Pronating osteotomy of the radius for forearm supination contracture in high-level tetraplegic patients TECHNIQUE AND RESULTS

Abstract

We report the results of performing a pronating osteotomy of the radius, coupled with other soft-tissue procedures, as part of an upper limb functional surgery programme in tetraplegic patients with supination contractures.
In total 12 patients were reviewed with a mean follow-up period of 60 months (12 to 109). Pre-operatively, passive movement ranged from a mean of 19.2° pronation (−70° to 80°) to 95.8° supination (80° to 140°). A pronating osteotomy of the radius was then performed with release of the interosseous membrane. Extension of the elbow was restored postoperatively in 11 patients, with key-pinch reconstruction in nine.
At the final follow-up every patient could stabilise their hand in pronation, with a mean active range of movement of 79.6° (60° to 90°) in pronation and 50.4° (0° to 90°) in supination. No complications were observed. The mean strength of extension of the elbow was 2.7 (2 to 3) MRC grading.
Pronating osteotomy stabilises the hand in pronation while preserving supination, if a complete release of the interosseous membrane is also performed. This technique fits well into surgical programmes for enhancing upper limb function.

Full text

828 THE JOURNAL OF BONE AND JOINT SURGERY
Pronating osteotomy of the radius for
forearm supination contracture in high-level
tetraplegic patients
TECHNIQUE AND RESULTS
B. Coulet,
J. G. Boretto,
Y. Allieu,
C. Fattal,
I. Laffont,
M. Chammas
From Lapeyronie
University Hospital,
Montpellier, France
B. Coulet, MD, PhD,
Orthopedic and Hand Surgeon
Y. Allieu, MD, Orthopedic and
Hand Surgeon
M. Chammas, MD, PhD,
Orthopedic and Hand Surgeon
Hand and Upper Limb Surgery
Department
I. Laffont, MD, PhD, Director
of Rehabilitation
Central Department of
Rehabilitation
Lapeyronie University Hospi tal,
371, avenue du Doyen Gaston
Giraud, 34295 Montpellier
Cedex 5, France.
J. G. Boretto, MD, Orthopedic
and Hand Surgeon
Hand and Upper Extremity
Surgery Department
Hospital Italiano de Buenos
Aires, Potosí 4247, C1199ACK
Buenos Aires, Argentina.
C. Fattal, MD, PhD, Director of
Rehabilitation
Centre Mutualiste
Neurologique Propara, 283
avenue du Caducée, 34195
Montpellier, France.
Correspondence should be sent
to Dr B. Coulet; e-mail:
bertrand-coulet@wanadoo.fr
©2010 British Editorial Society
of Bone and Joint Surgery
doi:10.1302/0301-620X.92B6.
23457 $2.00
J Bone Joint Surg [Br]
2010;92-B:828-34.
Received 21 September 2009;
Accepted after revision 27
January 2010
We report the results of performing a pronating osteotomy of the radius, coupled with other
soft-tissue procedures, as part of an upper limb functional surgery programme in tetraplegic
patients with supination contractures.
In total 12 patients were reviewed with a mean follow-up period of 60 months (12 to 109).
Pre-operatively, passive movement ranged from a mean of 19.2° pronation (-70° to 80°) to
95.8° supination (80° to 140°). A pronating osteotomy of the radius was then performed with
release of the interosseous membrane. Extension of the elbow was restored post-
operatively in 11 patients, with key-pinch reconstruction in nine.
At the final follow-up every patient could stabilise their hand in pronation, with a mean
active range of movement of 79.6° (60° to 90°) in pronation and 50.4° (0° to 90°) in supination.
No complications were observed. The mean strength of extension of the elbow was 2.7 (2 to
3) MRC grading.
Pronating osteotomy stabilises the hand in pronation while preserving supination, if a
complete release of the interosseous membrane is also performed. This technique fits well
into surgical programmes for enhancing upper limb function.
A supination contracture can be defined as an
inability to stabilise the hand in pronation. It
occurs as a result of an imbalance between the
functional supinator muscles, mainly the
biceps brachii and supinator, and the hypo-
tonic paralysed pronators.1 Initially a supina-
tion contracture can be reduced with
abduction and internal rotation of the shoul-
der, but over time it becomes permanent as the
biceps brachii and the interosseous membrane
contract. Apart from looking ‘odd’, a supina-
tion contracture seriously impedes hand func-
tion, which albeit rudimentary, is very
important to the tetraplegic patient. Correc-
tion of the supination deformity enhances the
usefulness of any remaining functional muscles
by the enabling key-pinch.
Unlike obstetric brachial plexus injuries,2,3
supination contractures in tetraplegic patients
occur infrequently and only arise in high-level
tetraplegia, groups 1 to 3 of the International
Classification of Surgery of the Hand in Tetra-
plegics,4 corresponding to neurological levels
C5 and C6. It is generally agreed that func-
tional upper limb surgery programmes should
aim to restore the pronated position of the
forearm, elbow extension and key-pinch.5,6
The treatment of a supination contracture
is difficult and controversial, and few studies
offer a specific therapeutic strategy for tetra-
plegic patients.7-11 None propose a global
strategy for functional upper limb rehabilita-
tion. Zancolli9 suggested a pronator transfer
of the biceps tendon in association with
release of the interosseous membrane release,
for fixed contractures. However, rerouting
the biceps risks both overcorrection and
slackening,10 with unpredictable results in
patients with a fixed deformity despite
interosseous membrane release.5,12
This study aimed to describe a pronating
osteotomy of the radius for correcting a supi-
nation contracture in the adult tetraplegic
patient, and to evaluate the functional results
using a complete upper limb rehabilitation
programme in this group of patients.
Patients and Methods
A total of 12 isolated pronating osteotomies of
the radius in eight high-level tetraplegic
patients with a supination contracture were
retrospectively reviewed. The mean post-
operative follow-up period was 60 months
(12 to 109). All patients gave informed con-
sent. Their mean age at the time of surgery was
37 years (24 to 54), and the mean time
between spinal injury and surgery was
73 months (14 to 287). From a neurological

PRONATING OSTEOTOMY OF THE RADIUS FOR FOREARM SUPINATION CONTRACTURE IN HIGH-LEVEL TETRAPLEGIC PATIENTS 829
VOL. 92-B, No. 6, JUNE 2010
point of view, the lowest useful motor level was C5 in seven
cases and C6 in five. The mean American Spine Injury
Association (ASIA)13 motor score was 16.2 (12.5 to 20.0)
out of 100. According to the International Classification of
Tetraplegics,14 four cases were group 1, five group 2 and
three group 3 (Table I).
None of our patients had active extension of the elbow.
Anterior stabilisation of the shoulder was poor owing to
paralysis of the pectoralis major.
The passive range of pronation and supination was mea-
sured with a goniometer. Pre-operatively, none of the
patients could stabilise their forearm in pronation. Mean
passive pronation was 19.2° (-70° to 80°), mean supination
was 95.8° (80° to 140°), and the mean deficit in passive
elbow extension was 19° (0° to 40°). In eight of the 12 a
fixed supination contracture was present, with passive
pronation < 40°. Mean passive wrist extension was 82°
(40° to 90°) and mean passive flexion was 15° (70° to -20°)
(Table II).
Surgical technique: pronating osteotomy of the radius. The
senior author (BC) performed every operation, with the
patient under general anaesthesia. After application of a
tourniquet the osteotomy was performed through an ante-
rior forearm approach. The pronator teres muscle, which
was atrophied in each case, was released from the radius.
The interosseous membrane was exposed and divided
throughout its length. The first three cases in the series had
only a limited release of the interosseous membrane to
allow for placement of the plate (Table I). Care was taken
to preserve the integrity of the anterior and posterior
interosseous pedicles (Fig. 1).
A mid-diaphyseal transverse osteotomy was performed
after inserting proximal and distal marking pins perpendic-
ular to the axis of the diaphysis of the radius. The mean
angle of pronation after osteotomy, measured by the mark-
ing pins to the distal segment, was 74° (60° to 90°). Osteo-
synthesis was performed using a seven-hole 3.5 mm
dynamic compression plate.
Ta b l e I . Demographic data and associated surgical procedures
Associated surgical
procedures
Patients Side
Age at
osteotomy
(years)
Time between
SCI and POR
(months)
ASIA score
(motor score)
(50)
International
classification
Lesion
level
Degree
pronation
osteotomy
Complete
release of
IOM
First
stage
Second
stage
1 R 30 29 8.5 G2 C6 60 - Osteotomy BB to TB
transfer +
Passive KP
2 R 24 24 7.5 G2 C6 80 - Osteotomy
+ BB to TB
transfer
Passive KP
L23 14 8 G2 C6 80 - Osteotomy +
BB to TB
tansfer
Passive KP
3 R 34 54 10 G3 C6 70 + Osteotomy BB to TB
transfer +
Active KP
(BR to FPL)
L 33 39 10 G3 C6 70 + Osteotomy BB to TB
transfer +
Passive KP
4 R 43 52 8 G1 C5 80 + Osteotomy +
BR to ECRB
transfer
BB to TB
transfer +
Passive KP
L45 76 8 G1 C5 80 + Osteotomy +
BR to ECRB
transfer
BB to TB
transfer +
Passive KP
5L4116 9G2C570+Osteotomy +
BB to TB
transfer
-
R 42 29 7.5 G1 C5 90 + Osteotomy +
BB to TB
transfer
Passive KP
6L5415 7.5G1C580+Osteotomy-
7 R 41 287 9 G3 C5 70 + Osteotomy BB to TB
transfer +
Passive KP
8 L 41 241 8 G2 C5 90 + Osteotomy +
BB to TB
transfer
Passive KP
SCI, spinal cord injury; POR, pronating osteotomy of the radius; ASIA, American Spinal Injury Association; IOM, interosseous membrane; BB,
biceps brachii; TB, triceps brachii; KP, key-pinch; BR, brachioradialis; FPL, flexon pollicis longus; ECRB, extensor carpi radialis brevis

830 B. COULET, J. G. BORETTO, Y. ALLIEU, C. FATTAL, I. LAFFONT, M. CHAMMAS
THE JOURNAL OF BONE AND JOINT SURGERY
Intra-operatively, the final position of the hand was
checked after fixing the osteotomy to ensure that it allowed
at least 50° of pronation and at least 50° passive supina-
tion. Where another surgical procedure took place during
the same operation, a pronating osteotomy of the radius
was performed first. Post-operatively, a cast immobilised
the elbow and the wrist for three weeks. Its position was
determined by the type of tendon transfer associated with
the pronating osteotomy of the radius. The elbow was
maintained in extension after a biceps-to-triceps transfer to
restore active elbow extension, and in flexion following
brachioradialis to extensor carpi radialis brevis (ECRB)
transfers. Forearm mobilisation was initiated within the
range of movement obtained intra-operatively.
Associated procedures within the functional upper limb sur-
gery programme. The pronating osteotomy of the radius was
the sole procedure in one limb in only one patient. The other
11 interventions required a two-stage procedure, involving
functional upper limb surgery with key-pinch reconstruction
(Table I). In four patients, the first stage was a pronating
osteotomy of the radius. In the second stage, the biceps brachii
was transferred to the triceps brachii and a key-pinch recon-
struction was performed.15 In two further cases the brachio-
radialis was transferred to the extensor carpi radialis brevis to
restore active extension of the wrist along with a pronating
osteotomy of the radius in the first stage. During the second
stage, the biceps brachii was transferred to the triceps and the
key-pinch reconstruction was carried out. In the five remain-
ing cases stage one included a pronating osteotomy and biceps
to triceps transfer with a key-pinch reconstruction in the sec-
ond stage in four (Table I).
Data collection. Each patient was clinically reviewed by an
independent clinician. The ability to stabilise the forearm in
pronation and to achieve active extension of the wrist dur-
ing key-pinch without supination was evaluated. The pas-
sive range of movement in pronation and supination was
assessed with the elbow in 90° of flexion.
Activities of daily living. Patients’ functional autonomy
was evaluated pre-operatively and at final review using
the Quadriplegia Index Factor.16 The maximum period of
autonomy was also recorded. This parameter is defined by
the amount of time a patient can spend alone without
requiring help from a third party. The Modified University
of Minnesota Tendon Transfer Functional Improvement
Questionnaire was also used.17,18 This assesses the
improvement in 30 general activities typically performed
by tetraplegic patients, and requires patients to classify
their functional abilities before and after surgery as ‘much
better’ (2 points), ‘better’ (1 point), ‘no change’ (0 points),
‘worse’ (-1 point), and ‘much worse’ (-2 points). The min-
imum possible score when all answers are ‘much worse’ is
-60. The maximum possible score when all answers are
‘much better’ is 60.
Ta b l e I I . Range of movement and functional results
Patients Side
Pronation
pre-op/final
follow-up (°)
Supination
pre-op/final
follow-up (°)
Wrist flexion
pre-op/final
follow-up (°)
Wrist ext. pre-op/
final follow-up (°)
Elbow deficit
ext. pre-op/
final follow-up (°)
Elbow extension
strength (MRC)
QIF† initial/
review (0/100)
Total autonomy
time initial/
review (minutes)
1 R 30/90 90/40 45/45 40/40 - 20/-17 3 30.7/40.3 180/240
2 R 40/90 90/20 70/55 80/70 - 40/-5 2.5 9.8/20.8 30/300
L 10/90 90/0 40/30 80/70 - 35/-5 3
3 R 80/80 80/80 20/45 90/50 - 10/-10 3 24.3/36.5 120/360
L 80/90 90/50 10/45 90/70 0/0 2.5
4 R 10/70 90/40 -10/ 20 90/45 0/-10 2.5 14.2/28.7 60/240
L 60/80 90/30 -20/ 30 90/60 0/0 2.5
5 L 0/85 90/85 -30/25 80/80 0/0 3 12.1/26.7 30/330
R 30/80 90/80 -10/30 90/60 - 15/0 2
6 L -30/60 140/90 -20/10 90/60 - 40/-20 NA‡15.7/16.5 60/120
7 R -70/60 80/50 30/30 80/60 - 30/-30 3 31/39 120/300
8 L -10/80 130/40 0/10 90/90 - 40/-20 2.5 15.7/22.75 60/240
*MRC, Medical Council Research
† QIF, Quadriplegia Index Factor
‡ NA, not available
Fig. 1
Photograph of an anterior forearm approach showing a section of the
interosseous membrane along its entire length. Pronating the forearm
creates a wider gap between the radius and the ulna.

PRONATING OSTEOTOMY OF THE RADIUS FOR FOREARM SUPINATION CONTRACTURE IN HIGH-LEVEL TETRAPLEGIC PATIENTS 831
VOL. 92-B, No. 6, JUNE 2010
Statistical analysis. P-values were calculated using non-
parametric tests, as our population did not have a normal
distribution nor similar variances. The Mann-Whitney U
test was used to compare patients with and without com-
plete interosseous membrane release, and those with or
without fixed supination contractures. Wilcoxon’s signed
ranks test was used to compare the range of pronation and
supination before and after treatment. A p-value of < 0.05
was deemed significant.
Results
At the final follow-up, all osteotomies united. None of the
plates needed to be removed, and there were no cases of
infection, hardware failure, forearm synostosis or complex
regional pain syndrome. However, in the month following
surgery two patients were temporarily transferred to inten-
sive care because of respiratory difficulties.
Pronating osteotomy of the radius. At final review, every
forearm was stable in pronation (Figs 2 and 3). Pronation
increased to a mean of 79.6° (60° to 90°) at the final
follow-up (p < 0.01). Conversely, supination decreased
significantly to a mean of 50.4° (0° to 90°) (p < 0.01) at
the end of the study. The mean arc of movement from full
supination to full pronation increased, albeit not signifi-
cantly (Wilcoxon, p = 0.45), from a mean of 115° (10° to
170°) to a mean of 130° (90° to 170°) (Table II).
The difference in the range of pronation and supination
at final follow-up between patients who had a fixed supina-
tion contracture (mean pronation 76.9° (60° to 90°), mean
supination 53.2° (0° to 90°) and those who had a flexible
supination contracture, mean pronation 85° (80° to 90°),
mean supination 45° (20° to 50°), was not statistically sig-
nificant (Mann-Whitney, pronation p = 0.22, supination
p = 0.18). In the first three cases, where the interosseous
membrane was only partially divided, a significant diminu-
tion in the range of supination, mean 20.0° (0° to 40°) was
observed, compared with those cases in which the
interosseous membrane was completely divided, regardless
of whether the supination contracture was fixed or flexible,
mean 60.6° (30° to 90°) (p = 0.04) (Fig. 4).
Results of the functional upper limb surgery programme. Active
wrist extension without forearm supination was achieved
for each patient. The mean strength of extension of the
elbow at final review was 2.7 (2 to 3), according to the
Medical Research Council scale,19 with a mean deficit in
active extension of -8.9° (0° to -30°) (Table II).
In terms of functional autonomy, the Quadriplegia Index
Factor increased significantly (p ≤ 0.01) from a mean of 19.2
(9.8 to 31) pre-operatively to a mean of 28.9 (16.5 to 40.3)
at final follow-up. The duration of maximum autonomy
increased by a mean of 183.5 minutes, from 82.5 (30 to 180)
minutes to 266 (120 to 360) minutes (p = 0.02). Pre-
operatively, all eight patients required help for the slightest
activity, such as holding a small object or a drink. At the final
review, for the three patients who did not have an indwelling
urinary catheter or a penile sheath, complete autonomy was
increased by two to three hours, while a third party inserted
Fig. 2
Photograph of supination attitude in a high-level tetraplegic
patient, group 2 of the Giens international classification. Pre-oper-
ative range of passive pronation and supination. The hand is
functionally unusable: no grip is possible.
Fig. 3
Photograph of the post-operative position of the hand, stable
in pronation with no recurrence of the supination attitude.

832 B. COULET, J. G. BORETTO, Y. ALLIEU, C. FATTAL, I. LAFFONT, M. CHAMMAS
THE JOURNAL OF BONE AND JOINT SURGERY
a urinary catheter or applied a penile sheath. The other five
patients only needed help with meal preparation.
The functional evaluation using the Activities of Daily
Living Functional Questionnaire17 showed great satisfac-
tion, with a mean score of 15.7 (11 to 22). Activities in
which patients reported the greatest improvement were the
manipulation of small objects; the ability to feed themselves
with the help of technical aids (excluding cutting food) and
the ability to use a conventional joystick controller on an
electric powered wheelchair. However, patients remained
unable to dress themselves or to move unaided from a
wheelchair to another seat.
All patients considered the operation highly beneficial,
and said they would have it again. It should be noted that
seven of the eight patients underwent the complete pro-
gramme of functional upper limb surgery with key-pinch
reconstruction, and that all patients with bilateral impair-
ments asked for surgery on both sides.
Discussion
Studies that specifically discuss the correction of supination
contractures in tetraplegic patients following a spinal cord
injury are rare.9,10 This impairment is encountered almost
exclusively in tetraplegic patients with high-level lesions,
when pronator teres is completely paralysed. Supination
contractures in tetraplegic patients can be functionally cat-
astrophic, because the tenodesis action of the wrist is
impaired, and thus any upper limb surgery programme is
doomed to fail. The first stage of the surgical programme
must correct this contracture, and the technique must be
integrated into an overall strategy for functional upper limb
rehabilitation.
Our results show that a pronating osteotomy of the radius
is a reliable technique. In every case in this series the hand was
stabilised in pronation, allowing a basic key-pinch for each
patient. We observed no relapse into the supination defor-
mity, as the biceps was transferred to the triceps to restore
elbow extension in almost every case. However, for the cases
in which the biceps brachii was transferred during the second
stage of surgery, we observed a tendency towards reduced
passive pronation. Similarly, in previous reports of rotational
forearm osteotomy without biceps brachii transfer after
obstetric brachial plexus injuries, supination frequently
recurred.2,20 In light of our results, we recommend correcting
the muscle imbalance between the supinator and pronator
muscles to avoid the return of the deformity.
Our experience shows that the role of the pronating
osteotomy of the radius may be extended to treat fixed
supination contracture through complete release of the
interosseous membrane.
Zancolli9 described release of the interosseous mem-
brane during re-routing of the biceps brachii for supination
contracture treatment in two patients with flexible supina-
tion contractures who subsequently recovered active
pronation of 50° to 60°. In contrast, Gellman et al10
obtained comparable results in eight patients without
Initial range of movement Range of movement at follow-up
Initial range of movement Range of movement at follow-up
Pronation Supination
26.7 90.0 Pronation Supination
20 c
90.0
Pronation Supination
16.7
97.8
Pronation Supination
60.6 c
76.1
Limited interosseous membrane release
Greater interosseous membrane release
Fig. 4
Diagram of the mean ranges of movement in pronation and supination before and after pronating osteotomy of the radius,
depending on the extent of release of the interosseous membrane. When the interosseous membrane is not completely
released, a significant loss of supination is observed.

PRONATING OSTEOTOMY OF THE RADIUS FOR FOREARM SUPINATION CONTRACTURE IN HIGH-LEVEL TETRAPLEGIC PATIENTS 833
VOL. 92-B, No. 6, JUNE 2010
releasing the interosseous membrane, even in cases with
fixed deformities. However, two patients suffered a com-
plete loss of supination due to overcorrection. Gellman et
al10 insisted on conserving 45° of supination. The fixed
supination contractures in our series had ranges of move-
ment similar to the flexible supination contractures at final
follow-up. Comparing the first three upper limbs that
underwent limited release of the interosseous membrane
(just enough to allow osteosynthesis placement) with the
rest of the series, we observed that failure to completely
divide the interosseous membrane does limit residual supi-
nation.
Our results show similar ranges of movement for both
pronation and supination at final follow-up to those
obtained by re-routing the biceps.
Even though few tools are sensitive enough to assess the
highest-level tetraplegic patients, the functional analysis of
our patients was very positive. We noticed that patients
who had been reduced to a state of total dependence after
their spinal cord injury had regained a degree of autonomy
by the final review.
Most daily activities require the forearm to be in a
pronated position. Because of this, a supination contracture
must be corrected as part of a systematic overall pro-
gramme for upper limb reconstruction that includes restor-
ing extension of the elbow. A pronating osteotomy of the
radius fits well into the functional upper limb surgery pro-
gramme as it preserves the biceps, allowing transfer to the
triceps to restore active extension of the elbow. This tech-
nique is useful when anterior stabilisation of the shoulder
by the pectoralis major is insufficient as found in all our
patients.21,22 The alternative, of transferring the posterior
deltoid to the triceps brachii in patients with a paralysed
pectoralis major, is problematic, because it causes the
shoulder to roll backwards during extension of the elbow.
In our series, biceps brachii transfer results were modest,
but good enough to position the hand at an above-the-
shoulder level.
A complete functional upper limb surgery programme
for high-level tetraplegic patients with a supination con-
tracture requires several operations, which should be co-
ordinated (Fig. 5).
A pronating osteotomy of the radius can always be under-
taken in conjunction with another operation. In patients
who have retained active extension of the wrist (groups 2
and 3 of the International Classification), pronation osteot-
omy of the radius is best performed with biceps to triceps
transfer, as the two approaches are quite distinct and the
osteosynthesis of the pronating osteotomy of the radius with
a dynamic compression plate does not hinder the biceps
transfer rehabilitation. Active or passive key-pinch construc-
tion can be carried out at a later stage. However, when
patients have no extension of the wrist (group 1) it is prefer-
able to transfer the brachioradialis to the extensor carpi radi-
alis brevis at the same time as the pronating osteotomy of the
radius. Biceps to triceps transfer and passive key-pinch con-
struction can be carried out at a later date. Reducing surgery
to two stages avoids exhausting these patients, for whom the
Goals of
functional
surgery
Group 1
First stage
Second stage
Groups 2 to 3
SC correction
Elbow extension
Wrist extension
KP reconstruction
SC correction
Elbow extension
KP reconstruction
1
2
4
1
2
3
4
POR + BR to ECRB transfer POR + BB to TB transfer
BB to TB transfer
Active KP reconstruction
BR to FPL transfer
Passive KP reconstruction
FPL tenodesis to the radius
1312
4
2
4
Fig. 5
Diagram of the functional upper limb surgery programme for high-level tetraplegic patients with supination contracture of the forearm.
Fixed supination contracture does not affect the therapeutic strategy. Only the neurological lesion level should be considered, (SC, supina-
tion contracture; KP, key-pinch; POR, pronating osteotomy of the radius; BR, brachioradialis; ECRB, extensor carpi radialis brevis; BB, biceps
brachii; TB, triceps brachii; FPL, flexor pollicis longus.

834 B. COULET, J. G. BORETTO, Y. ALLIEU, C. FATTAL, I. LAFFONT, M. CHAMMAS
THE JOURNAL OF BONE AND JOINT SURGERY
results of such a programme will always remain modest. We
suggest that the biceps should be rerouted to correct a
flexible supination contracture in high-level tetraplegics only
in exceptional cases, when patients have retained good ante-
rior stabilisation of their shoulder, thus allowing the transfer
of the posterior deltoid to the triceps. The basis for treating a
supination contracture lies in the suppression of the supinat-
ing action of the biceps, either by transferring it to the triceps
or by giving it a pronating function.
This study has certain limitations. First, it is retrospec-
tive, owing to the relatively low prevalence of supination
contractures in tetraplegic patients. Our oldest records in
this series date from ten years ago, which is why we only
used tests that had been validated at the time of the initial
functional evaluation assessment. Another difficulty
involved the evaluation of the results from a pronating
osteotomy of the radius in tetraplegic patients. Range of
movement is only one parameter, and although the stability
of the forearm in pronation seems to be more important for
function, it is difficult to quantify objectively. Functionally,
few scales are sensitive enough to highlight improvements
in high-level tetraplegia,23 for which reason we used the
Quadriplegia Index Factor and maximum autonomy time.
Nevertheless, the study remains homogeneous because all
of the patients were treated at the same institution accord-
ing to the same surgical and rehabilitation protocol.
A supination contracture in tetraplegic patients repre-
sents a complex surgical challenge. Our results show that a
pronating osteotomy of the radius can help correct it effec-
tively, and that it integrates well into a functional upper
limb surgical programme.
No benefits in any form have been received or will be received from a commer-
cial party related directly or indirectly to the subject of this article.
References
1. Coulet B, Allieu Y, Chammas M. Injured metamere and functional surgery of the
tetraplegic upper limb. Hand Clin 2002;18:399-412.
2. Zaoussis AL. Osteotomy of the proximal end of the radius for paralytic supination
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