choice of procedure for patients who have a flexion contractures greater than 45 degrees. the procedure will release the contracture and allows for active flexion by transferring the biceps. it is important that the psychological condition of the patient is evaluated before surgery. the dramatic change in the patient’s life requires a psychological adjustment. this should be evaluated and addressed before surgery. follow-up by a psychologist is necessary. patient must be psychologically ready to understand the surgical planning, aims and possible outcomes. the patient must be motivated, well-informed, in sound psychological condition and must have a precise and realistic need for rehabilitation. individual factors must be taken into account. (age, profession, hobbies, education, family support and social background). this is especially important in associated brain injury. contraindications contraindications for surgery are severe pressure sores, severe spasticity, inability to stabilize the trunk. spasticity, if present, can be very important. it is not a contraindication per se, but severe spasticity must be treated first depending in which muscle groups it is present. spascticity can be treated with botox or myotomies. in some cases spastic tone can be useful to facilitate hand grasp and grip. harmful spasticity that does not respond to medication or surgical treatment is a contraindication. the shoulder muscles, pectoralis major and latissimus dorsi, must be evaluated. the shoulder must not only have good motor condition but also good proprioceptive control. the trophicity and articular condition of the upper limb must also be considered. a poor condition requires a preoperative rehabilitation program. before any hand surgery is performed, the patient should be able to actively extend the elbow. therefore, if there is no active elbow extension, elbow extension reconstruction surgery should precede any hand surgery. a contraindication specifically for posterior deltoid to triceps transfer is a flexion contracture of the elbow, biceps to triceps transfer might then be a possible transfer for elbow extension reconstruction. the contraindications for biceps-to-triceps transfer relate to the muscle balance surrounding the elbow. the m. supinator and m. brachialis function is a prerequisite for this surgery. if one of these muscles is nonfunctional the patient will lose forearm supination and elbow flexion if the tendon is transferred. surgical procedures – active and passive tendon transfers in general, reconstruction of the upper limb can only be performed if active elbow extension is present. this stabilizes the elbow and gives the patient a reach. it will also allow the transfer of the other muscles crossing the elbow joint (like the m. brachioradialis and m. extensor carpi radialis longus). it is also an operation whose results allow the patient to gain confidence in the rest of the treatment. wrist-related tenodesis effect (tenodesis grasp) means that wrist flexion passively opens the hand and wrist extension passively closes the hand. (see pictures below) wrist-related tenodesis effect is the key point of any functional surgery in a paralyzed hand, therefore active wrist extension is required and reconstruction of this active wrist extension is of utmost importance for the tetraplegic hand. if no active wrist extension is available (ic group 0 and 1), the brachioradialis (only ic group 1) can be transferred to achieve wrist extension. wrist related tenodesis effect wrist related tenodesis effect active tendon transfers are possible if m. extensor carpi radialis longus and m. extensor carpi radialis brevis are present. the use of the m. extensor carpi radialis longus and the m. brachioradialis are possible to restore hand function. elbow deltoid-to-triceps transfer there are two major techniques used to gain elbow extension. deltoid-to-triceps transfer: for this transfer, the posterior part of the deltoid muscle is released from its origin and attached to the triceps muscle (usually by means of a tendon graft or a synthetic graft) leaving the rest of the deltoid muscle intact. this transfer is usually very successful because the line of pull of the posterior deltoid muscle is in the same direction as the triceps muscle. also, there is hardly any loss of function. the deltoid muscle is usually innervated by the fifth and sixth cervical nerve roots and is therefore often functional in patients with tetraplegia, though the triceps muscle, which is innervated by the seventh cervical root, is paralysed. because of the location at the back of the arm, the posterior part of the deltoid muscle can give strength in the same direction as the triceps muscle and is therefore theoretically a good donor to regain elbow extension. not only the direction of the strength provided by the donormuscle is important, smith et al. showed that the matching between the original functional properties of the donor and recipient muscles affects the outcome of the transfer. therefore, fridén studied the architectural properties of the deltoid and triceps muscle in cadavers and concluded that the posterior deltoid would be a very suitable transfer to provide elbow extension. since the tendon of the triceps is not long enough to reach the posterior deltoid muscle, an interposition graft is needed. different procedures have been described to achieve the transfer. moberg used free tendon grafts from the long toe extensors to connect the posterior deltoid to the triceps, other interposition grafts have been described, including fascia lata and a triceps tendon turnup. one should keep in mind that many patients hold out a hope for a cure and are therefore concerned about incurring a significant donor defect that could cause impairment if they recovered a lowerextremity function. the first part of the surgery should be to make an incision along the posterior border of the deltoid. the muscle is exposed to its insertion on the humerus. next the part of the muscles that originates from the spina scapulae, the posterior one third to one half, is isolated from the anterior portion of the muscle. the insertion of the posterior deltoid is then elevated of the muscle and the distance between the mobilized deltoid tendon to the olecranon is measured to determine the length of the interposition graft needed. the interposition graft must now be harvested from its donor site. it should be 5 to 10 cm longer than the gap. after this a longitudinal incision should be made over the triceps tendon in which two transverse slits are made. one end of the graft should be wrapped around the posterior deltoid and sutured securely to it, after which the grafted is passed through an intercutaneous tunnel towards the triceps tendon, woven through the transverse slits and sutured securely to the triceps tendon and itself. once the graft is securely in place, the wound is closed and a long armcast is applied with the elbow at 10 degrees of flexion. this tendon transfer has a high risk of being stretched, during the postsurgical period. it is extremely important that a challenging and precise post-surgical rehabilitation program is implemented, in order to maximize the results and prevent the tendon from becoming stretched. biceps-to-triceps transfer: the biceps muscle can only be used for this transfer if the other elbow flexors are intact (m. brachialis and m. brachioradialis). this procedure is typically performed under general anesthesia but can be performed under supraclavicular brachial plexus blockade. the incision depends on whether there is a contracture that needs to be released. if this is the case a wide exposure of the anterior side of the elbow joint is needed. the distal side of the incision should allow complete dissection of the tendon of the biceps. the primary tendon of the biceps is released from its insertion on the radius and then rerouted medial or lateral. if the ulnar nerve is functional a lateral route is favored to prevent compression, however, the lateral route can cause compression of the radial nerve. a second incision is made to expose the triceps insertion and the triceps is dissected from its insertion on the olecranon. a hole is then drilled in the olecranon and a gauge wire is then looped in the hole. the biceps is routed through a skin tunnel to the posterior side and woven into the triceps tendon to create more length. then the tendon is inserted to the olecranon. hand restoration of key pinch: in general for key pinch the thumb has to be activated. in the lower groups according to the international classification (ic groups 0–1) this can be done onyby means of tenodesis. in ic groups 2 and higher the m. brachioradialis is used to strengthen the thumb flexor. usually the thumb extensor is fixed to the extensor retinaculum and the carpometacarpal joint is fused in the right position. restoration of palmar grip: when active wrist extension is present, it must not be weakened. therefore, the extensor carpi radialis longus can only be used on patients in ic 3 and higher where active extension is supplied by both the extensor carpi radialis longus and the extensor carpi radialis brevis. in ic 2 patients active extension of the wrist depends only on the m. extensor carpi radialis longus, therefore this muscle must not be used for a transfer in this group of patients. the brachioradialis muscle is a versatile motor muscle and is used for different transfers in tetraplegic patients. in ic 1 it is used to restore wrist extension, while in ic 2–8 it is used to restore finger extension (m.extensor digitorum communis) and finger (m.flexor digitorum profundus) or thumb flexion (m.flexor pollicis longus). surgical techniques in this type of hand surgery are mainly the same for the different transfers. technique for transferring the m. extensor carpi radialis longus: the m. extensor carpi radialis longus tendon is divided at its insertion on the second metacarpal. the muscle is separated, and freed entirely from the surrounding tissues. the m. extensor carpi radialis longus tendon is strongly attached to the planned tendon under maximum tension. the m. extensor carpi radialis longus can be transferred to the flexor digitorum profundus or flexor pollicis longus. technique for transferring the m. brachioradialis: the brachioradialis is freed entirely from the surrounding tissues up to the elbow to get extra excursion. the brachioradialis tendon is strongly attached to the planned tendon. rehabilitation the post-operative regimens depend on the surgical procedures used. however, they tend to constrain the tetraplegic patient considerably. during most regimens they are not allowed to drive hand-driven wheelchairs, or to make transfers alone, because of the risk of rupturing a tendon suture. in general the elbow extension reconstructions are immobilised for a few weeks and then slowly allowed to flex the elbow in the following weeks, at a rate of 10 degrees per week. after 10 weeks the patient is allowed to move freely again. after the posterior deltoid-triceps transfer, a cast is applied with the elbow at 10 degrees of flexion. the cast should be worn for 4 to 6 weeks and then exchanged for an elbow brace with an adjustable range of motion. after the biceps-to-triceps surgery the patient’s arm is immobilized for 3,5 weeks in slight flexion, this only counts for patient who could fully extend their arm before the operation. otherwise the patient is immobilized in maximum extension and casted. this stays on for 10–14 days and a second cast is applied in further extension. after the immobilization the patient is given a protective polyaxial brace, which allows the patient to begin active limited flexion and still keep the full extension. this brace is worn by day and at night the patient wears a semi-firm splint that keeps the arm in maximal extension. with the emergence of the one step procedures for the hand, the post-operative rehabilitation programmes became even more important, since early movement is essential. patients are mobilised 24 hrs post-operatively, with protective splints. the regimen takes approximately 12 weeks, before the hand is allowed to be fully loaded. patients are not required to stay as an in-patient for the entire regimen, but can be treated as an outpatient after 1–4 weeks, depending on the centre where the procedures are performed.