Upper Limb

Indications for Surgery


Upper limb surgery is mainly in spastic hemiplegia

- many of the CP' s have sensory neglect for affected limbs   

- won't use limb post surgery anyway


Surgical indications

- a reasonable level of IQ (>70)

- spastic not athetoid 

- voluntary grasp and release

- intact sensation / stereogenesis

- good motivation

- hygiene




1.  Tendon lengthening / division

2.  Tendon transfer

3.  Tenodesis / arthrodesis




1. Lengthening is more predictable than transfer

2. Tendon transfers alone can never overcome rigid osseous deformity

3. Joints which are not under voluntary control should be tenodesed or arthrodesed before tendon transfer

4. Agonist-antagonist tenodesis (spastic coupling) is a good approach because it is symmetrical & balanced


Typical Posture


Shoulder - adducted and internally rotated

Elbow - flexed + pronated

Wrist - flexed + pronated

Fingers - swan-neck +/- flexed

Thumb - in palm




Soft tissue

- lengthening / release of P major and subscapularis



- external rotation osteotomy humerus





- contracture > 45o





- lengthen biceps / lacertus fibrosis / brachialis



- release CFO (Steindler) 

- distal release of brachioradialis and pronator teres + anterior capsulotomy



- release of pronator teres +/- transfer to radius (makes it a supinator of the forearm)

- if severe osteotomy of radius putting it in neutral rotation




Flexion deformity 


Class 1 (mild) 

- fingers can be extended with only 20o or less of wrist flexion 

- Release FCU or CFO slide (Steindler)


Class 2 (moderate)

- full flexion only possible with > 20o wrist flexion 

- A: extensor power present

- B: no extensor power

- CFO release

- transfer FCU to ECRB if no extensor power

- +/- FDS to ECRB transfer


Class 3 (severe) 

- great wrist & finger flexion deformity without extensor motors

- no functional gain is expected 

- surgery here is to improve cosmetic appearance only

- multiple releases +/- wrist arthrodesis




Swan neck deformity



- over pull of extrinsic extensors / central slip shortening / intrinsic spasticity

- final common pathway is volar plate incompetence with hyperextension at the PIPJ



- FDS tenodesis through a volar Brunner incision




Most crippling upper extremity deformity

- can be a significant hygiene problem in severely affected 

- may need surgery despite not fitting criteria set out above

- in practice surgery is directed at what the pathology is 


Type 1 

- weak EPL

- reroute EPL + reinforce with PL or FCR or brachioradialis


Type 2 

- intrinsic contracture & first dorsal interosseous tightness

- release webspace +/- Z plasty


Type 3 

- weak APL & EPB

- APL tenodesis reinforced with PL, FCR or brachioradialis


Type 4 

- spasticity of  FPL

- Z lengthening of FPL