (F)
Postoperative radiographs. (G,H,I,J) Functional outcome. The patient has gained one score on the Lindon scale.
 A. Landi et al / Hand Clin 19 (2003) 631–648
Fig. 1 (continued )
muscles in their capacity to contract and relax the
motor units. Moreover, the degree that the muscle
is influenced by movements associated with
minimum forces is evaluated.
Dynamic EMG study
The dynamic EMG study is performed using
fine wire electrodes in the muscles examined and
electronic goniometers at the elbow joint. The
patient is examined in the sitting position,
postured with the flexor muscles at maximum
stretch for 5–10 sec during simple flexor–extensor
movements of the elbow joint with a fixed
shoulder, of abduction of the shoulder and
internal and external rotation during a brief task
of maximal flexion of the contralateral elbow, of
flexion of the homolateral hip, and, when
possible, of a task with walking in place.
To define muscular activation the authors’
used the criteria of the Keenan [16] and Mayer
[17], introducing an additional classification cri-
teria for associated movements when studying
voluntary control. In particular, the following
637
muscles were evaluated at the shoulder: pectoralis
major, three heads of the deltoid, supra and
infraspinatus, latissimus dorsi, teres major, and
long head of the triceps.
The following muscles were studied at the
elbow: biceps, triceps, brachialis, long, middle,
and lateral heads of the triceps, and anconeus.
The last one has been studied particularly because
of the possible interference with active prono-
supination. Each muscle was studied to evaluate
the degree of spastic hypertonus, the capacity for
voluntary control, and the appearance of associ-
ated reactions. To study spastic hypertonus,
passive stretching movements at different speeds
were performed, and the muscle activity during
prolonged postures (5 sec) was evaluated with the
studied muscles in the stretched position.
Finally the surgical objectives are established
following the assessments mentioned previously in
which the priorities proposed by the patient and
caregiver are combined with a realistic assessment
of the level of function and use of the limb in
activities of daily living. It is then possible to place
the patient into one of three functional groups.
638 A. Landi et al / Hand Clin 19 (2003) 631–648
1. Personal hygiene. The patient has no capacity
for functional use of the upper limb in either
mono- or bimanual functions. Obligatory
function leads to major disability because of
pain and difficulty in managing dressing and
personal hygiene of the armpit, elbow, and
hand.
2. Functional outcomes. The patient has a dis-
crete capacity to use the plegic limb in mono-
and bimanual activities. In particular, the
patient shows at least a certain capacity to use
the plegic upper limb for digitopalmar grasp-
ing and is able to release the grip actively even
though lacking the capacity to use the limb
directly in single hand activities.
3. Mixed problems. The patient presents a cer-
tain degree of passive bimanual function,
though using for daily activities an alternative
grasp between the arm and chest wall or
forearm and abdomen or using the closed fist
to hold small objects. Problems with the
obligate posture and personal hygiene prevail.
Clinical and surgical experience
The authors have assessed 138 patients treated
surgically for spastic disorders. Fifty of these
underwent surgery of the shoulder or elbow
(Tables 1 and 2). Fifteen patients were tetraplegic,
13 as a result of head injuries and 2 with infantile
cerebral palsy. Thirty-five patients were hemi-
plegic, 17 following head injury, 12 following
CVA, 1 following a cerebral infection, and 5 with
infantile cerebral palsy.
There were 36 males and 14 females with an
age range of 17–73 years. The mean FIM motor
scale score of disability was 66.6 with a mean
Disability Rating Scale (DRS) of 9.2. Considering
the high correlation between the data obtained
with the DRS and FIM motor scale (r = 0.9,
P = 0.000), the authors considered the values of
the DRS in this study. Of the 15 tetraplegic
patients, 4 had surgery limited to the elbow, 4 had
surgery of the elbow and shoulder, and 4 had
surgery of the shoulder, elbow, and forearm. The
remaining three had surgery of the elbow and
forearm. None were treated for a shoulder prob-
lem alone. Of the hemiplegic patients, three had
operations on the shoulder alone, seven on the
elbow alone, one on the shoulder and forearm,
nine on the shoulder and elbow, nine on the elbow
and forearm, and six on the shoulder, elbow, and
forearm. Three patients also had surgery for HO
at the elbow joint.
Table 3 documents the surgical procedures that
were performed and the abbreviations that de-
scribe these. Table 4 describes the shoulder and
elbow procedures that were performed according
to the three groups of patients: (1) hygienic, (2)
functional, and (3) mixed.
All patients were followed at 6 months by
a medical team consisting of an orthopaedic
surgeon, a physiatrist, and a neurologist. The
patients were evaluated by and compared with the
preoperative rating scales, recording the achieve-
ment of targeted outcomes and observation of
videos made before and after surgery.
Group 1: surgery for personal hygiene
Twenty-three patients were operated on to
achieve improved personal hygiene (8 tetraplegic
and 15 hemiplegic). Twenty-one of the 23 patients
were operated on at the elbow for problems
correlated with contracted posture in flexion. Of
these 21 patients, 4 had surgery at only the elbow,
9 received an associated treatment at the elbow
and shoulder, and 5 had three interventions at the
shoulder, elbow, and forearm. Of the remaining
three, one had surgery at the elbow and wrist and
two at only the shoulder (Table 1).
The global disability scale of the FIM and the
DRS were not modified significantly, whereas the
scale of impact of spastic hypertonus on disability
(ad hoc scale) showed some change.
In particular, patients changed significantly
globally in the Bhakta rating scales for caregivers,
from 2.2 to 1.5, whereas no significant changes
were observed in the scales specific for disability.
All patients presented at the first intervention
a level of 6 on the Lindon scale and a value of 0–1
on the Pinzur scale. At follow-up, patients
operated on for personal hygiene did not show
a change on the Lindon scale.
Of the patients with surgery to the shoulder,
the main problem was related to shoulder
Table 2
Etiology
Group 1 Group 2 Group 3
Hygienic Functional Mixed Total
Perinatal (CP) 2 2 3 7
Cerebral 2 1 2 5
aneurism
Thrombosis 4 2 1 7
TBI 4 6 1 11
TBI with coma 11 4 4 19
Encephalitis — 1 — 1
 A. Landi et al / Hand Clin 19 (2003) 631–648 639

Table 3
Legend of the surgical procedures performed on muscles, tendons, and joints, and corresponding abbreviations
t Tenotomy
r Release Proximal release of a muscle at its origin
frlnt Fractional lengthening Surgical technique of lengthening of a myotendineous
unit by a single or multiple tenotomies at the
myotendineous junction
zlnt Z lengthening Surgical technique of lengthening of a myotendineous
unit at the distal tendon
AD Anterior deltoid muscle —
MD Middle deltoid muscle —
PD Posterior deltoid muscle —
LD Latissimus dorsi —
TM Teres major —
PM Pectoralis major —
CB Choracobrachialis —
BC Brachialis —
Anc Anconeous muscle —
IM Interosseous membrane —
STP Superficialis to profundis —
MS Muscle sliding Release of a group of muscles within a muscle compartment
Bbr Biceps bipolar release Biceps fractional lengthening at the short head and at
the myotendineous junction
BRpr Brachioradialis proximal release —
BRdr Brachioradialis distal release Fractional lengthening of brachioradialis at the
myotendineous junction
MEMr Medial epicondylar muscle release —
MEMbr Medial epicondylar muscle Proximal muscle release + fractional lengthening of pronator
Bipolar release teres, Flexor carpi radialis, and palmaris longus
LEMr Lateral epicondylar muscle release —
PRC Proximal row carpectomy —
Er Elbow arthrolysis —
Caps Anterior elbow capsulotomy —
UNant Ulnar nerve anteposition —
PINd Posterior interosseous nerve —
decompression
Grilli — Biceps rerouting
HOr Heterotopic ossification removal —

Table 4 adduction and internal rotation. Patients had

Surgical procedures performed in the hygienic (1), difficulties with oral hygiene and pain during
functional (2), and mixed (3) groups of patients dressing maneuvers and had difficulties during
Group 1 Group 2 Group 3 sleep because of pressure of the internally rotated
Procedure Hygienic Functional Mixed Total spastic limb on the abdomen (Fig. 2).
Of the 16 patients undergoing surgery of the
PMr-t 15 7 7 29
LDr-t 5 1 6
shoulder, the preoperative degree of passive
TMr-t 6 1 7 abduction was 75 , with a median score on the
Adr 2 1 3 Ashworth scale for spasticity of the adductor
MDr 1 1 muscles of the shoulder of 3. Limitation of
SHB and 7 4 4 15 external rotation of the shoulder was on average
CBr-t 22 . Surgical intervention led to a mean abduction
Bt-frlnt 14 5 5 24 of the shoulder of 120.4 , with a passive external
BCr-t 9 3 3 15 rotation of 55 (P < 0.01).
BRr 14 4 4 22 Of the 23 patients surgically treated for
MEMr-br 9 6 6 21
personal hygiene outcomes, 10 patients reported
640 A. Landi et al / Hand Clin 19 (2003) 631–648
pain during personal hygiene, with the main
problems related to difficulties in personal hygiene
and dressing. All patients who reported pain
obtained resolution during daily hygiene man-
euvers following surgery.
All patients receiving surgery of the shoulder
for problems of personal hygiene and posture had
a characteristic activation on the dynamic EMG
of the anterior, middle, and posterior deltoid
muscles, pectoralis major, latissimus dorsi, teres
major, and supraspinatus, ranging from III B
(prolonged phasic stage) to IV(continuous activa-
tion) and V (spastic without voluntary control).
Muscles with the greatest involvement were the
pectoralis major, deltoid, latissimus dorsi, and
teres major.
Of the 21 patients who had surgery to the
elbow, all patients presented with a flexed elbow,
difficulty in extension, and difficulties with dress-
ing and maintaining adequate hygiene of the
elbow fold.
The flexor muscles of the elbow studied
(biceps, brachialis, and brachioradialis) presented
an activation ranging from IIIB (prolonged phasic
phase) and VI (absence of activity). The biceps
presented with more frequent activity of type IIIB
or IIIC (phasic with continuous activity), whereas
the brachioradialis more frequently had level IV
activation (spastic and loss of voluntary control).
The performance of the brachialis was more often
similar to that of the biceps, and in six patients did
not show any activity (grade VI). The biceps had
more frequent activation in the context of
associated reaction to minimum efforts, whereas
the brachioradialis had a greater spastic activity to
passive mobilization. Passive elbow extension
increased from 52.3 to 20.2 . Accordingly, the
passive range of motion of the elbow increased
from 12% to 73% of the complete range, on
average 27.8%. At the t-test for paired data, the
improvement reached significance at a level of
P < 0.01.
Group 2: surgery for functional outcome
Preoperatively the 16 patients receiving surgery
for functional target had a mean score of 11 on
the Sollerman scale for bimanual or single hand
activities.
The mean score following the performed tests
of the Jebsen scale was 2, whereas on bimanual
tasks the mean ranged from 2–3 (2.5) out of the
five tasks proposed.
The Lindon scale in patients with functional
objectives ranged from 4–6 (mean 5.4), whereas
the mean Pinzur [18] score was 1. Five patients
had surgery limited to the elbow, one to the elbow
and shoulder, five to the elbow and forearm, and
four to the shoulder, elbow, and forearm. Patients
with surgery to the elbow and shoulder district
presented problems with flexion and abduction of
the shoulder and extension of the elbow for
reaching objects placed anteriorly or laterally.
All patients who had surgery to the elbow,
using the functional objectives, showed a qualita-
tively normal dynamic EMG activation pattern
preoperatively in the three heads of the triceps.
The flexor muscles of the elbow present a type
IIIA or IIIB activation pattern (prolonged acti-
vation for a brief period in successive phases),
with similar behavior in the brachioradialis,
biceps, and brachialis muscles.
The surgical procedures performed in the
Functional Group are documented in Table 5.
Of these 16 subjects, 4 did not achieve functional
benefits on the Lindon scale (25%), and 2 (12.5%)
showed an improvement of two ranks on this
scale. The remaining patients improved by one
level (62.5%). At statistical analysis with the
Wilcoxon test for paired data, the improvement
on the Lindon scale reached statistical significance
at a level of P < 0.01.
At the modified Sollerman scale, the mean
increment in upper arm function reached 3 points
(from 11 to 14.3 points) (P < 0.05).
In the single hand (dexterity) test of Jebsen, the
score increased on average by one item. Only four
patients with surgery targeting improved func-
tional objectives did not improve on the Jebsen
scale, even though one of these patients had
a better performance on the bimanual testing.
No significant differences were observed in the
Jebsen single hand instrumental scale in compar-
ison with the Wilcoxon test for paired data,
whereas a weak significance for the bimanual test
per paired data was found.
Group 3: surgery for mixed problems
Eleven subjects underwent surgery for a mixed
target in which improvement was tied in part to
personal hygiene and to a modest increase in bi-
manual activity, for the most part passive (Table 1).
Of these patients, four had a true improvement
of bimanual functioning at the Lindon scale,
whereas all patients had better range of motion
 A. Landi et al / Hand Clin 19 (2003) 631–648 641

Fig. 2. (A,B) Left spastic hemiplegia following rupture of a cerebral aneurism. The main symptom was overnight undue
pressure by the spastic limb on the abdomen. (C,D) Follow-up following PMt, Bbr, ADr, MEMr, and BRdr. Posture
and speed on walking were affected positively and the pressure on the abdomen was relieved completely.

and higher scores on the items assessing disability
and caregiver perception.
Discussion and conclusions
The etiologic factors underlying spastic disor-
ders of the upper limb have altered in the last
century. Cerebral palsy from perinatal affections
has decreased because of the improvement of
neonatal resuscitation facilities. CVA and TBI are
now more common causes of spasticity.
In close relationship with the etiology, the
average age for upper limb surgery has increased
consistently. Of the head-injured patients in the
present series, 19 recovered from coma and 12 out
of 50 had a CVA. The authors therefore tend to
operate when consensus has been achieved be-
tween the medical team, patient, and family, with
 642

Table 5
Surgical procedures performed in the functional group (2) including the ones on joints, nerves, and tendons
Patient Age Sex Etiology Diagnosis Segment Site Procedures Joint Nerve Tendon transfers
FL 56 M C.V.A. Hemi S R PMr,CBr,SHBr — —
OG 25 F C.P. Tetra S+E+ F L PMr,ADr,Bzlnt,FCRt — —
De D 26 M T.B.I. Hemi S+E+ F R PMr,SHBr,CBr,LDr,TMr,MEMbr — —
VG 52 F C.V.A. Hemi S+E+ F L PMr,SHBr,CBr,MEMbr — —
BA 18 M C.P. Hemi S+E+ F L PMr,SHBr,CBr,BRdr,MEMr,PRC PRC — —
VF 37 M T.B.I. Hemi S+E R PMr,Er Er — —
PG 33 M T.B.I. Hemi S+F L PMr,FCUr,FCRr,PINd PINd —
MA 22 M T.B.I. Hemi E L Bzlnt,BCt,Er,UNant,HOr Er, HOr UNant —
MM 34 M T.B.I. Tetra E L Br,BRpr,Er Er —
T.R 27 F T.B.I. Hemi E R Er,UNant Er UNant —
PF 22 M T.B.I. Hemi E R Bltn,BCt,Er,HOr Er, HOr —
L 26 M T.B.I. Hemi E+F R MEMr,UNant,Er,HOr Er, HOr UNant —
G. S 27 M T.B.I. Tetra E+F L BRpr,FCUt,FCRt,PRC PRC — —
RC 29 M T.B.I. Tetra E+F R MEMbr,AbPLtoECRB — AbPLtoECRB
C.M 24 M C.V.A. Hemi E+F L MS,IMr,Grilli IMr — Grilli
Hemi Bzlnt,BCr,BRpr,MEMr,LEMr, Caps — FCRto ECRB
A. Landi et al / Hand Clin 19 (2003) 631–648

TD 20 M Enc. — E+F L FCRtoECRB,Caps —

10 cases 4 cases 3 cases
CP, cerebral palsy; CVA, cerebral vascular accident; TBI, traumatic brain injury; Enc, encephalitis; S, shoulder; E, elbow; F, forearm; Hemi, hemiplegia; Tetra, tetraplegia;
Hor, heterotopic ossificatio removal; PRC, proximal row carpectomy; IMr, interosseous membrane release.
 A. Landi et al / Hand Clin 19 (2003) 631–648
the provision that the neurologic conditions are
stabilized. In seven cases of cerebral palsy, surgery
has been deferred in some instances to adulthood
when new functional requirements became appar-
ent. Although surgery performed in adolescence
carries a better prognosis [19], the authors agree
with Manske [20] that surgery also maintains its
efficacy in adulthood (Fig. 3). Many clinical
pictures might be encountered when accurate
assessment of the entire upper limb is made. The
need to provide a simple chart that summarizes
clearly the clinical picture at a glance has emerged
from the study of the authors’ case series. The
modified Pinzur evaluation method [5,21] that
included the evaluation of the shoulder and elbow
segments was considered in the end to be in-
adequate. The authors now have adopted in all
neurorehabilitation centers of the Region of
Emilia-Romagna a simple chart that offers at
a glance a comprehensive picture of spasticity of
the upper limb and also provides a more objective
method of recording data, which is a prerequisite
for future outcome studies in this field (Boxes 1–
3). Distinction is made between fixed postures
(Box 1) and the residual active range of motion at
the shoulder and elbow. Assessment of the
antagonistic muscles represents a crucial issue, as
these can be potentiated. In the present classifica-
tion, for example, the shoulder external rotators
might be present and can actively externally rotate
the arm. Alternatively they might still be present
and palpable but cannot be detected because of
the overwhelming activity of the internal rotators.
Their presence or function can be identified easily
on dynamic EMG studies. For example, following
release of the pectoralis major, coracobrachialis,
and subscapularis, a shoulder with no active
external rotation before surgery might be
upgraded to level 3 with the newly added possi-
bility of active external rotation in addition to the
increased active range of motion. The same
applies to active antero- and retroposition.
Clinical examination of the elbow allows us to
classify the patients in the group of fixed posture
or within the group with an active range of
motion. It is therefore possible to define the active
range of motion, to record the speed of move-
ment, and to assess the capacity for active pro-
no-supination with the elbow in the flexed or
extended extreme activity range. Dynamic EMG
studies are essential for understanding the degree
of spasticity and dyssynergy related to each single
muscle. Prono-supination might be impaired only
by a dyssynergic anconeus muscle, as the authors
643
were able to ascertain and treat in two cases, one
of which belonged to the present series (patient
number 46).
Surgery might carry undesired effects and
complications, such as the negative impact of
scars on the psychology of the patient, especially
when the whole limb is affected, requiring ex-
tensive surgical procedures. The authors there-
fore have abandoned the deltopectoral incision
and introduced the subpectoral approach (Fig. 3).
Probably in the future an endoscopic release
might be used.
When performing tenotomies of latissimus
dorsi and teres major, the possibility of creating
a cord effect at the axilla should be explained to
the patient (Fig. 4). This deformity is not
encountered after functional lengthening of lat-
issimus dorsi and teres major. The range of
motion of the shoulder and elbow following
surgery is improved significantly, as already
observed in the literature [22]. In the authors’
series, improvement at the elbow was obtained in
extension, passive (in those patients surgically
treated for personal hygiene objectives) and active
for reach dexterity, as evaluated on dexterity tests
(tapping board performed on the vertical plane).
Undoubtedly, the muscle to be surgically treated
must be chosen carefully. In particular, evaluation
of the elbow is pivotal when deciding to intervene
on all three heads of the flexors or to limit surgery
to one of these.
It is known that the brachioradialis muscle
often becomes dyssynergic [16,22]. In dynamic
EMG in this series, the authors observed that the
brachioradialis most frequently had a spastic
activation profile during passive mobilization.
The biceps and brachialis often maintained a cer-
tain degree of voluntary control that prolonged
activation, usually in the opposite phase; these
muscles often were involved in associated reaction
following minimal effort. Surgical intervention in
this context aims to achieve significant objectives
for the patient or caregiver. In some patients the
most important issue was flexion of the elbow
during deambulation, which blocked posture or
transfers. In these situations, dynamic EMG
evaluation of associated contractions, prevalently
of the biceps muscle, should orient the surgical
approach toward a lengthening procedure of the
biceps rather than release of the brachioradialis
muscle. In other instances in which difficulties in
dressing activities are recorded on the part of
caregivers, the hypertonic muscles evident on
passive mobilization should be addressed.
644 A. Landi et al / Hand Clin 19 (2003) 631–648

Fig. 3. (A) CP in premature birth. Clinical picture of spastic tetraparesis. (B) Surgical release of PM, B, BR, FCU, and
FCR. (C) The subpectoralis surgical approach allows proximal release of PM and short head of biceps and can be
concealed easily. (D,E) Surgery was performed with success at the age of 26 years for hygienic purposes.

All subjects undergoing interventions for
personal hygiene and posture defects reached the
established surgical objectives. These objectives
prevalently focused on hygiene of the armpit, pain
control during mobilization of the elbow and
shoulder, and improved capacity for dressing. In
particular, improvement was significant in tests
measuring caregiver workload in assisting the
patient, whereas specific and global disability tests
were not modified significantly. This is not
surprising because many of these scales are not
sensitive to the real impact of spastic hypertonus

Box 1. Box 2.
Classification of spastic disorders at the Shoulder functional assessment based on
shoulder and elbow: the fixed the active range of abduction from an
postures. internally rotated posture.
 A. Landi et al / Hand Clin 19 (2003) 631–648 645

explanation lies in the loss of biomechanical

Box 3. advantage introduced after muscle lengthening.
In this case after surgical repositioning, the muscle
Elbow
a,b does not exert sufficient force on the joint be-
c cause the system of levers becomes less powerful.
a,b Indeed, surgery targeting personal hygiene aims to
a,b weaken the muscle by means of a substantial
d reduction of muscle mass, repositioning of the
a,b mechanical levers of action, detensioning of
a,b stretching receptors of the muscle, or lengthening
c of the muscle in case of retraction.
d In the interventions by the authors’ team for
a,b personal hygiene, the authors observed a remark-
able decrease of muscle activation during passive
stretching and these modifications remained at
follow-up over time.
and most patients submitting to surgery required Of the 16 patients treated for functional
a high degree of caregiver assistance. Patients with outcomes, the global level of disability on the
the most severe disabilities only showed improve- DRS was 6.2, equivalent to a moderate to severe
ment in the scales assessing caregiver burden and level; in patients with head trauma the cognitive
nonsignificant changes in scales evaluating dis- level was on average 7 (appropriate–automatic).
ability; this relates to the high degree of motor Even in this group of patients the disability scales
impairments (mean DRS of 11.7, equivalent to did not improve significantly after functional
severe disability), requiring a great deal of surgery. Concurrently, an increment in dexterity
assistance from caregivers for activities of daily on bimanual movements and on rapid movements
living. Moreover, subjects with head trauma who of the elbow in flexion–extension on the tapping
underwent surgery for personal hygiene objectives board was observed.
had a level of cognitive functioning of 5 on the In addition to a degree of improvement in
LCF scale (inappropriate–confused). dexterity on the Lindon scale, no significant
Surgery also improved range of motion of the improvements on the scales for specific or global
joints treated and permitted a significant reduc- disability were observed.
tion of spastic hypertonus as measured by the This may be explained by a low sensitivity of
Ashworth scale. The reduced hypertonus and the global disability scale. Another possibility is
improved range of motion can be explained by that many patients presented a stable clinical pic-
the lower traction of the myotactic spindle ture and a consolidated functional behavior that is
consequent on muscle lengthening. A possible difficult to modify. Significant improvement in the

Fig. 4. (A,B) TBI leading to a severe spastic tetraplegia with significant cognitive and behavioral disturbances. For
hygienic purpose an extensive shoulder release was performed (PMt, Bbr, BCr, LDt, TMt, BRpr, and MEMbr). The
cordlike effect caused by the myodesis effect by the retracted LD and TM is shown clearly on the lower border of the
axilla.
646 A. Landi et al / Hand Clin 19 (2003) 631–648

number of activities performed on single hand and
bimanual items of the Jebsen test was not
detected, whereas the number of bimanual tasks
performed increased significantly. The better posi-
tion of the shoulder and elbow may play an imp-
ortant role in these improvements (Fig. 5). The
improvement of some bimanual functions, how-
ever, may not have an impact on the patient’s
degree of disability.
Patients thus have an improved capacity to use
both hands in activities requiring dexterity that,
however, need not translate into a greater level of
autonomy in activities of daily living. Manual
dexterity in tasks for the instrumental activities of
daily living (IADL) improved in some patients,
such as use of utensils and computer keyboard
and capacity to grasp a bicycle handlebar. Para-
doxically, some patients report improved trans-
fers from sitting to standing position and better
deambulation.
A limited number of patients (three) had an
appreciable increment of single hand and bi-
manual activities.
The hemiparetic side generally showed negative
signs such as weakness and insufficient muscle
recruitment as the principal problem, whereas
impairment caused by spastic hypertonus and
retraction contributes only in part to the disability.
For the most part subjects tend to use the plegic
limb only for support. Releasing procedures on
joints had a positive influence on the final range of
motion. Tendon transfers confined to a functional
group and decompressive procedures on the
affected peripheral nerves improved the final
outcome. Significant improvement in posture and
walking was obtained in two patients from Group
1, two patients from Group 2, and five patients
from Group 3. The outcome measurements
selected were not sufficiently sensitive to detect
the numerous but sparse improvements achieved
in individual patients, who nonetheless considered
surgery rewarding. Though outcomes exceeded
patient expectations in 10 cases, the authors had
to face a deluded patient and family in two cases.
Patients did not always have a clear idea of the
objectives to be reached by surgery, and the

Fig. 5. (A) TBI in a sportsman. Concomitant compression of the PIN. (B) PMr, FCUr, and FCRr were performed in
conjunction with decompression on the posterior interosseous nerve because of a hypertrophic supinator brevis. (C) The
subpectoralis approach is easily conceivable. (D) Return of PIN function. (E) Good outcome with significant gain in
shoulder abduction. The patient now can swim the breaststroke and practice boxing at the gymnasium better.
 A. Landi et al / Hand Clin 19 (2003) 631–648
Fig. 5 (continued)
medical team was not always able to appreciate
the true expectations of the patient. Although
some rating scales used furnished a measure of the
improvement of specific gestures, they do not
provide a comprehensive evaluation of the gain in
autonomy. With these considerations in mind, the
authors added two tests to the assessment battery
to identify objective gains in autonomy and
patient expectations and to integrate the poor
sensitivity of the other tests. The two tests chosen
for their simple administration and efficacy were
the Katz index and the COPM [10,23,24]. The
former is a standardized test that evaluates the
capacity for self care in basic activities of daily
living (six hierarchically-ordered activities re-
quired for autonomous living), with the aim of
documenting the level of independence before and
after surgery. These data are used to classify the
patients based on the level of independence. The
shift from one class to a higher level permits
measurement of the efficacy of the intervention,
especially in patients with functional objectives.
The second test fulfills the initial need to better
understand patient objectives that often are not
647
in line with the realistic possibilities and effective
disabilities. Moreover, in the final evaluation this
test helps quantify the level of satisfaction and
capacity of performance perceived by the patient
in surgery for personal hygiene and aesthetics and
for recovery of gestures.
The literature does not present case series
reporting this type of surgery. The absence of
recurrence in the authors’ series makes surgical
treatment of the shoulder and elbow an interesting
approach as compared with other methods that
have a high recurrence, such as hyponeurotization
or the use of botulinum toxin.
In particular, the use of botulinum toxin for
segmental hypertonus should be limited to diag-
nostic use and to the early phases of disease,
whereas surgery should be proposed in later
stages, after the possible objectives to be reached
have been elucidated and other more conservative
methods exhausted.
The proposal for surgical treatment in any case
must be associated with an adequate program of
motor rehabilitative and occupational therapy.
Functional improvements are not possible with-
out an appropriate period of restorative care in
the postoperative period. This explains in part the
results obtained in the authors’ series in which
improvements in personal hygiene and posture
were evident, whereas functional objectives had
a less predictable, though generally appreciable,
outcome.
Finally, when spasticity of the upper arm is
managed with a global approach and objectives
are defined clearly in advance with the patient and
caregivers, treatment of shoulder and elbow de-
formities can achieve important results for per-
sonal hygiene. When functional objectives are
targeted, surgery at these proximal sites is a critical
step that provides a releasing effect on the distal
joints [5,21] and prepares the upper limb for pos-
sible functional interventions at the forearm and
hand.
References
[1] Thilmann AF, Burke DJ, Ryme WZ, editors.
Spasticity mechanism and management. Berlin:
Springer-Verlag; 1993. p. 35–42.
[2] Herman R. The myotatic reflex. Clinico-physiolog-
ical aspects of spasticity and contracture. Brain
1970;93(2):273–312.
[3] Zancolli E. Structural and dynamic bases of hand
surgery. 2nd edition. Philadelphia: Lippincott; 1979.
p. 263–83.
648 A. Landi et al / Hand Clin 19 (2003) 631–648
[4] Landi A, Saracino A, Leti Acciaro A, Esposito M.
Patologia neurologica: Il gomito nella spasticità-
SICM, editors. La patologia traumatica del gomito.
Parma: Mattioli; 1998. p. 80–90.
[5] Landi A, Caserta G, Leti Acciaro A, Della Rosa N,
Gagliano MC. Il trattamento della spasticità
dell’arto superiore a livello di spalla e gomito. Riv
Chir Mano 2002;39(1):3–14.
[6] Braun RM, Botte MJ. Treatment of shoulder
deformity in acquired spasticity. Clin Orthop
1999;368:54–65.
[7] Hoffer MM, Waters RL, Garland DE. Spastic
dysfunction of the elbow. In: Morrey BF, editor.
The elbow and its disorders. Philadelphia: WB
Saunders; 1993. p. 763–71.
[8] Garland DE, O’Hollaren RM. Fractures and
dislocations about the elbow in the head-injured
adult. Clin Orthop 1982;168:38–41.
[9] Keenan MA. Management of shoulder problems in
neurologic patients. In: Pajardi G, editor. La
chirurgia funzionale nelle paralisi spastiche dell’arto
superiore. Milan: Edizioni Centro Studi Mano;
2002. p. 20–3.
[10] Law M, Baptiste S, Pollock N, Carswell A, McColl
MA. Canadian Occupational Performance Mea-
sure. Training Video. Ottawa: CAOT Publications
ACE; 2000.
[11] Guide for the uniform data set for medical re-
habilitation (including the FIMä instrument) Ver-
sion 5.1. Buffalo, NY: University at Buffalo; 1997.
[12] Bhakta BB, Cozens JA, Chamberlain MA, Bamford
JM. Quantifying associated reactions in the paretic
arm in stroke and their relationship to spasticity.
Clin Rehabil 2001;15(2):195–206.
[13] De Renzi E, Lucchelli F. Ideational apraxia. Brain
1988;111(Pt 5):1173–85.
[14] Fugl-Meyer AR, Jaasko L, Leyman I, Olsson S,
Steglind S. The post-stroke hemiplegic patient. 1.
A method for evaluation of physical performance.
Scand J Rehabil Med 1975;7(1):13–31.
[15] Bohannon RW, Smith MB. Interrater reliability of
a modified Ashworth scale of muscle spasticity.
Phys Ther 1987;67(2):206–7.
[16] Keenan MA, Haider TT, Stone LR. Dynamic
electromyography to assess elbow spasticity. J Hand
Surg 1990;15A(4):607–14.
[17] Mayer NH. Upper extremity movement analysis in
patient with an upper motoneuron syndrome. In:
Pajardi G, editor. La chirurgia funzionale nelle
paralisi spastiche dell’arto superiore. Milan: Edi-
zioni Centro Studi Mano; 2002. p. 12–5.
[18] Pinzur MS. Flexor origin release and functional
prehension in adult spastic hand deformity. J Hand
Surg 1991;16B(2):133–6.
[19] Nachemeson AK. Functional outcome after cere-
bral palsy surgery of the upper extremity in
children. In: Abstracts of the 43rd annual meeting
of the Japanese Society for Surgery of the Hand.
Kyoto. 2000. p. 11–2
[20] Manske PR. Cerebral palsy of the upper extremity.
Hand Clin 1990;6(4):697–709.
[21] Landi A, Mulcahey MJ, Caserta G, Della Rosa N.
Tetraplegia: update on assessment. Hand Clin
2002;18(3):377–89.
[22] Keenan MA, Perry J. Evaluation of upper extremity
motor control in spastic brain injured patients using
dynamic electromyography. J Head Trauma Reha-
bil 1990;5(4):13–22.
[23] Katz MM, Lyverly SB. Methods for measuring
adjustment and social behaviour in the community:
rational, description, discriminative validity and
scale development. Psychol Rep 1963;13:503–35.
[24] Katz S, Ford AB, Moskowitz RW, Jackson BA,
Jaffe MW. Studies of illness in the aged. The index
of ADL: a standardised measure of biological and
psychological function. JAMA 1963;185(12):914–9.
 Hand Clin 19 (2003) 649–655
Surgical management of forearm pronation
Claudia R. Gschwind, MD, FMH, FRACS
Department of Hand Surgery and Peripheral Nerve Surgery, Royal North Shore Hospital,
St. Leonard NSW, 2065 Sydney, Australia
Pronation contracture of the forearm is part of
the common pattern of upper limb deformity in
cerebral palsy. It is caused by a muscle imbalance
between supinatory and pronatory muscles. Spas-
ticity in pronator teres, pronator quadratus, and
the whole flexor group can mask coexisting supi-
nation activity.
To separate elbow, wrist, finger, thumb, and
pronation deformity into separate groups seems
artificial. It is, however, didactically helpful and in
clinical examination improves the understanding
of the dynamics of deformity. Understanding
muscle imbalance is necessary when devising a
treatment plan. Important points of preoperative
assessment (eg, general neurologic condition, type
of neuromuscular disorder, extent of limb in-
volvement, age, and volitional control over limbs)
have been outlined by Zancolli [1] and others [2,3].
To select suitable candidates for surgery, repeated
clinical examination is necessary. The active and
passive range of joint motion, hand sensibility,
and the functional level of the limb are noted. The
principle of surgery is to decrease tone in over-
active muscle groups with release procedures and
to augment weak muscles by tendon transfers.
Joint or soft tissue contractures have to be
released first to allow passive motion. Only if
joints and ligaments permit motion can muscle
releases and tendon transfers be successful.
Effective treatment of elbow, wrist, and finger
flexion deformity alter the balance between mus-
cles involved in pronation and supination of the
forearm. Box 1 lists all procedures improving
supination (Fig. 1). Several different classifications
of wrist and finger deformity have been proposed
in the literature [2–5]. A classification for prona-
tion deformity, a proposed treatment plan, and
results of surgery were published in 1992 (Box 2)
0749-0712/03/$ - see front matter Ó 2003 Elsevier Inc. All rights reserved.
doi:10.1016/S0749-0712(03)00030-1
[6]. All groups had significant improvement of
forearm supination postoperatively.
In Group 1 with active supination beyond
neutral, no specific procedure is indicated to
improve supination.
In Group 2 with active supination up to or less
than neutral, a release of spastic muscles with
pronatory activity should improve supination.
The degree of active supination and the residual
contracture in the flexor pronator group deter-
mine the range of active forearm rotation
achieved in this group.
In clinical examination, Groups 3 and 4 show
no active supination. In Group 3, passive supina-
tion is easily possible, and the main problem,
therefore, is the lack of an active supinator. This
deficit can be corrected by a pronator teres trans-
fer or even a flexor carpi ulnaris (FCU) transfer.
In Group 4, a release of spastic muscles with
pronatory effect is indicated to allow possible ac-
tive supination to be unmasked. If after a release
there is no active supination present, a pronator
teres transfer may be contemplated (Box 3).
In children with severe hyperpronation, radial
head dislocations have been described [7]. The re-
commended treatment is pronator teres rerouting,
rather than excision of the head, which leads to an
increase of the deformity. Radial osteotomy also
has been advocated to improve forearm position
in severe cases. Inferior radioulnar joint fusion
may be an option if the pronatory forces cannot
be overcome by soft tissue procedures or in athe-
toid disorders in which tone changes unpredict-
ably. This fusion is performed in slight supination
with the radial head in a reduced position [8].
The worst complication of surgery for pro-
nation deformity is to create a supination de-
formity. The author therefore cautions against
650 C.R. Gschwind / Hand Clin 19 (2003) 649–655
Box 1. Procedures altering balance in favor of forearm supination
Releases
Pronator teres release
Pronator quadratus release
Flexor pronator slide
Flexor aponeurotic release
Fractional lengthening of flexor tendons
Flexor carpi ulnaris tenotomy
Transfers
Pronator teres rerouting
Flexor carpi ulnaris to extensor carpi brevis transfer
Flexor carpi ulnaris to extensor digitorum communis transfer
Extensor carpi ulnaris to extensor carpi radialis brevis transfer
Flexor profundus to flexor superficialis transfer
releasing pronator teres distally at its insertion
and pronator quadratus at the same time. The
danger of creating a supination deformity is less
pronounced if pronator teres is only partially
released, as in a proximal flexor aponeurotic
release, but is certainly present when the release
is distal at its insertion or massive, as in a flexor
pronator slide. Supination deformity is a function-
al disadvantage to chair-bound patients [9].
Typical activities in the wheelchair, like typing,
grasping and releasing, and pointing are easier in
pronation than supination (Fig. 2).
Surgical procedures for pronation deformity
Releases
Pronator teres release
Surgical technique. A longitudinal 3-cm incision is
made over the middle third of the radius, dorsal to
Fig. 1. Extensor carpi ulnaris to extensor carpi radialis
longus for rebalancing of the wrist in extension also
produces a supinatory effect.
the brachioradialis musculotendinous junction.
In the subcutaneous layer, the lateral cutaneous
nerve of the forearm and the superficial branch
of the radial nerve are preserved. Between the
brachioradialis tendon and the wrist extensors,
the insertion of pronator teres is identified and the
tendon is transversely divided. Some investigators
suggest excision of some of the tendon [10]
(Fig. 3).
Pronator quadratus release
Electrophysiologic studies on volunteers by
Basmajian and Delucca found pronator quad-
ratus to be the prime pronating muscle in the
forearm. This was irrespective of angulation of the
elbow joint or position of the forearm in space
[11]. No studies have been performed to clarify if
this is similar in patients with a spasticity disorder.
The pronator quadratus release rarely is men-
tioned in the literature [3,5,12,13]. After an ag-
gressive flexor pronator slide or a distal pronator
teres release, pronator quadratus remains as the
only pronator. If it is under poor volitional con-
trol, pronation may be inadequately initiated or
maintained. This may result in a supination de-
formity, particularly if at the same time an FCU
to extensor carpi radialis brevis (ECRB) or exten-
sor digitorum communis (EDC) transfer for wrist/
finger flexion deformity is performed. In such
a case the author recommends that pronator
quadratus not be released.
Surgical technique. A 4-cm longitudinal incision is
placed radial to the radial artery in the distal
aspect of the forearm. Care is taken to cauterize
small branches of the radial artery. The pronator
 C.R. Gschwind / Hand Clin 19 (2003) 649–655 651

Box 2. Classification of pronation deformity

Group 1 Active supination beyond neutral

Group 2 Active supination to or less than neutral
Group 3 No active supination: free passive supination
Group 4 No active supination: tight passive supination

quadratus is detached from its insertion into the
radius, and with an elevator is detached all across
and from the interosseous membrane (Fig. 4).
Flexor aponeurotic release
The flexor aponeurotic release (FAR) was
described by Zancolli and is suitable in children
only. In adults there is usually a component of
myostatic contracture present, and a flexor pro-
nator slide or fractional lengthening of tendons is
recommended instead. FAR allows muscle fibers
to be stretched after release of all fascial en-
velopment but does not tenotomize any tendons
extramuscularly. A ‘‘distal FAR’’ divides not only
the fascia and septa but also the intramuscular
tendon, as in fractional lengthening [8]. If in
Group 4 a ‘‘distal FAR’’ is performed at the same
time as an FCU to ECRB or to the finger extensor
and is used to improve wrist and finger extension,
the author does not recommend a release of
pronator quadratus at the same time, or a supina-
tion deformity may develop. Because pronator
teres has been divided distally, the only option for
correcting the supination deformity is to then
perform a biceps rerouting [6] (see Fig. 2).
Surgical technique. A 5-cm transverse incision is
placed in the proximal forearm, 6 cm distal to the
medial epicondyle. In the subcutaneous layer, the
medial cutaneous nerve of the arm and the larger
veins are protected. A strip of 2 cm of forearm
fascia is excised transversely over the flexor
pronator mass. All fascial septa down to the ulna
and interosseous membrane are divided. The
median and ulnar nerves are identified and
protected (Fig. 5). The more radical distal FAR
is performed through a transverse incision 9–12
cm distal to the medial epicondyle.
Flexor pronator slide
This procedure, first described by Page, ad-
dresses several problems [14]. The release of the
flexor pronator mass from the epicondyle im-
proves flexion contractures of the elbow and of
the wrist and fingers (Fig. 6). Detachment of the
pronator teres origin decreases the pronatory
effect of pronator teres in the forearm. This
procedure often is performed in conjunction with
releases/lengthening of biceps, brachialis, and bra-
chioradialis to improve elbow contractures. The
flexor pronator slide is an extensive procedure and
may lead to substantial weakening of the finger
flexors [8,15]. Some investigators believe it should
be performed only if finger flexion causes a hygiene
problem and not in the functional hand [4].
Recently, selective release of the flexor origin in
conjunction with FCU transfer was described [16].
Surgical technique. A lazy S or a straight incision
is made, starting 5 cm proximal to the medial
epicondyle and extending to the proximal third of
the forearm. The ulnar nerve, median nerve, and
brachial artery are identified and preserved. The
flexor pronator mass is detached from the medial
epicondyle, the proximal ulna, and the interos-
seous membrane. The slide allows for 4–6 cm of
lengthening (Fig. 6).

Box 3. Recommended procedures for pronation deformity

Group 1 No specific surgery indicated

Group 2 Pronator quadratus release ± flexor aponeurotic release
Group 3 Pronator teres transfer
Group 4 Pronator quadratus release + flexor aponeurotic release
652 C.R. Gschwind / Hand Clin 19 (2003) 649–655
Fig. 2. Postoperative supination deformity on the left
after release of pronator quadratus, distal flexor
aponeurotic release, proximal row carpectomy, and
flexor carpi ulnaris to extensor carpi radialis brevis
transfer. This complication required correction by a bi-
ceps rerouting procedure.
Tendon transfers
Pronator teres rerouting
This procedure, described by Sakellarides,
reverses the rotational action of pronator teres
Fig. 3. Pronator teres release with or without excision of
tendon.
Fig. 4. Pronator quadratus has been detached from the
radius and interosseous membrane.
on the radius [17]. In the original description, the
tendon is detached with a strip of periosteum and
rerouted through a bony canal in the radius. In
two patients in his series of 22 cases, a fracture of
the radius occurred [18]. A simplification of the
procedure in analogy to Zancolli’s biceps rerout-
ing procedure has since been described [6].
Surgical technique. Through a longitudinal in-
cision dorsal to the brachioradialis musculotendi-
nous junction in the mid third of the radius, the
pronator insertion is identified. The tendon is
tenotomized in a Z-fashion whereby the proximal
limb of the Z is lengthened with a periosteal strip.
The distal Z limb is rerouted around the radius to
create a supinatory effect (Figs. 7 and 8).
Fig. 5. A 2-cm strip of fascia and all septa has been
removed. The median nerve is preserved. The tendon of
pronator teres is preserved in this flexor aponeurotic
release. In the distal, more aggressive release, the tendon
would be divided.
 C.R. Gschwind / Hand Clin 19 (2003) 649–655 653

Fig. 6. The muscles of the flexor pronator mass are

detached from the medial epicondyle and the ulna. This
allows a slide of 4–6 cm.

Fig. 7. Pronator teres rerouting. (A) The tendon is

divided at its insertion and may be elongated with a strip
of periosteum. A drill hole is placed at the site of
insertion. (B) The tendon has been rerouted and is fixed
with sutures into the drill hole to create a supinatory
effect on the radius.

Fig. 9. The flexor carpi ulnaris to extensor carpi brevis

transfer around the ulnar border of the forearm
produces a supinatory effect.

Flexor carpi ulnaris transfer

Fig. 8. Modified pronator teres rerouting procedure. (A)
The tendon is tenotomized in a Z fashion. (B) Routing of
the tendon insertion reverses pronatory action of pro-
nator teres.
Rerouting of FCU around the ulnar border of
the wrist into the short radial wrist extensor
(Green transfer) or into the EDC tendons will, by
its due course, have a supinatory effect on the
forearm [19,20]. The surgical technique is de-
scribed elsewhere (Fig. 9).
654 C.R. Gschwind / Hand Clin 19 (2003) 649–655
Postoperative treatment
The position and duration of immobilization
often is determined by other procedures per-
formed in conjunction with surgery for pronation
deformity. Immobilization in submaximal supina-
tion and elbow extension for 4–5 weeks is
recommended.
Surgery is seldom performed for pronation
deformity alone. It is usually addressed at the
same time as correction of flexion deformity of the
elbow, wrist, and fingers is undertaken. Improve-
ment of rotation can be expected after all
procedures decreasing flexor/pronator tone or im-
proving wrist and finger extension. The recom-
mended procedures for pronation deformity
therefore have to be viewed in the context of
surgery for elbow, wrist, and finger flexion
deformity. If a patient in Group 1 (in whom no
specific surgery is indicated to improve supina-
tion) undergoes a FAR for wrist and finger flexion
deformity, supination improves by 20 –30 [6].
One can expect similarly approximately 20 of
increased supination if FCU is transferred around
the ulnar border into ECRB to improve wrist
extension [21]. If the Green transfer is performed
on a patient in Group 3, a pronator teres re-
routing may not be necessary or may be per-
formed secondarily if supination is inadequate.
In 1988, Strecker et al compared results of
pronator tenotomy with pronator rerouting and
found a greater increase of supination after
pronator teres rerouting than after tenotomy
[22]. Their preoperative assessment did not reveal
details of passive preoperative supination. Per-
haps rerouting of pronator teres alone, in the
presence of contractures of all flexors and tight
passive supination, would not result in improved
supination unless these muscles are released.
Summary
Active volitional supination enhances upper
limb function. In the spastic forearm with pro-
nation deformity, careful preoperative assessment
of muscle function is necessary to design a treat-
ment plan to improve supination. Concomitant
procedures performed for flexion contractures
have to be taken into consideration. The release
of the forearm, wrist, and fingers from a con-
tracted pronated position may unmask active
supination or may make the need for a tendon
transfer with supinatory activity obvious.
References
[1] Zancolli EA, Zancolli E Jr. Surgical rehabilitation
of the spastic upper limb in cerebral palsy. In: Lamb
DW, editor. The paralysed hand. Edinburgh:
Churchill Livingstone; 1987. p. 153–68.
[2] Swanson AB. Surgery of the hand in cerebral palsy.
In: Flynn JE, editor. Hand surgery. Baltimore:
Williams and Wilkins; 1982. p. 476–88.
[3] Goldner L. The upper extremity in cerebral palsy.
In: Samilson RL, editor. Orthopaedic aspects of
cerebral palsy. New York: Harper and Row; 1975.
p. 221–57.
[4] Gerwin M. Cerebral palsy. In: Green DP, Hotchkiss
RN, Pederson WC, editors. Green’s operative hand
surgery. 4th edition. New York: Churchill Living-
stone; 1998. p. 259–86.
[5] Zancolli E. The structural and dynamic bases of
hand surgery. 2nd edition. Philadelphia: Lippincott;
1968. p. 263–83.
[6] Gschwind C, Tonkin M. Surgery for cerebral palsy:
part 1. Classification and operative procedures for
pronation deformity. J Hand Surg 1992;17B(4):
391–5.
[7] Pletcher DF, Hoffer MM, Koffman DM. Non-
traumatic dislocation of the radial head in cerebral
palsy. J Bone Joint Surg 1976;58A(1):104–5.
[8] Tonkin MA. The upper limb in cerebral palsy.
Current Orthop 1995;9:149–55.
[9] Zancolli EA, Goldner LJ, Swanson AB. Surgery of
the spastic hand in cerebral palsy: report of the
Committee on Spastic Hand Evaluation (Interna-
tional Federation of Societies for Surgery of the
Hand). J Hand Surg 1983;8(5 part 2):766–72.
[10] Gelberman RH. Cerebral palsy. In: Gelberman RH,
editor. Operative nerve repair and reconstruction.
Philadelphia: Lippincott; 1991. p. 1455–75.
[11] Basmajian JV, De Luca CJ. Muscles alive, their
functions revealed by electromyography. 5th edition.
Baltimore: Williams and Wilkins; 1985. p. 561.
[12] Pollock GA. Surgical treatment of cerebral palsy.
J Bone Joint Surg 1962;44B:68–81.
[13] Samilson RL, Morris JM. Surgical improvement of
the cerebral-palsied upper limb. J Bone Joint Surg
1964;46A(6):1203–16.
[14] Page CM. An operation for the relief of flexion
contracture in the forearm. J Bone Joint Surg
1923;5:233–4.
[15] Hoffer MM. The use of pathokinesiology laborato-
ry to select muscles for tendon transfers in the
cerebral palsy hand. Clin Orthop 1993;288:135–8.
[16] El-Said NS. Selective release of the flexor origin
with transfer of flexor carpi ulnaris in cerebral
palsy. J Bone Joint Surg 2001;83B(2):259–62.
[17] Sakellarides HT, Mital MA, Lenzi WD. The
treatment of pronation contractures of the forearm
in cerebral palsy. J Hand Surg 1976;1(1):79–80.
[18] Sakellarides HT, Mital MA, Lenzi WD. Treatment
of pronation contractures of the forearm in
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cerebral palsy by changing the insertion of the
pronator radii teres. J Bone Joint Surg 1981;
63A(4):645–51.
[19] Green WT. Tendon transplantation of the flexor
carpi ulnaris for pronation-flexion deformity of the
wrist. Surg Gynecol Obstet 1942;75:337–42.
[20] Green WT, Banks HH. Flexor carpi ulnaris trans-
plant and its use in cerebral palsy. J Bone Joint Surg
1962;44A:1343–52.
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[21] Beach WR, Strecker WB, Coe J, Manske PR,
Schoenecker PL, Dailey L. Use of the Green transfer
in treatment of patients with spastic cerebral
palsy: 17-year experience. J Pediatr Orthop 1991;11:
731–6.
[22] Strecker WB, Emanuel JP, Dailey L, Manske PR.
Comparison of pronator tenotomy and pronator
rerouting in children with spastic cerebral palsy.
J Hand Surg 1988;13A(4):540–3.
 Hand Clin 19 (2003) 657–665

Surgical management of wrist and finger deformity

Ann E. Van Heest, MD
University of Minnesota, Department of Orthopedic Surgery, Hand Surgery Section,
Gillette Children’s Specialtycare, Shriner’s Hospital–Twin Cities Unit, 2450 Riverside Avenue South,
R200, Minneapolis, MN 55454, USA

The major goal in surgical reconstruction of problem of inadequate release is as much of a

the wrist and fingers is to restore muscle force
balance across the joints to improve function and
provide a less ‘‘palsied’’ appearance. Treatment
is aimed at altering the imbalance between the
spastic flexor-pronator muscle group and the
paretic extensor–supinator group. Additionally,
surgical treatment targets treating joint imbalance
to prevent fixed deformity.
The surgeon is required to assess carefully the
type of deformity and its treatment at each upper
extremity joint separately and then combine them
to organize a comprehensive surgical reconstruc-
tive plan. Adequate shoulder, elbow, and forearm
function is necessary for the patient to be able to
position the limb in space appropriately; adequate
wrist, finger, and thumb function is necessary for
appropriate grasp, pinch, and release. Because the
extrinsic finger muscles are biarticular (ie, they
cross the wrist and finger joints), the position of
the wrist significantly affects the position and
function of the finger extrinsic muscles. The wrist
and fingers thus commonly are assessed together.
Evaluation of wrist and finger deformity most
commonly has followed Zancolli’s classification
[1] as shown in Box 1.
A normal pattern of grasp and release is
necessary for hand function. When the wrist is
in substantial flexion, grasp strength is decreased
as the finger flexors become relatively shortened.
If the wrist is corrected to neutral, manually or in
a splint, finger flexion strength increases, but often
there is a loss of the ability to release. The
E-mail address: vanhe003@umn.edu
0749-0712/03/$ - see front matter Ó 2003 Elsevier Inc. All rights reserved.
doi:10.1016/S0749-0712(03)00076-3
functional concern as inadequate grasp strength.
Finger and wrist deformity must be addressed to
provide overall grasp and release function.
Wrist treatment options
The most common deformity of the wrist is
flexion, usually with ulnar deviation. This is
probably the most functionally disabling defor-
mity of the upper limb in cerebral palsy, as it
significantly interferes with grasp and release
function. The wrist flexion deformity is often the
most obvious physical manifestation of the pa-
tient’s cerebral palsy and correction of the ‘‘palsy’’
position helps with the patient’s self esteem.
Several different surgical options exist; the
choice depends on the degree of deformity and
the extent of volitional control of each muscle
involved. Application of the following surgical
principles is a necessary part of the art of designing
a successful reconstructive plan: release or length-
ening the deforming spastic muscles (flexor carpi
ulnaris [FCU], flexor carpi radialis [FCR]), transfer
of tendons to augment the weak antagonist muscles
(extensor carpi radialis longus/brevis [ECRL/B]),
and stabilization of the joint only for the severe,
fixed, nonfunctioning wrist (wrist fusion). Surgical
treatment options for correction of wrist and finger
deformities are outlined in Table 1.
Release/lengthening of spastic flexor muscles
If the wrist flexion deformity is mild and wrist
extensor control exists, weakening the wrist
flexors through surgical fractional lengthening
or with a series of botulinum injections [2] in
658 A.E. Van Heest / Hand Clin 19 (2003) 657–665

Box 1. Zancolli classification [1]

Group 1. Active finger extension with less than 20 of wrist flexion
Group 2. Active finger extension with more than 20 of wrist flexion
Group 2a. Active wrist extension with the fingers flexed
Group 2b. No active wrist extension with the fingers flexed
Group 3. Wrist and finger extension absent even with full wrist flexion

combination with serial casting, splinting, or
stretching may provide sufficiently increased wrist
flexor muscle lengthening to decrease overall wrist
flexion posturing. If the mild wrist flexion de-
formity exhibits concomitant wrist ulnar devia-
tion, the FCU only would be lengthened. If a more
severe wrist flexion deformity exhibits concomi-
tant finger flexion and pronator spasticity, the
entire flexor pronator mass can be lengthened
using a flexor pronator slide [3,4].
Tendon transfers to augment weak or absent
wrist extensors
If the wrist flexor deformity is more severe and
wrist extensors are not functional, tendon trans-
fer surgery to augment wrist extension may be
necessary. Muscles that can be transferred into
wrist extensors include the brachioradialis (BR),
the extensor carpi ulnaris (ECU), or the FCU.
Using the BR or the ECU as the donor tendon has
the advantage of leaving both flexor tendons
intact, thus avoiding overcorrection, but has the
disadvantage of not achieving balance unless the
wrist flexors are lengthened if their spasticity is
significant. Using the ECU tendon has the
advantage of correction of the ulnar deviation
deformity, although this may require FCU length-
ening concomitantly, but has the disadvantage of
not providing significantly more wrist extension
force than is already present. Using the FCU
tendon has the advantage of removing its force as
a spastic wrist flexor/ulnar deviator while trans-
ferring its forces into wrist extension, but has the
disadvantage of overcorrection if the deformity is
not severe or if the transfer is sutured too tightly,
particularly in the younger child. FCU to ECRB
tendon transfer is demonstrated in Fig. 1.
The FCU to radial wrist extensor tendon
transfer was first described by Green [5]. Many
studies have reported the functional improvement
seen by improved wrist function after the Green
tendon transfer [6–9]. Wolf et al [10] reported 16
children treated with FCU to ECRL tendon
transfer with an average follow-up of 4 years
(range, 1–9 years). Average final resting position
was 9 of extension with 14 of 16 patients reporting
improved function and 16 of 16 patients report-
ing improved cosmesis. El-Said [11] has described
the use of a selective release of the flexor origin
concomitantly with transfer of the FCU in 35
patients with an average follow-up of 4 years. The
appearance of the hand and forearm improved in
all patients; all gained improved mobility of the

Table 1
Surgical treatment options
Wrist flexion ulnar deviation Finger deformities
Tendon Flexor pronator slide Flexor pronator slide
Release/Lengthenings FCR lengthening FDS lengthening
FCU lengthening FDP lengthening
Tendon transfers FCU to ECRB Superficialis to profundus transfer
FCU to EDC Lateral band rerouting (swan neck)
BR to ECRB
ECU to ECRB
Joint stabilization Wrist fusion PIP fusion
Proximal row carpectomy DIP fusion
BR, brachioradialis; DIP, distal interphalangeal joint; ECRB, extensor carpi radialis brevis; ECU, extensor carpi
ulnaris; FCR, flexor carpi radialis; FCU, flexor carpi ulnaris; PIP, proximal interphalangeal joint.
From Zancolli EA. Structural and dynamic bases of hand surgery. 2nd edition. Philadelphia: JB Lippincott; 1979;
with permission.
 A.E. Van Heest / Hand Clin 19 (2003) 657–665
forearm, wrist, and hand. Long-term follow-up of
25 patients [7] treated at a mean age of 8 years with
a mean follow-up of 8 years, 7 months reported
a final arc of motion of 44 of wrist extension and
19 of wrist flexion. Two patients required revision
for overcorrection into a wrist extension/supina-
tion deformity. They recommended FCU to radial
wrist extensor tendon transfer for patients who
lack active wrist extension but who have good
digital extension with the wrist passively extended
above neutral.
Newer concepts in determining optimal intra-
operative tension have been described recently.
Lieber et al [12] reported the use of intraopera-
tive sarcomere length measurements and its rela-
tionship to tensioning of tendons during tendon
transfer surgery. Because it is not possible to
predict the relationship between passive tension
and muscle length, these investigators have advo-
cated the experimental use of an intraoperative
device that allows measurement of sarcomere
length as a basis for tensioning tendon transfers.
Although this new measurement modality has been
shown to be significant in an experimental model
[13–16], it has not been tested specifically in the
clinical setting. Whether transfers set at optimal
sarcomere length are associated with improved
functional outcomes remains to be studied.
Another concern regarding the FCU transfer
into the ECRB/L is the optimal vector for
placement (ie, the extent to which the FCU origin
should be released and the angle at which the
tendon is inset). In the original description, Green
[5] recommended the FCU transfer be into the
‘‘tendon of the ECRB to give more central action
in dorsiflexion, whereas the tendon of the ECRL,
which is more radial in position, gives a better
direction of pull for supinator action and gives
better correction of the ulnar deviation.’’ Cada-
veric studies subsequently have shown that in-
sertion into the ECRB versus the ECRL did not
change the supination effect of the transfer sig-
nificantly. Rather, freeing the muscle up to the
proximal one third of the forearm gave it a less
acute angle of insertion and increased its supina-
tion effect [17]. The FCR should not be used as
a transfer for wrist extension, as it would provide
a secondary pronation vector that would exacer-
bate the patient’s pronation deformity.
In all cases of transfer into the wrist extensors,
the finger function must be assessed preopera-
tively with the wrist in neutral, the desired
postoperative position. If the finger flexors are
too tight when the wrist is brought into neutral,
659
a finger flexor lengthening will be necessary as
part of the procedure. This is a common combi-
nation of procedures for many surgeons [18,19]. If
the patient does not have finger extensor control
to allow for release of grasped objects, a transfer
into the finger extensors (EDC) may be indicated.
Other series have found that transfer of the FCU
into the EDC is rarely necessary [8,20], as bal-
ancing the wrist may be the key component to
unmasking finger function.
Wrist stabilization
If the patient has a severe wrist joint contracture
limiting functional use of the hand (even as a
paperweight), consideration should be given to
a proximal row carpectomy (PRC) to shorten the
skeleton or a wrist fusion to hold the wrist in a fixed,
more functional position. The PRC is used in
combination with tendon transfers and releases in
patients in which passive extension of the wrist does
not reach the neutral position. Passive mobility
of the wrist is a necessary prerequisite to tendon
transfer surgery, which aims to improve active
mobility. Tonkin and Gschwind describe treatment
of 34 patients with wrist and finger flexion de-
formities; four patients were treated with a combi-
nation of PRC, FCR, or FCU to ECRB, flexor
aponeurotic release, and thumb and pronation
procedures. The postoperative extension was 8
and all regained some ability to extend the fingers.
Wrist fusion predictably maintains the wrist in
a fixed position and usually is indicated for
improved cosmesis and use of the hand as a
paperweight in the skeletally mature individual
[21]. The proximal carpal row can be removed as
part of the wrist fusion to facilitate positioning of
the wrist into slight extension [22], as shown in Fig.
2. Hargreaves et al [23] reported 11 wrist fusions in
10 patients treated at an average age of 18.8 years
(range, 13–35). Concomitant PRC was performed
in eight wrists and soft tissue releases in three.
Improved function from preoperative ‘‘none’’ or
‘‘assist’’ levels was improved postoperatively to
‘‘assist’’ to ‘‘simple’’ function. Fusion was achieved
in all cases, using plate fixation in nine patients and
crossed K-wires (because of open physes) in two
patients. Wrist fusion is contraindicated in the
individual who uses wrist flexion tenodesis for
release function, as this function would be lost if
the wrist were to be fixed in a single position. It
may be particularly beneficial when an athetoid
component dominates.
660 A.E. Van Heest / Hand Clin 19 (2003) 657–665
 A.E. Van Heest / Hand Clin 19 (2003) 657–665 661

Finger surgery extrinsic flexors may unmask intrinsic spasticity

that may need to be addressed secondarily.
The most common finger deformities are the
In addition to release of the spastic flexors of
spastic flexion deformity and the swan neck
the fingers, the question may arise as to whether
deformity. Spastic flexion deformities causing
tendon transfers may be necessary to augment
a clenched fist need to be addressed in conjunc-
finger extension. Smith [27] recommends tendon
tion with the wrist flexion deformity. The flexor
transfers for finger extension only after release
digitorum superficialis (FDS) and flexor digito-
procedures are completed to the wrist and fingers.
rum profundus (FDP) muscles are biarticular,
Often it may take 6 months or longer until the tone
crossing the wrist and finger joints. They thus
of the digital extensors returns after the persistent
need to be lengthened in concert with the wrist
stretch of the extensors has been released by
flexion deformity correction as part of a flexor
lengthening of the flexors. Hoffer et al [28]
pronator slide or with selective fascial length-
reported 38 patients treated with tendon transfers
enings. The flexor pronator slide was described
to improve extension of the wrist and fingers.
originally by Page [24] in 1923, reporting on six
Twenty patients were treated with transfer of the
patients of whom two had cerebral palsy. Several
FCU to the ECRB and 18 patients were treated
subsequent reports [3,4] discuss the role of the
with transfer of the FCU into the EDC. Of these
flexor pronator slide in decreasing spastic forces in
18 patients, 16 showed significant functional
the wrist and finger flexors simultaneously and
improvement. He recommended that the FCU be
how this may unmask wrist and finger extension.
transferred to the EDC in patients with the
For the more severe clenched fist deformity,
apparent inability to release their hands (ie, cannot
cosmesis and hygiene may be the greater concern.
extend their digits with their wrist extended).
Superficialis to profundus (STP) transfer is used
Other series have found that transfer of the
to treat severe spastic flexion contractures of
FCU into the EDC is rarely necessary [8,20], as
the hand. It is the treatment of choice in the
balancing the wrist may be the key component to
nonfunctional hand with a spastic clenched fist
unmasking finger function.
deformity. Palma et al [25] have performed more
After clenched fist deformity, the next most
than 75 STP transfers to relieve pain, improve
common deformity seen is the swan neck. The
hygiene, and ease daily activities for patients and
pathophysiology of this deformity in cerebral
caregivers and found the procedure to be effective,
palsy is the dynamic imbalance of the muscles
predictable, and safe. It was combined commonly
acting on the proximal interphalangeal (PIP)
with a wrist arthrodesis, carpal tunnel release, and
joint, causing PIP joint hyperextension with distal
ulnar motor neurectomy. Braun et al [26] reported
interphalangeal joint flexion (Fig. 3). In cerebral
that the STP operation ‘‘attained the limited goals
palsy, swan neck deformities are caused by
set for this initial group of patients with severe
intrinsic muscle spasticity, often augmented by
flexion problems, who had little hope for restored
overactivity of the extrinsic finger extensors.
function of individual flexor tendons. In twenty
Spasticity of the intrinsic muscles causes overpull
one patients, the resting position of the hand was
of the lateral bands, accentuating PIP joint
improved.’’ They warn that release of the spastic

b
Fig. 1. (A) Preoperative view of dynamic wrist flexion deformity resulting in a poor active assist hand with significant
disability for grasp and pinch functions. This 16-year-old girl had normal intelligence, moderate sensibility (10 of 12
objects stereognosis function), and high motivation. No active wrist extension was present preoperatively, with good
control of active finger extension. She showed good preoperative selective control of the FCU despite its spasticity. (B)
Through a longitudinal incision extending the distal two thirds of the forearm along the ulnar border, the FCU was
harvested from its insertion. (C) A curvilinear incision over the radial wrist extensors was used for weaving the FCU into
the ECRB just proximal to the extensor retinaculum. The same incision was used as part of the EPL rerouting. A
separate incision was used in the antecubital fossa for a biceps lengthening and brachialis fascial release. (D) The FCU is
harvested off its pisiform insertion and freed from its fascial attachments. (E) The FCU tendon is transferred dorsally,
removing it as a wrist flexor and providing its force as an active wrist extensor. The tendon is tensioned so that the wrist
lies antigravity at rest in a neutral position. (F) Following the procedure, active wrist extension was achieved for effective
grasp. Finger function was good for release. Good active assist function was achieved.
662 A.E. Van Heest / Hand Clin 19 (2003) 657–665

Fig. 2. (A) Preoperative radiographs of a fixed flexion wrist contracture in a skeletally mature 17-year-old boy. Note the
finger extension present preoperatively, indicating minimal finger flexor contractures. (B) Proximal row carpectomy
combined with wrist fusion by plating was used. Adequate finger excursion was present so that concomitant finger flexor
lengthening was not necessary in this case.

extension. With chronic intrinsic spasticity, over-
pull of the lateral band causes incompetence of the
transverse retinacular ligament, stretching of the
PIP joint volar plate, and resultant dorsal sub-
luxation of the lateral bands. Additionally, some
patients with cerebral palsy have better volitional
control of their extrinsic finger extensors than they
have of their wrist extensors. Patients thus at-
tempt to extend their wrists through activation
of their extrinsic finger extensors, causing meta-
carpophalangeal (MCP) joint extension and exac-
erbating PIP joint hyperextension (swan-necking).
Finally, excessive lengthening or surgical release
of the FDS, such as used in the STP transfer, often
unmasks intrinsic spasticity, resulting in significant
swan neck deformities, as the flexion forces on the
PIP joint are diminished iatrogenically.
The indication for surgical correction is lock-
ing swan neck deformities (usually greater than
40 ) that are not responsive to splinting and that
interfere with function.
For the patient with significant wrist flexion
deformities and only mild swan-necking, surgi-
cal correction of wrist position alone may be
 A.E. Van Heest / Hand Clin 19 (2003) 657–665 663

Fig. 3. (A) Pathophysiology of swan neck deformity in cerebral palsy. In cerebral palsy, the intrinsic muscles are spastic.
The extrinsic finger extensors are overactive in their attempt to augment wrist extension when a wrist flexion deformity
exists. Intrinsic spasticity combined with extrinsic overpull causes PIP joint hyperextension with resultant incompetency
of the transverse retinacular ligament and volar plate. PIP joint hyperextension concentrates the extension forces at the
PIP joint with slackening of the terminal tendon allowing DIP joint flexion. (B) This patient exhibits swan neck
deformities that lock in extension and inhibit his abilities to grasp his walker.

adequate for treatment. For the patient with
severe swan necking (>40 ), rebalancing of the
muscle forces at the PIP joint is necessary.
Surgical options include lateral band rerouting
[29,30], lateral band tenodesis [31], superficialis
tenodesis [32], spiral oblique ligament reconstruc-
tion [33], intrinsic muscle slide [34], or a resection
of the ulnar nerve motor branch in Guyon’s canal
[35]. The author’s preferred method is the lateral
band rerouting procedure shown in Fig. 4,
because it requires less extensive dissection and
rebalances the intrinsic and extrinsic tendon
deforming forces.
Summary
The surgical results of upper extremity in-
tervention have been shown to improve hand
function from paperweight/passive assist function
to active assist function [20]. Although children
with cerebral palsy commonly have a sensibility
deficiency in conjunction with their motor de-
ficiency [36,37], several recent studies have dis-
proved the previous doctrine that hand surgery
should not be performed on children with
sensibility deficiencies. The author’s report [20]
of 134 children treated surgically showed that
preoperatively 50% had impaired two-point discri-
mination and 75% had impaired stereognosis;
impaired sensibility had no adverse effect on
surgical results. Eliasson et al [18] reported on 32
children treated surgically with tendon transfers
and muscle releases. Impaired sensibility before
the surgery did not influence the outcome. In fact,
Dahlin et al [38] reported 36 patients treated
operatively and followed for 18 months, finding
an improvement in stereognosis function associ-
ated with the improvement in their motor
function, presumably because of improved func-
tional use.
Children with cerebral palsy can improve their
motor function and perhaps also their sensibility
function with appropriately planned and executed
664 A.E. Van Heest / Hand Clin 19 (2003) 657–665

Fig. 4. (A) The extensor mechanism is incised longitudinally in the interval between the central slip and the lateral band
to allow the volar mobilization of the lateral band to the level of the volar plate. The A3 pulley is opened and sutured
closely around the lateral band, anchoring the lateral band volar to the axis of the PIP joint. The rerouting is tensioned
so that the PIP has light resistance to extension past 30 of flexion and does not extend past 5 of flexion. (B) Following
lateral band rerouting, this patient can actively extend his fingers without locking and can grasp his walker effectively.

tendon release and transfer surgery. Balance of
the wrist and fingers is the key element in im-
provement of upper limb function.
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 Hand Clin 19 (2003) 667–677

Surgical management of the thumb in cerebral palsy

Richard D. Lawson, MB, BS, FRACSa,1,
Michael A. Tonkin, MD, FRACSa,b,*
a
Department of Hand and Peripheral Nerve Surgery, Royal North Shore Hospital,
St. Leonards, NSW 2065, Australia
b
University of Sydney, Department of Surgery, Blackburn Building D06, St. Leonards,
NSW 2006, Australia

Deformity develops in cerebral palsy (CP) as
a result of muscle imbalance. The posture of the
thumb is determined by the balance of spasticity
and weakness in the intrinsic and extrinsic muscles
of the thumb, and the stability of the carpo-
metacarpal, metacarpophalangeal (MCP), and
interphalangeal (IP) joints. The typical thumb
deformities in CP are adduction contracture and
adduction–flexion contracture (thumb-in-palm
deformity).
Thumb-in-palm deformity impairs grip and
appearance and in severe cases may affect hygiene.
Not only does the position of the thumb make it
difficult to place objects in the palm, it may excite
continued flexion of the fingers, compounding
the usual finger flexion deformity [1]. The lack
of thumb extension limits hand span and hence
the size of objects that can be grasped [2]. The ap-
pearance of the thumb is of importance to many
patients, with approximately 50% of patients
seeking cosmetic improvement [3].
Natural history
Infants with thumb-in-palm deformity may
have a spontaneous resolution during the first
year. If the deformity persists after the age of 1
year it is unlikely to resolve. The initial deformity
is dynamic, but with time the affected muscles
1 2.
Present address: Discipline of Pediatrics and Child
Health, University of Sydney, New South Wales, NSW
2145, Australia.
* Corresponding author.
E-mail address: mtonkin@surgery.usyd.edu.au
(M.A. Tonkin).
0749-0712/03/$ - see front matter Ó 2003 Elsevier Inc. All rights reserved.
doi:10.1016/S0749-0712(03)00042-8
may undergo fibrosis and develop a fixed de-
formity; this is termed a myostatic contracture.
The skeleton fails to develop fully and the affected
thumb is typically 1.4–1.7 cm shorter than the
contralateral normal thumb [4].
Keats stated that only 5% of the patients he
examined would be helped by surgery [1].
Swanson later estimated that approximately
10%–20% of patients with upper limb involve-
ment in CP might benefit from surgery [3]. Careful
selection is necessary to identify this group.
Assessment
The examination of a child with CP is difficult
and requires patience and repeated assessments.
Because stress or excitement may increase spas-
ticity, the surgeon must win the child’s trust by
providing a nonthreatening environment and
enlisting the aid of other professionals. A skilled
occupational therapist may be able to demon-
strate actions and abilities that had been masked.
Videotaping of the child engaged in play activities
is useful in assessing the child’s abilities. The
parents’ input is vital.
The specific areas that need to be considered
include:
1. Etiology and pattern of CP
Manifestations in upper limb
3. Specific patterns of involvement in thumb
4. Voluntary movement
5. Sensory deficit
6. Intelligence
7. Parental comprehension and expectations
668 R.D. Lawson, M.A. Tonkin / Hand Clin 19 (2003) 667–677
The diagnosis of CP should be confirmed,
reassuring the clinician that the neurologic deficit
is static.
The pattern of CP must be established. CP of
the spastic variety can be treated with good
results, but the athetoid variety should be
approached with great caution. Although release
of contractures and stabilization of joints may be
indicated for reasons of hygiene [5], tendon
transfers have unpredictable results in athetoid
CP and should be avoided.
The thumb-in-palm deformity usually occurs
in conjunction with other upper limb deformities,
and the treatment of the thumb should be part of
a coordinated strategy to improve the function
of the limb. A plan must be developed to address
the forearm pronation, wrist flexion, and finger
flexion deformities that often accompany thumb-
in-palm. Shoulder and elbow dysfunction also
may need consideration.
To formulate a logical treatment plan it is
necessary to establish the muscles involved in the
deformity and the motion and stability of the
thumb joints. Assessment of individual muscle
function usually is achieved through observation
and palpation of the contracting muscle bellies,
but electrophysiologic testing and selective nerve
blocks may have a role. It is also necessary to
establish which muscles are available as motors if
tendon transfers are contemplated. In thumb-in-
palm deformity, the potential motors may include
brachioradialis (BR), flexor carpi radialis (FCR),
flexor carpi ulnaris, palmaris longus (PL), and the
superficial finger flexors [5]. Wrist flexors often are
unavailable, however, following rebalancing of
wrist and finger deformities.
The adductor pollicis (AP) is involved in most
cases of thumb deformity. The flexor pollicis
brevis (FPB) muscle is not always spastic and the
position of the thumb differs with involvement of
FPB. If involved, the resultant MCP joint flexion
causes the thumb to lie across the palm with its tip
close to the base of the little finger; if not, the AP
causes the first web space to be tightly closed with
the thumb and second metacarpal closely approx-
imated [6]. The abductor pollicis brevis usually is
not involved in spastic cerebral palsy but may be
affected in athetoid CP [7].
The flexor pollicis longus (FPL) muscle is
involved variably. The thumb extensors typically
are weakened and the tendons may be stretched.
The long thumb abductor (APL) is affected
similarly.
If the examiner is unsure about the function of
the extensor and abductor muscles after a period
of observation, a median nerve block at the elbow
may unmask extensor function [8].
The motion and stability of the thumb joints
can be assessed by documenting the passive range
of motion, the position of each joint during active
fist formation and active radial abduction with
simultaneous finger extension.
House [5] and other authorities place great
emphasis on the need to establish the muscle
groups under voluntary control, considering this
the most important determinant of success. The
child should be watched while performing a vari-
ety of tasks. The ability to open the hand can be
assessed formally by measuring with disks of
various sizes from 6–18 cm, and the ability to
grasp can be documented by observing the child
grasp balls of varying sizes. The varying types of
pinch should be assessed also [9].
Sensory deficit is common, particularly pro-
prioception, stereognosis, and vibration. Most
believe function and surgical results are superior
if good sensory function is present. Normal vision
may compensate for sensory deficits, however [5].
Rayan [10] found that sensory deficiencies did not
affect the results of his surgery.
Some investigators believe that an intelligence
quotient of greater than 70 is desirable if surgery
is contemplated [9]. Manske [11] and others, how-
ever, have treated the deformity successfully with-
out reference to the child’s intellectual capacity.
The surgeon should ensure that the child and
the parents have an understanding of the likely
effects of treatment and that unrealistic goals are
not set. The child will not gain fine, coordinated
activity following surgery. [8]. Normal hand
function is not possible.
Classification
House published a classification of thumb-in-
palm deformity in 1981 [5].
Type I—simple metacarpal adduction contracture
Spasticity of the AP and first dorsal inteross-
eous causes adduction of the thumb metacarpal
and first web space contracture. The MCP and IP
joints are mobile.
Type II—metacarpal adduction contracture and
metacarpophalangeal flexion deformity
In addition to the contractures mentioned
previously, FPB spasticity leads to flexion de-
formity at the MCP joint. The IP joint is mobile.
 R.D. Lawson, M.A. Tonkin / Hand Clin 19 (2003) 667–677 669

Type III—metacarpal adduction contracture

combined with a metacarpophalangeal
hyperextension deformity or instability
The long and short thumb extensors act
across a mobile MCP joint to compensate for
the adduction deformity of the metacarpal, but
the result is hyperextension of the MCP joint. The
FPL is not spastic.
Type IV—metacarpal adduction contracture
combined with metacarpophalangeal and
interphalangeal flexion deformities
This deformity may arise from FPL spasticity
alone or in concert with spasticity of the thumb
intrinsics.
Type I deformity was the most common in
House’s series, and type IV deformity was most
severe
The senior author has proposed a modification
of this classification [12]. The patient is instructed to
make a fist while attempting to maintain the thumb
in a lateral pinch position. Observation then
permits assignment of the patient into one of three
groups:
Type 1—intrinsic deformity
The spastic intrinsic muscles (AP, FPB, and
the first dorsal interosseous) cause adduction of Fig. 1. Type 1: intrinsic deformity. (From Tonkin MA,
the thumb metacarpal, flexion of the MCP joint, et al. Surgery for cerebral palsy. Part 3: classification and
and extension of the IP joint. The APL and short operative procedures for thumb deformity. J Hand Surg
and long thumb extensors are paretic (Fig. 1). 2001;26B(5):465–70; with permission.)

Type 2—extrinsic deformity

The dominant deforming force is the FPL,
opposing a weak extensor pollicis longus (EPL).
Metacarpal adduction is less marked. This pattern
of deformity is uncommon (Fig. 2).
Type 3—combined deformity
There is spasticity of the intrinsic muscles and
the flexor pollicis longus, with weakness of the op-
posing muscles. The result is adduction of the
thumb metacarpal and flexion of the thumb MCP
and IP joints, with a thumb-in-palm posture (Fig. 3).
Nonoperative treatment
Nonsurgical treatment may achieve limited
results. A rigid orthosis may maintain the thumb
out of the palm but at the expense of thumb
mobility. Softer splints can be used in mild
deformities and can assist in maintaining thumb
abduction while permitting some movement [12].
Injection of botulinum toxin into the adductor
may aid in assessment and management.
Surgical treatment
Principles of treatment
The key concept in the surgical treatment of
thumb-in-palm deformity is to rebalance the forces
acting across the thumb joints by decreasing de-
forming forces and augmenting opposing muscles.
Unstable joints may need stabilization or arthrod-
esis. All elements of the thumb-in-palm deformity
should be addressed in the same sitting, as serial
interventions have a higher risk for failure or
recurrence of the deformity [8].
Neurectomy (for example, of the deep motor
branch of the ulnar nerve) is not recommended;
it is preferable to weaken a muscle rather than
defunction it totally [3], because this decreases the
possibility of overcorrection. Release of a spastic
muscle dampens the overactive stretch reflex
and decreases spasticity, while preserving some
function.
670 R.D. Lawson, M.A. Tonkin / Hand Clin 19 (2003) 667–677
Fig. 2. Type 2: extrinsic deformity. (From Tonkin MA,
et al. Surgery for cerebral palsy. Part 3: classification and
operative procedures for thumb deformity. J Hand Surg
2001;26B(5):465–70; with permission.)
The opposing muscles may be assisted by
a combination of tenodeses, tendon rerouting
and tendon transfers. Although not ideal for
tendon transfers, spastic muscles can be trans-
ferred and can maintain adequate function [5].
Pulp pinch is rarely achievable if not present
preoperatively [3]. The objective should be to
obtain lateral or key pinch grip between the
middle phalanx of the index finger and the thumb
during grasping activities and thumb abduction
and extension during release.
Additional goals are to improve the patient’s
psychologic well being [9] and to improve the
appearance of the hand.
Timing and staging of treatment
The pattern of deformity is usually apparent
by age 3 years. The optimal time for surgery may
be at approximately age 5 or 6 years, when the
child is old enough to comply with postoperative
therapy. Zancolli [9] believed that adults with
a deformity dating from infancy usually had
accepted the deformity and were not good surgical
candidates. Others believe the deformity can be
corrected at any age [8]. Manske [11] noted, in
a series of patients ranging from ages 5–17 years,
that the age of the patient at the time of surgery
was not related to the result.
It is usually appropriate to start proximally in
the plegic upper limb and work distally [12].
Shoulder and elbow function must be adequate to
position the hand in space [5]. If surgery to the
shoulder or elbow joints is proposed, this should
be performed before surgery on the thumb.
Although Zancolli [7] and other authorities
believe that the elbow, forearm, and hand should
be addressed in the same sitting, it is difficult to
position the limb correctly postoperatively if the
thumb and hand are treated concurrently; fur-
thermore, the position of the wrist and its motors
influence the thumb position and any proposed
transfers. The senior author therefore prefers to
operate on the thumb 6–12 months after correc-
tion of wrist deformity [12].
House addressed the thumb-in-palm deformity
using three steps [5]:
Step I—Release of contractures
Step II—Augmentation of weak muscles
Step III—Joint stabilization
Step I—release of contractures
Matev [13] considered release of the thenar mus-
cles (intrinsic release) to be the most important
aspect of surgical treatment of thumb-in-palm
deformity. Extrinsic flexor (FPL) involvement
may require extrinsic release. The skin and dor-
sal fascia also may be contracted, necessitating
a four-flap or z-plasty of the first web space and
release of the dorsal fascia [5].
Intrinsic release
Release of the insertion of AP into the ulnar
sesamoid may unduly weaken thumb flexion at
the MCP joint and lead to a swan neck deformity
of the thumb. Matev advocated release of the
origin of AP (along with FPB and most of the
abductor pollicis brevis) by way of a curved
incision in the line of the thenar crease, extending
distally from the transverse carpal ligament. The
flexor tendons and neurovascular bundles are
retracted ulnarly, and the transverse head of AP
released from its origin along the length of the
third metacarpal, working from distal to proximal.
 R.D. Lawson, M.A. Tonkin / Hand Clin 19 (2003) 667–677
Fig. 3. Type 3: combined deformity. (From Tonkin MA, et al. Surgery for cerebral palsy. Part 3: classification and
operative procedures for thumb deformity. J Hand Surg 2001;26B(5):465–70; with permission.)
The muscle is displaced distally and radially. The
deep branch of the ulnar nerve and deep palmar
arch is seen in the depths of the wound and
protected. The thenar branch of the median nerve
is identified and preserved [13]. The oblique head
of AP, taking origin from the bases of the second
and third metacarpals and the capitate and
trapezoid, is released also. If a deforming force,
FPB may be released by way of the same thenar
crease incision, at its origin from the trapezium
and the transverse carpal ligament (Fig. 4).
House [5] prefers an intramuscular release of
the AP tendon through an incision in the first web
to avoid excessive weakening of the adductor, but
states that longstanding and severe contracture
may need release of the adductor origin as
described by Matev. This incision provides access
to the first dorsal interosseous and can be
combined with a four-flap Z-plasty.
Hoffer [14] performed electromyography of the
AP in a group of patients with contractures of the
first web space to determine if the adductor
muscle contraction was continuous or selective.
AP did not contract during grip release in patients
with selective firing. In this group of patients,
Hoffer performed only a partial release of the
muscle insertion, retaining the insertion of the
oblique head of AP. By performing a limited
release he was able to retain side pinch. He found
that patients with selective firing of AP were over
weakened by a complete adductor release from its
origin.
671
The first dorsal interosseous may be released at
its insertion or origin. Release from the first
metacarpal origin is the preferred procedure, as
release from the second metacarpal may lead to
intrinsic dysfunction of the index finger. Matev
[13] describes releasing the distal portion of the
muscle from the ulnar border of the first meta-
carpal using the thenar based incision for the
adductor release.
Extrinsic release
A spastic FPL tendon can be weakened by
a tendon slide at the musculotendinous junction.
A small incision is made in the distal volar
forearm and the tendon is released; the thumb
IP joint is hyperextended and the tendon should
be seen to slide 1 cm distally (Fig. 5). FPL
contracture may be managed by an intratendinous
Z-lengthening, with 0.5 mm of lengthening for
each degree of correction desired [4].
Step II—augmentation of weak muscles
The options for augmenting APL, EPL, and
extensor pollicis brevis (EPB) are many and need
to be directed toward the patient’s specific
problems. The main surgical procedures are
tenodeses, tendon rerouting to alter the direction
of action, and tendon transfers. If the EPL or EPB
tendon is strengthened, stability of the MCP joint
is essential to avoid the development of a swan
neck deformity.
672 R.D. Lawson, M.A. Tonkin / Hand Clin 19 (2003) 667–677
Fig. 4. Incision for release of adductor pollicis. (From
Tonkin MA, et al. Surgery for cerebral palsy. Part 3:
classification and operative procedures for thumb de-
formity. J Hand Surg 2001;26B(5):465–70; with permis-
sion.)
Fig. 5. Intramuscular slide of flexor pollicis longus (From Tonkin MA, et al. Surgery for cerebral palsy. Part 3:
classification and operative procedures for thumb deformity. J Hand Surg 2001;26B(5):465–70; with permission.)
Reeducation of transferred muscles may be
more unpredictable and difficult in patients with
cerebral palsy than those with peripheral nerve
lesions because of the underlying central de-
ficiency [11].
Abductor pollicis longus
The APL acts to abduct the thumb metacarpal.
An adduction posture can be treated by transfer
of BR, PL, or a tendon of flexor digitorum
superficialis [8]. APL usually has multiple slips.
During surgery these are pulled on in turn to
determine the slip that best draws the thumb out
of the palm (Fig. 6).
House advocated translocation of the APL
tendon palmar-ward through release of the first
dorsal compartment and strengthening of its
action by an end-to-side transfer of PL [5].
An alternative procedure is to divide the APL
tendon proximally. The distal end is directed
volarly and attached end-to-end with a suitable
motor (eg, PL) and the proximal end is attached
end-to-side under greater tension to EPB to
augment its action [5]. The biomechanics of such
a procedure may compromise EPB muscle con-
traction, however, simply replacing it with in-
adequate APL contractility.
If there is no satisfactory muscle for transfer,
another option is to produce a dynamic abductor
tenodesis effect. APL is divided, the distal end is
attached end-to-side to FCR and the proximal
 R.D. Lawson, M.A. Tonkin / Hand Clin 19 (2003) 667–677 673

Fig. 6. Intraoperative traction to determine which tendon best positions the thumb. (From Tonkin MA, et al. Surgery
for cerebral palsy. Part 3: classification and operative procedures for thumb deformity. J Hand Surg 2001;26B(5):465–70;
with permission.)

end is attached to EPB [5]. APL also can be

tenodesed around brachioradialis or the first
dorsal compartment [2], tenodesed to the distal
radius [9], or plicated to increase the tension in the
muscle.

Extensor pollicis brevis

If the MCP joint is not hyperextensible after
release of any contractures, then plication of the
EPB tendon may be helpful in drawing the prox-
imal phalanx away from the palm [4]. Transfer
to EPB may be considered if the tendon is of
satisfactory size and intraoperative traction re-
sults in improved thumb position. The EPB also
can be tenodesed to FCR [5].

Extensor pollicis longus

The normal passage of EPL around Lister’s
tubercle imparts an adduction moment. By
rerouting the tendon more radially this moment
can be reversed.
Manske [11] detailed treatment of a group of
patients with thumb-in-palm deformity with
voluntary action of EPL and no fixed flexion
Fig. 7. The Manske procedure (A) Release and mobi-
deformity of the IP joint. He divided EPL 10 mm
lization of EPL. (B) Rerouting of EPL through the first
distal to the MCP joint and rerouted the tendon dorsal compartment. (C) Reattachment of EPL through
radial to Lister’s tubercle, through the first dorsal dorsal MP joint capsule to the extensor mechanism.
extensor compartment (or around the tendons of (Adapted from Manske PR. Redirection of extensor
EPB and APL if the compartment was too tight pollicis longus in the treatment of spastic thumb-in-palm
to accept passage of the EPL tendon) and then deformity. J Hand Surg [Am] 1985;10A(4):553–60).
674 R.D. Lawson, M.A. Tonkin / Hand Clin 19 (2003) 667–677
through a tunnel in the MCP joint capsule. The
end of the tendon was then advanced 1 cm and
sutured under some tension back into the defect
in the extensor apparatus, with the thumb held
in abduction and extension (Fig. 7).
The EPL tendon may be divided proximal to
Lister’s tubercle and dissected free distally, then
passed through the first dorsal compartment and
the ends rejoined under tension, with the thumb in
extension and abduction to produce a result
analogous to Manske’s operation [10].
EPL may be reinforced by the transfer of BR or
a tendon of flexor digitorum superficialis [8], or PL.
A superficialis tendon can be detached at the wrist
and passed through the interosseous membrane to
insert into EPL, or passed radially and subcutane-
ously if EPL has been rerouted. Goldner felt that
FCR was too strong to use as a motor for EPL [8],
but Swanson states that it is used commonly [3].
Step III—joint stabilizations
The early procedures for thumb-in-palm de-
formity relied on arthrodeses of the carpometa-
carpal and MCP joints, but the improvement in
position was at the expense of thumb motion and
function [8]. Stabilization of the thumb joints now
is performed only if they remain unbalanced after
tendon release and transfers [5]. The MCP joint
most often needs attention.
Carpometacarpal joint
Intermetacarpal bone block once was used to
stabilize this joint, but this greatly limited thumb
movement and is now performed not. If meta-
carpal adduction cannot be controlled by other
methods, a carpometacarpal arthrodesis is pre-
ferred. This preserves some movement at the
scaphotrapezial joint.
Metacarpophalangeal joint
In the presence of thumb MCP joint hyperex-
tension, tendon transfers to augment thumb
extension lead to further metacarpal adduction
and MCP joint extension. Hyperextension of
more than 20 warrants treatment [7]. Excess
extension of the joint may be addressed by
capsulorrhaphy, sesamoid arthrodesis, or fusion
of the MCP joint. The first two procedures involve
proximal advancement of the palmar plate and
maintain some thumb flexion.
In capsulorrhaphy the proximal attachment
of the palmar plate is divided and a notch created
in the neck of the metacarpal to receive the
roughened surface of the palmar plate as it is
advanced. The plate is fixed by way of pull-out
sutures tied dorsally, and the joint is stabilized in
10 –15 of flexion with a temporary Kirschner
wire [3,15].
Alternatively, the sesamoid may be advanced
with the palmar plate. In Zancolli’s technique
of sesamoid arthrodesis, the MCP joint is ap-
proached using a curved dorsoradial incision
and the palmar plate is mobilized after division
of the accessory collateral ligament insertion. The
sesamoid is denuded of cartilage and fixed in a
defect created at the head–neck junction of the
metacarpal with the thumb in 30 of flexion. Two
intraosseous sutures are passed across the sesa-
moid and tied over the dorsal surface of the
metacarpal. The joint then is stabilized with
a Kirschner wire that is removed at 5 weeks
(Fig. 8A, B). In a series of 20 patients with MCP
joint hyperextension seen at an average of 32
months after surgery, the preoperative hyperex-
tension averaged 38 and the postoperative
hyperextension 3 , whereas postoperatively 45
of flexion were retained [16] (Fig. 8C).
Fusion is useful in recalcitrant thumb flexion
and hyperextension deformities [4]. The joint is
approached by way of a dorsoulnar incision and the
extensor apparatus incised. The joint is entered
after detachment of the ulnar collateral ligament
from the metacarpal head. The articular cartilage is
removed with a scalpel and the epiphysis of the
proximal phalanx is preserved. The MCP joint is
fused in a position of 10 of flexion, 10 of
abduction, and slight pronation [3]. The arthrod-
esis is stabilized by smooth crossed K-wires. If the
epiphyseal plate is not damaged, there is little
additional shortening of the thumb [4]. Before
fusion of a thumb joint, provisional fixation with
temporary K-wires can be useful to assess the
consequences of an irreversible procedure [12].
Interphalangeal joint
The interphalangeal joint generally does not
need stabilization, but this may be required in the
event of a FPL rupture post-lengthening [5] or in
the presence of a severe and intractable IP joint
flexion contracture. The technique for fusion of
the MCP joint is used.
Authors’ recommended procedures
Type 1 (intrinsic) deformity
Adductor/FPB release in the palm (younger
patients) or by way of a dorsal approach
 R.D. Lawson, M.A. Tonkin / Hand Clin 19 (2003) 667–677 675

Fig. 8. Sesamoid arthrodesis. (A) The palmar plate is mobilized by dividing the accessory collateral ligament at its
insertion into the palmar plate. The articular surface of the sesamoid is denuded of cartilage. A cortical defect is made at
the head–neck junction of the metacarpal. (B) Two straight needles loaded into a Kirschner wire driver are used to pass
a Prolene suture through the sesamoid-palmar plate complex and metacarpal neck to secure the sesamoid into the
cortical defect created. (C) The intraosseous suture is tied over the metacarpal under the extensor tendons as a permanent
suture. A Kirschner wire is placed across the MPJ to maintain the joint in approximately 30 flexion. The seam in the
collateral ligament is repaired and the proximal radial edge of the palmar plate is sutured to the metacarpal periosteum
and aponeurotic fibers of the abductor pollicis brevis. (From Tonkin MA, et al. Sesamoid arthrodesis for hyperextension
of the thumb metacarpophalangeal joint. J Hand Surg 1995;20A:334–8; with permission.)
676 R.D. Lawson, M.A. Tonkin / Hand Clin 19 (2003) 667–677
(older patients with established myostatic
contractures)
First dorsal interosseous release after adductor
release if required
Augmentation of thumb extension and abduc-
tion with EPL reroute to EPB in combina-
tion with BR-to-APL transfer
Stabilization of MCP joint by way of capsu-
lodesis if required; MCP joint fusion as
a salvage procedure
Type 2 deformity
FPL tendon slide
Other contractures are addressed as required
Type 3 deformity
Adductor release in palm
First dorsal interosseous release if required
FPL tendon slide
Augmentation of thumb extension and abduc-
tion with EPL reroute to EPB in combina-
tion with BR-to-APL transfer
Stabilization of MCP joint by way of capsu-
lodesis if required; MCP joint fusion as
a salvage procedure
IP joint fusion if recalcitrant flexion deformity
Postoperative care
Matev [13] considered that after a properly
conducted operation, the thumb would be drawn
out of the palm with the MCP and IP joints
slightly flexed. The thumb is maintained in full
radial abduction and 20 of palmar abduction for
5 weeks in a plaster cast. When positioning the
thumb, it is important to ensure that abduction of
the metacarpal is occurring, rather than hyperex-
tension of the MCP joint.
A removable splint is used thereafter while the
hand therapist works with the child to reeducate
any transfers and obtain active thumb abduction
and controlled lateral pinch.
Results
Results are difficult to describe and interpret
because the pathology and preoperative hand
function varies so widely. Furthermore, functional
and cosmetic improvement results from finger,
wrist, and more proximal limb surgery.
Swanson has proposed a simple classification
of results, used in the assessment of hand function
as a whole and easily applied [3]. House has
designed a more complex functional classification
system for assessment of surgical results [5].
In Matev’s series, 3 of 21 patients had un-
satisfactory results, 2 of whom had athetosis. Of
the remainder, 6 patients obtained good grip and
pinch and 12 had a thumb that did not interfere
with finger flexion and participated to some
degree in grasp [13].
In Tonkin’s 2001 series of 32 patients, the
procedures recommended previously were used.
The thumb was maintained out of the palm in 29
patients and lateral pinch was obtained in 26
patients. None was made worse by the surgery [2].
Improved position and function of the thumb
may lead to improved stereognosis, perhaps
because of cortical reorganization following mod-
ified afferent input [17].
Summary
Surgical treatment of the thumb in cerebral
palsy is complex and treatment must be directed
toward the specific deformities. Thumb-in-palm
deformity can be treated successfully in patients
with spastic CP, but caution is required in patients
with other varieties of CP. The main deforming
force is contracture and spasticity of the intrinsic
thumb muscles. Treatment involves release of the
deforming muscles and other soft tissue, augmen-
tation of opposing muscles, and stabilization of
appropriate joints.
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 Hand Clin 19 (2003) 679–686
Functional and cosmetic outcome of surgery for
cerebral palsy in the upper limb
Bruce R. Johnstone, MBBS, FRACSa,*,
Philip W.F. Richardson, MBBS, FRACSa,
Christopher J. Coombs, MBBS, FRACSa,
Josie A. Duncan, BAppSc, OTb
a
Department of Plastic and Maxillofacial Surgery, Royal Children’s Hospital, Parkville, Victoria 3052, Australia
b
Department of Occupational Therapy, Royal Children’s Hospital, Parkville, Victoria 3052, Australia
Cerebral palsy is a group of nonhereditary
neurologic disorders caused by prenatal, perina-
tal, or postnatal insults to the motor portion of
the central nervous system [1]. It is characterized
by paralysis, weakness, loss of coordination, and
defective motor control, and also can include
sensory loss, neglect, developmental delay, seiz-
ures, and learning disabilities [2].
Most patients have spastic cerebral palsy and
show increased tone, reduced voluntary control,
and hyperactive stretch reflexes; these patients
tend to benefit most from surgery as compared
with those with movement disorders such as
dystonia. Thorough assessment is critical [3,4]
and this should define the patient with potential
for worthwhile improvement. This is best done in
a multidisciplinary setting that includes plastic
surgeons, orthopedic surgeons, hand therapists,
and physiotherapists [5]. It is essential to establish
what the patient can and cannot do and what
specific problems they face, including dressing and
hygiene. Cognitive capacity, neglect, and sensation
of the limb also are noted, as these affect outcome.
Nonoperative management options include
casting, splinting, muscle stretching, muscle
training, reeducation and rehabilitation [5–7],
and botulinum toxin injections [8]. Principles of
surgical management include release, lengthening,
* Corresponding author. 7th Floor, 766 Elizabeth
Street, Melbourne, Victoria 3000, Australia.
E-mail address: bjkr@bigpond.com (B.R. Johnstone).
0749-0712/03/$ - see front matter Ó 2003 Elsevier Inc. All rights reserved.
doi:10.1016/S0749-0712(03)00031-3
or paralysis of deforming spastic muscles, tendon
transfers, and joint stabilizations [9]. The goals of
surgery are to improve cosmesis [4,6,7,10–12],
function [4,5,11,13], ease of dressing, and ability
to clean the limb [12], while minimizing surgery-
related scars. Completely normal hand function
cannot be achieved [14]. Disappointment with the
results of surgery usually is a result of unrealisti-
cally high expectations [7]. The highest levels of
postoperative satisfaction can be achieved by
preoperatively establishing appropriate expect-
ations in the minds of the caregivers and the
patient.
Planning surgical treatment is complex, as no
two patients are alike [3]. Many but not all children
with cerebral palsy are surgical candidates [5,9].
Those children most likely to benefit are motivated
[1,11], have sufficient IQ and emotional stability
[1,6,15], and do not have neglect [11]. Patients with
spastic cerebral palsy [7,15,16] and those with good
sensibility [1,7,15], voluntary control, and adequate
strength [7] tend to do better. Those with athetosis,
dystonia, and neglect [2,7,16] may benefit from
static procedures such as tenodeses, joint stabiliza-
tions, and arthrodeses.
The results of nonoperative treatment have been
acceptable in selected patients with specific indica-
tions [8,17,18]. The results of surgery are variable,
and Rosenbaum in 1990 [19] noted an absence of
validated measures of outcome. A 0–8 scale of
functional level was developed by House in 1981 [3].
Van Heest et al [11] reported an improvement in
function of 2.6 levels on average using this scale in
680 B.R. Johnstone et al / Hand Clin 19 (2003) 679–686

134 patients over 25 years, as assessed by clinicians.
They stressed the use of multiple simultaneous
procedures averaging 4 per operation. Better out-
comes were seen when original function was fair to
good. Sensibility did not seem to affect outcome.
House et al in 1981 [3] reported that the age of
surgery made little difference in outcome. Roth et al
[20] showed on average a functional improvement
of 1.8 on the modified House Scale [9], again, as
judged by clinicians. They also looked at parental
assessment and 65% believed there was definite
improvement and 35% some improvement. Fifteen
of 17 parents were satisfied, but this was not related
to functional levels after surgery or degree of
improvement. Mowery et al in 1985 [22] studied
12 patients and noted improved appearance of the
hand according to ‘‘several parents’’ and that
adolescents no longer kept their hand hidden.
Improved self care, grasp, and cosmesis were noted
by Eliasson et al in 1998 [10], who reviewed 32
children, and Dahlin et al 1998 [20] reported ex-
pectations fulfilled in 28 of 29 parents followed for
18 months. Tonkin et al 1992 [4] reported that 30 of
34 patients had an improvement in function or
cosmesis but these did not necessarily go together.
Samilson et al in 1964 [11] showed improved
function and cosmesis in 40 patients, whereas
Keenan et al in 1987 [12] showed improved func-
tion, cosmesis, and hygiene in 27 patients. These
results contrast with those of Phelps who, in 1957
[23], after operating on 242 patients, concluded
that tendon transfers usually failed.
There is, however, a paucity of knowledge on
the effects of surgery on patients’ function,
cosmesis, hygiene, and ability to dress, from
a patient/caregiver perspective. Information about
caregiver-based outcomes in these areas conveys
what can be realistically achieved and provides
realistic individual goals. Furthermore, there is
little in the literature regarding patient/caregiver
overall satisfaction.
The authors’ study consisted of two parts. First,
a retrospective review was conducted of all 68
patients operated on by the senior investigator
between April 1992 and April 2001 for upper limb
spasticity. Fifty-one patients had spastic hemi-
plegic cerebral palsy, 12 had spastic quadriplegic
cerebral palsy, and 5 had either strokes or head
injuries leading to spastic hemiplegia. A total of
52% of patients were female. Surgery was per-
formed on the right upper limb on 41 occasions, on
the left on 33 occasions, and on both on 5 occasions.
Data were collected on types and numbers of
procedures per operation, age at surgery, anesthetic
duration, and date of operation.
Second, a telephone interview was conducted
with the parents, caregivers, or patient, depending
on who was most appropriate. Outcomes of their
surgery were scored in function, cosmesis, ease of
dressing, and hygiene, relative to their preopera-
tive status. Overall satisfaction also was assessed.
These questionnaires were administered by a re-
search fellow not involved with their surgery. The
validated House scale [3,9,20] was used for
functional assessment (Table 1). New scales were
developed because of the paucity of validated
scales for cosmesis, dressing, and hygiene (Tables
2–4). Descriptions were selected based on the
language used by many of the patients and
caregivers to describe their problems before and
after surgery.
Surgery
A comprehensive preoperative surgical plan is
important and must aim to rebalance the upper
limb at all levels. This plan is based on a thorough
preoperative assessment by a hand surgeon and
hand therapist. A video of the patient allows
documentation of the preoperative status and
fine-tuning of the surgical plan.

Table 1
Function
Score Category
0 Does not use
1 Poor passive assist
2 Fair passive assist
3 Good passive assist
4 Poor active assist weakly
5 Fair active assist
6 Good active assist
7 Spontaneous use, partial
8 Spontaneous use, complete
Description
Does not use
Uses as stabilizing weight only
Can hold object held in hand but not grasp
Can hold object and stabilize it for use by other hand
Can actively grasp object and hold it
Can actively grasp object and stabilize it well
Can actively grasp object and manipulate it
Can perform bimanual activities and occasionally uses the hand spontaneously
Uses hand completely independently without reference to the other hand
 B.R. Johnstone et al / Hand Clin 19 (2003) 679–686 681

Table 2
Dressing
Score Category Description
0 Very difficult Completely dependent on caregivers; requires extensive modification to
clothing, tight muscles causing distress getting arms through
1 Difficult Can wear normal clothes but dependent on caregivers; some difficulty getting
arms through but no distress
2 Moderate assistance Completely dependent but not difficult
3 Minimal assistance Child does most of the dressing
4 Completely independent No help required if clothes are selected for them

More recently, the Melbourne assessment of
unilateral function in the upper limb in cerebral
palsy [24] has been used for planning and to
document function objectively as part of a pro-
spective study.
It is important to prevent fixed deformities of
the shoulder, elbow, forearm, and wrist, and the
authors do this with passive ranging, serial splints
and casts, and botulinum toxin. Obtaining a bal-
anced wrist, preferably with active extension, is an
essential foundation for improving thumb and
finger posture. The variety of procedures used on
the upper limb reflects the complex and unique
patient profiles. The preoperative plan sometimes
may include botulinum toxin injections or phenol
injections of motor nerves in combination with
surgery.
The treatment of fixed deformities is challeng-
ing and must address skin, musculotendinous and
aponeurotic structures, joint capsule, and bone.
The humerus or forearm bones may need osteot-
omies, whereas the wrist may require a proximal
row carpectomy. Tendon transfers to augment
wrist extension and radial deviation may be
limited in effect because of abnormal axes of
wrist motion. Rarely would the authors recom-
mend wrist fusion.
Operative technique
Access incisions are planned for all procedures
to minimize length but maximize the maneuvers
performed through them. Shoulder procedures are
performed before a pneumatic tourniquet is ap-
plied for elbow releases and more distal proce-
dures. These are completed in a swift and systematic
fashion. Meticulous skin closure with subcuticular
absorbable suture is completed to minimize post-
operative scarring. An epidural catheter is placed
in the brachial plexus for local anesthetic infusion
following any axillary surgery. Accurate and safe
immobilization is achieved with a padded plaster
of Paris splint in the appropriate position. A
plaster slab optimally immobilizing the thumb,
fingers, and wrist is allowed to set before an
above-elbow ‘‘sugar tong’’ cast is applied to hold
the forearm supinated with the elbow flexed to
90 . Patients who have had elbow flexor length-
ening and pronator releases are immobilized in
a compromised position of 45 of elbow flexion. A
body spica is not required for shoulder proce-
dures, as caregivers are instructed in frequent
passive shoulder abduction and external rotation.
Postoperatively, the plaster is maintained for 4
weeks and then replaced by a thermoplastic splint
that is removed initially only for daily baths but
progressively for longer periods until it is used as
a night splint only in the third postoperative
month. Early scar hypertrophy is treated with
silicon gel pads and pressure.
Results
Surgical data
The surgical details on 84 limbs in 68 patients
were analyzed. The average age at the time of
surgery was 15.6 years and ranged from 6–47

Table 3
Hygiene
Score Category
0 Impossible to clean
1 Severely difficult to clean
2 Moderately difficult
3 Minimal difficulty
4 No hygiene problems
Description
Can’t get into armpit/hand, unable to cut nails
Smelly, skin breakdown problems, extensive skin buildup
Occasionally smells, occasional skin breakdown and debris buildup
Rarely smells, no skin problems, rare debris buildup
No hygiene problems
682 B.R. Johnstone et al / Hand Clin 19 (2003) 679–686

Table 4
Cosmesis
Score Category
0 Severe deformity
1 Moderate deformity
2 Mild deformity
3 Minimal deformity
4 No deformity
Description
Contractures at rest, extremely embarrassing for patient/caregiver, very low self-esteem
Contractures obvious, embarrassing, low self-esteem
Contractures present, mildly embarrassing
No deformity at rest, if using hand, one can tell there’s a problem
No deformity at any time

years. Follow-up duration ranged from 6 months
to 8 years, 10 months, with an average of 3 years,
11 months. The mean number of operations
required per patient was 1.2. Ten patients had
more than one operation and no patients required
more than three operations. The average number
of procedures per operation was 4.5 and ranged
from 1–12, all of which were completed in a single
tourniquet run. Each operation had an anesthetic
time of 78 minutes on average, with a range of 10–
240 minutes. The most common procedures were
the pronator teres release and Green transfer. A
total of 374 procedures have been performed, with
22 involving the shoulder, 39 the elbow, 74 for
pronation, 93 to rebalance the wrist, 17 for the
finger flexors, 9 for the extensors, and 120 to
correct the thumb (Appendix).
Questionnaire results
Forty-eight patients or their caregivers (71%)
could be contacted for a telephone interview re-
garding outcome assessment. Forty-one (85.4%)
believed that the outcome was worthwhile, with
26 (54.2%) reporting a good or excellent result
(Table 5).
Statistical analysis
Results were analyzed using the nonparametric
sign test. There was a statistically significant
increase in functional status (P < 0.001), hygiene
(P < 0.001), ability to dress (P < 0.001), and
cosmesis (P < 0.001) (Fig. 1). Function improved
from a median of 2 to 4 using the 0–8 House scale.
Hygiene increased from a median of 2 to 3 on the
0–4 scale. The median score for ability to dress did
not change, but the mean increased from 2.54 to
3.08. Cosmesis was most dramatically improved
from a median of 1 to 3 on the 0–4 scale.
Using the Two-sample Wilcoxon rank-sum
(Mann-Whitney) test, the patients were subdi-
vided first into two groups according to age more
than or less than 14 years. There was no statistical
difference in change in function (P = 0.88),
dressing (P = 0.0517), hygiene (P = 0.12), cos-
mesis (P = 0.90), or level of satisfaction (P = 0.24)
between the two groups.
With respect to patients with hemiplegia versus
other types of cerebral palsy, improvement in
cosmesis was significantly more in the hemiplegic
group with a median change of 2.0 compared with
1.0 (P = 0.0014). There was no significant differ-
ence between the two groups with respect to
function (P = 0.58), hygiene (P = 0.38), dressing
(P = 0.48), and satisfaction (P = 0.31).
With respect to time since the last operation
(less than or greater than 3.5 years), there was no
difference between the groups with respect to
function (P = 0.090), hygiene (P = 0.17), cos-
mesis (P = 0.53), dressing (P = 0.98), and satisfac-
tion (P = 0.63).
Gender made no difference in outcome in
function (P = 0.66), hygiene (P = 0.20), cosmesis
(P = 0.71), dressing (P = 1.0), and satisfaction

Table 5
Overall satisfaction results in 48 patients
Score Category Description Number of patients
0 poor worse than preoperative 2 (4.2%)
1 marginal was not worth doing 5 (10.4%)
2 minor worthwhile gain little improvement, but worthwhile 15 (31.3%)
3 good results reached expectation 22 (45.8%)
4 excellent results better than expected 4 (8.3%)
 B.R. Johnstone et al / Hand Clin 19 (2003) 679–686 683

Fig. 1. Graphs showing pre- versus postoperative scores of function, cosmesis, ability to dress, and ease of cleaning.
These box plots display the non-normality of the distribution of the variables. The change in the median and the range of
distribution are displayed. The median (50th percentile) is marked with a solid line. The boxes represent the 25th to 75th
percentile range and the T shaped ‘‘whiskers’’ extend to the closest data point within 1½ times the interquartile range.
The o indicates an extreme value. The median score for dressing did not change but the mean increased from 2.54 to 3.08.

(P = 0.51). It was not possible statistically to
compare changes between patients with lower
levels of function with those with higher levels
because of regression toward the mean.
Discussion
Patients with cerebral palsy encounter problems
with upper limb function and cosmesis, and some
have problems getting dressed and cleaning the
axilla and hand [14]. Not all patients are surgical
candidates [15]. Complicating factors include re-
duced sensation in approximately 50% of patients
[25] hemineglect, reduced IQ [14], elements of
extrapyramidal movement disorder [15], and fixed
deformity.
In surgical candidates, other investigators have
shown improvements in function [9,11,12,15] and
cosmesis [11,12,21] as judged by health profes-
sionals.
Quantitative patient- or caregiver-based as-
sessment in the fives areas of function, dressing,
hygiene, cosmesis, and overall satisfaction has not
been published previously. The authors’ assess-
ment of function used the validated House scale
[9,17,22]. The authors’ scales for assessing other
areas have been based on the terminology used by
caregivers or patients in clinic before the start of
this study.
The important findings from this study were as
follows. First, the authors agree with Van Heest
and House [9] that a large number of procedures
684 B.R. Johnstone et al / Hand Clin 19 (2003) 679–686
are possible during one operation. This allows
fewer anesthesias and hospital visits. Second, the
authors have shown a significant improvement in
function, cosmesis, hygiene, and ease of dressing,
as assessed by caregivers after considerable
follow-up. Furthermore, the authors have shown
high overall satisfaction levels, with 41 of 48
(85.4%) patients followed reporting that surgery
was worthwhile. Hemiplegic patients tended to
show larger improvements in cosmesis compared
with quadriplegics. With time, patients remained
satisfied with the outcomes.
These results are clinically relevant. They allow
clinicians to counsel new patients and caregivers
about the potential long-term outcome in areas of
upper limb function, cosmesis, and ability to dress
and clean. Patients can be given more specific
goals of surgery, depending on their age and type
of limb involvement, what areas may be im-
proved, and by how much. Caregivers and pa-
tients can be reassured that most patients who
have had upper limb surgery for spasticity have
been glad they had it done.
Summary
Function, cosmesis, hygiene, and ability to
dress can be improved by appropriate surgery.
This frequently involves multiple simultaneous
procedures and addresses the muscles, their
tendons, and the joints they pass over. The
improvement in cosmesis is most profound in
hemiplegic patients. Overall, patients are satisfied
with the results of surgery.
Acknowledgments
The authors thank Professor John Carlin,
Director of the Clinical Epidemiology and Bio-
statistics Unit of the Murdoch Children’s Re-
search Institute, Melbourne, and Gabrielle Davie
for their statistical analysis.
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Appendix
Surgical procedures and numbers ECU stabilization 1
Dorsal capsule plication 1
Shoulder Radial styloidectomy 1
Pectoralis major release 7 ECRB tenodesis 1
Subscapularis release 6 ECRL tenodesis 1
Biceps short head release 4 ECRL to FCR transfer 1
Coracobrachialis release 4 ECRL to APL/EPL transfer 1
Pectoralis minor release 1 ECU to ECRL 1
FCU to ECRL transfer 1
Elbow
Biceps and brachialis lengthening 15 Finger flexors
Phenol musculocutaneous nerve 9 Lengthening 6
Brachioradialis release 8 STP (superficialis to profundus transfer) 6
Botulinum toxin (elbow flexors) 5 Botulinum toxin 3
Crush musculocutaneous nerve 1 Carpal tunnel release 1
Neurectomy musculocutaneous nerve 1 Median and ulnar neurectomy 1

Forearm Finger extensors

Pronator teres release 31 Side-to-side coaption 5
Bicipital aponeurosis release 19 FCU augmentation 2
Pronator teres reroute 16 BR augmentation 1
Interosseous membrane release 6 EDC tenolysis 1
Flexor origin release 1
Botulinum toxin pronator teres 1 Thumb
Adductor release 17
Wrist EPL reroute 13
Green transfer (FCU to ECRB) 48 APL tenodesis 11
FCR release 13 Sesamoid arthrodesis 10
Arthrodesis 7 PL/EPL augment 9
FCU release 4 FDI release 9
PL release 3 First web Z plasty 8
ECRL/B release/lengthen 2 FDS opponensplasty 7
Proximal row carpectomy 2 Manske EPL reroute 7
Volar capsule release 2 FPL lengthen 6
ECU release 1 Crush terminal ulnar nerve 6
BR to ECRL transfer 1 MPJ arthrodesis 5
Botulinum toxin wrist flexors 1 IPJ arthrodesis 2
686 B.R. Johnstone et al / Hand Clin 19 (2003) 679–686

EPL tenolysis 2 APB tenodesis 1

Botulinum toxin first web 2 Extensor tenolysis 1
APL to EPL transfer 1 EIP to EPL transfer 1
EPL plication 1
FDS to APL transfer 1 Total 374
 Hand Clin 19 (2003) 687–699

Brachial plexus dorsal rhizotomy in

hemiplegic cerebral palsy
Jayme Augusto Bertelli, MD, PhDa,b,c,*,
Marcos Flávio Ghizoni, MDa,b,d, Thatiana Rodrigues Frasson, PTb,
Karla Samara Fernandes Borges, PTb
a
University of the South of Santa Catarina, Unisul, Department of Biological and Health Science,
CCBS, Praca Getulio Vargas, 322, Florianópolis, SC 88020030, Brazil
b
Joana de Gusma~o Children’s Hospital
c
Governador Celso Ramos Hospital, Department of Orthopedic Surgery, Praca Getulio Vargas,
322 Florianópolis, SC 88020030, Brazil
d
Nossa Senhora da Conceiça~o Hospital, Department of Neurosurgery, Praca Getulio Vargas,
322, Florianópolis, SC 88020030, Brazil

Historical aspects and evolution of posterior abolition of the tonic reflexes of the neck. In this
rhizotomy for spasticity relief connection, Heimburger et al [6] operated on 15
patients and added partial section of C4 to the
Posterior rhizotomy for relief of spasticity first
procedure. Spasticity of the neck, spine, arms, and
was reported experimentally by Sherrington in
legs decreased in 13 of the 15 patients. The
1898 [1] and later in 1908 when Foerster [2]
improvement was not dramatic in any of them,
introduced it into clinical practice. Foerster
however. Fraioli et al [7] increased the extent of the
credited Monro with performing similar work as
rhizotomy, sectioning bilaterally from C1 to C6.
early as 1904. At that time, Foerster proposed for
Their patients presented with athetosis and dysto-
the treatment of upper limb spasticity dorsal
nia. Despite the achievement of useful results, the
rhizotomy of C4 to T2 preserving C6, or al-
authors call attention to the high rate of re-
ternatively partial dorsal rhizotomy of all these
spiratory complications caused by the large num-
roots. Foerster stated that the effect of posterior
ber of sectioned dorsal roots. The results for
rhizotomy was likely to be better in the lower limb
cervical rhizotomy were not entirely satisfactory.
than in the upper limb [3]. In the last decade,
Benedetti et al [8] therefore combined upper
major interest in this topic has emerged and
cervical dorsal rhizotomy and partial rhizotomies
posterior rhizotomy now is frequently used to
of C4 to C7 in a two-stage surgery, reporting a good
treat lower limb spasticity [4]. The literature has
result in one patient.
less to say about the treatment of upper limb
In 1976, Fasano et al [9] described a new
spasticity by cervical dorsal rhizotomy.
technique of posterior rhizotomy for treatment of
In 1970, Kottke [5] reported on six patients
spasticity in the lower limbs. They stimulated fasci-
whose spasticity diminished after bilateral C1–C3
cles of the posterior roots electrically and found
posterior rhizotomy. He attributed the result to
that some fascicles responded to stimulation with
tonic muscle contractions. They cut these fascicles,
* Corresponding author. Governador Celso Ramos
preserving those with a weaker reaction or with no
Hospital, Department of Orthopedic Surgery, Praça reaction. Laitinen et al [10] used a similar technique
Getulio Vargas, 322 Florianópolis, SC, 88020030, on one patient with spasticity of the arm, sectioning
Brazil. 60%–80% of C6–C8 dorsal rootlets. The patient
E-mail address: bertelli@matrix.com.br (J.A. Bertelli). showed a good reduction of spasticity. In this
0749-0712/03/$ - see front matter Ó 2003 Elsevier Inc. All rights reserved.
doi:10.1016/S0749-0712(03)00038-6
688 J.A. Bertelli et al / Hand Clin 19 (2003) 687–699
connection, Xu et al [11] operated on 12 patients,
dividing 30%–60% of the posterior rootlets. These
investigators claim a spasticity resolution of 95%.
Alternatively, Sindou et al [12] proposed a selec-
tive drezotomy for the treatment of spasticity. In
1986, this author (ie, Sindou) reported good results
from the procedure at the level of the brachial
plexus in 16 hemiplegic patients [13]. Barbaro [14],
however, suggested that this procedure to the spinal
cord should be used in painful conditions rather
than in spasticity, because rhizotomy alone is
a more straightforward and less risky technique.
Based on modern reconstructive approaches to
brachial plexus injuries and anatomic studies in
animals, the authors recently have performed
brachial plexus dorsal rhizotomies for the treat-
ment of upper limb dysfunction following CNS
injury. Sixty-one patients have been operated on
with encouraging results [15,16].
Pathophysiologic basis of brachial plexus dorsal
rhizotomy
Damage to the CNS produces abnormal upper
limb function secondary to spasticity, paresis,
general neurologic disorders, and disturbances
in hand sensibility. These abnormal signs evolve
into a clinical syndrome known as upper motor
neurone syndrome. The clinical features of move-
ment dysfunction in upper motor neurone syn-
drome are positive and negative. Negative features
correspond to loss of dexterity and weakness. Posi-
tive features consist of spasticity, which is related to
the tonic stretch reflex release and hyperreflexia and
clonus, which are based on the phasic stretch reflex
release. The release of cutaneous and nociceptive
reflexes, including the flexor withdrawal reflex and
extensor reflexes, are also positive signs. Hyperex-
citability of spinal reflex forms the basis of most of
the positive clinical signs, which have in common
excessive muscle activity [17]. All of these disin-
hibited spinal reflexes have an afferent pathway,
entering the spinal cord by way of the dorsal roots.
The law of Bell and Magendie states that ventral
spinal roots contain only efferent or motor fibers
and dorsal roots contain only afferent or sensory
fibers. The discovery of this separation of function
occurred in the early 1800s and is one of the
principles of modern neuroanatomy [18]. Recently,
afferents have been demonstrated in the ventral
roots [19]. The functional significance of these
afferents is not yet clear, but evidence suggests that
these fibers mediate radicular and leptomeningeal
mechanosensitivity [20]. The dorsal root is there-
fore the sole anatomic site at which muscle afferents
run separately from the motor efferents. Here, the
afferents can be divided surgically without section-
ing the efferents. Because regeneration of the dorsal
root fiber into the spinal cord is abortive, there is no
need to remove any portion of the roots. Indeed,
simple crushing is sufficient to promote a permanent
lesion (for review, see [21]).
Anatomic basis of brachial plexus
dorsal rhizotomy
Upper limb innervation arises from the bra-
chial plexus that is formed by the union of C4
to T2 ventral and dorsal roots. Nonetheless,
the main roots are C5 to C8. The proprioceptive
ganglionic neurones are situated at the same root
as the motor neurone pool in the spinal cord. The
exteroceptive ganglionic neurones present a more
even distribution along the roots. As a general
rule, a muscle is innervated by two roots, whereas
a dermatome receives contributions from three
roots [22]. Dorsal root section at two levels
therefore abolishes muscle afferent information
but preserves dermatome sensibility [15,16].
C5, C6, and C7 emerge from the intervertebral
foramen above the vertebrae of their same
number. C8 emerges from the intervertebral
foramen between C7 and T1. Hence, a three-level
hemilaminectomy from C5 to C7 allows exposure
of the C5 to C8 dorsal roots. The dorsal roots are
formed by closely compacted filaments called
rootlets. Between these rootlets, vessels are ob-
served easily, especially in the pediatric patient,
and should be preserved during surgery.
The brachial plexus is divided functionally into
three groups: C5 and C6 innervating shoulder and
elbow, C8 and T1 controlling hand function, and
C7 functionally innervating shoulder, elbow, wrist,
and hand. C7 traditionally has been related to the
radial nerve [23]. When C7 motor rootlets are
sectioned for transfer in brachial plexus repair,
however, the authors have observed in 80% of
patients a temporary decrease in grasping and
pinch strength [24]. This means that C7 plays a role
in extrinsic finger flexor muscle innervation. C7 is
also the root responsible for pronator teres and
flexor carpi radialis innervation [25]. On that
account, when the shoulder and elbow are spastic,
C5, C6, and C7 dorsal roots are divided. If the
spasticity in the wrist and hand is more pro-
nounced, C8 dorsal rhizotomy should be added. If
shoulder adductors are not involved but elbow,
wrist, and digital muscles are spastic, C6 to C8
 J.A. Bertelli et al / Hand Clin 19 (2003) 687–699
dorsal rhizotomy is performed. Any involvement
of finger flexors in the spastic disease calls for a C8
dorsal rhizotomy. When only the wrist and finger
flexors are spastic, C7 and C8 are divided. T1 is
never divided, because adding a fifth section to the
procedure might jeopardize hand sensibility. Spas-
ticity in hand intrinsic muscles, leading to intrinsic
plus deformity is, in the authors’ experience, an
exceptional situation. The authors have found it
only in poststroke patients and at no time in
patients with cerebral palsy. In this situation,
however, a T1 dorsal rhizotomy should be con-
sidered but C8 should be spared. In cerebral palsy,
when the thumb intrinsic muscles (C8 and T1
innervation) are involved, being a component of
the classic thumb-in-palm deformity, orthopedic
procedures are preferable to T1 section.
Patients
Only spastic patients capable of understanding
and following instructions, under the age of 20
years, were included in this study. Disturbances in
hand sensibility and mild athetosis did not preclude
surgery. To be candidates for dorsal rhizotomy,
patients had to have more than one muscle scoring
grade 3 (considerable increase in tone, passive
movement difficult) or higher on the Ashworth
scale [26]. For instance, in patients with only the
flexor carpi ulnaris quoted as 3, there is no indi-
cation for rhizotomy but rather a simple tenotomy.
Between 2000 and 2001, 20 patients underwent
surgery. Eleven were male and 9 were female, with
an average age of 12.3 years (range 4–20 years).
Sixteen patients suffered from congenital hemi-
plegia, two had traumatic brain injury, and two
were victims of stroke. The traumatic brain injury
and the stroke accidents occurred during the first
year of life. Athetosis was observed in five patients.
Patients were assessed before surgery and at 3 and
15 months after surgery. Assessment was perfor-
med by two independent examiners, blind to the
extent of the surgical procedure already performed
and to previous evaluation results. Means were
compared by the ANOVA I method. A difference
of 5% in level was considered significant. No
patient underwent any kind of physiotherapy
during the postoperative period.
Assessment
Range of active motion (RAM)
Initially, patients were asked to touch their
contralateral knee and then their nose, with the
689
eyes open and closed, to detect any disturbance in
coordination. They then were asked to raise their
arm, subsequently flexing and extending the
elbow, wrist, and fingers. Finally, they were asked
to pronate and supinate. Alternatively, they were
told to kiss the palmar and dorsal sides of their
hand. During this phase, goniometry was per-
formed. The patient was requested to walk and
the degree of elbow flexion was measured.
Patients were videotaped and the goniometry
was checked further in digital images.
Spasticity and athetosis evaluation
Patients were assessed sitting on a chair or,
depending on their age, sitting on their mothers’
knees. Muscle stretching was tested with variable
speeds (ie, from 30
–120
/s). This was important
because spasticity is velocity dependent. The
authors assessed the shoulder adductors, elbow
flexors and extensors, wrist flexors and extensors,
digit flexors and extensors, prono-supinators, and
the thumb adductor. Any fixed contracture was
noted, but also was confirmed in the operating
room under general anesthesia. Muscle stretch
response to a single, moderate brisk speed was
classified according to the Ashworth scale. Re-
cently, a modified Ashworth scale has been pro-
posed [27]. In this version, a score between grades
1 and 2 has been introduced. It is the authors’
opinion that this new score measures something
without clinical significance. Only patients with
Ashworth grade 3 or higher need treatment.
By definition, athetosis is the incapacity to
maintain finger position. Patients therefore were
asked to hold their digits extended and time was
measured. When the position was changed, timing
was interrupted.
Hand sensibility
Moving light touch and pinprick was assessed
initially in all the fingertips. Further quantification
then was obtained with Semmes-Weinstein mono-
filaments (Sorri, Bauru, SP) and with the moving
two-point discrimination test. These advanced
sensorial tests give comparable or even superior
results to the more tedious shape-recognition tests
in children with cerebral palsy [28].
Grasping strength
Grasping strength was measured with a vig-
orimeter [29]. The bulb was placed between the
thumb and fingers. In older children, grasping
strength was measured with the Jamar dynamom-
eter (Baseline) allowing thumb use, and pinch
690 J.A. Bertelli et al / Hand Clin 19 (2003) 687–699
strength (key pinch) was measured with a pinch-
ometer (Baseline). The best value of three
consecutive attempts was recorded.
Functional examination
In general, reports of the results of surgical
treatment of the upper limb in cerebral palsy focus
on hand position and overall motion. Eliasson
et al [30] have recently included functional studies
in their evaluation protocol.
Functional studies are related to the impact of
the cerebral palsy on a child’s health and well being
and also the use of the hand in programmed
activities, allowing evaluation of fine coordination
and dexterity. In the former situation, several tests
have been described [31]. From among these tests,
the authors have adopted the Pediatric Evaluation
and Disability Inventory (PEDI) [32], which con-
sists of 197 items indicating what children with
disabilities are capable of doing and 20 items to
assess the degree of caregiving assistance and
equipment modifications needed to accomplish
complex functional skills, such as eating and comm-
unity mobility. For the present study, only activities
related to the upper limbs, including self-care and
mobility, were assessed (maximal score = 67). The
PEDI was developed for children with disabilities
and its use is more likely to identify subtle differ-
ences in functional performance after treatment
[33]. Several tests have been proposed to evaluate
fine motor coordination of the upper limb [34]. The
Box and Block test [35] and the Jebsen-Taylor hand
function test [36] were selected because they are
easy to apply, are reliable, and have been validated
in the assessment of neurologically disabled
patients [37–39]. The Jebsen-Taylor hand function
test consists of seven activities that are timed:
writing, turning over 12  7-cm cards (simulating
page turning), picking up small common objects,
simulated feeding, stacking checkers (to assess fine
motor coordination), picking up large, light ob-
jects, and picking up large, heavy objects. Not all
patients are able to perform all these activities.
In the Box and Block test, patients are asked to
pick up a block and place it in an attached com-
partment. The number of blocks moved is counted
over a period of 15 seconds. Before assessment in
the Jebsen-Taylor and Box and Block tests,
children underwent two training trials.
Radiographic studies of the cervical spine
Radiographies of the cervical spine were ob-
tained in AP view, neutral, and flexion–extension
profiles. Radiographic studies were performed 1
week preoperatively and 3 and 15 months
postoperatively.
Surgical technique
After general anesthesia induction, the patient
was placed prone with the head in a Mayfield pin
head-holder. The spinous processes of C2 and C7
were marked and confirmed by fluoroscopy. A
midline incision was made across the cervical
region. A two- or three-level hemilaminectomy
was performed. The yellow ligament was divided
and the duramere was opened. The dorsal roots
were identified and sectioned; major vessels always
were preserved. The duramere was closed with
a watertight seal and the yellow ligament sutured.
The removed bone chips then were replaced. The
muscle and fascial layers were reapproximated and
the skin was closed (Fig. 1). No postoperative neck
immobilization was used.
Results
Brachial plexus dorsal rhizotomy significantly
relieves spasticity according to the Ashworth scale
(P < 0.05). Increase in the range of motion
(P < 0.05) was observed, including wrist extension
and supination. Marked improvement in hand
dexterity and in the speed of movements
(P < 0.05) was demonstrated. Grasping strength
was augmented in all the patients except two
whose preoperative performance was unchanged.
In these two patients, however, pinch strength
increased. Indeed, pinch strength increased in all
the patients (P < 0.05). Amelioration in daily
activities measured by the PEDI test was a con-
stant (P < 0.05; Table 1). All the patients and
parents were satisfied with surgery and certainly
would do it again. Several home activities became
possible after surgery, such as video game playing,
shaving of the contralateral axilla, deodorant
application, eating, drinking, turning the lights
on and off, and opening doors. Before surgery,
athletic patients were unable to keep their fingers
extended for more than 3 seconds. Fifteen months
after surgery (Figs. 2 and 3) they were able to
retain extension for more than 15 seconds
(maximal time counted).
Differences between data collected at 3 months
and at 15 months postoperatively consisted
mainly of improvement in dexterity and in
functional activities. Recurrence of spasticity was
not demonstrated. When standing or walking,
 J.A. Bertelli et al / Hand Clin 19 (2003) 687–699 691

Fig. 1. (A) Left C5–C7 hemilaminectomy. The duramere (D) has been opened exposing the dorsal roots (DR). The
dentate ligament (DT) separates the dorsal roots from the anterior roots. (B) C5–C8 dorsal roots have been divided.
Vessels alongside the dorsal roots have been preserved. (C) The duramere has been closed and the yellow ligament has
been sutured (arrow). (D) The removed bone chips have been replaced. (E) The surgical incision covered by an adhesive
dressing.

elbow flexion was abolished in all patients except
one. This patient was operated on again and the
biceps motor branch was sectioned. This surgery
was successful and active supination and elbow
flexion were preserved.
Contractures were documented in 10 patients
before surgery. The shoulder was never involved
and the elbow was involved in three patients. In
only one patient was an elbow contracture
important (90
of flexion). In the remaining
patients, the elbow flexion contracture was less
than 30
. The wrist and digital flexors were affected
more frequently. Ten patients are now candidates
for tendon lengthening or transfer (Table 2).
Surgical complications did not occur. None of
the patients lost any movement or ended up with
an ataxic limb. Sensibility was largely preserved,
even in a four-root section. Initially, several
patients complained about numbness, but this
gradually disappeared. Fifteen months after sur-
gery, numbness persisted in only three patients.
Deafferentation pain and complete hand anesthe-
sia were never observed. When two roots were
sectioned, preoperative sensibility was unchanged.
When three roots were sectioned, fine sensibility
(ie, two-point discrimination less than 5 mm) was
preserved. When four roots were sectioned,
sensibility perception decreased, but two-point
discrimination persisted in all patients except
one. In this patient, two-point discrimination was
no longer possible in digits III and IV. Three
patients had their sensibility improved after
surgery (Table 3). Preoperative sensibility deficit
did not influence functional results.
Table 1
692
Patient information and results of Ashworth, PEDI (Pediatric Evaluation and Disability Inventory), B-Block (Box and Block test), J-Taylor (Jebsen-Taylor hand function
test), grasp strength, pinch strength, and RAM (Range of Active Motion) assessments
Case Age Sex Side Rhizotomy Ashworth PEDI B-Block J-Taylor Grasp Pinch RAM
1 19 F R C5–7 SA 1/0, EF 4/2, EE 3/0, P 2/0, 63/75 4/6 102/14 9/20 5/13 Normal/normal
WF 4/0, DF 3/0, TA 2/0
2 12 M L C5–7 SA 3/0, EF 4/1, EE 4/1, P 5/2, 54/60 4/5 25/1a 10/16 3/5 SA 145/170, S 10/80, WE 30/70
WF 4/0, DF 3/0, TA 1/0
3 11 M R C5–8 SA 2/0, EF 3/0, P 5/2, WF 4/0, DF 4/0 56/67 6/8 20/11a 8/10 3/4 S 0/20
4 14 M R C5–7 EF 4/0, EE 4/0, P 5/1, WF 3/1 60/64 6/8 58/33 16/16 7/10 SA 130/170, EE 160/175,
S 80/140, WE 50/70
5 4 F L C6–8 EF 4/0, EE 2/0 P 3/0, WF 3/0, DF 2/0 54/67 4/6 99/15 100/140 — S 0/30, WE 0/30
6 9 F R C5–8 EF 4/1, P 4/1, WF 4/1, DF 4/1 53/66 3/6 33/14a 2/10 0.8/3 S 0/60, WE 0/40
7 5 F R C5–8 EF 3/2, EE 4/1, P 3/1, WF 3/1 52/67 3/5 31/13a 60/95 S 0/30, WE 0/10
8 10 M R C5–8 SA 2/0, EF 5/0, P 4/0, WF 4/0, DF 4/0 54/67 3/8 45//22 75/120 1.5/3.5 SA 120/170, EE 45/160, S 30/90,
WF 30/60, WE 10/45
9 15 M L C6–8 EF 3/1, EE 2/1, P 2/1, WF 5/2, DF 2/0 50/65 4/5 88/25 9/13 — EE 100/140
10 4 F L C5–8 SA 2/0, EF 4/0, P 4/1, WF 2/0 53/67 4/8 99/14a 65/120 0.8/2 SA 140/180, EE 110/150,
S 0/20, WE 0/40
11 20 M R C7–8 P 3/0, WF 3/0, DF 3/0 62/66 4/8 62/27 23/26 — S 20/130, WE 0/10
12 16 M R C5–8 SA 2/0, EF 4/2, P 4/2, WF 4/2, DF 4/2 54/57 3/4 88/65 11/13 — SA 60/120, EE 0/120, EF 0/120
13 6 F R C5–8 EF 3/0, P 3/0, WF 3/0, DF 3/0 53/62 4/6 87/26a 65/130 — S 0/80
14 16 M R C6–8 P 4/2, WF 4/2, DF 4/2 60/64 4/6 58/36 22/26 4/5 WE 0/30
15 16 F L C5–8 EE 4/0, EF 4/0, P 4/0, WF 4/0, DF 4/2 61/66 3/4 41/35 60/80 — EE 110/140, S 0/50, WE 0/70
16 20 F L C7–8 WE 4/0, DF 4/0 51/61 3/4 87/55 65/75 — S 0/65
17 14 M R C5–8 EF 3/0, EE 2/0, P 4/2, WF 4/2, DF 4/0 46/66 4/6 37/14b 1/11 2.2/4 SA 140/180, S 10/90, WE 0/20
18 8 M L C7–8 WF 4/2, DF 4/0 46/56 3/5 55/36 65/85 — WE 0/30
J.A. Bertelli et al / Hand Clin 19 (2003) 687–699

19 — — L C7–8 EF 4/0, P 4/2, WF 3/0, DF 3/2 62/66 4/6 45/26 120/160 — WE 0/20
20 20 M L C5–8 SA 2/2, EF 4/2, P 4/2, WF 2/2, DF 2/2 62/67 4/8 66/25 20/20 5/6 P 120/160
Ashworth, SA (shoulder adductors), EF (elbow flexors), EE (elbow extensors), P (pronators), WF (wrist flexors), DF (digital flexors). 0–5 are the degrees of spasticity
according to Ashworth scale.
B-Block, values refer to transposed blocks.
J-Taylor, values are expressed in seconds. a ¼ one, b ¼ two new tasks regained.
Grasp, values less than 30 are expressed in kilograms and were measured with the Jamar dynamometer. Values greater than 30 are expressed in mm Hg and were measured
with the vigorimeter. The patients were unable to press the Jamar dynamometer because of weak grasp.
Pinch, values in the pinch column are expressed in kilograms.
RAM, SA (shoulder abduction), EE (elbow extension), S (supination), P (pronation), WE (wrist flexion), WE (wrist extension). The values following characters are the
results of goniometry and are expressed in angular degrees (
).
Test results are presented as pre/post operative values, with postoperative evaluation made at 15 months.
 J.A. Bertelli et al / Hand Clin 19 (2003) 687–699 693

Fig. 2. (A) Preoperative view of the hand in case 6. When trying to grasp, the digits flexed before reaching. There is no
thumb extension. (B) Fifteen months after surgery. Full digital extension is observed. Contact with the object did not
induce uncontrolled digital flexion. (C) More appropriate grasping with the object placed in the palm of the hand.
694 J.A. Bertelli et al / Hand Clin 19 (2003) 687–699

Fig. 3. (A) Preoperative view of the hand in case 11. (B) Postoperative view.

Greater improvement in function with preserva- noted by a higher score obtained in the Box and
tion of sensibility and more natural use of the Block and Jebsen-Taylor tests, which reflects
operated hand was observed in patients younger progress in dexterity and speed of movements.
than 9 years of age. None of these patients Goniometric studies point to a significant gain in
presented with digital or wrist contractures. amplitudes, especially prono-supination and wrist
No abnormalities in the radiographic studies extension. Grasping and pinch strength were
were noted. augmented. Elbow flexion during walking was
abolished. There was a marked improvement in
Discussion the performance of daily activities, expressed in the
PEDI test results and parents’ opinions according
Brachial plexus dorsal rhizotomy largely re- to their answers in questionnaires. Changes were
duced spasticity in all of the authors’ patients. observed immediately after surgery, excluding
There was a significant improvement in function amelioration caused by CNS maturation. Func-
tional improvement, however, was greater in late
Table 2 controls. Contractures were noted only after 9
Contractures, athetosis, and possible candidates for years of age, mainly in the pronator and wrist and
orthopaedic surgery digital flexors. Athetosis improved in all cases.
Contractures The results observed here demonstrate that
Orthopedic
Case EF P W D Athetosis surgery
dorsal rhizotomy not only addresses positive signs
of upper motor neurone syndrome, but also
1 X negative signs such as muscle weakness.
2 X X
3 X X Age for surgery
4 X X X
5 Nelson and Ellemberg found that half the
6 X children with a diagnosis of cerebral palsy during
7 the first year of life lost the motor signs of upper
8 X X X motor neurone syndrome by the seventh year [40].
9 X X X Seven years or later therefore has been postulated
10 as the best age for surgical treatment [41]. The
11 X X X
diagnosis of cerebral palsy, however, should be
12 X X X X
confirmed by the second year of life [42]. It is
13 X
14 possible that several of Nelson and Ellemberg’s
15 X X X patients did not have cerebral palsy. Slight
16 X X resolution of spasticity is seen in patients of 2–4
17 X X X X years of age; however, by the age of 6–9 years,
18 X fixed contractures develop [43]. Spastic muscles do
19 X not grow normally and permanent muscle con-
20 X tractures, especially of the pronators and the wrist
EF, elbow flexion; P, pronation; W, wrist flexion; D, and finger flexors, are the result of the rapid
digital flexion; X = present. growth phases [44]. When established, these
 J.A. Bertelli et al / Hand Clin 19 (2003) 687–699 695

Table 3
Fingertip sensibility after brachial plexus dorsal rhizotomy
Monofilaments (gr) Moving 2-point (mm)
Case Pre Post Pre Post Numbness
1 0.05 0.05 3 4 II
2 0.05 0.05 3 3
3 0.05 0.05 4 5
4 0.05 0.05 3 I–IV(3), V(4)
5 2.00 0.2 N/A N/A
6 0.05 I–III(0.05), IV–V(2) 3 I–III(4), IV–(6)
7 N/A N/A N/A N/A
8 0.05 I–IV(0.05), V(0.2) 3 I–IV(3), Va
9 I, V(4), II–IVa I,V(4), II–IVa N/A N/A
10 N/A 0.20 N/A N/A
11 0.05 0.05 6 I(7), II–IV(6)
12 0.20 0.20 8 8
13 2.00 2.00 N/A N/A
14 0.05 0.05 3 I–IV(3), V(4)
15 I(4), II–V(2) 2.00 Ia, II–V(8) 8
16 0.05 0.05 3 3
17 I(0.2), II–V(2) I(0.05), II–V(0.2) 8 9 IV, V
18 2.00 2.00 N/A N/A
19 0.05 0.05 3 I–IV(3), V(4)
20 0.05 I,II,V(0.2), II–IV(2) 4 I(4), II, V(5), III–IVa II, IV
a
No sensorial discrimination; N/A, data not available.
All results are for digits I–V unless otherwise indicated; postoperative evaluation was performed at 15 months.

deformities need, besides dorsal rhizotomy, ten-
don lengthening. The latter procedure carries the
serious risk for causing weak grasp. Physiother-
apy has a questionable role in the prevention of
fixed contractures, because to be effective, muscle
stretching should be performed at least 8 hours
daily [45]. Splinting is controversial and in most
cases discourages the use of the hand [43]. Botulin
toxin might be helpful, but the benefits of
functional use do not outweigh the weakness in
grasping. The most notable change is the cosmetic
benefit of reduced involuntary elbow flexion.
Moreover, in some patients functional deteriora-
tion in the hand occurs [46]. An important finding
of the present study is that children of lesser age
present not only a more spontaneous use of the
hand but also a great functional improvement in
daily activities. Hence, based on the considerations
described and the present observations, it is the
authors’ opinion that hemiplegic children should
preferentially undergo brachial plexus dorsal
rhizotomy between the ages of 5 and 6 years.
Grasping strength
In hemiplegic children, there is no increase of
grasping strength with age [47]. The improvement
in grasping observed here therefore is related
strongly to surgery. Improvement in grasping
strength might result from better wrist position.
Improvement in grasping strength also was ob-
served in the patients with wrist contractures,
however, who did not regain dorsal wrist exten-
sion. Experimentally, it has been demonstrated
that dorsal rhizotomy elicits plasticity in descend-
ing neurochemical pathways. For instance, dorsal
rhizotomy augments descending serotonergic
pathways from the raphe nuclei to the spinal cord
[48]. Dorsal rhizotomy is associated with slight
enlargement of motor neurones and up-regulation
of BDNF and NT-3 in the ventral horn [49].
Plasticity induced by dorsal rhizotomy therefore
could have played a role in the clinical ameliora-
tion of the authors’ patients. Improvement in
strength could be related to resolution of co-
contractions. In a preliminary study, however, the
authors were unable to reliably confirm this
hypothesis (unpublished observations).
Preservation of hand sensibility
Complete hand anesthesia was not observed in
any of the authors’ patients. When two or three
roots were divided, sensibility recovered to nor-
mal. When four roots were sectioned, there was
preservation of sensibility on the radial side of
696 J.A. Bertelli et al / Hand Clin 19 (2003) 687–699
the hand, including sensibility to light touch. The
ulnar digits presented a variable diminution in
sensibility. Gains in motor performance and use of
the hand in daily activities largely outweighed the
sensorial downgrading in every patient. Sensory
preservation is explained by the overlapping of
cutaneous territory from the peripheral to the
central nervous system. The removal of sensory
input from the limb in adult and young animals by
dorsal rhizotomy or dorsal column or spinal nerve
sectioning results in a major expansion of neigh-
boring body-part representation into cortical areas
previously served by deafferentated limbs [50].
Cusick and colleagues [51] showed that a time
course of 1–3 days was sufficient for total re-
organization to occur, but stabilization was
achieved 8 months later. The rapid cortical
reorganization is probably caused by activation
of silent synapses (subthreshold input). For in-
stance, Li and Waters [52] have demonstrated that
the cortical region of digit III (D3) in the rat
receives suprathreshold input not only from D3
but also subthreshold inputs from the remaining
digits. This demonstration suggests that sub-
threshold input might play a role in rapid cortical
reorganization following the loss of afferent input,
whereby neurones in the deafferentated cortex
could become activated by inputs from neighbor-
ing digits. As quoted by Foerster [3], Clark,
Taylor, and Hildebrand have demonstrated that
the division of four or even five adjacent thoracic
roots produces no apparent disturbance of sensi-
bility. Burchiel [53] states that the overlapping of
sensory dermatomes is so extensive that to pro-
duce just a zone of hyperesthesia, three or more
continuous dorsal roots must be sacrificed. In
hand surgery, sensory preservation is a common
observation in tetraplegic patients [54]. In general,
the level of motor palsy does not correlate with the
level of sensory loss, which is preserved distally
[55]. Finally, the contribution of the afferents in
the ventral root to hand sensibility preservation
remains to be determined.
Motor control after dorsal rhizotomy
The effects of dorsal root section on limb control
have been extremely controversial [56]. None of the
authors’ patients presented limb ataxia after
surgery. In fact, motor control was largely im-
proved. Gandevia et al [57] studied hand intrinsic
muscle voluntary activation after complete deaf-
ferentation by anesthetic block of the ulnar nerve.
These investigators deduced that in the complete
absence of muscle feedback, subjects could volun-
tarily recruit motor neurones, grade their dis-
charge, and sustain a constant level of activity.
They found that inhibition of motor neurones
during contractile fatigue was impaired. The
afferents responsible for this monosynaptic reflex
inhibition enter the spinal cord through the ventral
and dorsal roots [58]. In the authors’ patients,
therefore, this mechanism likely was preserved,
because ventral roots were spared. Moreover, the
authors have demonstrated that muscles could be
functionally reinnervated exclusively by motor
axons. Even in the absence of any muscle feedback,
patients were able to learn new movements [24].
Transoperative rootlet electric stimulation for
dorsal rhizotomy
Fasano et al [9] proposed the idea that not all the
dorsal rootlets are ‘‘spastic’’ and that the affected
ones could be identified by electrophysiologic
monitoring. Based on this concept, lower limb
dorsal rhizotomy currently is performed after
electrical stimulation [59,60]. The electrophysio-
logic criteria for identifying abnormal rootlets,
however, have been modified frequently and the
skepticism about this time-intensive monitoring
technique has grown over the last decade [61].
Moreover, Sacco et al [62] have demonstrated
similar outcomes between patients undergoing
selective dorsal rhizotomy with electrophysiologic
monitoring and those undergoing a random section
of 60% of the dorsal rootlets. These investigators
suggest that selective dorsal rhizotomy based on
electrophysiologic parameters is rather nonselec-
tive. It is the authors’ opinion that all dorsal
rootlets related to a spastic muscle are affected
equally and should be sectioned. Partial dorsal
rhizotomy, as originally proposed by Foerster [2,3],
is not only a source of incomplete relief of spasticity
but also a source of recurrence. Electrophysiologic
monitoring is time-consuming and increases the
rate of anesthetic complications [63].
Spinal cord stability
In children, multiple level laminectomies may
cause kyphosis, anterior subluxation, and instabil-
ity of the cervical spine [64]. The deformity after
laminectomy is a consequence of the loss of the
posterior elements [65]. The incidence of spine
deformity following laminectomy is approximately
49% [66]. The incidence of deformity has been
decreased largely after the introduction of the
replacement laminoplasty technique [67]. In seven
 J.A. Bertelli et al / Hand Clin 19 (2003) 687–699
cases of extended replacement laminoplasty (5 to 7
levels) with an average follow-up of 42 months,
Bergoin et al [68] found no cases of kyphosis. In
fact, the complication noted in one case was
a hyperlordosis.
The spinal canal of the authors’ patients was
approached by a hemilaminectomy, the yellow
ligament was reconstructed, and the bone re-
placed. The authors’ strategy resulted in a high
conservation of the posterior elements, without
spinal cord deformities or instabilities. Longer
postoperative controls would be of interest and
fall within the authors’ plans for the future.
Orthopedic procedures
Several of the authors’ patients are now
candidates for orthopedic surgery, which in the
authors’ department is always performed after
dorsal rhizotomy. Tendon transfers are a routine
procedure to reanimate wrist and digital extension
[69]. Any spastic muscle transfer needs to be
considered carefully, however, because the risk for
deformity inversion exists [70]. Flexor tendon
lengthening is well indicated [69], but again the
possibility of provoking grasping weakness should
be taken into account [70]. It is the authors’ belief
that dorsal rhizotomy should be performed
preferentially before the establishment of muscle
contractures, in the hope of avoiding them.
Concomitant dorsal rhizotomy and orthopedic
surgery is not a practice the authors recommend.
Experimental data indicate that dorsal rhizotomy
induces motor plasticity and that limb casting,
which is used routinely after orthopedic surgery,
inhibits plasticity and thus restricts recovery [71].
Summary
Brachial plexus dorsal rhizotomy releases
spasticity, improving the functional use of the
hand. Grasping and pinch strength are augmented,
together with movement speed and dexterity. Even
when four dorsal roots have been sectioned, hand
sensibility is largely preserved. Movement control
is improved and equally advantageous in athetotic
patients. Brachial plexus dorsal rhizotomy does
not exclude the use of tendon lengthening or
transfer procedures, but it is the authors’ opinion
that orthopedic procedures should be performed
after dorsal rhizotomy. Children aged 5–6 years
without muscle contractures are the ideal candi-
dates to benefit fully from dorsal rhizotomy.
697
Acknowledgments
The authors would like to thank the medical
staff members of the Department of Anesthesiol-
ogy at Joana de Gusmão Children’s Hospital for
their enthusiasm and expert assistance in patient
care.
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 Hand Clin 19 (2003) 701–716

Cumulative Index 2003

Volume 19
February MUTILATING HAND INJURIES, pages 1–210
May THE MUSICIAN’S HAND, pages 211–360
August ADVANCES IN OBJECTIVE ASSESSMENT OF HAND FUNCTION AND
OUTCOME, pages 361–544
November THE UPPER LIMB IN CEREBRAL PALSY, pages 545–716
Note: Page numbers of article titles are in boldface type.

A industrial, syndrome of, 325

ABILHAND, 371, 374 of instrumental musician,
instrument for, 374–375 325–326, 328–329
calibration of, 375, 376 shoulder, and hand disabilities, questionnaire
procedures for, 375 of, 366
Algodystrophy. See also Reflex Arthritis Hand Function Test, 475
sympathetic dystrophy. Arthrodesis, scapho-trapezo-trapezoid, center of
causes of, 511 rotation location and,
detection of, at 1 week, 514 414–415
diagnosis of, 513–514 cineradiography for measurement of, 413,
finger stiffness in, measurement of, 414
511–515 electrogoniometric and radiologic
following Colles fracture, 512 evaluation of, 411–419
goniometry measurements in, 513, 514 electrogoniometry for measurement of,
Amputation(s), adaptation following, 185–186 412–414
biomechanical impact of, 19–24 patients for, 412
cause for, 185 pivot points and, 415, 418
elective, length and, 185 Arthrodesis/arthroplasty, in musician,
guillotine-type, functional outcome following, 254–255
197, 198 hand therapy following, 294
in fractures of mutilated hand, 54
Arthrograph, limitations of, 511
‘‘Antagonistic’’ muscles, 218 to quantify joint stiffness, 511
Antibiotics, choice of, for mutilating hand Arthrosis, nonarticular, in swan neck deformity in
injuries, 36–37 proximal
for prophylaxis in surgery, 33 interphalangeal joint, 249, 250–251
in extremity trauma, 2–3, 34–36
side effects of, 37 Atopic dermatitis, musical instrument and, 489
Antimicrobials, in management of mutilating
injuries, 33–39
topical, irrigation with, 36 B
Baclofen, in spasticity and dystonia, 586, 587
Arm, examination of, in focal dystonia, 310
pain in, in musicians, causes of, 234 Behavioral therapy, in musicians’ dystonia, 534

0749-0712/03/$ - see front matter Ó 2003 Elsevier Inc. All rights reserved.
doi:10.1016/S0749-0712(03)00108-2
702 Cumulative Index / Hand Clin 19 (2003) 701–716

Bennett fractures, in musician, repair of, 252, 253 cingulate motor area of, 527, 529
imaging of, and assessment of fine motor
Benzhexol, in spasticity and dystonia,
control, in musicians,
586, 587
523–538
Birth defects, cerebral palsy and, 550 methods of, 523–524
Blood vessels, repair of, following mutilating of musician, auditory-sensory motor regions
injuries of hand, 5–6, of, 529, 530
8–9, 135 structural changes in, 526,
used as ‘‘spare parts’’ in mutilating injuries, 79, 527–528
83–85 regions in sensory and motor music processing,
525
Bone(s), healing of, following mutilating injuries structure of, 524–525
of hand, 135–136 supplementary motor area of, 526, 528, 529
secondary procedures on, in
mutilating injuries, 150, 151 Brass musicians, instrument-related examination
used as ‘‘spare parts’’ in mutilating injuries, 79, of, 230
83–85 British Performing Arts Medicine Trust (Britain),
Botulinum toxin, in musicians’ dystonia, 534 317, 351–353

Botulinum toxin A, in spasticity and dystonia,

585, 601 C
in upper limb spasticity in cerebral palsy, Carpal tunnel syndrome, clinical provocative tests
591–600 in, 387–391
intramuscular, clinical trials of, diagnosis of, 279
592–593 Durkan’s test in, 388, 389
effects of, 592 early, management of, 280–281
equipment for, 596, 597 evaluation of, 280
indications for, 597–598 questions in, 387
injection aftercare, 595–596 Gilliat’s test in, 388, 390
results and complications of, 597–599 hand therapy for musician in,
target muscles for, location of, 595, 596, 597 294–295
selection of, 594–595 history taking in, 387–388
treatment goals in use of, 594 local ischemia of nerve in, 279
types of, 592 management of, 243–244
Phalen’s test in, 388, 389
Brachial plexus dorsal rhizotomy. See Rhizotomy,
surgery in, 281, 282
brachial plexus dorsal.
rehabilitation following, 281
Brachial plexus palsy, obstetric, Tinel’s sign in, 388, 389
biophysical measurements in, 394 treatment of, nonoperative, 280
diagnosis and treatment of,
Carpectomy, proximal row, in wrist joint
393–394
contracture, 659, 662
evaluation techniques and scoring systems
in, 394 Cellists, hand problems of, 322–323
high spatial resolution electromyography
Central nuclei, 219
and video-assisted movement analysis
in, 393–399 Cerebellum, subcortical nuclei and,
physiotherapy in, 393–394 218–219
range of motion measurements in, 394
Cerebral cortex, 219–220
Bracing, dynamic orthotic traction, and electrical
Cerebral palsy, assessment and nonsurgical
stimulation, in spastic deformity, 603–605
management of, 545–606, 679–680
Brain, activity of, assessment of, 523–524 classification of, 560–561, 566, 567, 568
in musicians’ dystonia, 530, 531, 532, cosmesis in, assessment of, 682
533 definition of, 609
 Cumulative Index/ Hand Clin 19 (2003) 701–716
dressing in, assessment of, 681
etiology of, 547–555
evaluation of sensibility in, 570
functional assessment in, 680
aided by motion laboratory studies,
565–571
functional examination of, 561
functional strength in, 575–576
functional testing in, 567–568
hand deformity and dysfunction in, casting,
splinting, and physical and occupational
therapy in, 573–584
hand dysfunction in, analysis and treatment in,
576–577
hemiplegic, brachial plexus dorsal rhizotomy
in, 687–699
history taking in, 566
hygiene in, assessment of, 681
hypertonicity and contracture in, 574
infant characteristics associated with, 548–550
interventions in, principles of, 573
juvenile, evaluation of, 602
neuromusculoskeletal pathology of,
591–592
spasticity management in, 592
motion laboratory assessment in, 568–570
neuromuscular disorders in, 610–612
hand sensory impairment in, 612–613, 614,
615, 616, 617
physical examination in, 566–567
postneonatally-acquired, 552
preoperative examination in, 562–563
prevalence of, 547
prevention of, 552
problems of upper extremities in,
545–699. See also specific problems.
replacement laminoplasty in, 696–697
risk factors for, antepartum, 548
intrapartum, 550–551
preconception, 547–548
sensory examination of, 561
spasticity of upper limb in, botulinum toxin A
in, 591–600
surgery in, assessment for, 679
data on, 681–684
planning for, 679, 680
technique of, 681
surgery of hand in, evaluation following, 625
goals of, 613
indications for, 616–618
preoperative evaluations for, 609–612
procedures for, 618–625
prognosis in, 613–616
703
results of, 625–627, 628
surgical management of, 607–699
surgical management of shoulder and elbow
deformities in, 631–648
three subgroups of, 585
thumb in, surgical management of, 667–677
upper limb in, functional and cosmetic
outcome of surgery of, 679–685
spasticity and dystonia in children,
pharmacologic management of,
585–589
Cervical radiculopathy, 279
Child(ren), hand injuries in, types of, 121
mutilating injuries in, 1, 2, 46–47, 121–132
passive hand prostheses for, 186
Cineradiography, for measurement of
scapho-trapezo-trapezoid arthrodesis,
413, 414
Clarinet, ‘‘Boutonniere’’ position required on,
249
weight of, 487–488, 489
Clarinetist, ulnar nerve damage in, hand therapy
following, 289
Claw nail deformity, 275
Cochin Rheumatoid Hand Disability
Scale, 478
Colles fracture, algodystrophy following, 512
Complex regional pain syndrome Type I. See
Algodystrophy.
Constraint-induced movement therapy, in
musicians’ dystonia, 534
Contractures, and hypertonicity, in cerebral
palsy, 574
Counter Opposition Test, of thumb, 385
Cross hand transfer, for replantation in mutilating
injuries, 103
Cubital tunnel syndrome, diagnosis of, 279
evaluation in, 280
local ischemia of nerve in, 279
treatment of, nonoperative, 280
surgical, 282, 283
D
de Quervain tendonitis, in musician, management
of, 255
704 Cumulative Index / Hand Clin 19 (2003) 701–716
Desensitization, to treat scar hypersensitivity, 138
Dexterity, evaluation of, in impairment of hand
and wrist, 374
Diazepam, in spasticity and dystonia, 586, 587
Digital neuritis, 284
Digit(s). See also Finger(s); Thumb.
amputation of, in musician, management of,
251
fusion of, biomechanical of, 24–26
loss of, 23–24
motion of, improvement following mutilating
injuries, 156–157
replanted, lengthening of, 270
salvaging of, in mutilating injuries,
6, 13
Disability of Arm, Shoulder, and Hand index, 477
Distal replantation, nail bed, and nail problems,
in musicians, 259–272
Dolorimeter, 512
Dupuytren contracture, hand therapy for
musician in, 293
surgery in, 253–254
Durkan’s test, in carpal tunnel syndrome, 388, 389
Dystonia, dopa-responsive, 587
focal. See Focal dystonia.
functional. See Focal dystonia.
of upper limb, in cerebral palsy, 585, 586
pharmacological management of, 586–587
E
Edema, control of, after mutilating injuries of
hand, 137
Elbow, and shoulder, deformities of, in cerebral
palsy, surgical management of, 631–648
hypertonus of flexor muscles of,
634–635, 636
pain in, in musicians, 234
ulnar neuropathy at, 281–282
Electric hand, for myoelectric prosthesis, 188,
189–190, 191
Electric hook, on wrist level disarticulation
prosthesis, 187, 189, 190
Electrical stimulation, in management of spastic
deformity, 601–606
dynamic orthotic traction bracing and,
603–605
equipment for, 602–603
patient selection for, 602
Electrogoniometer, 6-DoF, for wrist
motion recording, 418
Electrogoniometry, for measurement of
scapho-trapezo-trapezoid arthrodesis,
412–414
Electromyography, high spatial resolution, in
obstetric brachial plexus palsy, 394–396
in cerebral palsy, 563
Emergency room, management of mutilated hand
in, 51
Epicondylitis, in musicians, 235, 284
European Association of Medicine for the Arts
(France), 343–347
Exercise(s), in treatment of musicians, 237
instrument-specific, in hand therapy for
musician, 291, 292
protective motion, following replantation in
mutilating injuries, 143–145
stability strengthening, in hand therapy for
musician, 297–298
F
Failing Ulnar Hook Test, of ulnar palsy, 385–386
Fatigue, lactic acid accumulation and, 217
Federation Internationale of Medicine,
1999 survey of, 318, 320–323
Fibrous contracture, in cerebral palsy,
559–560
Fine motor control, assessment of, and brain
imaging, in musicians, 523–538
Finger(s), and wrist, deformity of, classification
of, 602
surgical management of, 657–665
Zancolli’s classification of, 560, 658
as composite tissue transfer in mutilating
injuries, 79, 85
clenched fist deformity of, surgery in, 661–663,
664
distal amputation of, management of, 261
extension of, scale of, 384
flexion of, scale of, 382–384
flexor tendon surgery of, methods of
assessment of, 496
for use in mutilating injuries, 75
function of, analysis of, 421–430
dynamic measurement protocol in,
425–426
 Cumulative Index/ Hand Clin 19 (2003) 701–716
finger movement evaluation equipment
for, 424–425
grip and pinch strength equipment for,
424
hand assessment protocol in, 425
maximal isometric contraction
equipment for, 422–424
measurement instruments for, 426
preliminary measurements for, 426–429
objective analysis of, 421–430
fusion of, 24–25
giant cell tumor in pulp of, 248
hyperextensible, excessive extrinsic muscle
activity in, 235
index, importance of, 22
ray, elective loss of, 22–23
individual, functional contribution of, 1
long and ring, central ray deletion in, 23
microsurgical reconstruction of,
osteo-onychocutaneous flap
for, 275
multiple, amputation of, toe transplantation
for, 169–171, 173
multiple replantation of, in mutilated hand,
102, 109–111
nonreplantable, nail salvage in,
263–264
passive prosthesis for, 180–181
permanent impairment of, evaluation of, 2
reconstruction of, toe-to-hand transplantation
for, 169–171, 172
single, amputation of, toe transplantation for,
169, 172
small, flexion by, 23
stiffness in, in algodystrophy, measurement of,
511–515
stump of, coverage of, 268
transverse amputation of, remodeling of nail
in, 268
volar oblique amputation of, nail-recession
flap technique in, 268–270
Finger fillet flap, lengthening of, 76
Fingertip, amputation(s) of, 260
management of, 261–263
‘‘cap’’ composite graft, in mutilating injuries,
74, 75–78
injuries to, management of, 251
replantation of, 261–263
Flexor aponeurotic release, in pronation of
forearm, 651
Flexor carpi ulnaris transfer, in pronation of
forearm, 653–654
705
Flexor pollicis longus repair, assessment of, 501
Flexor pronator slide, in pronation of forearm,
651–652
Flexor tendon, assessment of function of, after
primary tendon repair, 495–503
Flute player, hyperextended wrist in, 237
Flutist, musician’s cramp in, 531
Focal dystonia, brain imaging and fine motor
control, in musicians, 523–538
characteristics of, 530
in musicians. See Musicians’ dystonia.
musicians at risk for developing,
530–531, 532
neuroanatomic and neurophysiologic
background of, 523–525
of musician(s), 303–308, 318–320
characteristics of, 303
diagnosis of, 306
examination of instrument in, 311–312
frequency, age, sex, and localization of,
305–306
in psychological problems, 305
onset and symptoms of, 304
physical and neurologic examination in,
304–305
rehabilitation in, 309–316
four parts of, 313–315
physical, 312–313
physical assessment for, 309–311
treatment of, 306–307
results of, 307–308
symptoms of, 531
treatment of, 534–536
outcome of, 536
Foot, surgical anatomy of, toe-to-hand
transplantation and, 167
Forearm, examination of, in focal dyatonia,
310–311
hand and, as source of reusable parts in
mutilating injuries, 80–81,
85–86
pronation of, classification of, 651
flexor aponeurotic release in, 651
flexor carpi ulnaris transfer in, 653–654
Forearm
flexor pronator slide in, 651–652
pronator quadratus release in, 650–651
pronator teres release in, 650
pronator teres rerouting in,
652–653
706 Cumulative Index / Hand Clin 19 (2003) 701–716

Forearm (continued) Grip, directional, 18

surgical management of,
649–655
complication of, 650, 652
postoperative treatment in, 654
procedures for, 650–654
supination of, procedures improving, 649, 650
Foucher’s tension band nail synthesis,
266, 267
Fracture(s), complex, in mutilated
hand, 53
healing of, biomechanic evaluation of, 366
in musician, repair of, 252
in mutilated hand, amputation in, 54
cases illustrating, 54–57, 58, 59
management of, 5, 7–8, 52
rehabilitation following, 57–59, 138–140
repair and reconstruction in,
53–54
treatment of, and revascularization in, 52
malunited, in musician, repair of,
252–253
simple, in mutilated hand, 52–53
Free flaps, in mutilating hand injuries,
142–143
Functional dystonia. See Focal dystonia.
G 581–582
Ganglionectomy, hand therapy for musician
following, 294
German Society for Music Physiology and
Musician’s Medicine (Germany),
347–350
Giant cell tumor(s), in musician, management of,
254
in pulp of finger, 248
Gilliat’s test, in carpal tunnel syndrome, 388, 390
Glasgow Pain Questionnaire, 450–451
Gonimeter, to measure hyperlaxity in proximal
interphalangeal joint, 232
Goniometer, hand, 512
Goniometry, for measurements in algodystrophy,
513, 514
Grap Ability Test, 476
Grasp, power, 18, 19
span, 18, 19
hook, 18, 19
Grips plus action test, of hand, 385
Growth restriction, cerebral palsy and, 549
Guitarist(s), barrée function of,
examination of, 229
distal amputation of thumb of, management
of, 276–277
examination of, 228–229
hand problems of, 322
inclination and torsion of guitar and,
assessment of, 229
musculoskeletal problems in, 236
over-tensioning of strings and, 488
plucking techniques of, assessment of, 229
H
Hand(s), and forearm, as source of reusable parts
in mutilating injuries, 80–81, 85–86
and wrist. See Wrist, and hand.
cross transfer of, for replantation in mutilating
injuries, 103
electric, for myoelectric prosthesis, 188,
189–190, 191
essentials for, 17
examination of, in focal dystonia, 311
fisted with no wrist flexion or extension, in
cerebral palsy,
function of, assessment instruments
of, 472–474
objective single measures of,
474–475
prerequisites for, 573
tests of, 475–476
grips plus action test of, 385
injuries of, in children, types of, 121
metacarpal, reconstruction of, toe
transplantation in, 171, 174
mutilating injuries of. See Mutilating injuries.
of musician. See Musician(s),
hand(s) of.
basic physiologic notions of,
215–221
examination of, 225–226
‘‘functional disorders’’ of, 215
partial, passive prosthesis for,
180–181
prehension of, 17
problems of, in musicians, dystonia as,
318–320
 Cumulative Index/ Hand Clin 19 (2003) 701–716
hypermobility, 317–318
in old injury, 317
prevention of, 317–324
prostheses for. See Prosthesis(es).
reflex sympathetic dystrophy of. See Reflex
sympathetic dystrophy.
replants from, for replantation in mutilating
injuries, 103, 113, 114
sensory impairment in, in neuromuscular
disorders in cerebral palsy, 612–613, 614,
615, 616, 617
seven basic maneuvers of, 17–18
surgery of, in cerebral palsy. See Cerebral
palsy, surgery of hand in.
in infantile spastic hemiplegia, 609–629
outcome studies in, 457–458
outcomes analysis in, 431–436
data collection process in, 433, 434
measurement instrument for, 434–435
questionnaire(s) for, choice of,
433–435
examples of, 434
steps for conducting, 431–433
transplantation of, assessment of functional
outcome in, 505–509
Chen’s score for, 507, 508
Ipsen score for, 508
Tamai’s score for, 508
evaluation chart in, 506–507
trauma to, biomechanics and, 17–31
classification of, 19
Hand posture, and hand therapy for musician,
298
Hand therapy, for musician, 287–301
assessment of bony alignment in, 296
assessment of muscle strength in, 296–297
early return to modified playing and,
288–289
early return to playing and, 291
following arthrodesis and arthroplasty,
294
following ganglionectomy and benign
tumor removal, 294
following surgery and open trauma, 287
following ulnar nerve decompression, 295
good practice habits and, 290, 298–299
hand posture and, 298
in carpal tunnel syndrome,
294–295
in degenerative conditions, 293
in Dupuytren contracture, 293
in hyperlaxity, 296
in muscle imbalance, 296
707
in non-specific wrist and hand pain,
295–296
treatment goals for, 297–298
in thumb carpometacarpal joint arthritis,
295
instrument-focused rehabilitation in,
289–290
instrument modification in, 293
instrument-specific exercises in, 291, 292
instrument-specific manual therapy in,
291–292
maintenance of musical fitness in, 292
multidisciplinary approach to, 292–293
proprioception retraining in, 298
range of movement for musical position
in, 288
rehabilitation using instrument, 290–291
sensory re-education in, 289
splinting of hand in, 299–300
stability strengthening exercises in,
297–298
strengthening in, 289
treatment goals in, 287
wound, scar, edema, and pain management
in, 287
Harpists, musculoskeletal problems in, 236
Hematoma, of nail bed, 265–266
Henneman’s principle, ‘‘unit recruitment’’ and,
216–217
Hook, electric, on wrist level disarticulation
prosthesis, 187, 189, 190
Hypermobility, as problem in musicians, 317–318
Hypertonicity, and contracture, in cerebral palsy,
574
Hyponychium, 259
Hypoxia, intrapartum, cerebral palsy and, 551
I
Infection, antepartum, cerebral palsy and, 548
as cause of loss of salvaged limb, 196
Infertility treatment, cerebral palsy and, 547–548
Injuries, mutilating. See Mutilating injuries.
Instrument, adjustments to, 489
atopic dermatitis and, 489
musculoskeletal pain related to, locations and
mechanisms of, 234–236
size and shape of, for physique of musician,
487
708 Cumulative Index / Hand Clin 19 (2003) 701–716
Instrument (continued)
weight and tension of, for physique of
musician, 487–488
International Classification of Functioning,
Disability, and Health, dimensions of, 371–372
in outcome evaluation of hand and wrist,
371–378
Ischemia, in mutilating injuries, functional
outcome and, 198
J secondary procedures in, 150, 151
Jamar Hand Dynamometer, 421
Jebson Hand Function Test, 476
Joints, laxity of, in musicians, 235
range of motion of, in cerebral palsy, 560–561
secondary procedures on, in mutilating
injuries, 156–159
stiffness of, in algodystrophy, 511
treatment following mutilating injuries,
140, 141
used as ‘‘spare parts’’ in mutilating injuries,
79, 83–85
K wrist, 373–374
Keitel Function Index/hand Functional Index,
475
Keyboard players, musculoskeletal problems in,
236
L 565–566
Laminoplasty, replacement, in cerebral palsy,
696–697
L-Dopa, in spasticity and dystonia, 586, 587
Limb, survival of, and limb function, 195–196
upper, clinical evaluation of, in cerebral palsy,
557–563
evaluation of spasticity of, in cerebral palsy,
558
functional and cosmetic outcome of surgery
of, in cerebral palsy, 679–685
general assessment of, in cerebral palsy,
557–564
in cerebral palsy, surgical management of
shoulder and elbow deformities in,
631–648
joint function of, clinical evaluation of,
379–386
motor assessment of, in cerebral palsy,
558–559
resting posture of, in cerebral palsy,
557–558
spastic and dystonic, in children with
cerebral palsy, pharmocologic
management of, 585–589
spasticity of, in cerebral palsy, botulinum
toxin A in,
591–600
M
Malunion/nonunion, in mutilating injuries,
Manipulation, and dexterity, in cerebral palsy,
576
Memory, stages of, 220
Metacarpal boss(es), in musician, management of,
254
Michigan Hand Outcomes Questionnaire, 477
Microsurgical reconstruction, secondary, in nail
problems in musicians, 273–278
Misuse syndrome(s), 328
Moberg pickup test, in impairment of hand and
Motion analysis, video-assisted, in obstetric
brachial plexus palsy, 396–399
Motion laboratory studies, for functional
assessment in cerebral palsy, 565–571
purpose of, in cerebral palsy,
Motor action, study of, elementary level of,
215–217
Motor tract, 215, 216
Motor unit(s), connections of, 217–218
Movement disorders, motion analysis in,
396–397
Muscle fatigue, 327
Muscle strength testing, in impairment of hand
and wrist, 373
Muscles, response to excitation, 217
Muscular fiber, 215, 216
Musculoskeletal pain, in musicians, prevention of,
239
treatment of, 236–238
related to instrument, locations and
mechanisms of, 234–236
 Cumulative Index/ Hand Clin 19 (2003) 701–716
Musculoskeletal pain syndrome, 233–234
Musculoskeletal problems, in instrumental
musicians, 231–239
in string players, 235–236
Music performance, neurophysiology of,
525–527
Musical instrument. See Instrument and specific
instruments.
Musician(s), anatomic compromise in, adjustment
to, 249, 250
anatomic reconstruction in, 248
brain of, auditory-sensory motor regions of,
529, 530
structural changes in, 526,
527–528
carpal tunnel syndrome in. See
Carpal tunnel syndrome.
chronic pain in, 238–239
distal replantation, nail bed, and nail problems
in, 259–272
doctor communicating with, 223
examination and interface with,
223–230
exercise in treatment of, 237
focal dystonia, brain imaging, and fine motor
control in, 523–538
hand(s) of, acute trauma to, surgical
management in, 243
and visual and technical motion analysis
studies of, 226
basic physiologic notions of,
215–221
biomechanic examination of, 226
clinical evaluation of, 484
extremity and, 484
interface in, 484–486
evaluation of instrument and, 486–488
examination of, 225–226
function and outcome assessment of,
483–493
‘‘functional disorders’’ of, 215
injuries of, objective assessment of, 491
instrument-related examination of,
226–230
investigation of, special techniques of,
489–490
musical instrument digital interface and,
226
physical examination of, 242
surgery on, planning of, 490–491
treatment of, advances in,
490–491
709
hand symptoms in, 224–225
hand therapy for. See Hand therapy, for
musician.
highly trained, loss of manual coordination in,
530–531
incisions in, planning and location of, 247
injuries of, determination of structures injured
in, 242
instrumental, musculoskeletal problems in,
231–239
managers of, prevention of hand problems by,
323
medical care of, national organizations
involved with, 343–353
misuse, overuse, and repetition in,
controversies surrounding,
325–329
musculoskeletal pain in, prevention of, 239
treatment of, 236–238
musculoskeletal problems in, categories of, 231
evaluation of, 232
frequency of, 231
risk factors for, 232–234
nail problems in, secondary microsurgical
reconstruction of, 273–278
nerve compression syndrome in, management
of, 243, 279–286
nontrauma conditions of, surgical
considerations in, 253–254
pain as symptom in, 225
performance-induced problems in, 231
physical therapy in treatment of, 235
practice habits of, assessment of, 224
special operative considerations in, 247–258
surgery in, contraindications to,
242–243
rehabilitation and return to play following,
249–253
results of, 256–257
surgical assessment of, 241–245
trauma to, requiring surgery, incidence of, 247,
248
Musician(s)
results of, 249
with hand problems, history taking in, 223–224
with pain, by instrument and gender, 233
Musician’s cramp. See Focal dystonia.
Musicians’ dystonia, 530–531
assessment of brain acitivity in, 530, 531, 532,
533
diagnosis of, 490
maladaptive plasticity and, 531–534
710 Cumulative Index / Hand Clin 19 (2003) 701–716
Musicians (continued)
musicians at risk for developing,
530–531, 532
musician’s cramp in, examples of, 530, 531
psychologic support in, 535–536
treatment of, 534–536
Mutilating injuries, antimicrobial management of,
33–39
bacteriology of, 33–34
bones, tendons, nerves, vessels, and joints used
in, 79, 83–85
‘‘cap’’ composite tip graft in, 74, 75–78
complex, management of, 6–9,
10–13, 14
crush, outcomes after, 196
debridement and irrigation in, 4–5
electrical, outcomes after, 196, 197
emergency room management of, 51
etiology of, 51, 63
finger as composite tissue transfer in, 79, 85
finger for use in, 75
fracture fixation in. See Fracture(s),
in mutilated hand.
hand and forearm as source of reusable parts
in, 80–81, 85–86
healthy adjustment of, promotion of, 43–44
history taking in, 1–3
in children, 1, 2, 46–47, 121–132
delayed treatment of, 128–130, 131
initial management and preoperative eva-
luation in, 121–124
operative procedure in, 124–125
replantation and revascularization in,
125–126
soft tissue coverage in, 126–131
initial surgery of, 52
injury-related issues in, 41–42
limb of hand salvage in, factors influencing,
194–195
management of, and principles of, 1–15
factors influencing, 63
immediate, 1, 2, 3, 4–5
reconstructive algorithms in, 63–65
outcomes after, 193–204
age as influence on, 198
assessment of, 199
clinical outcomes, 195–200
factors influencing, 193, 196–197
goals of, 195
objective assessment of, 201–202
outcomes research on, 201
salvage of function and, 193, 194
scoring systems for, 200–201
treatment views and, 195
outcomes in, 51
pain in, 45–46
patient evaluation in, 73–75
perionychium for reconstruction in, 75, 78–80
physical examination in, 3–4
principles of, and management of, 1–15
psychological aspects of, 41–49
psychological intervention strategies in, 44–45
psychological responses to, 42–43
rehabilitation process for, 133
replantation in. See Replantation, in mutilated
hand.
secondary procedures following, 149–163
early care influencing, 150
involving nerves, 155–156
on bone, 150, 151
on joints and tendons, 156–159
on soft tissue, 151–152
on thumb, 159–161
requirements for hand function and, 13, 150
to release scar, 152–155
skin harvesting in, 76–78, 80–83
soft tissue coverage in. See Soft tissue coverage,
in mutilating injuries.
special issues in, 45–47
stabilization of patient in, 1
therapy following, 133–148
early phase (protective), 133–134
healing process and, 134–136
intermediate phase (mobilization), 134
late phase(strengthening), 134
use of ‘‘spare parts’’ in, 73–87
Myotatic reflex, 218
N
Nail(s), anatomy of, 260
Foucher’s tension band synthesis of, 266, 267
injury(ies) of, basic principles of management
of, 264
isolated, 264–268
techniques to save nail in,
260–261
lesions of, classification of, 264
distal phalanx and, 260
loss of, due to trauma, 275
microsurgical reconstruction of, free
vascularized composite partial toe transfer
in, 273–276
free vascularized nail graft in, 273, 274
surgical technique for, 273–276
microsurgical transfer of, 263
 Cumulative Index/ Hand Clin 19 (2003) 701–716 711

problems of, distal replantation, and nail bed secondary procedures on, in
problems, in musicians, 259–272 mutilating injuries, 155–156
in musicians, secondary microsurgical used as ‘‘spare parts’’ in mutilating injuries, 79,
reconstruction of, 273–278 83–85
remodeling of, in transverse amputation, 268
Nerve compression, in musician, management of,
salvage of, in nonreplantable finger, 263–264
243
reposition-flap technique for, 263, 264
whole composite reattachment of, 263–264 Nerve compression syndrome(s), in musician, 256
incidence of, 279
Nail bed, 259
management of, in musicians,
hematoma of, 265–266
279–286
loss of substance of, 266, 268, 269
problems of, distal replantation, and nail Nerve impulse, definition of, 215
problems, in musicians, Neuritis, digital, 284
259–272
repair of, 260–261 Neurologic disorders, cerebral palsy and, 547
split-thickness graft of, 266, 269 Neuroma, management of, following mutilating
wounds of, 265–266, 267 injuries, 156
Nail complex, anatomy of, 259–260 Neuromuscular disorders, in cerebral
Nail flap, thenar, de-epithelialized, repair of, 266, palsy, 610–612
268 hand sensory impairment in, 612–613, 614,
615, 616, 617
Nail graft, free vascularized, in microsurgical
reconstruction of nail, 273, 274 Neuromuscular spindle, 218
Nail matrix, 259 Neuron, 215
lesions of, management of, 266–268, 269 Nonsteroidal anti-inflammatory drugs, in
Nail plate, soft tissues beneath, 259 musculoskeletal problems, 237–238
Nail-recession flap technique, in volar oblique
amputation, 268–270 O
Osteomyelitis, following mutilating injuries,
Nail walls, 259–260
150–151
lesions of, repair of, 268, 269
Osteosynthesis, in replantation in
Nail-recession flap technique, in volar oblique
mutilated hand, 96, 98
amputation, 268–270
Outcome study(ies). See also under specific areas
Nerve(s), delayed repair of, following mutilating
studied.
injuries, 5, 9, 155–156
initiation of, measurements and,
healing of, following mutilating injuries of
458–459
hand, 135
negotiation in, 459–460
lacerations of, in musician, repair of,
patient recruitment for,
251–252
460–461
peripheral, functional recovery of, outcome
study design and, 459
study of, 458
prospective, difficulties in conducting,
protection of, following mutilating injuries of
457–462
hand, 137–138
repair of, outcome after, Overuse syndrome(s), 233–234, 326
development of model occupational, 327, 333–335
instrument for, 464–468 classification of, diagnostic algorithm for,
new model instrument for, 463–470 335
outcome measures after, currently used, 464 nonspecific, background of,
numeric test protocol for, 466–467, 468 331–333
requirements for, 463–464 classes of, 334
problem after, 463 definitions of, 333–335
712 Cumulative Index / Hand Clin 19 (2003) 701–716

Overuse syndrome (continued) Posterior interosseous nerve syndrome, 283–284

in musicians, pathophysiology of, treatment of, 284
331–341
Pre-eclampsia, cerebral palsy and, 548
research findings in,
336–339 Pronator quadratus release, in pronation
research orientation and methodology of forearm, 650–651
for study of, 335–336 Pronator teres, release of, in pronation of
subcategories of, 334 forearm, 650
pathophysiology of, 326–327 rerouting of, in pronation of forearm, 652–653
study in musicians, 327–328
Prosthesis(es), active, 13, 185–191
patient acceptance of, 186–188
P fabrication of, 187, 189, 190
Pain, chronic, in musicians, 238–239 flexible silicone sleeve of, 189, 191
in mutilating injuries, 45–46 passive, 177–183
candidates for, 177, 178
Patient-Rated Wrist Evaluation questionnaire, distal phalanx, 183
477–478 finger, 183
Pedicle flaps, in mutilating hand injuries, 142 for child, 186
goals and expectations for, 13, 177–178, 179
Percussionists, musculoskeletal problems
master plan for treatment using, 179
in, 236
middle phalanx, 183
Performing Arts Medicine Association (USA), new material and technology
350–351 for, 180
partial hand, 180–181
Perionychium, reconstruction of, in mutilating
proximal phalanx, 183
injuries, 75, 78–80
thumb for, 181–183
Phalanx, distal, 259 types of, 179–183
and nail lesions, 260 suspension on limb, 189, 190–191
proximal, passive prosthesis for, 183 transcarpal level, with electric hand, 188,
Phalen’s test, in carpal tunnel syndrome, 388, 189–190, 191
389 voluntary closing grasping device on, 190, 191
wrist level disarticulation, electric hook on,
Pharmocology, in management of upper limb 187, 189, 190
spasticity and dystonia, in children with with semi-flexible inner socket, 188, 191
cerebral palsy, 585–589
Proximal interphalangeal joint, hyperlaxity in,
Physical therapy, in treatment of gonionmeter to measure, 232
musicians, 235 splints to support, 234
Pianist(s), brain of, 529, 530 swan neck deformity in, nonarticular arthrosis
examination of, 228 in, 249, 250–251
hand problems of, 321
musician’s cramp in, 531 R
pressure development in, ergonomic Radial tunnel syndrome, 284
considerations in, 228
musical instrument digital interface and, Radiculopathy, cervical, 279
228, 229 Radiography, in cerebral palsy, 563
weight of piano and, 488
Range of motion measurements, in impairment of
Pinch, key, 18 hand and wrist, 373
oppositional, 17–18
Reflex sympathetic dystrophy, of hand,
precision, 17
517, 518
Position tolerance, gravity-dependent, after assessment of severity of, scoring system in,
mutilating injuries of hand, 137 517–521
 Cumulative Index/ Hand Clin 19 (2003) 701–716
classification of, 517, 520–521
incidence of, 517
signs and symptoms of, 517, 518, 519–520
three-phase bone scintigraphy in, 518, 519
Rehabilitation, following fractures in mutilated
hand, 57–59
following mutilating injuries, 133,
138–141, 142
following toe-to-hand transplantation,
171–172
Repetition strain injury. See Overuse syndrome(s),
occupational.
Replantation, in mutilated hand, 89–119
care of amputed part for, 91, 94
debridement and labeling for,
92–94, 96
hand replants in, 103, 113, 114
history of, 89, 90, 91, 92
indications for, 89–91, 92, 93
issues in, 47
multiple finger replantation for, 102,
109–111
operative considerations for,
92–100, 101, 102, 103, 104
osteosynthesis techniques for,
96, 98
outcomes following, 107, 199
postoperative care following, 103–105
preoperative considerations for, 91–92, 94,
95
protective motion exercises following,
143–145
repair of volar structures for,
98–100, 101, 104, 105
special considerations for,
100–107
tendon repair for, 98, 99, 100
thumb replants for, 100–102, 105–109
upper extremity replants for, 102–103,
111–112
Rheumatoid arthritis, postoperative outcome in,
wrist and hand handicap and, 471–481
Rhizotomy, brachial plexus dorsal, anatomic
basis of, 688–689
candidates for, 689, 694–695
in hemiplegic cerebral palsy,
687–699
motor control after, 696
pathophysiologic basis of, 688
patient assessment for, 689–690
results of, 690–694
713
surgical techniques for, 690
transoperative rootlet electric stimulation
for, 696
posterior, for spasticity, history and evolution
of, 687–688
S
Scapho-trapezo-trapezoid arthrodesis. See
Arthrodesis, scapho-trapezo-trapezoid.
Scaphoid, fracture of, 3D reconstruction of,
405–406
unstable, evaluation of, 404, 406
Scapholunate instability, evaluation of, 404
Scar, management of, after mutilating injuries of
hand, 137
palmar contracture, following crush injury,
management of, 153–156
release of, in mutilating injuries,
152–155
web contracture, following crush injury,
management of, 152,
153, 154
Semmes-Weinstein monofilament test, in
impairment of hand and wrist, 373
Sensory evaluation, quantitative, in impairment of
hand and wrist, 373–374
Sesmoid arthrodesis, in thumb-in-palm deformity,
674, 675
Shape/Texture Identification test, 465
Shoulder, acquired spasticity of,
631–634
surgery in, indications for,
635–638
procedures in, 640, 642
results of, 638–647
and elbow, deformities of, in cerebral palsy,
surgical management of,
631–648
Shoulder
as three-axes joint, 379–386
extension of, 379
Intercalcted Fist Test of, 382, 383
scapulohumeral internal rotation and
abduction of, 634
scapulohumeral internal rotation and
adduction of, 634
triple point test of, 379–382
Waiter’s Test of, 382, 383
714 Cumulative Index / Hand Clin 19 (2003) 701–716
Shoulder girdle, examination of, in focal dystonia,
310
Skin, harvesting of, in mutilating injuries, 76–78,
80–83
therapy of, following mutilating injuries of
hand, 134–135
Skin flaps, for reconstruction of mutilated hand,
65–67
Soft tissue, beneath nail plate, 259
damage to, in mutilating injuries, 197
secondary procedures on, in
mutilating injuries, 151–152
Soft tissue coverage, in mutilating injuries, 63–71
assessments for, 4, 6–7
cases illustrating, 67–69, 70
distant flaps for, 65–66
free flaps for, 66–67
in children, 126–131
local flaps for, 65
regional flaps for, 65
of mutilating injuries, 142–143
Spastic deformity, dynamic orthotic traction
bracing and electrical stimulation in, 603–605
management of, electrical
stimulation in, 601–606
Spastic hemiplegia, infantile, surgical
management of hand in, 609–629
Spasticity, acquired, conditions leading to, 631,
632–633
management of, in juvenile cerebral palsy, 592
of upper limb, evaluation of, in cerebral palsy,
558
in cerebral palsy, 585, 586
pharmacological management of, 586–587
posterior rhizotomy in, history and evolution
of, 687–688
Spinal axis, examination of, in focal dystonia, 310
Spinal cord, 218
Spine, assessment of, in focal dystonia, 310
Splinting, and casting, in cerebral palsy, 574–575
in hand therapy for musician, 299–300
in musculoskeletal problems, 237
Splints, traction, in fractures in mutilating
injuries, 138, 140
Split-thickness graft, of nail bed, 266, 269
String players, musculoskeletal problems in,
235–236
Subcortical nuclei, and cerebellum,
218–219
Südeck atrophy. See Algodystrophy.
Superficialis tendon, for reconstruction of thumb,
21
Swan neck deformity, in proximal interphalangeal
joint, nonarticular arthrosis in, 249, 250–251
Swan-neck deformity, 617, 622–623
pathophysiology of, 661–662, 663
surgical correction of, 623–625,
662–663, 664
Swellings, in hand of musician,
management of, 254
Synapse(s), 216
T
Teachers (music), and prevention of hand
problems in students, 323–324
Tendonitis, de Quervain, in musician,
management of, 255
in musicians, 235
Tendon(s), extensor, injuries of, 27
flexor, loss of function of, 28
healing of, following mutilating injuries of
hand, 135
injuries of, in musician, repair of, 252
loss of, and hand function, 26–28
primary repair of, assessment of flexor tendon
function after, 495–503
Buck-Gramcko methods of assessment of,
499, 501
current methods of assessment following,
497–501
failure of, assessment of, 496
Louisville method of assessment of, 498
Moiemen-Elliott method of assessment of,
500
partial failure of, assessment of, 496–497
Strickland methods of assessment of,
498–499
TAM method of assessment of, 498
repair of, for replantation in mutilated hand,
98, 99, 100
secondary procedures on, in
mutilating injuries, 156–159
secondary reconstruction of, following
mutilating injuries, 159
used as ‘‘spare parts’’ in mutilating injuries, 9,
79, 83–85
 Cumulative Index/ Hand Clin 19 (2003) 701–716
Tennis elbow, in musician, 255
Tenolysis, following mutilating injuries, 157–159
Thoracic outlet syndrome, 282–283
symptoms of, 283
treatment of, 283
Thrombophilias, cerebral palsy and, 550
Thumb, adduction of, and minimal wrist flexion,
in cerebral palsy, 576–577
avulsion of nail complex of, toe transfer in,
273, 274
carpometacarpal joint arthritis in, hand
therapy for musician in, 295
Counter Opposition Test of, 385
distal amputation of, whole toe transfer in,
273–275, 276–277
for passive prosthesis, 181–183
functional importance of, 1, 19–20
in cerebral palsy, surgical
management of, 667–677
level five injuries of, 21–22
level four injuries of, 21
level three injuries of, 20–21
reconstruction of, priorities of, 20
toe-to-hand transplantation for, 167
replants for, in mutilated hand,
100–102, 105–109
secondary reconstruction of, in mutilating
injuries, 159–161
Total Opposition Test of, 384
Thumb-in-palm deformity, assessment of, 667
classification of, 668–669, 670
extrinsic release in, 671–674
in cerebral palsy, 667–668
intrinsic release in, 670–671, 672
joint stabilizations in, 674
muscles involved in, 668
natural history of, 667
nonoperative treatment of, 669
sesmoid arthrodesis in, 674, 675
surgical treatment of, 669–674
timing and staging of treatment of, 670
Thyroid disease, cerebral palsy and, 548
Tinel’s sign, in carpal tunnel syndrome, 388, 389
Toe-to-hand transplantation, 165–175, 194
for finger reconstruction, 169–171, 172
for thumb reconstruction, 167
great toe wraparound flap, 168
harvesting of toe for, 166
in mutilating injuries, motion program
following, 145–146
715
insetting of transplants in, 167
intraoperative and postoperative
complications of, 172–174
late complications of, 174–175
postoperative management for, 171
preparation for, 165
recipient site preparation for, 166–167
rehabilitation following, 171–172
second toe transplantation for,
168–169, 171
surgical anatomy of foot and, 166
timing of, 165
total great toe transplantation in, 167
trimmed great toe transplantation in, 167–168
Toe transfer, free vascularized composite partial,
in microsurgical reconstruction of nail, 273,
274
in avulsion of nail complex of thumb, 273, 274
Total Opposition Test, of thumb, 384
Trigger finger, in musician, management of, 255
Trihexyphenidyl, in spasticity and dystonia, 586,
587
Tumors, benign, removal of, hand therapy for
musician following, 294
U
Ulnar nerve, decompression of, hand therapy for
musician in, 295
Ulnar neuropathy, at elbow, 281–282
in clarinetist, hand therapy following, 289
Ulnar palsy, Failing Ulnar Hook Test of, 385–386
Upper extremity(ies), motion analysis in, 397
mutilated, replantation in, replants for,
102–103, 111–112
mutilating injuries of, use of ‘‘spare parts’’ in,
73–87
trauma to, antibiotics in, 34–36
side effects of, 37
V
Vasculitis, focal nerve pathology in, 279
Vibration perception thresholds determinations,
in impairment of
hand and wrist, 373
Violinist(s), bow positions of, 227
bow techniques of, 227
examination of, 226–228
716 Cumulative Index / Hand Clin 19 (2003) 701–716
Violinist(s) (continued)
fingering techniques of, 228
hand problems in, 321–322
instrument characteristics and, 228
musician’s cramp in, 531
shifting between positions and, 227–228
W in, 658–659, 660–661
Woodwind musicians, instrument-related
examination of, 230
musculoskeletal problems in, 236
Wound care, after mutilating injuries of hand,
136–137
Wrist, and hand, clinical evaluation of, 361
functional evaluation of, 361–362
and outcome evaluation of,
361–369
four-hundred points score, 363, 364
recent progress in, 362–366
impairment of, dexterity evaluation in, 374
evaluation of, 372–374
Moberg pickup test in, 373–374
muscle strength testing in, 373
quantitative sensory evaluation in,
373–374
range of motion measurements in, 373
Semmes-Weistein monofilament test in,
373
vibration perception thresholds
determinations in, 373
non-specific pain in, hand therapy for
musician in, 295–296, 297–298
outcome evaluation of, Biometrics system
in, 361, 362
health-related quality of life and,
375–377
International Classification of
Functioning, Disability, and Health
in, 371–378
and hand handicap, postoperative outcome
evaluation in rheumatoid arthritis,
471–481
computed tomography of, 401–402
electrogoniometric evaluation of, 364
extension with intrinsic hypertonicity, in
cerebral palsy, 580–581
fingers and, deformity of, classification of, 602
surgical management of, 657–665
Zancolli’s classification of, 560, 658
flexion deformity of, and no active wrist
extension, in cerebral palsy, 578–580
release/lengthening of spastic flexor muscles
in, 657–658
tendon transfers to augment wrist extensors
treatment options in, 657, 658
wrist stabilization in, 659
function of, evaluation of, medical
imaging-based kinematic analysis in,
401–409
functional motion of, requirements for, 25
fusion of, 25–26
ganglions of, in musician,
management of, 254
hyperextended, in flute player, 237
isokinetic and isometric dynamometry of,
364–366
joints of, measurement of, 362
limited fusions of, 25–26
minimal flexion of, and thumb adduction, in
cerebral palsy, 576–577
moderate flexion of, and active wrist extension,
in cerebral palsy, 577–578
pathology of, 401
patient-focused outcome instrument for,
activities of daily living and, 437–438
construct validity of, 449–450, 451–452, 453
detection of change over time in,
452–454
development of, 437–448
frequency of responses in,
440–441, 442
preliminary testing of, 439
recruitment of subjects for,
450–451, 452
response options on, 438
statistical analysis in, 451
test-retest reliability of, 441–443
validity of, 449–455
three-dimensional imaging of, 401
three-dimensional reconstruction of, 402, 403
clinical application of, 404–407
qualitative analysis of, 404
quantitative analysis of, 404, 405